Attitudes and knowledge of obesity risks among Male high school students in Al-Madinah , Saudi Arabia

Article history: Received on: 25/08/2016 Revised on: 04/09/2016 Accepted on: 30/09/2016 Available online: 29/10/2016 The study aimed to evaluate the knowledge about obesity risks and attitude towards obese persons along with prevalence of obesity among high school students in Al-Madinah. This cross-sectional descriptive study included 314 male students enrolled in the secondary schools in Al-Madinah.Multi-stage random sampling technique was applied. Two reliable and valid questionnaires were utilized for data collection; The Obesity Risk knowledge scale (ORK) and Attitude toward Obese Persons (ATOP). Students’ age ranged between 16 and 19 years with a mean of 17.08 years. The prevalence of overweight and obesity were 11.8% and 16.2% respectively. Overall, the knowledge score ranged between 0 and 7. Among 314 students, 241 had insufficient knowledge regarding obesity related issues with just 73 having sufficient knowledge. Students with positive attitude towards obese person were 53.2% whereas 46.8% had negative attitude. There was no association found between student’s age and body mass index (BMI) with their knowledge regarding obesity risks & attitude towards obese person. The study revealed Knowledge of the students regarding obesity risk factors was insufficient whereas their attitude towards obese persons is considered satisfactory along with high prevalence of overweight and obesity among the male adolescent population in Al-Madinah, KSA.


INTRODUCTION
Most of the world's population live in countries where overweight and obesity kills more people than underweight.Overweight and obesity are defined as abnormal or excessive fat accumulation that may impair health (WHO-Obesity and overweight, 2015).Non-communicable diseases (NCDs) kill 38 million people each year.Tobacco use, physical inactivity, the harmful use of alcohol and unhealthy diets all increase the risk of dying from an NCD (WHO-Noncommunicable diseases, 2015).Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.In 2012, more than one third of children and adolescents were overweight or obese (Ogden et al., 2014;National Center for Health Statistics, 2011).Obesity is defined as having excess body fat (Krebs et al., 2007), whereas over weight defined as increased body weight in relation to height when compared to standard of acceptable or desirable weight (Childhood overweight and obesity-Atlanta, 2012).Obesity is considered most important public health issue in male adolescents and it is growing concern in high school students.Several studies have been done on this subject either nationally or internationally.The prevalence of obesity estimated in USA, Kuwait and Germany is 24.6%, 24% and 19% respectively (Bonauto et al., 2014;Karageorgi et al., 2013;Hoffmann et al., 2013).One study conducted in three major cities of Saudi Arabia: Al-Khobar, Jeddah, and Riyadh during 2009-2010 among Saudi adolescents has shown the prevalence of overweight (19.5%), obesity (24.1%), and abdominal obesity (35.9%), among male students of secondary school (Al-Hazzaa et al., 2014).
In Europe, a study was conducted to determine and compare attitudes, skills, and practices in childhood obesity management in 4 European countries namely France, Italy, Poland, and Ukraine.The study underlined insufficient implementation of national guidelines for management of obesity regardless of the country and its health system (Artur et al., 2013).
Both regional and national studies showed a trend of rising obesity over time.The latest national data revealed that the rates of overweight and obesity among school-age children have reached 23% and 9.3%, respectively (Ali et al., 2013).
In order to prevent this increasing obesity prevalence, it is important that individuals are educated on obesity risk factors.Providing continuous professional education in obesity has been considered as the key factor by primary health care providers (Mazur et al., 2013).The main purpose of this study was to evaluate knowledge about obesity & its risk factors and attitudes of male students toward the obese person.The study also included comparison between student's age and BMI with their knowledge and attitude towards obese person.

Study Design
The study was conducted in Al-Madinah, second holiest city in Islam in 2014.This cross-sectional descriptive study included 314 male students enrolled in the secondary schools.Inclusion Criteria: All high school male students in the selected schools were eligible for study inclusion.Exclusion Criteria: No exclusion criteria.

Sampling Technique
Multi-stage random sampling technique was adopted as follows: Stage 1: Stratifying Al-Madinah city into four geographical areas (east, west, north and south) Stage 2: List all male schools in the different areas north, south, East and West.Stage 3: Selection of one school (using simple random method) from each of the four geographical areas was done.
Stage 4: In each school, there are three educational levels.The researcher selected one class from every level by using simple random method.Stage 5: By using clustering method, all the students in the selected class were included in the study.

Obesity Risk knowledge & Attitude Test Construction
Two reliable and valid questionnaires were used for data collection.First one is The Obesity Risk Knowledge scale (ORK).This questionnaire was self-administered and includes 9 items designed by Swift, Glaze brook and Macdonald (2006).The score ranged from 0-9 (Swift et al., 2006).
The second questionnaire was Attitude toward Obese Persons (ATOP).This questionnaire was self-administered and includes 15 items developed by Allison, Basile and Yuker (Allison et al., 1991).The scale is based on a six-point (ranging from -3 = strongly disagree to +3 = strongly agree), participants have to indicate the extent to which they agree or disagree with twenty statements regarding obese people.After finishing questionnaire Body mass index (BMI) was calculated for each student.

Obesity Risk knowledge & Attitude Test Validity & Reliability
As described by Kline, the ORK-10 scale having a level of internal consistency which exceeds the accepted minimum of a Cronbach's alpha >0.7 compared to the total scale.This scale measures extensive area of knowledge with relatively few items; which could be the cause for reduction in internal consistency.Considering the above fact significant results may be obtained (Kline, 2000).

