Due to its significant negative impact on the health and well-being of the world population, childhood obesity is a major global health issue. This study assessed a variety of risk factors contributing to childhood obesity in a sample of overweight/obese children compared with normal weight controls residing in Saudi Arabia. The findings of this study showed that paternal body mass index (BMI) is a risk factor for childhood overweight/obesity. Saudi children with an overweight/obese father were almost twice as likely to be overweight/obese compared to those with a normal weight father. These findings coincide with other studies which reported that parental BMI was a significant factor associated with childhood and teen obesity [15,16,17]. Previous local studies tackling childhood obesity, such as that conducted in the Al-Hasa region of Saudi Arabia, revealed that there is a higher prevalence of obesity and overweight among children whose parents are also overweight/obese [18]. In comparison to the study conducted in Al-Hasa, the current investigation was more specific as it demonstrated that father’s BMI, and not necessarily mother’s BMI, is predictive of excessive weight in children. Contrary to the findings of this study, other studies have supported the claim that maternal BMI is a more significant predictor of child weight than paternal BMI [7, 19,20,21,22]. Authors of childhood obesity literature have argued that the influence of maternal BMI can be explained by the fact that mothers are the primary caregivers of their children, and, therefore, influence the behaviors and lifestyles, such as food intake and physical activity habits, of their children [19]. It is understandable that paternal BMI would have a stronger impact on child BMI in a gender-segregated society such as Saudi Arabia in which most of the decision-making regarding household conduct and activities are the responsibility of the father [14]. Our findings showed the prevalence of overweight or obesity among fathers to be alarmingly high in the sample analyzed. Regarding eating behavior, children in the sample who were frequent snack eaters were significantly more likely to be overweight or obese compared to those who did not snack. These findings highlight the importance of planning and implementing awareness campaigns that are targeted toward parents and which place special emphasis on dietary behavior and how it affects weight gain and lifetime health. Results from a national survey showed that obese children between the ages of 2 and 5 years are at greater risk of becoming obese adults [17]. Paternal BMI and eating behavior are modifiable risk factors for childhood obesity in Saudi Arabia. These risk factors can be addressed with public health efforts and through the implementation of planned and targeted interventions.
Daily screen use was identified as a modifiable risk factor for overweight and obesity in this study. Using screens for more than 2 h per day increased the risk of being overweight/obese among this group of children. Screen time has been associated with increased risk of being overweight or obese among children in the literature [23, 24]. Children who spend long hours using screens tend to snack while doing so, and eventually, gain weight because they increase their energy intake while seated for a long period of time. Additionally, excessive media exposure has been repeatedly linked to unhealthy life choices [25, 26]. It is worth noting that significant time spent watching television or playing video games was associated with physical inactivity, which in turn is a major risk factor for being overweight or obese in all age group [2, 20, 21, 27, 28]. Children in our study who spent 30 min or more in active play on a daily basis were almost half as likely to be overweight or obese. It is important that parents abide by the recommendations for screen time use among children and employ strict parenting when it comes to the excessive use of screens [29].Controlling screen time use among children and encouraging active play is challenging in Riyadh, Saudi Arabia, due to limited access to neighborhood parks that are safe for children, and unfavorable weather conditions with excessive heat throughout most of the year. Children in Riyadh seek entertainment with electronic devices because they spend long hours indoors with their caregivers, and in private cars commuting to schools in a country with a male dependent driver system that lacks public transportation [30]. Recently, women were permitted to drive in Saudi Arabia. However, the practice of driving remains limited to very few women with jobs and from families that perceive it as culturally acceptable. Public health efforts should focus on planning for accessible indoor exercise facilities and on finding strategies that parents can apply in order to replace the frequent use of screen time.
Additionally, findings from this study suggested cesarean section delivery as risk factor for childhood obesity. This finding is consistent with a prospective cohort study in the literature that reported a fivefold higher odds of childhood obesity associated with cesarean delivery [31, 32]. Cesarean delivery is a non-modifiable risk factor for childhood obesity in this population. However, the deployment of a health message informs that cesarean delivery may increase the likelihood of childhood obesity to parents that are electively considering cesarean delivery, may be beneficial.
Although not all indicators in this study had a significant association with childhood obesity, some family characteristics, such as father unemployment status was shown to be a factor. Unemployment could be a proxy for low family income. This finding coincides with a previously conducted study linking a low socioeconomic status with childhood obesity [33, 34]. This new finding is alarming and should be considered by policy makers as they strategically plan to improve the country’s health and economy.
Parental perception about child weight status was significantly associated with child weight. These results are in accordance with findings from other studies [7]. A meta-analysis suggested that almost 50% of all the parents underestimate their children’s weight status [35, 36]. This proportion was increased among parents of young children (aged 2–6 years) [35, 37]. It has been previously documented that precise parental recognition of the weight of their children is related to a willingness to make changes associated with weight improvement [35, 36].
Obesity among children is a serious global health concern and has profound negative implications that can extend into adulthood. Our findings indicate that the main risk factors contributing to childhood obesity among Saudi Arabian children in Riyadh include paternal BMI, paternal unemployment, dietary behavior in the form of frequent snacking, screen time exceeding 2 h per day, less than 30 min of daily active play, cesarean delivery, and incorrect parental perceptions of child weight status. The evidence from this study reinforces the importance of educating and raising awareness about childhood obesity. This education should be implemented within families, schools, communities, and among policy makers.
Change is required at a multitude of levels. Policy makers should support efforts for the implementation and regulation of interventions aimed at reducing childhood obesity. Further research is needed at the national level to better address the risk factors associated with obesity among children that were identified through this study.
This study includes limitations. The first major limitation was that parental data (such as age, height, and weight) was self-reported rather than measured by research assistants or taken from medical files. This may have resulted in reporting error as under or over estimations may have occurred. In addition, some study variables were not measured objectively. This study relied on parents to recall such things as their children’s level of physical activity, meal duration, fast food meal frequency. This may have resulted in some recall error. Our study had a 15.3% non-respond rate.
