Prevalence of overweight and obesity in children and adolescents in the Northern region of Saudi Arabia: a cross-sectional study Open Access

According to the WHO, the rate of overweight and obesity in children and adolescents aged 5–19 has significantly increased from 4% in 1975 to more than 18% in 2016 (Organization, W.H, 2021), with similar trends observed in both genders (18% for girls and 19% for boys). Although obesity is a preventable condition, in 2020, approximately 39 million children under the age of 5 were classified as overweight or obese, almost half of them lived in Asia, and in 2016, over 340 million individuals aged 5–19 were classified as overweight or obese globally (Organization, W.H, 2021). In Africa, the number of overweight children under 5 years old increased by nearly 24% by the year 2000. Recent observational studies showed an increasing incidence of overweight and obesity worldwide (Morgen and Sørensen, 2014; Spinelli et al., 2019; Wells et al., 2012), including in the Gulf Cooperation Council (GCC) nations (AlAbdulKader et al., 2020; Al-Haifi et al., 2022; Alhyas et al., 2011; Al Hammadi and Reilly, 2019; Oguoma et al., 2021; Al Yazeedi and Berry, 2019), in which Saudi Arabia is the largest member both in terms of surface area and population. Also, the GCC countries share many common socio-cultural and economic factors that can contribute to non-communicable diseases (NCD), along with their economic burdens. Previously viewed as an issue primarily affecting high-income nations, the prevalence of overweight and obesity is now increasing in low- and middle-income countries, especially in urban areas. Ng et al. (2014) showed that the rise of overweight and obesity in children and adolescents is occurring at a faster pace in developing nations compared to industrialized ones. Also, it showed that the prevalence of these conditions increased in the same age group from 8.1% to 12.9% for boys and from 8.4% to 13.4% for girls (Ng et al., 2014).

Overweight and obesity refer to the abnormal or excessive buildup of fat that poses a risk to health. A body mass index (BMI) of 25 or higher is classified as overweight, while a BMI of 30 or above is categorized as obese (Organization, W.H, 2021). The global epidemic of childhood obesity has reached unprecedented proportions, with the World Health Organization (WHO) documenting a dramatic increase from 4% in 1975 to over 18% in 2016 among children and adolescents aged 5–19 years worldwide (Organization, W.H, 2022). This is further illustrated by the significant rise in Disability-Adjusted Life Years (DALY) attributed to non-communicable diseases (NCD) in sub-Saharan Africa, which increased from 90.6 million in 1990–151.3 million in 2017 (Bigna and Noubiap, 2019). This alarming trend represents not merely a statistical concern but a fundamental threat to global public health, with profound implications for healthcare systems, economic development and individual quality of life across generations.

The Kingdom of Saudi Arabia, as the largest member of the GCC, exemplifies the complex epidemiological transition occurring in rapidly developing nations. Recent data indicate that the crude prevalence of overweight/obesity among those 5–19 years of age is one of the highest in the world at 36%, twice the global average in 2016 (Gosadi, 2024). This extraordinary burden reflects the confluence of multiple factors including rapid economic development, urbanization, dietary westernization and sedentary lifestyle adoption. Al Hammadi and Reilly (2019) conducted a comprehensive systematic review of obesity prevalence across GCC states, revealing that Saudi Arabia consistently demonstrates elevated rates compared to regional counterparts, with childhood obesity prevalence ranging from 5.0% to 25.0% across different studies and regions within the Kingdom (Al Hammadi and Reilly, 2019).

The pathophysiological consequences of childhood obesity extend far beyond aesthetic concerns, encompassing a comprehensive spectrum of immediate and long-term health complications. Obese children face significantly elevated risks of developing type 2 diabetes mellitus, cardiovascular disease, metabolic syndrome, nonalcoholic fatty liver disease and orthopedic complications (Almubark et al., 2023). Moreover, the psychological impact of childhood obesity, including reduced self-esteem, depression and social stigmatization, creates additional layers of complexity requiring multidisciplinary intervention approaches. The temporal relationship between childhood obesity and adult morbidity has been extensively documented, with longitudinal studies demonstrating that childhood obesity significantly predicts adult cardiovascular disease, diabetes and premature mortality independent of adult weight status.

