Obesity is a global health issue occurring due to high-energy intake (World Health Organization, 2010). In addition, socio-economic factors, physical activity, genetic and environmental factors have been closely associated with the development of obesity (Rubenstein, 2005; Al-Isa, 2004).
Obesity and overweight are currently among the major disturbing health problems where over 32% of school-going children have developed problems related to unhealthy increase in weights (Salman & Ajeel, 2013; Rolland-Cachera, Hercberg & Castetbon, 2011; Popkin, Adair & Nig, 2012; Olds, Maher & Zumin, 2011; Ariza, Laslo, Thomson, Seshadri & Binns, 2009). Besides, childhood obesity and overweight presents many challenges and hazards ranging from health consequences to psychological difficulties. Moreover, early years of childhood are critical in the development of health behaviours and outcomes that determine future health of an individual (McMurray, Harrell, Deng, Bradley, Cox & Bangdiwala, 2012).
In Kuwait, obesity is prevalent and the levels are continuously increasing (World Health Organization, 2010; Rubenstein, 2005; Al-Isa, 2004). Moreover, Kuwait is one of the countries with highest predominance of obesity among children (World Health Organization, 2010; Rubenstein, 2005; Al-Isa, 2004; Campbell, Al-Isa & Desapriya, 2010). Besides, an estimated 75% of Kuwaiti adults are obese and several reports indicate pervasiveness of obesity among the youth and children in varying age groups (World Health Organization, 2010; Rubenstein, 2005; Al-Isa, 2004; Campbell et al., 2010). As indicated, rapid modernisation resulting in changed dietary and physical activity is often hypothesised to be the major cause of prevalence of obesity in Kuwait (Al-Isa, 2004; Campbell et al., 2010). As such, learning about the prevalence, causes, associated risk factors prevention and intervention measures of childhood obesity in Kuwait is critical.
The literature review will tend to examine the manner in which various risk factors such as economic, cultural, genetic, family environment, sedentary lifestyle, diets, lack of physical activity and mass media are associated with the increased obesity and prevalence in Kuwaiti school-going children.
Risk Factors Associated with the Prevalence of Obesity and Overweight among Schoolchildren
Economic Factors
Various studies have indicated positive relationship between the prevalence of obesity and overweight among schoolchildren and economic factors (Cawley, 2010; Sugimori, Yoshida & Izuno, 2004; Vidal, Al-Kandari & Thomas, 2008); Darawshah & Ahmed, 2011; Ogden, Carroll, Curtin, Lamb & Flegal, 2010). In addition, economic factors that tend to explain the current trend in the rise of obesity often emphasizes on the changes that offer increased incentives leading to overconsumption of calories as well as decreased levels of energy burnouts (Newby, 2003; McMurray et al., 2012). For instance, family income levels are one of the socio-economic changes that offer increased leading to overconsumption of food with high-energy content.
Rolland-Cachera et al. (2011) conducted a cross sectional study to determine the prevalence of obesity and overweight among schoolchildren between the ages 9 and 13 years in developed and developing countries. Rolland-Cachera et al. (2011) study indicated that obesity is prevalent among low-income families in developed countries. As indicated, in developed countries, income levels of families are inversely related to the prevalence of obesity among schoolchildren.
Similar findings have also been indicated by the studies conducted by Monasta, Lobstein, Vignerová and Cattaneo (2011) to determine the manner in which Socio-economic factors are associated with body fatness among schoolchildren and adolescent in New South Wales. The study reported increased body fatness (BMI >25%) among the children in low-income families (r = 0.362, P ≥ 0.01) against schoolchildren from high-income families (r = 0.196, P ≥ 0.01). In addition, the study conducted by (Cawley, 2010) on the factors contributing to the increased prevalence of obesity also indicated similar inverse relationship between low-income obesity prevalence in developed countries and high-income obesity related families in developing countries. Moreover, children from high-income families reported high prevalence rates over 58.6% compared with children from low-income families recording prevalence rate of over 33.1%.
In relation to income, Robert (2010) study reported that the prevalence of obesity is among the children of females whose income higher and have relatively good occupations. Further, reported that the prevalence of obesity among the children of rich families was 56.3% while the prevalence of obesity in children decreases gradually as the family income decreases to a record low of 33.5%.