Pilot Study
A pilot study was conducted on a purposive sample of 10 students which was not included in the main study.The main goals were to assess the accessibility, time required to fill the questionnaire, questions understanding and the response rate.As a feedback, the questionnaire was clear and an average of 10 minutes was required to complete it.

Data analysis
Data collection was done using excel and SPSS version 20.0.Descriptive statistics was done using frequency and percentage, whereas analytic statistics was done using chi-square test (x 2 ).
For Knowledge questions (n=9), a score of "1" was assigned to a correct response while a score of "0" was assigned to wrong or do not know response.Students scored at or above 50% were considered as having "sufficient knowledge".For attitude questions (n=15) a score ranged between -3 (strongly disagree) to +3 (strongly agree) was assigned to each statement.Students scored above the midpoint were considered as having "positive attitude" like moderately agree and above and those who scored below the midpoint were considered having negative attitude (moderately disagree and above).

Ethical Considerations
Ethical clearance was obtained from vice chair of medical research center, college of medicine, Najran University, KSA.The author took the approval from the male school authorities who gave the permission letter to all high schools directors to facilitate the work for the investigator.Written Consent was obtained from every individual.

Body mass index
The study included 314 students.Their age ranged between 16 and 19 years with a mean of 17.08 years.The prevalence of overweight and obesity were 11.8% and 16.2% respectively whereas underweight was reported among 15% of the participants.From Table 1, it is demonstrated that there was no significant association between body mass index (BMI) and student`s age.

Obesity knowledge
Table 2 depicts the obesity knowledge among male high school students.Overall, the knowledge score ranged between 0 and 7 with a mean of 3.5 ± 1.3.Out of 314, only 73(23.2%)students had sufficient knowledge regarding obesity risks whereas 241(76.8%)had insufficient knowledge.

Attitude towards obese persons
Out of 314 students 53.2% (167) of the students had positive attitude towards obese person whereas the remaining 46.8% (147) had negative attitude towards it (Table 3).There was no significant association between the student's age and BMI with their knowledge regarding obesity related risk factors.Also there was no significant correlation between the age of the students and BMI with their attitude towards obese person, as shown in Table 4.
From table 5, it was clear that there was no association between obesity knowledge among male high school students and their attitude towards obese persons.

DISCUSSION
This study reveals relatively high widespread presence of overweight and obesity among the male adolescent population in Al-Madinah, KSA.The prevalence of overweight (11.8%) and obesity (16.2%) observed in this study are comparable with overweight (13.4%) and obesity (13.5%) observed among adolescents in Jeddah (Abalkhail et al., 2002), overweight (13.8%) and obesity (20.5%) reported among adolescent males in Riyadh (Al-Rukban, 2003).The extensiveness of overweight and obesity observed in the current study are within the range compared to other Arab countries (Musaiger et al., 2012).
The relatively high widespread presence of obesity in male adolescents in Madinah, KSA indicates that the community has undergone intense social and behavioral modifications over last few decades (Al-Rukban, 2003).Obesity is fast turning out to be a major cause of concern for the Kingdom with seven out of 10 Saudis suffering from obesity, A recent study revealed that a whopping SR500 million per year was spent by people suffering from obesity in the Kingdom on treatment (Musaiger et al., 2012).
The distinct differences in the overweight and obesity rates observed from various studies conducted in different parts of KSA may be partly associated with the difference in socioeconomic standing of the study population, because social status is a key factor to nutritional habit which in turn is a risk factor of overweight and obesity (Fouzia, 2014).
Another study indicates high rates of obesity across all segments of the population in KSA and the reason found was most are physically inactive and consume low levels of fruits and vegetables.Furthermore, strong associations were found between obesity and diabetes, hypercholesterolemia, and hypertension (Ziad et al., 2014).
In the present study, knowledge of obesity-related risk factors (ORK) was insufficient and it was not significantly .associated with BMI and age of the students.A UK prospective study measured ORK in 66 patients who have attended National Health Service (NHS) weight management clinic for 18 months.Above study was conducted to find whether ORK was associated with greater weight loss (Lee and Ahn, 2007).ORK-10 scores amongst the 66 participants were relatively low, which was surprising considering they have been attending weight management clinic for 18 months.In addition, there was no significant (p = 0.31) association between weight loss and ORK-10 scores.
In the current study almost half of the male high schools students in Al-Madinah had positive attitude towards obese persons and no significant difference was observed between attitude towards obese persons with BMI and age of the students.A study carried out by Gipson et al. 2005 in 191 students attending Virginia State University measured attitudes towards obese persons by utilizing ATOP scale questionnaire (Gipson et al., 2005).
They revealed no significant difference in attitudes between gender and BMI categories.Similar findings were apparent from a study conducted in Korean fifth grade students (Lee and Ahn, 2007).
From literatures, positive attitudes towards obese persons were apparent amongst 10-12year olds; this suggests that negative attitudes may begin in older aged participants.Vartanian, 2010 revealed mixed findings regarding age and BMI as predictors of attitudes (Vartanian, 2010).
Although this study revealed no association between knowledge of obesity related risk factors and attitude towards obese person with BMI and age of the student, the results analysis should be made by considering some limitations.Only male students were enrolled in the study and these students' knowledge level does not depict other student's knowledge either nationally or internationally, the differences found might be due to socioeconomic status of the study participants.

Table 1 :
Age & BMI of male high school students.

Table 2 :
Students Response to obesity related questionnaire.

Table 3 :
Attitude of male high school students towards obese persons.

Table 4 :
Association between student's age and BMI with their knowledge of obesity and attitude towards obese person.

Table 5 :
Association between students` obesity knowledge and their attitude towards obese persons.