Research suggests that individuals with severe obesity in this age demographic face a higher risk compared to others for developing hypertension, type 2 diabetes, metabolic syndrome, nonalcoholic fatty liver disease, atherosclerosis and adult obesity (World Obesity Federation, 2024). Obese children may experience breathing difficulties, sleep apnea and increased fracture risk. Other studies have also shown a strong relationship with asthma, hepatic steatosis, high cholesterol, menstrual abnormalities, impaired balance and psychological and orthopedic implications (Caprio et al., 2020; Malik et al., 2020; Smith et al., 2020; Weihrauch-Blüher et al., 2019; Weihrauch-Blüher and Wiegand, 2018). In addition, women of childbearing age who are obese face a higher risk of negative pregnancy outcomes, including maternal mortality, delivery complications, preterm birth and intrauterine growth retardation (Bendor et al., 2020; Frederiksen et al., 2018; Melchor et al., 2019; Shaukat and Nasrullah, 2019; Singh et al., 2013). Moreover, childhood and adolescent overweight and obesity have been linked to lower academic attainment (Amis et al., 2014; Cohen et al., 2013) and make them more likely to be targeted by food marketing than adults (Ertz and le Bouhart, 2022; Potvin Kent et al., 2019; Smith et al., 2019). Efforts to prevent and reverse excess weight in this age group are crucial because they tend to lead to lifelong weight disturbances (Czepiel et al., 2020; Oosterhoff et al., 2016; Rodriguez-Martinez et al., 2020; Santos et al., 2020).

From an economic perspective, the burden of obesity-related healthcare costs represents a substantial threat to national healthcare sustainability. Elmusharaf et al. (2022) calculated that the economic impact of noncommunicable diseases on the GCC was nearly US$50bn in 2019, representing 3.3% of its gross domestic product, with obesity serving as a primary driver of this economic burden(Elmusharaf et al., 2022). The direct medical costs associated with childhood obesity treatment, combined with the indirect costs related to reduced productivity and premature mortality, create compelling economic arguments for intensive prevention and early intervention strategies.

Contemporary research has increasingly recognized the importance of understanding obesity within the broader context of nutritional transition, particularly in developing countries experiencing rapid socioeconomic change. Qureshi et al. (2022) documented the coexistence of undernutrition and overnutrition within Saudi Arabian populations, reflecting the complex interplay between traditional dietary patterns, economic development and lifestyle modernization(Qureshi et al., 2022). This phenomenon, commonly referred to as the “double burden of malnutrition,” presents unique challenges for public health policy development and intervention program design.

Previous studies conducted in various regions of Saudi Arabia have reported varying prevalence rates, reflecting the complex interplay between regional characteristics and obesity risk factors. Al-Hussaini et al. (2019) found significant regional variations in childhood obesity prevalence across the Kingdom, with rates ranging from 8.7% to 27.4% depending on the specific geographical area and population characteristics studied(Al-Hussaini et al., 2019). A recent multicenter study by Osman et al. (2023) found that overall, about one-fifth of the population was overweight (11.2%) or obese (9.4%), with the prevalence of obesity highest among children aged 2–6 years (12.3%)(Osman et al., 2023). In addition, national school screening data analyzed by AlQurashi et al. (2023) revealed that nearly 10.4% of students were overweight, 10.7% were obese and 4.50% were severely obese, indicating substantial heterogeneity in prevalence patterns across different regions and age groups within the Kingdom(AlQurashi et al., 2023).

The Northern Region of Saudi Arabia presents a unique epidemiological context, characterized by distinct geographical, cultural and socioeconomic factors that may influence obesity prevalence patterns. This region, comprising approximately 364,761 inhabitants across 35 villages, represents a predominantly rural-to-semi-urban population with traditional lifestyle patterns increasingly influenced by modernization pressures(Media, M, 2024). Understanding the specific prevalence patterns within this region is crucial for developing targeted intervention strategies that respect local cultural contexts while addressing global health imperatives.