Ariza et al. (2009) found out that high income, excess supply of food, access to high calorie snacks and lack of physical activities are to blame for the increasing rates of obesity and overweight among the schoolchildren.
Cultural Factors
Cultures have greater influence on the child-feeding patterns in relation to the beliefs, attitudes, and behaviours regarding various foods (Nasreddine, Mehio-Sibai, Mrayati, Adra & Hwalla, 2010; Habib & Saha, 2010). In other words, Cultural factors that contribute to the increased levels of body mass gain are derived from the belief system of the society. For instance, in Kuwait and other Arab countries women find difficulties taking part in any recreational activities such as active sports and exercises (Musaiger, Sadeq & Obeid 2011). In addition, young girls find difficulties participating in sports or outdoor active exercises particularly in the presence of men (Nasreddine et al., 2010).
A study by Musaiger et al. (2011) based on 310 women indicated that negative attitudes by family members towards women practicing sports have significant contribution towards unhealthy increase of body mass. In addition, the study indicated that 24% of women perceive the belief system that women are not supposed to participate in physical activities with male counterparts contributes to increased prevalence of obesity and overweight among the Kuwaiti women. The study also discovered increased sex discrimination regarding sports and recreational facilities due to cultural orientations.
Besides, cultural beliefs towards obesity also explain high prevalence rates of obesity. A study by Al-Qahtani (2011) on strategies to combat obesity and to promote physical activity in Arab countries indicated that beliefs and attitudes towards obesity should be put into consideration while identifying factors connected to physical activities in Arab countries. For instance, the belief in eating certain foods that contributes to reduction of body weight and participating in some medicinal aspects such as sauna baths to reduce overweight and accumulated fat has been practiced instead of taking part in active physical activities. As such, there is no need to practice other methods of body weight reduction.
The belief systems of the society and social stratifications also have a profound effect on the health of the children (Caprio, Daniels, Drewnowski, Kaufman, Palinkas, Rosenbloom and Schwimmer (2008). For instance, a review by Caprio et al. (2008) on the influence of race, ethnicity and cultures on childhood obesity within the US society indicated that the diverse belief systems among the races have a profound effect on childhood obesity. The study observed that the belief in fast and junky food among the white race has contributed to increased prevalence rate of obesity among the white children. On the other hand, the belief in lean and low fatty Asian foods has significantly contributed to decreased prevalence of overweight among the children of Asian origin. Moreover, the study indicated that social classes have significant effect on childhood obesity. The study observed that children from families believed to be of higher class have increased chances of becoming overweight in relation to children from low-class families. Social class closely relate to race and ethnic orientation which are linked to the prevalence of childhood obesity (Caprio et al., 2008).
Cultural factors also influence the eating patterns. For instance, in Arab countries where religious beliefs control all activities, it is a custom to eat in groups and offer food to the needy (Sibai et al., 2010). In the situations where food is taken in groups, the likelihood of taking extra food is high (Habib & Saha, 2010; Nasreddine et al., 2010; Al & is taken in groups, the likelihood of taking extra food is high (Habib & Saha, 2010; Nasreddine et al., 2010; Al-Qahtani, 2011; Musaiger et al., 2011). In addition, there are certain foods that are religiously allowed including rice that have high carbohydrate content and meat containing increased fats. The nutritional value of such food is likely to cause increased body weight particularly when take in uncontrolled large quantities.
A cross-sectional study by Kovalskys, Rausch and De Gregorio (2011) indicated close relationships of food rich in fatty acids and increased risk of developing obesity. The study indicated that in some societies overweight children are believed to be stronger and healthy and as such are constantly offered meals with increased fat contents. Such children rarely participate in physical activities and are likely to be obese or overweight. Further, the study closely linked religious belief system with controlled nutritional behaviours of children and increased prevalence of obesity.
