An Exploration of Multilevel Factors Contributing to Childhood Overweight and Obesity in Saudi Arabia

Background: Childhood obesity is widely recognised as a pressing public health concern. In Saudi Arabia, obesity affects individuals across all age groups and contributes significantly to the rising incidence of diabetes and cardiovascular diseases. However, childhood obesity warrants particular attention for several critical reasons. Children who are overweight or obese are more likely to become obese adults, and childhood obesity is associated with a range of physiological and psychosocial consequences, with health problems traditionally observed in adults now emerging in children. Furthermore, the effects of obesity are long-term, with a substantial delay between the onset of risk factors and the manifestation of adverse health outcomes. These considerations underscore the importance of implementing obesity prevention strategies early in life. Obesity is a multifaceted and complex condition influenced by a variety of systemic and causal factors. To account for this complexity, this thesis adopts Bronfenbrenner’s ecological systems theory as a guiding framework. This theory provides a lens through which to examine the multiple factors contributing to childhood obesity within the interconnected contexts of the child’s home, school, and broader community. Aim and Objectives: The overall aim of this research is to identify the key factors contributing to childhood overweight and obesity in Saudi Arabia and to assess the relative influence of different ecological contexts. Specifically, the study seeks to explore how home, school, and community environments shape children’s dietary behaviours, physical activity, and sedentary lifestyles within the Saudi context. Methodology: A mixed-method sequential explanatory design was employed, consisting of two quantitative studies followed by a qualitative study. The quantitative phase utilised cross-sectional survey questionnaires, while the qualitative phase involved semi-structured interviews designed to build upon and deepen understanding of the quantitative findings. Study one involved distributing a survey to a sample of 787 participants, each of whom had at least one child aged 6–18 years and resided in Najran, Saudi Arabia. This study focused on dietary habits, physical activity, and sedentary behaviours, which represent key behavioural determinants of childhood obesity. Particular attention was given to family dynamics and parental behaviours, examining how home environmental factors contribute to unhealthy lifestyles and obesity among Saudi children. Study two recruited school employees in the Najran region (n = 459) to complete a cross-sectional survey questionnaire. This study aimed to identify the cultural, environmental, and organisational factors within schools that influence children’s eating habits and physical activity behaviours. It also explored teachers’ knowledge of obesity-related issues, their understanding of the role of diet and physical activity in obesity prevention, and their perceptions of their responsibility in addressing childhood obesity within schools. Study three employed qualitative semi-structured interviews to gain deeper insights into the findings of the previous two studies and to identify barriers and facilitators to promoting healthy diets and physical activity in Saudi Arabia. This study examined the existence and effectiveness of relevant policies and programmes, their implementation and dissemination, and the extent of collaboration between key sectors, including the Ministries of Health and Education, the Municipality Department, and the Authority of Youth and Sport. A purposive sampling technique was used to recruit twelve stakeholders at the management level from various organisations for in-depth interviews. Findings: The findings of this thesis highlight several key factors influencing childhood obesity in Najran, including cultural, societal, and environmental influences. Gaps in parental knowledge regarding nutrition were identified, indicating a need for targeted educational programmes to promote healthier food environments within the home. Environmental barriers, such as unsafe neighbourhoods and limited access to play areas, were found to restrict opportunities for children’s physical activity, highlighting the importance of urban planning improvements. Cultural norms, particularly gender roles, were shown to limit mothers’ participation in physical activity, emphasising the need for culturally sensitive interventions. Within the school environment, the lack of structured nutrition education and physical education, along with limited sports infrastructure, revealed significant gaps in health promotion efforts. Although some policies addressing childhood obesity are in place, the findings indicate that more effective collaboration, consistent enforcement, and public education are required to address childhood obesity in Najran. Discussion: Overall, the findings demonstrate that childhood obesity in Saudi Arabia is shaped by a complex interaction of factors across multiple ecological levels. The interdependence of home, school, and community environments highlights the limitations of interventions that focus solely on individual behaviour change and underscores the need for a systems-based approach to obesity prevention. Conclusion and recommendations: This thesis contributes to a comprehensive understanding of the multifactorial nature of childhood obesity in Saudi Arabia, with a particular focus on the ecological contexts of home, school, and community. Promoting healthier behaviours among children requires a multifaceted and holistic approach that enhances parental knowledge, creates supportive home and neighbourhood environments, and addresses cultural and societal constraints on physical activity. Future interventions should move beyond individual-level strategies and instead focus on broader environmental and structural influences. Policymakers, schools, and communities must work collaboratively to develop and implement coordinated, culturally appropriate interventions that create supportive environments and enable children to lead healthier lives.