While a recent multicenter population-based study by (Alenazi et al., 2023) provided valuable national estimates of obesity prevalence among Saudi children and adolescents using Saudi growth charts, significant regional heterogeneity persists within the Kingdom. The Northern Region, with its predominantly rural-to-semi-urban demographic profile and distinct socio-cultural practices, remains underrepresented in national data. Furthermore, the present study is the first to systematically document the “double burden of malnutrition” (coexistence of underweight with overweight/obesity) in this specific region using standardized WHO BMI percentile criteria derived from primary healthcare records. This region-specific evidence fills a critical research gap by highlighting localized patterns that national multicenter studies may mask and directly informs targeted public-health interventions under Saudi Vision 2030.

This study aims to provide comprehensive epidemiological data on childhood and adolescent obesity in the Northern Region of Saudi Arabia, contributing to the broader understanding of obesity patterns within the Kingdom while informing evidence-based public health policy development and intervention program design. The investigation specifically seeks to quantify current prevalence rates across age and gender categories, identify potential risk factor patterns and contextualize findings within both national and international frameworks to support targeted intervention strategy development.

We conducted a cross-sectional study using electronic medical records (EMRs) from all participating primary healthcare centers (PHCs) in the Northern Region of Saudi Arabia. The target population comprised children aged 6–13 years and adolescents aged 14–18 years who accessed PHC services between 1 August 2023 and 1 November 2024. To minimize selection bias, participants were enrolled consecutively (the first 1,191 eligible patients with complete anthropometric data). This approach, while pragmatic for a real-world PHC setting, means the sample is not a random population-based probability sample but rather a consecutive clinical sample. Consequently, findings are most generalizable to children and adolescents who use primary healthcare services and may overestimate prevalence if individuals with weight-related concerns are more likely to attend.

The target population comprised all children aged 6–14 years and adolescents aged 14–18 years who accessed primary healthcare services within the Northern Region between August 1, 2023, and November 1, 2024 (Table 1). Inclusion criteria encompassed children aged 6–13 years (defined as the pediatric group), adolescents aged 14–18 years (defined as the adolescent group), residents of the Northern Region with documented healthcare visits, complete anthropometric data available in EMRs and informed consent or assent obtained according to age-appropriate protocols. Exclusion criteria included individuals with suspected secondary causes of weight disturbance, including endocrine disorders such as thyroid dysfunction, Cushing’s syndrome and growth hormone deficiency, neurological conditions affecting metabolism or mobility, genetic syndromes associated with obesity such as Prader-Willi syndrome and Bardet-Biedl syndrome, chronic medication use affecting weight including corticosteroids and antipsychotics, and incomplete or unreliable anthropometric measurements.

Height and weight measurements were obtained using standardized protocols implemented across all healthcare facilities, following World Health Organization recommendations (Organization, W.H, 2023). To ensure randomization and limit selection bias, the first 1,191 children and adolescent patients who visited participating PHCs were enrolled immediately. (Table 1 illustrates their age and gender distribution.) Subsequently, the participants were classified based on their BMI as overweight, obese class 1, class 2 and class 3 groups, according to the WHO classification (Organization, W.H, 2000).

BMI was calculated using the standard formula (weight in kg/height in m²) and the classification system used defined underweight as BMI less than the 5th percentile, normal weight as BMI between the 5th and 84th percentiles, overweight as BMI between the 85th and 94th percentiles and obesity categories as Class I (BMI 95th-98th percentile), Class II (BMI 99th-99.9th percentile) and Class III (BMI ≥ 99.9th percentile).