Genetic Factors
Genetic factors contribute hugely to the development of obesity among the children (Veerman, 2011). In fact, genetic factors originate from the manner in which individual genes influences physiological activities, growth and adaptation to the environment. Genes determines the functioning of all aspects of human physiology (Veerman, 2011; Rampersaud, Mitchell, & Pollin, 2008). In addition, genes influences the way individuals develop and adapt to the environment. The development of obesity is no exception to the genetic control (Veerman, 2011; Rampersaud et al., 2008; Ruiz, Labayen & Ortega, 2010). In addition, genes determine the manner in which body fats are converted into energy. Moreover, the genetic characteristics influence the way body fats are burnt out while an individual engages in active physical activity (Veerman, 2011; Ruiz et al., 2010).
Gene interactions within the body determine eating habits, appetite control as well as energy conversions. Studies have found that genes resulting from monogenic mutations have greater chances of causing obesity and overweight among the children (Veerman, 2011; Rampersaud et al., 2008; Ruiz et al., 2010; Jonsson, Renstrom & Lyssenko, 2009; Walley, Asher & Froguel, 2009). Essentially, genes that code for leptin hormone resulting from monogenic mutations are closely associated with development of obesity and overweight. For instance, genetic syndromes resulting from chromosomal abnormalities and gene alterations have also been identified as the major cause of obesity among the children (Walley et al, 2009).
A twin study conducted by Rampersaud et al. (2008) based on 25 twin pairs and 50 genetic and adoptive family members suggest that increased body mass has links to genetic factors. Moreover, current studies that utilize genome-wide associations have identified obesity-related gene variants situated on the sixteenth chromosome (Veerman, 2011; Rampersaud et al., 2008; Ruiz et al., 2010; Jonsson et al., 2009; Walley et al., 2009). Additionally, the fat mass and obesity-associated genes have increased chances (30 to 40%) of causing unhealthy body weight. Another gene that is closely associated with a rear form of monogenic obesity has been discovered within chromosome eighteen (Jonsson et al., 2009).
However, the manner in which genes interact with the external environment is relatively stable (Veerman, 2011; Walley et al., 2009). In other words, the way social, economic, political and physical environments influences the eating patterns as well as physical activities often have rare effect on the genetic makeup (Veerman, 2011; Walley et al., 2009). In essence, the genetic structured of individuals fairly remain stable for longer periods. Thus, other environmental factors that contribute to over eating and decreased physical activity levels could explain the current rise in obesity.
A study conducted by Ruiz et al., 2010 on the correlation between body mass index, a single obesity-promoting gene and physical activity based on 17058 adults indicate that active physical behaviors compensates the influences of a single obesity-promoting gene. Further, the results of the study indicate that individual with a single obesity-promoting gene and not involved in any physical activity had higher body mass index in relation to those without the gene variant and physically inactive. However, the study suggests that the genetic predisposition is not significant for people who were physically active.
In order to arrive at definite conclusion, Rampersaud et al. 2008) combined and analysed the data collected from 45 studies conducted on adults and nine on children. However, the study also suggests that people involved in physical activity have decreased chances of developing obesity even though they possess the gene variant.
The results of the study indicated close relations between obesity and genetic factors. In addition, the studies suggest that people in good physical shape and lead active lifestyle have higher chances of offsetting the gene-related risks of developing obesity (Veerman, 2011; Rampersaud et al., 2008; Ruiz et al., 2010; Jonsson et al., 2009; Walley et al., 2009).
Family Environment
Parents and families shape the home environment in which the children grow (Stevenson, 2010; Olds et al., 2011). Moreover, parenting styles and family attributes have greater influence on dietary behaviours and physical activity levels of children (Ariza et al., 2009; Lien et al., 2010; Styne, 2012). Besides, the parental body mass is frequently used to predict the possibility of obesity in offspring or later in adulthood (Anderson, & Butcher, 2006). The reason is not only due to the predisposition of genetic characteristics that parents and children share but also the common attitudes and behaviours that progenies and the parents have (Lobstein, Baur & Uauy, 2004).
