TopicsFood & NutritionDiet, exercise and gestational body weight in Saudi Arabia

Diet, exercise and gestational body weight in Saudi Arabia

 

Hessah Al Suwaidan and Leena R Baghdadi on the relationship between dietary habits, physical exercise and body mass index in Saudi women.

Authors: 

Hessah I Al Suwaidan, clinical epidemiologist, Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.

Leena R Baghdadi, assistant professor and clinical epidemiologist, Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.

The second author contributed equivalently with the first author.


Research summary

Excessive gestational weight gain (GWG) is common among Saudi Arabian women. They are largely unaware of the impact of unhealthy habits on GWG. We evaluated the relationship between dietary habits and physical activity on gestational weight change in Saudi Arabia.

This three-month, analytical cross-sectional study involved 200 participants attending antenatal outpatient clinics at King Khalid University Hospital, Riyadh, Saudi Arabia.

Dietary habits and physical activity levels were evaluated using validated Saudi food frequency and international physical activity questionnaires.

Of the 200 participants, 33% were classified as obese, 34% as overweight, 20.5% as normal weight, and 1% as underweight.

The mean consumption of sweets, cereals and dairy products was high, and low for fruits and vegetables. Analysis of dietary habits showed a statistically significant positive association between intakes of white bread, white rice, sugar, fried eggs and red tea and the participants’ BMI.

Dietary habits and physical activities play a major role in GWG of Saudi Arabian women. A priority key health policy should include long-term maternal advice about excessive GWG as well as increased awareness of balanced diets and physical activities for pregnant women in Saudi Arabia.


ABSTRACT

  • Introduction: Excessive gestational weight gain (GWG) is common among Saudi Arabian women. They are largely unaware of the impact upon GWG from unhealthy habits. We evaluated the relationship between dietary habits and physical activity on gestational weight change in Saudi Arabia.
  • Methods: This three-month, analytical cross-sectional study involved 200 participants attending antenatal outpatient clinics at King Khalid University Hospital, Riyadh, Saudi Arabia. Dietary habits and physical activity levels were evaluated using validated Saudi food frequency and international physical activity questionnaires. Hospital records provided anthropometric measurements. The statistical tests used, mean, standard deviation and regression.
  • Results: Of the 200 participants, most were central region Saudis. Their body mass index (BMI) classified 33% as obese, 34% as overweight, 20.5% as normal weight, and 1% as underweight. The mean consumption of sweets, cereals and dairy products was high, and low for fruits and vegetables. Analysis of dietary habits showed a statistically significant positive association between intakes of white bread, white rice, sugar, fried eggs and red tea and the participants’ BMI. They took part in less than the recommended amount of physical activity, with only 23% doing moderate and 16% doing vigorous physical activity. There was no significant difference between the level of physical activity and BMI. Average blood pressure and glucose levels were normal, although average cholesterol levels were marginally high.
  • Conclusion: Dietary habits and physical activities play a major role in GWG of Saudi Arabian women. A priority key health policy should include long-term maternal advice about excessive GWG as well as increased awareness of balanced diets and physical activities for pregnant women in Saudi Arabia.

Keywords: gestational weight gain, dietary intake, physical activity, pregnant women, Saudi Arabia


INTRODUCTION

Weight gain during pregnancy is normal. The American College of Obstetricians and Gynaecologist (ACOG) has guidelines for healthy gestational weight gain (GWG) based on the existing body mass index (BMI) of pregnant women (Potti et al, 2010). Weight management during pregnancy is important in order to avoid inadequate or suboptimal weight gains associated with many complications of maternal and infant health (Wahabi et al, 2016).

Globally, in 2014, there were estimated to be 38.9 million overweight and obese pregnant women (Chen et al, 2018). In Saudi Arabia in 2015, of the pregnant women attending primary health care centres, 32% were obese and 38% overweight (Al-Asmari et al, 2015). A multicentre cohort study in Riyadh confirmed that >68% pregnant women were overweight or obese (Wahabi et al, 2016).