Statistical analysis was conducted using IBM SPSS Statistics version 29.0 with supplementary calculations performed using Microsoft Excel for data validation. The analytical approach encompassed both descriptive and inferential statistical methods. Frequencies, percentages, means and standard deviations were calculated for all variables, with age-specific and sex-specific prevalence rates computed with 95% confidence intervals to provide precision estimates. Chi-square tests were used to examine associations between categorical variables, with Fisher’s exact test used when expected cell frequencies were less than five. Independent t-tests were used for continuous variable comparisons between groups, with statistical significance set at p < 0.05 for all analyses. The sample size of 1,191 participants was determined to provide adequate power (>80%) to detect prevalence differences of 5% or greater between subgroups, assuming an alpha level of 0.05 and accounting for potential stratification effects.

The study protocol was reviewed and approved by the Research Ethics Committee of the Northern Armed Forces Hospital, KSA, in accordance with the Declaration of Helsinki principles. Given the retrospective nature of the study using existing medical records, individual informed consent was waived, but all data were anonymized prior to analysis to ensure participant confidentiality and privacy protection, following established guidelines for medical record research in the Kingdom of Saudi Arabia.

A total of 1,191 participants were enrolled in this cross-sectional study, comprising 437 children aged 6–13 years and 754 adolescents aged 14–18 years. The demographic distribution demonstrated a relatively balanced gender representation within each age group, with 230 males (52.6%) and 207 females (47.4%) in the pediatric cohort and 462 males (61.3%) and 292 females (38.7%) in the adolescent cohort (Table 1).

The analysis of the pediatric cohort revealed significant patterns in weight status distribution with notable gender-specific variations that warrant detailed examination (Table 2). The overall prevalence of overweight among children was 16.9% (95% CI: 13.5–20.7%), while obesity prevalence was 9.4% (95% CI: 7.0–12.4%), resulting in a combined overweight and obesity prevalence of 26.3%. These figures represent substantial public health concerns, particularly when contextualized within the broader framework of childhood obesity trends documented in recent literature.

Childhood prevalence of overweight and obesity subclass demonstrated that overweight in female children was significantly higher at 40 cases (19.3%) compared to male children with 34 cases (14.8%) (p < 0.001), contributing to an overall overweight prevalence of 74 cases (16.9%). Conversely, the overall obesity prevalence was higher in male children at 23 cases (10.0%) than in females with 18 cases (8.7%) (p < 0.001), with an overall obesity prevalence for both sexes of 41 cases (9.4%). The data clearly demonstrate that overweight is more prevalent in childhood than obesity (16.9% compared to 9.4%, respectively, p < 0.001).

Among obesity subclasses, Class I obesity emerged as more common in both genders compared to other subclasses, with a notable tendency to be higher in female children at 13 cases (6.3%) compared to male children at ten cases (4.3%) (p < 0.001). It was also observed that Classes II and III obesity demonstrated higher prevalences in male children compared to females. An important incidental finding beyond the primary scope of this investigation was the prevalence of underweight, which affected 19 male children (8.3%) and 17 female children (8.2%), resulting in a total underweight prevalence of 36 children (8.2%).

The adolescent cohort demonstrated substantially higher overall prevalence rates compared to the pediatric group, indicating a clear age-related increase in weight-related issues that has significant implications for public health intervention timing and strategy development (Table 3). As evidenced in the data, less than half of the adolescent participants, specifically 332 individuals (44.0%), maintained normal weight status. There was a higher overall overweight prevalence in adolescents at 138 cases (18.3%) compared to children at 74 cases (16.9%), representing a statistically significant difference (p < 0.001). Similarly, the overall obesity prevalence in adolescents reached 14.6% compared to 9.4% in children, with both observations demonstrating statistical significance (p < 0.001).

Class I obesity emerged as the most prevalent among obesity subclasses for both genders, with a notably higher occurrence in males at 44 cases (9.5%) compared to females at 23 cases (7.9%) (p < 0.001). The age-related progression in obesity prevalence suggests cumulative risk exposure and potentially inadequate early intervention strategies, highlighting the critical importance of implementing prevention programs during early childhood before weight-related issues become established.