A cross sectional study conducted by Magarey, Daniels, Boulton and Cockington (2003) on the relationship between the parental BMI and the children BMI indicates the link between the BMI of the parents and the children. The study indicated that the mothers’ and the fathers’ BMIs were significantly but weakly correlated with the children BMI. Moreover, the relationship varies with age groups. Another study by Arredondo, Elder, Ayala, Campbell, Baquero and Duerksen (2006) found that children with obese fathers and mothers consistently have higher BMIs and the adolescents of between 16 and 18 years. BMIs are significantly predicted by the BMIs of the mothers and the fathers. Further, a study by Wake, Nicholson, Hardy and Smith (2007) on preschoolers found that children with overweight parents have three times chances of becoming obese or overweight compared to children with lean parents.
The behaviours and the parenting styles have also been hypothesised as having influence on the weight status of the child (Popkin, Adair & Nig, 2012; Al-Sendi & Shetty, 2003; Stevenson, 2010; Newby, 2003). However, a study conducted on Australian children between the ages four to five years indicated no correlation between the mothers parenting behaviours and style and the weight gain of the children. Conversely, the relationship was positive with fathers. For instance, children with more controlling fathers had 26% increases in BMI.
Further, other factors such as maternal smoking during pregnancy and enhanced breast-feeding behaviours have also been associated with the risk of being overweight and obese of the adult children (Bauer, Nelson, Boutelle and Neumark-Sztainer, 2008).
Sedentary Lifestyle Factors
Various studies have associated sedentary life with increased prevalence of obesity and overweight among school going children (Kriemler, Zahner & Schindler, 2010; Campbell, Al-Isa & Desapriya, 2010; Al-Rashdan & Al-Nesef, 2010; Wojcicki & Heyman, 2010; Salman & Ajeel, 2013). In other words, sedentary life factors have been reported to be the major cause of obesity and overweight among the children. El-Bayoumy et al., (2009) cross sectional study indicated that obesity and overweight is higher among the children leading sedentary lifestyles. In the study, El-Bayoumy et al., (2009) indicated that obese children spend a lot of time sleeping 8.9 + – 2.3 compared with 8.8 + – 1.2 among the normal children. Besides, El-Bayoumy et al., (2009) reported the time spent by school-going children watching TV and playing video games. The report showed that children spending more hours per day 2.8 + -1.9 are likely to be obese and overweight compared with children spending less hours per day 2.1 + – 1.9. El-Bayoumy et al., (2009) study indicated sporting hours per week reported 4.8 + – 2.1 among the obese children compared with 5.2 + – 2.9 in normal weight children.
Various international studies have also endeavoured to approximate the correlation between the SSR and weight (Wake et al. 2007; Al-Rashdan & Al-Nesef, 2010; Wojcicki & Heyman, 2010; Salman & Ajeel, 2013; Hesketh, Wake, Graham & Waters, 2007; Marshall, Biddle, Gorely, Cameron and Murdey, 2004). In a longitudinal study conducted by Hesketh et al., (2007) indicated significant relationship between Small Screen Recreation (SSR) and Body Mass Index (BMI). The study indicated that an extra hour spent on SSR increases the BMI by 3%. Marshall et al. (2004) also found similar results in a meta-analysis of children from various countries. Moreover, the study by Marshall et al. (2004) indicated positive relationship between various types of SSR and the body fatness.
Lack of Physical Activity
The changes in the socio-economic statuses and the way people live in Kuwait significantly influence the physical activities undertaken by the people. In addition, the patterns of outdoor exercises have also changed and diminished drastically. a cross-sectional study by El-Bayoumy et al (2009) indicated that lack of physical activity have contributed to the increased prevalence of obesity and overweight among the intermediate adolescent school going children of between the ages ten and fourteen. The study indicated close negative association of obesity and overweight with increased physical inactivity. In fact, the study indicated that the majority of adolescents of children between the ages 10 and 14 increased body weights and obesity increased due to physical inactivity. About 97% of the obese and overweight children had their general body mass values below the median range of 65-79.
Another study conducted by Campbell et al (2010) study that the physical exercise was inversely related to the prevalence of obesity and overweight. According to Campbell et al., (2010) study, non-exercising young men had significantly (P < 0.05) increased risk (2.23) of being obese compared to the young men who were not exercising. The study indicated that physical inactivity was majorly caused by the sedentary lifestyle. Moreover, the study indicated that time limit is the major cause of physical inactivity while reduction off body fats and being fit were the major reason why people engaged in physical activity.