Excessive GWG is a risk factor for adverse maternal and infant health outcomes, resulting in numerous pregnancy-related complications (preterm birth, caesarean delivery, preeclampsia, gestational hypertension, gestational diabetes, high birth weight, and being overweight and/or obese in childhood) (Marchi et al, 2015).

An unbalanced diet in pregnancy is more common in developing countries, and varies based on the geographical location, dietary habits, and the presence of chronic diseases or medications that increase weight (Gebregziabher et al, 2019). The food pattern of pregnant Saudi women showed an unbalanced nutritional status, characterised by excessive protein and carbohydrate consumption and low consumption of fruits and vegetables (Al-Jaroudi, 2015). Pregnant women in Jazan had high consumption of desserts (90%), fast food (81%), and canned food (71%) (Al Bahhawi et al, 2018).

Pregnant women tend to reduce levels of physical activity, fearing harm to the fetus and discomfort during exercise – especially among those with a history of abortion or infertility treatments (Nascimento et al, 2015).

Women’s health-related quality of life in western Saudi Arabia showed unhealthy lifestyle patterns associated with obesity and type 2 diabetes (T2D) (Al Sadat et al, 2016), and women with T2D have a higher rate of excessive weight gain affected by unbalanced diets, physical inactivity and unmanaged T2D (Al Sadat et al, 2016).

Cultural diversity has a relation to pregnancy-related food practices. Recent research in the UK assessed pregnancy-related cultural eating behaviours among Pakistani women and recommended that midwives consider the ethnic community’s cultural and traditional knowledge when planning a nutritional strategy (Hussai et al, 2021).

Cultural aspects might play a part in GWG, with the possible influence of Middle Eastern cultural values and misbeliefs about dietary habits and physical exercise during pregnancy (Herforth et al, 2019). Sedentary behaviour is more prevalent among women in Arab nations; the hot weather inhibits walking or exercising outside, and social gatherings during leisure time taking precedence over all other activities (Sharara et al, 2018).

Emphasising the importance of a healthy lifestyle during pregnancy supports the overall health of pregnant women. Studying patterns of eating habits and levels of physical activity in pregnant Saudi women might help prevent obesity and associated comorbidities. It also supports the future Saudi strategic plan of Vision 2030, a new health care program that emphasises the promotion of healthy living, ensuring the availability of healthy food, and developing better behavioural and social actions, thus enabling the health sector to seek improvements and preventions (Alshuwaikhat and Mohammed, 2017).

This study aims to find the relationship between dietary habits and the level of physical activity with body weight changes among pregnant women in Riyadh, Saudi Arabia, as well as estimate the prevalence of obesity and other comorbidities among pregnant women. This study could help improve the lifestyle of pregnant women and reduce the burden of obesity and its associated comorbidities, both regionally and nationally.


MATERIALS AND METHODS

Study design, setting, and duration

This was an analytical cross-sectional study of pregnant women who attended the antenatal outpatient clinics at King Khalid University Hospital (KKUH) in Riyadh. KKUH was chosen because of its accessibility and the variety of perceptions, thoughts, and attitudes towards dietary intake among women from different ages and regions across Saudi Arabia which could be obtained there. Data was collected from 1 June 2019 for three to four days a week in the outpatient clinics while women waited for their antenatal check-ups, between 8am and 2pm.

Study population, sample size, and techniques:

Pregnant women aged ≥18 years, who attended the antenatal outpatient clinics at KKUH in Riyadh, were recruited by random selection (probability sampling). Sample size was calculated by the formula: n= Z2 [p(1-p)]/d2, where n= sample size, Z= Z statistic for a level of confidence, P= expected prevalence/proportion, and d= precision. The level of confidence was set at 95% and Z-value was set at 1.44. The prevalence of obesity in Riyadh, Saudi Arabia was 52% among pregnant women attending antenatal clinics (El-Gilany and El-Wehady, 2009). Therefore, sample size was calculated as N=260, assuming response rate at 80%, with a confidence level of 95%; N=(1.44)2 [0.52 (1-0.52)]/0.052 = 260.