Notably, there was a high rate of underweight among the adolescent population, which accounted for 117 cases (25.3%) in male adolescents and 57 cases (19.5%) in female adolescents, resulting in an overall prevalence of underweight in adolescents of 174 cases (23.1%). This finding represents a critical public health concern that has received insufficient attention in previous research focusing on the obesity epidemic in Saudi Arabia.

The distribution of weight status categories across the entire study population reveals the complexity of the nutritional landscape in the Northern Region (Table 4). Among children, 78.5% maintained normal weight status, while 8.2% were classified as underweight, 16.9% as overweight and 9.4% as obese across all classification levels. The adolescent population showed a markedly different distribution, with only 44.0% maintaining normal weight status, 23.1% classified as underweight, 18.3% as overweight and 14.6% as obese. These distributions indicate that the majority of adolescents in the Northern Region exhibit some form of weight-related deviation from normal status, whether toward underweight or overweight/obesity categories.

When examining obesity classification patterns specifically, Class I obesity represented the predominant form across both age groups and genders, accounting for 5.3% of children and 8.9% of adolescents. Class II obesity affected 2.5% of children and 3.4% of adolescents, while Class III obesity showed prevalences of 1.6% and 2.3%, respectively. The increasing prevalence of higher-grade obesity categories with advancing age suggests progressive severity of weight-related issues and highlights the urgency of implementing effective intervention strategies before obesity becomes more severe and potentially more difficult to address through lifestyle interventions alone.

The comparative analysis between age groups reveals several critical patterns that have important implications for public health policy and intervention program development. The combined overweight and obesity prevalence increased from 26.3% in children to 32.9% in adolescents (p = 0.020), representing a 25% relative increase that suggests either inadequate prevention efforts during the transition from childhood to adolescence or the presence of risk factors that become more influential during adolescent development. This trend parallels international patterns documented in longitudinal studies of childhood obesity, where adolescence represents a critical period for weight gain acceleration.

This comprehensive cross-sectional study provides critical epidemiological evidence documenting the substantial burden of overweight and obesity among children and adolescents in the Northern Region of Saudi Arabia, while simultaneously revealing the complex coexistence of undernutrition within the same population. The observed prevalence rates position this region within the global spectrum of childhood obesity epidemics while demonstrating region-specific characteristics that demand targeted intervention approaches informed by local cultural, social and economic contexts.

The combined prevalence of overweight and obesity observed in our study (26.3% in children and 32.9% in adolescents) aligns with recent national data while potentially exceeding some previously reported regional estimates of obesity among children at 14.6%, with 33.3% of children being overweight(GASTAT, 2024). The study findings are consistent with those of Al-Hussaini et al. (2019), who found childhood obesity prevalence rates of 21.3% among intermediate school students and 17.7% among primary school students in other Saudi regions (Al-Hussaini et al., 2019). Similarly, our results align with Al-Shaikh et al. (2020), who reported overweight and obesity rates of 13.4% among school-aged children (6–16 years) in Riyadh(Al-Shaikh et al., 2020). These comparative findings suggest that the Northern Region may experience slightly elevated rates, potentially reflecting unique geographical, cultural and socioeconomic characteristics.

When contextualized within international frameworks, our findings demonstrate both convergence with and divergence from global childhood obesity trends. The prevalence rates observed in the Northern Region exceed those documented in many developed countries but remain consistent with patterns observed in other rapidly developing nations experiencing similar socioeconomic transitions. Recent European data from Spinelli et al. (2019) reported obesity prevalences ranging from 2.2% to 25.2% among primary school children across 21 European countries, with our findings falling at the upper end of this spectrum(Spinelli et al., 2019). The Phelps et al. (2024) has documented accelerating obesity trends in developing countries (Phelps et al., 2024), with childhood prevalences often exceeding those observed in traditional high-income nations, supporting our findings within the broader context of global epidemiological transitions.