Television
Various studies suggest that incessant watching television is associated with inactivity, which in turn causes unhealthy weight gain (Nasreddine et al., 2010; Darawshah & Ahmed, 2011; Ogden et al., 2010; Al-Sendi & Shetty, 2010; Lien et al., 2010). In Kuwait, Armstrong, Lambert and Lambert (2011) study found that the associated risk of being obese was 1.4 for male children between the ages of six to ten spending over four hours watching television compare to 0.72 relative risks of similar male children developing obesity while spending less than four hours watching television. However, in a separate study conducted by Lien et al. (2010) found that among adolescents in European countries television viewing and obesity are not associated and distinct entities.
Cross-sectional study by Cattaneo, Monasta and Stamatakis (2010) indicate that the about seventeen percent of school-going children between six and sixteen years spend more than two hours watching television. The study also indicated that the proportion of time spent watching television increases with age. The proportion was approximately 0.14 for nine years olds and below while the proportion rises with age to approximately 0.25.
Media Advertising include the Television, Newspapers and other Media Channels
Media advertising including television, newspapers, radio and the internet is increasing influencing the type of lifestyle people are adopting and consequently leading to healthy living habits. The media advertising and increase in body mass have been found to be indirectly related. The reason is that media advertising have increased contributed to health-promotion campaigns that has led to increased awareness on better eating habits and intake of healthy foods. A study by Popkin et al. indicated that the mass media provide some form of health-promoting messages, which significantly contributes to decreased levels (11.1%) of obesity and overweight among the male children compared to children with no access to media adverts (38.5%).
Snacking Habits
The kind of food consumed between meals and the way they contribute to calorie intake in relation to overall diet is essential in the control of developing unhealthy weight patterns among the school-going children (Gupta, Goel, Shah & Misra, 2012). For instance, most girls prefer taking snacks instead of breakfast or lunch. A study by Musaiger et al. (2011) indicated that 23% of adolescent girls between the ages of 11 and15 years respectively continuously take snacks between lunch and breakfast. However, 17.6% of girls aged 16 years and above were found to be taking snacks between the major meals. The snacks that were commonly taken range from carbonated beverages to liver sandwiches. Further, Musaiger et al. (2011) study indicated that the 66% of children who constantly take snacks have high risk of developing increased body mass. The reason is that snacks contain high content of sugars (carbohydrates) which increases calories in the body.
Food
Various studies have shown positive correlation between the type of food taken and the development of overweight and obesity. In fact, the types of food determine the quantity of calories consumed per day. High-energy content foods including fats and sugars have increased calories than vegetables, fruits and whole grain. In addition, children constantly consuming high fat and sugar content foods are likely to develop problems relating to overweight and obesity.
A cross sectional study conducted by El-Bayoumy et al (2009) indicated that Kuwaiti intermediate school adolescent children aged between the ages 10 and 14 years are likely to consume food containing high amount of fat and sugar sodium than vegetables fruits and whole grain. In addition, the study indicated that the overall prevalence rate of obesity among the intermediate adolescent schoolchildren consuming high-energy content foods were higher. In fact, the overall obesity and overweight measured in terms of BMI index indicated that adolescents consuming fats constantly recorded BMI index of over 95% while those consuming low fatty foods, fruits and vegetables recorded around 29.3%.
However, food intake is determined by various factors. A study conducted by Campbell et al (2010) to explore the family risk factors associated with overweight in children aged 6-10 years in Kuwaiti found out that families have greater influence on the type of food and the manner in which the food is taken. Further, the study evaluated the correlation between dieting and nutrition to obesity. In the correlation, the study used the Statistical Program for the Social Sciences (SPSS) and the X2 tests to explore the link between various factors to obesity. Moreover, logistic regression applied binary variable non-obese (BMI < 25 kg/m2) and obese (BMI > 30kg/m2) as well as overweight (BMI ≥ 25 kg/m2) as dependent variables. Further, a P–value of ≤ 0.05 was used as the measure of statistical significance. Data from chi-square analysis suggested that the incidence of obesity in children was approximately 17%.