Assessment tools and measurements:

Self-reported information had socio-demographic details including the medical record number, nationality, region, age, and education level. Education was categorised as did not finish school/high school/diploma degree/bachelor’s degree/graduate degree. Working status included monthly income levels classified from <SR 10,000 to ≥SR 35,000 per month.

Other information collected was past or current medical issues, medications or supplements, weight, height, physical activity practices, and past food frequency consumption during pregnancy. Information about parity, defined as a history of past deliveries or the number of times of giving birth to a fetus with a gestational age of 24 weeks or more, was also recorded. Women were classified as nulliparous women, primiparous, multiparous and grand multipara. The data collected through self-reported forms and the quality of the findings were checked and reviewed by both authors. Also, we collected the medical record information from the patient to verify the data sources (objective information) such as BMI, age, medication, and medical examination.

The tools used to collect the data were validated questionnaires. One is a 140 food items-based validated Saudi Food Frequency Questionnaire (FFQ) (Appendix 1) (Gosadi et al, 2017). It evaluates the food portions and frequency of consumption per day, week, and month. It also determines the consumption of fat and salt used in cooking. The second assessment tool was adopted from the international physical activity questionnaire (short form) to evaluate physical activity levels during pregnancy (Appendix 1) (International Physical Activity Questionnaire, 2002). Physical activity was categorised into vigorous, moderate and simple physical activity. To avoid individual dietary intake error, medical records were used to minimise bias and ensure data quality by completing missing information from the questionnaire (whenever available), and collecting data about anthropometric measurements, blood pressure, comorbidities, blood sugar, glycated haemoglobin (HbA1c), and cholesterol levels.

Independent variables are any associated factors considered high risk for the outcome, measured through the assessment tools. The dependent variable was body weight. In addition, BMI was categorised according to the World Health Organization classifications for maternal BMI (underweight: BMI <18.5 kg/m2; normal weight: BMI 18.5–24.9 kg/m2; overweight: BMI 25.0–29.9 kg/m2; and obese: BMI ≥30 kg/m2). (Potti et al, 2010).

Research ethics

This study was approved by the Institutional Review Board committee at King Saud University (approval no. E-19-3924). Participants gave informed written consent before beginning the study (Appendix 2). No identifying data was collected, and participation was voluntary. This study was carried out following the principles of the declaration of Helsinki.

Statistical analysis

The Statistical Package for Social Sciences version 23.0 (IBM SPSS Statistics, Chicago, USA) was utilised. Data was cleaned and edited for inconsistencies before obtaining results for descriptive and analytical analyses. Data was tested for normality using the Kolmogorov-Smirnov test, skewness, kurtosis, and graph plotting. Means and standard deviations were calculated for continuous variables, frequencies for categorical data, and BMI with reported weight and height.

Some food items were reverse coded due to the negative reverse-scored questions on some principal food components (fibre, fat, and sugar). Regression analyses were used to predict the relationship between body weight (dependent variable) and exposure to different types of diets and levels of physical activity (independent variables). The relationship between dietary habits and physical activity in terms of BMI was obtained by linear regression. Adjusted dietary habits and BMI were estimated using multiple linear regressions to adjust the effect of possible confounders (age, socio-demographic factors, education, working status, medical and physical health and parity). The confidence interval was 95% and a p-value ≤0.05 was considered statistically significant.