Gender-specific patterns showed higher overweight among female children and higher obesity among males. These differences are consistent with previous GCC studies and may reflect cultural influences on physical activity and dietary behaviors; however, the cross-sectional design precludes causal attribution (Al-Hazzaa et al., 2020; Musaiger et al., 2012).

The high prevalence of underweight (23.1% in adolescents) alongside elevated overweight/obesity rates illustrates the double burden of malnutrition in this transitioning region. This finding exceeds previous Eastern Province estimates and underscores the need for integrated nutrition strategies rather than obesity-focused programs alone (Qureshi et al., 2022).

The temporal progression from childhood to adolescence observed in our data reveals critical insights into the natural history of weight-related issues within this population. The substantial increase in combined overweight and obesity prevalence from 26.3% to 32.9% between childhood and adolescence suggests either the emergence of new risk factors during adolescent development or the inadequacy of current prevention strategies during this critical developmental period. This pattern aligns with longitudinal research by Ward et al. (2017), who demonstrated that adolescence represents a high-risk period for weight gain acceleration, potentially related to hormonal changes, increasing autonomy over food choices, social pressures and lifestyle modifications that characterize this developmental stage(Ward et al., 2017).

The healthcare system implications of these findings are substantial and multifaceted. Recent economic analyses by Elmusharaf et al. (2022) calculated that the direct medical costs associated with childhood obesity treatment in the GCC exceed US$50 billion annually, with Saudi Arabia contributing significantly to this burden(Elmusharaf et al., 2022). The prevalence rates documented in our study suggest that the Northern Region may be experiencing healthcare utilization patterns and associated costs that exceed national averages, requiring enhanced resource allocation and specialized service development.

The concurrent presence of undernutrition and overnutrition within the same population presents unique challenges for healthcare provider training and service delivery. Traditional approaches focusing exclusively on either undernutrition or overnutrition may be inadequate for addressing the complex nutritional landscape observed in our study population. Healthcare providers require enhanced training in recognizing and managing the full spectrum of nutritional disorders, while healthcare systems must develop integrated approaches capable of addressing both under- and over-nutrition within comprehensive care frameworks.

These findings support the following concrete actions within Saudi Vision 2030:

• integration of routine BMI screening plus underweight assessment in all Northern PHCs;

• school-based programs offering gender-sensitive physical activity opportunities and nutrition education that address both under- and over-nutrition; and

• community-level interventions improving access to affordable healthy foods in rural areas.

Such targeted, multilevel approaches are essential to reduce the dual nutritional burden observed.

The research implications of our findings extend beyond immediate public health concerns to encompass fundamental questions about the mechanisms underlying the observed patterns and the effectiveness of various intervention approaches within this specific cultural and geographical context. The unexpectedly high prevalence of underweight among adolescents warrants dedicated investigation to understand underlying causes, which may include cultural factors, economic constraints, food insecurity, eating disorders or medical conditions that have not been adequately recognized or addressed.

Longitudinal research tracking weight status changes from childhood through adolescence and into adulthood represents another critical research priority suggested by our findings. Understanding the natural history of weight-related changes within this population, including identification of critical periods for intervention and factors associated with positive or negative trajectories, could inform the development of more effective and targeted intervention strategies.

The cross-sectional design precludes causal inference. Data were obtained from PHC attendees, introducing potential selection bias; therefore, results may not be fully generalizable to the entire Northern Region population.

The authors thank the healthcare providers at the Northern Region primary healthcare centers for their cooperation in data collection. The authors also acknowledge the Research Ethics Committee of the Northern Armed Forces Hospital for their guidance in ethical considerations.

The authors acknowledge the use of artificial intelligence tools, specifically Claude (Anthropic) and Copilot, for proofreading, editing and general organization of this manuscript. These AI tools assisted with language refinement, reference formatting and structural improvements. However, all scientific content, methodology, analysis, interpretation of results and conclusions remain solely the work and responsibility of the authors. The authors have thoroughly reviewed and revised the AI-assisted content and take full responsibility for the accuracy and validity of all presented information.