Campbell et al (2010) found out from chi-square analysis that the prevalence of overweight and obesity among dieting children was 8.2% and 9.9% respectively. The study also found the frequency of dieting as a major risk factor for obesity and overweight among children. Specifically, the results showed that male children aged 6-10 years who never dieted have overweight and obesity prevalence rates of 98% and 76% respectively. Nonetheless, students who had high frequency of dieting (≥ 4) had 3.0% and 5.4% occurrence rates of overweight and obesity respectively. Data from logistical regression demonstrated that the prevalence of overweight and obesity in male children that did not diet had an Odd Ratio (OR) of 0.4 and 0.5 correspondingly (Campbell et al., 2010).
Beverages
Rising consumption of sugary beverages contributes to the increasing prevalence of obesity particularly among the children (Kovalskys et al., 2011; Ogden et al., 2010). The reason is that almost all types of beverages contain over eighty percent sugar that when consumed contributes to increased calories in the body. In addition, children consume higher amount of beverages per day in relation to other meals contributing to over two-thirds of calories in their daily diets. Scientific evidence suggests that consuming twenty gram of soda add over 240 calories in the body while sixty-four grams of fountain cola drink would add up to 700 calories in the body (Ogden et al., 2010; Olds et al., 2011). In fact, consuming beverages do not make children full compared with equal quantity of solid food yet beverages contain high amount of calories. As such, there are increased chances of consuming more beverages per day compared with other solid foods.
A study conducted by Ogden et al. (2010) indicated a rising consumption of sugary beverages causing increased harm to health. The study indicated that by 2010, children were consuming over 2224 calories per day from beverages adding up to about eighty-nine percent of their daily calorie intake. Among the children aged 6-11 calories intake from sugary beverages increased by over 60%. In addition, the number of children consuming sugary beverages also rose by 79%. Further, the study indicated 26% increased risk of developing obesity and overweight related complications among the children and youths consuming sugary beverages. Besides, a similar study conducted by Nasreddine et al. (2010) indicated increased risk (30%) of developing overweight related complications among the Kuwaiti children.
References
Al-Isa, A. N. (2004). Bodymass index, overweight and obesity among Kuwaiti intermediate school adolescents aged 10-14 years. European Journal of Clinical Nutrition, 58(9), 1273–1277.
Al-Kandari, Y. Y. (2005). Prevalence of obesity in Kuwait and its relation to sociocultural variables. Obesity Reviews, 7(1), 147–154.
Al-Qahtani, A. (2011). Strategy to combat obesity and to promote physical activity in Arab countries. Diabetes, Metabolic Syndrome and Obesity, 4(1), 234-237.
Al-Rashdan, I., & Al-Nesef, Y. (2010). Prevalence of overweight, obesity, and metabolic syndrome among adult Kuwaitis: results from community-based national survey. Angiology, 61(1), 42-48.
Anderson, P. M. & Butcher, K. F. (2006). Childhood obesity: trends and potential causes. The Future of Children, 16(2), 19 – 45.
Ariza, A. J., Laslo, K. M., Thomson, J. S., Seshadri, R., Binns, H. J. (2009). Promoting growth interpretation and lifestyle counseling in primary care. The Journal Pediatrics, 154(6), 596-601.
Armstrong, M. E., Lambert, M. I. & Lambert, E. V. (2011). Secular trends in the prevalence of stunting, overweight and obesity among Kuwaiti schoolchildren (1994-2004). European Journal of Clinical Nutrition, 65(5), 835-840.
Arredondo, E. M., Elder, J. P., Ayala, G. X., Campbell, N., Baquero, B., & Duerksen, S. (2006). Is parenting style related to children’s healthy eating and physical activity in Latino families? Health Education Research, 21(6), 862-871.
Bauer, K., Nelson, M., Boutelle, K., & Neumark-Sztainer, D. (2008). Parental influences on adolescents’ physical activity and sedentary behavior: longitudinal findings from Project EAT-II. International Journal of Behavioral Nutrition and Physical Activity, 5(1), 12-17.