RESULTS

Of the overall 200 studied pregnant women, all the socio-demographic characteristics varied significantly from the expected frequencies (Table 1). Nearly all the participants were Saudi, with 77% from the central region. Their educational levels varied significantly. The majority held a bachelor’s degree (59%). About 64% participants were unemployed. Half the participants’ (49.5%) monthly income was low to marginally middle class. Regarding parity, 39% women were primiparous, 30.5% multiparous and 15% grand multipara. There were few missing data, and the non-response rate was <20%. However, most of these women did not provide medical record numbers, which made contacting them difficult. There was a statistically significant difference among the participants’ BMI. More than half of the respondents reported simple physical activity, with 23% and 16% performing moderate and vigorous exercise respectively. Generally, the respondents’ data showed insufficient physical activity compared to the recommended guidelines during pregnancy. Linear regression analysis was used to check the relationship between physical activity and BMI amongst the participants (Supplementary Table 1). No significant correlation was observed between the types of physical activity and BMI in pregnancy.

Table 2 shows the anthropometric measurements of the participants. The overall mean age was 31±6.16 years. Mean BMI was 29.42±10.27, which is overweight. Mean total cholesterol was marginally high, while average blood pressure and overall mean blood sugar levels were both normal. Mean HbA1c was 5.52±0.57%, glucose intolerance was 4.35±1.07 MmolL, and fasting blood sugar was 4.17±0.81 Mmol/L.

Table 3 illustrates medical factors of the participants including past or current health issues, medications, and vitamins. Anaemia was more prevalent (28%) than other medical comorbidities, followed by T2D (12%). Prevalence of prescribed medications was Glucophage (metformin) 3% and insulin 1%; some participants used prescribed inhalant corticosteroids (Symbicort). There was low intake of folate and omega-3 supplements. About 19% of the participants took iron tablets, 15% took multivitamins, and 9% took calcium.

From the mean sum score of consumption within each food category, sweets and snacks was high (85.75±23.49) followed by bread and cereals (79.29±24.39), and dairy products (64.12±21.40), compared to low consumption of fruits (37.67±16.86) and vegetables (47.52±21.14). Table 4 shows the most, medium, and least frequently consumed foods. Foods most commonly eaten by participants per day were chicken and lamb kabsa in the meat category, and white bread and white rice in the bread and cereals group. Fried and boiled egg sandwiches, shawarma and chicken sandwiches were popular preferences during pregnancy. Additionally, 19% participants drank full-fat milk and used added sugar. There was high consumption of pure fruit juice, spaghetti, and ice cream during the week. Oranges, bananas, lettuce and carrots were only 30% of the weekly diet. There was medium consumption of French fries, potato chips and soft drinks.

The participants identified meat kababs, liver sandwiches, and meat burgers as monthly foods. There was low consumption of Vimto (fruit flavoured syrup). Asida, maasob and hummus were not frequently eaten.

The relationship between dietary habits and weight change was calculated by simple linear regression (Table 5). Most of the values revealed no significant differences and only some foods showed a significant association with weight change. There was a significant positive association between consumption of white bread and weight change. With every unit increase of eating white bread, GWG increased by 0.94kg (p=0.038). Fried egg consumption was associated with a 1.44kg weight increase (p=0.023). Unexpectedly, red tea (rooibos) correlated with a 0.50kg increase in body weight (p=0.020). Results showed sugar intake associated with increases of 0.40kg in BMI (p=0.038). Eating a fried egg sandwich showed a similar but borderline relationship with BMI (p=0.079). Multiple regression analyses were carried out considering possible confounders. After adjusting for age, region, education, working status, socioeconomic status, parity and medical and medications history, the level of BMI was significantly higher among pregnant women who consumed white rice and red tea. Although there was a positive relationship between consuming carbohydrates, especially sweets and bread, BMI did not reach the statistically significant level (Table 5).


DISCUSSION

This cross-sectional study in Riyadh performed a comprehensive assessment of 200 participants during the gestational period, with an FFQ for nutrition, anthropometric measurements, clinical evaluation of medical history, and medications.

The hypothesis was substantiated by appreciable findings in the study. The majority of pregnant women were educated, unemployed Saudis in their thirties, from the lower to middle economic class. Studies exploring the influences of older age, higher educational level, and medium socioeconomic status on dietary habits during pregnancy report similar findings (Al Bahhawi et al, 2018; Wesołowska et al, 2019).