Campbell, J., Al-Isa, A., & Desapriya, E. (2010). Factors associated with overweight and obesity among Kuwaiti elementary male schoolchildren aged 6−10 years. International Journal of Pediatrics, 1(1), 1-6.
Caprio, S., Daniels, S. R. Drewnowski, A., Kaufman, F. R., Palinkas, L. A., Rosenbloom, A. L., & Schwimmer, J. B. (2008). Influence of race, ethnicity, and culture on childhood obesity: implications for prevention and treatment. Diabetes Care, 31(11), 2211-2219.
Cattaneo, A., Monasta, L. & Stamatakis, E. (2010). Overweight and obesity in infants and pre-school children: a review of existing data. Obesity Review, 11(3), 389-398.
Cawley, J. (2010). The economics of childhood obesity. Health Affairs, 29(3), 364-371.
Darawshah, M. A. & Ahmed, M. N. (2011). Anthropometric indicators of overweight and obesity and dietary habits of schoolchildren 6–12 years in Kuwait. Arab Journal of Food Nutrition, 3(1), 225–240.
El-Bayoumy, I., Shady, I., & Lotfy, H. (2009). Prevalence of obesity among adolescents (10 to 14 Years) in Kuwait. Asia-Pacific Journal of Public Health, 21(2), 153-159.
Gupta, N., Goel, K., Shah, P. & Misra, A. (2012). Childhood obesity in developing countries: epidemiology, determinants, and prevention. Endocrinal Review, 6(1), 7-9.
Habib, S. H. & Saha, S. (2010). Burden of non-communicable disease: global overview. Diabetes and Metabolic Syndrome, 4(1), 41–47.
Hesketh, K., Wake, M., Graham, M. & Waters, E. (2007). Stability of television viewing and electronic game/computer use in a prospective cohort study of Australian children: relationship with body mass index. International Journal of Behavioral Nutrition and Physical Activity, 4(1), 1-60.
Jonsson, A., Renstrom, F., & Lyssenko, V. (2009). Assessing the effect of interaction between an FTO variant (rs9939609) and physical activity on obesity in 15,925 Swedish and 2,511 Finnish adults. Diabetologia, 52(4), 1334–1338.
Kovalskys, I., Rausch, H. C. & De Gregorio, M. J. (2011). Nutritional status of school-aged children: data-using three references. Journal of Public Health, 33(1), 403-411.
Kriemler, S. L., Zahner, C., & Schindler, C. (2010). Effect of school based physical activity programme (KISS) on fitness and adiposity in primary schoolchildren: cluster randomised con-trolled trial. British Medical Journal, 40(785), 475-478.
Lien, N., Henriksen, H. B., Nymoen, L. L., Wind, M. & Klepp, K. I. (2010). Availability of data assessing the prevalence and trends of overweight and obesity among European adolescents. Public Health Nutrition, 13(2), 1680-1687.
Lobstein, T., Baur, L. & Uauy, R. (2004). Obesity in children and young people: a crisis in public health. Obesity Reviews, Supplement, 5(1), 4–104.
Magarey, A. M., Daniels, L. A., Boulton, T. J., & Cockington, R. A. (2003). Predicting obesity in early adulthood from childhood and parental obesity. Int J Obes Relat Metab Disord., 27(1), 505–513.
Marshall, S. J., Biddle, S. J., Gorely, T., Cameron, N., & Murdey, I. (2004). Relationships between media use, body fatness and physical activity in children and youth: a meta-analysis. Int. J. Obes. Relat. Metab. Disord., 28(10), 1238–1246.
McMurray, R. G., Harrell, J. S., Deng, S., Bradley, C. B. Cox, L. M. & Bangdiwala, S. I. (2012). The influence of physical activity, socioeconomic status, and ethnicity on the weight status of adolescents. Obesity Research, 8(2), 130–139.
Monasta, L., Lobstein, T., Vignerová, J. & Cattaneo, A. (2011). Defining overweight and obesity in pre-school children: IOTF reference or WHO standard? Obesity Review, 12(3), 295-300.
Musaiger, A. O., Sadeq, A. & Obeid, O. (2011). The paradox of nutrition-related diseases in the Arab countries. Journal of Environmental Research and Public Health, 8(9), 3637–3671.
Nasreddine, L., Mehio-Sibai, A., Mrayati, M., Adra, N. & Hwalla, N. (2010). Adolescent obesity in Kuwait: prevalence and associated factors. Child: Care, Health and Development, 36(3), 404–413.
Newby, P. K. (2003). Dietary patterns and changes in body mass index and waist circumference in adults. American Journal of Clinical Nutrition, 77(3), 1417-1425.
Ogden, C. L., Carroll, M. D., Curtin, L. R., Lamb, M. M. & Flegal, K. M. (2010). Prevalence of high body mass index in US children and adolescents. Journal of the American Medical Association, 303(3), 242–249.
Olds, T., Maher, C., & Zumin, S. (2011). Evidence that the prevalence of childhood overweight is plateauing: data from nine countries in Middle East. International Journal of Pediatric Obesity, 6(2), 342-360.
Popkin, B. M., Adair, L. S. & Nig, S. W. (2012). Global nutrition transition and the pandemic of obesity in developing countries. Nutrition Review, 70(1), 3-21.
Rampersaud, E., Mitchell, B. D., & Pollin, T. I. (20008). Physical activity and the association of common FTO gene variants with body mass index and obesity. Arch Intern Med., 168(16), 1791–1797.
Robert, C. A. (2010). The home environment and childhood obesity. Human Nutrition, Foods and Exercise, 43(2), 31-52.
Rolland-Cachera, M. F., Hercberg, S. & Castetbon, K. (2011). Stabilization of overweight prevalence in three countries from Middle East between 2000 and 2007. International Journal of Pediatric Obesity, 4(2), 66-72.
Rubenstein , A. H. (2005). Obesity: a modern epidemic. Transactionsof the American Clinical and Climatological Association, 116(1), 103–113.
Ruiz, J.R., Labayen, I. & Ortega, F. B. (2010). Attenuation of the effect of the FTO rs9939609 polymorphism on total and central body fat by physical activity in adolescents: the HELENA study. Arch Pediatr Adolesc Med., 164(6), 328–333.
Salman, M. A. & Ajeel, N. A. H. (2013). Prevalence of overweight and obesity among public primary school children in Basrah City. Journal of Communication and Media, 7(2), 103-108.
Sibai, A. M., Nasreddine, L., Mokdad, A. H., Adra, N., Tabet, M. & Hwalla, N. (2010). Nutrition transition and cardiovascular disease risk factors in Middle East and North Africa countries: reviewing the evidence. Annals of Nutrition and Metabolism, 57(3), 193–203.
Stevenson, N. (2010). Examination of family environmental factors associated with obesity in African American youth resides in Baltimore city. American Journal of Clinical Nutrition, 45(4), 257-268.
Styne, D. M. (2004). Puberty, obesity and ethnicity. Trends in Endocrinology and Metabolism, 15(10), 472–478.
Sugimori, H., Yoshida, K., & Izuno, T. (2004). Analysis of factors that influence body mass index from ages 3 to 6 years: a study based on the Toyama cohort study. International Journal of Pediatrics, 46(3), 302–310.
Veerman, J. L. (2011). On the futility of screening for genes that make you fat. PLoS Med., 8(11), 1001-1114.
Vidal, V. L., Al-Kandari, F., & Thomas, D. (2008). Health-promoting lifestyle and body mass index among college of nursing students in Kuwait: a correlational study. Nursing and Health Sciences, 10(2), 43–50.
Wake, M., Nicholson, J. M., Hardy, P., & Smith, K. (2007). Preschooler obesity and parenting styles of mothers and fathers: National population study. Pediatrics, 120(6), 520-1527.
Walley, A. J., Asher, J. E. & Froguel, P. (2009). The genetic contribution to non-syndromic human obesity. Nat Rev Genet., 10(2), 431–442.
Wojcicki, J. M. & Heyman, M. B. (2010). Let us move—childhood obesity prevention from pregnancy and infancy onward. The New England Journal of Medicine, 362(16), 1457–1459.
World Health Organization (2010). Obesity: preventing and managing the global epidemic: Report of a WHO consultation. Technical Report Series, 894(7), 1-253.