Our research closely resembles that of the Gosadi et al (2017) study, with a slight variation. We targeted a different population with more information about their health background, anthropometric measurements, and physical activity assessment. However, the findings from the FFQ were similar, emphasizing the validity of the tools and generalisation of the data in Saudi Arabia (Gosadi et al, 2017).

The nutritional value of diets in the study sample was poor. The mean consumption of sweets, cereals, and dairy products was high. These findings vary from studies on Polish and Norwegian women; who consumed more fruits and vegetables during pregnancy (Skreden et al, 2017; Wesołowska et al, 2019). However, it is important to consider the differences between populations, dietary habits, people’s preferences, geographical area, environmental and cultural contexts. Saudi culture emphasises the responsibility for social gatherings and elegant hospitality, which includes providing generous amounts of food for guests (Herforth et al, 2019). Traditional dishes are known for their high fat and complex carbohydrates, especially during religious occasions like Ramadan and Eid, when Saudi women cook and eat substantial amounts of fat, salt and sugar. This study showed low consumption of Vimto (a seasonal habit). Asida, maasob, and hummus were not frequently consumed in Saudi’s central region.

Rapid economic growth affects food consumption patterns in Saudi Arabia. The new trend of social media advertisements has increased restaurant visits as options to celebrate festivals and events like Al Jenadrih, weddings, and graduation parties. Restaurant food contains high amounts of fat and sugar leading to unhealthy eating habits (Bouznif et al, 2018).

The dietary habits analysis showed that the intakes of white bread, white rice, sugar, and fried eggs were significantly associated with positive increases in BMI among the study participants, which might explain the prevalence of diabetic pregnant women (7%) in the study. These values are consistent with a previous finding that around 60% of diabetic Saudi women consumed white sugar, eggs, juices, and carbohydrates during pregnancy (Al Sadat et al, 2016). Evidence supports our finding of increased consumption of energy-dense snacks strongly related to the chance of gestational diabetes mellitus (Li et al, 2015). Consuming fried egg sandwiches showed a borderline relationship with BMI (p = 0.08).

An unanticipated finding was the significant association between drinking red tea and increased weight. Consuming caffeine such as Arabic coffee and red tea is prevalent among Arabs and a common Saudi cultural tradition (Gosadi et al, 2020). A possible explanation for increased body weight from drinking red tea is the addition of sugar or other sweeteners. This, and previous studies, have demonstrated that caffeine is widely consumed by pregnant women, (Gosadi et al, 2020). Li et al (2015) showed that sweetened tea consumption during pregnancy was associated with 87% increase in the risk of childhood obesity ratio (OR =1.87, 95% CI 1.12, 3.12).

The most prevalent comorbidities were anaemia (28%), T2D (6%) and hypertension (4%). These findings are almost consistent with the 2018 Saudi study of about 500 pregnant Saudi women with anaemia (19%), T2D (7%), and hypertension (5%) (Khan et al, 2018). The prevalence of iron deficiency is comparatively higher in our study. Low to mild anaemia was reported among Ethiopian pregnant women due to the promotion of health and control of anaemia (Gebregziabher et al, 2019). This is probably due to the low consumption of dark, leafy green vegetables such as broccoli and spinach. These were the least-consumed foods along with kiwis and strawberries, both rich in vitamin C that help iron absorption (Di Renzo et al, 2015). Additionally, consumption of iron-rich red meat such as lamb was low. Participants consumed more eggs, full-fat yogurt and cheese. Dairy products containing high levels of calcium are known to inhibit iron absorption, especially if iron-rich and calcium-rich foods are consumed together (Candia et al, 2018).

Several studies highlight the importance of supplement use among pregnant Saudi women (Alfawaz et al, 2017). The most consumed supplements were iron (19%), multivitamins (15.5%), calcium (12%) and folic acid (9%). The use of other medications such as metformin significantly decreases GWG, and improves maternal and infant outcomes (D’Ambrosio et al, 2019). In contrast, Dodd et al (2018) reported that metformin has no appreciable effect on decreasing GWG and is associated with the risk of adverse pregnancy outcomes.

Most guidelines for physical activity during pregnancy recommend moderate to intense physical activity for benefits including weight management (Evenson et al, 2014). Generally, our respondents revealed low physical activity, with no significant effect on body change. The majority of participants were not following the recommended physical activity guidelines. In contrast, the quality of pregnant life among Polish women had a significant positive correlation with intense physical activity (Wesołowska et al, 2019). Three-quarters of pregnant Ethiopian women did ≥30 min of moderate to intense physical activity most days (Gebregziabher et al, 2019). However, there was no record of anthropometric measurements (BMI) and subjective information received from participants (Gebregziabher et al, 2019).

More than half of our study participants (63.5%) were unemployed, which could explain extended periods spent indoors, leading to lethargy and lack of physical activity. Nevertheless, England’s midwives have reported a misconception about physical activity benefits during pregnancy, as well as limited advice and knowledge in the clinic from the professionals where the information about physical activity during pregnancy is not adequately explained or followed-up (De Vivo and Mills, 2019).

The major strength of this study is the comprehensive nutritional assessment. Medical records provided objective measurements to minimise biases and maintain the accuracy of data. Generalisation of the findings is possible, and the sample is representative of Saudi women. Also, the number of calculated sample size was achieved. The KKUH governmental hospital setting (which is accessible for all) allows for more characteristics than may occur elsewhere. KKUH was chosen because of its accessibility and the variety of perceptions, thoughts, and attitudes of dietary intake among women from different ages and regions across Saudi Arabia. Generally, the portion of sample size calculation was examined to represent the population at large, including the variety of characteristics in the study group.

Another strength is using a validated FFQ, which is cost-effective and assesses comprehensive dietary information with scale and proportion. However, the study has a few limitations. Factor analysis for food frequency consumption is based on subjective decisions, which could affect results. Accurate gestational age would help establish better accuracy of the weight gain for each gestational age. Many pregnant women were tired, came very early with older children and some had travelled long distances. We tried to contact the participants again or use hospital records to obtain data about the gestational age, but not all the women agreed to share their medical records or contact information due to privacy.


CONCLUSION AND RECOMMENDATION

This study investigated the relationship between dietary habits and physical activities in terms of body weight (BMI) among pregnant women in Saudi Arabia. The findings revealed unhealthy lifestyle habits during pregnancy. Physical activity among pregnant women was below the recommended range. Dietary habits emerged as reliable predictors significantly associated with increases in pregnancy weight. Greater efforts at nutritional education and health pregnancy programs are needed for women in Saudi Arabia to improve their dietary habits and increase physical activity levels.

The results from our study can be of great help not only for physicians, but also for nutritionists, community practitioners and other healthcare professionals working with the relevant cultural population at the UK. Inner-city parts of the UK are well known to have multi-ethnic diversity and high socioeconomic deprivation (Poston et al, 2015). This study reported that about 26% of black obese pregnant women were the predominant minority ethnic subgroup. Individuals of this ethnic origin have a high risk of obesity during pregnancy in the UK (and worldwide), which has been strongly linked to socioeconomic deprivation. The UK attracts many Saudis – especially students, medical residents, and businessmen. It was estimated that there were about 21,000 Saudi Arabian nationals residing in the UK in 2020, an increase from the 15,000 Saudi Arabian nationals residing in the UK in 2008 (Statista, 2021). Traditional Saudi staple foods include white rice and bread, which might be associated with extra weight gain during pregnancy. Therefore, having a better understanding of their eating habits and beliefs around exercise during pregnancy – and then implementing prenatal behavioural intervention focussing on the diet and physical activity – could help to prevent gestational obesity.

A further study could provide an educational pre-pregnancy health program and test the level of awareness post-pregnancy, to evaluate the long-term effects and the precise mechanism of the intervention in order to increase our understanding in this area to and thereby improve the lifestyle of pregnant women.


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