Saudi Arabia struggles with the burden of obesity
He is forced awake several times a night by sleep apnea - his breathing stops. He does not play football with his classmates because running is too difficult. The dark patch on his fleshy, creased neck means he is pre-diabetic. And in a 20-minute conversation, he manages to flash one weak smile.
"I'm not comfortable with my shape," said the boy, who asked that his name not be used. "And when I walk, I get tired."
Standing 1.5 metres tall and weighing 118kg, this child's burden is obesity.
He is not alone. An estimated one in three of the Saudi population is obese, putting the Kingdom high on the list of countries suffering from what many health officials are calling an international obesity epidemic.
Worldwide, obesity now matches smoking as a leading preventable cause of death because it leads to a long list of diseases such as diabetes, coronary heart disease and even cancer, said Dr al Qahtani, the director of the Sheikh Ali bin Sulaiman Al Shehri Obesity Chair at Riyadh's King Saud University.
In the United States, where some experts predict that five years from now four of every 10 Americans may be obese, the first lady, Michelle Obama, has launched a national campaign to fight childhood obesity.
There are no up-to-date, definitive national statistics for the prevalence of obesity in the Saudi population. However, a series of selective sample studies done since 2004 and supplied to The National by the nutritionist Khalid al Madani, a former vice-president of the Saudi Society for Food and Nutrition, shows that on average 29 per cent of adult males and 37 per cent of adult females are obese.
Similarly, selective studies done between 2005 and 2008 found more than one in ten - 11.1 per cent - of Saudi children and teenagers is obese. Dr Al Qahtani, however, asserts that the real rate today "is approaching 35 per cent".
Health officials and physicians, whose alarm is based on what they see in their offices, blame the Kingdom's unhealthy lifestyle for their countrymen's swelling size. Overly abundant diets that are rich in fats, carbohydrates and processed foods, as well as a lack of physical activity, are the main culprits.
Dr Khaled bin Obaid Bawakid, the secretary general of the Society of Family and Community Medicine in Jeddah. said: "Our main problem in the Saudi population regarding obesity is that we do not have a good concept of a healthy lifestyle [and] the importance of making daily exercise. Most people are using their cars even to go to the nearest place, like the mosque. They have to use their legs instead of their car . [and] if they want to eat junk food OK, but not three to five times a day, and not every day, and not all the time!"
Studies consistently show that obesity is more prevalent among Saudi women than men, due partly to restrictions on their movements, physicians and dieticians said. There are few indoor gyms for females and they are expensive. And while it has become acceptable in recent years for women to walk for exercise in certain areas of Riyadh and Jeddah, elsewhere it remains taboo.
Even if they want to exercise, most women need a male to accompany them.
Sabrina Bitar, a dietician and manager of the Riyadh office of Diet Watchers, a commercial weight-loss programme, said: "Unless they find a brother, or a father, it's not feasible or easy to go for a walk. But eating, this is the big problem. For women who are not working and are sitting all day at home, they are eating all day. And for women who are working, they don't have the time to cook, so they depend on fast food."
It is the fast-rising rate of obesity among children, however, that has Saudi health officials most concerned. Dr Bawakid said: "When I go into schools, I am really shocked to see young children who are overweight."
Basim Fota, the head of the education committee of the Saudi Diabetes and Endocrinology Association, said rising childhood obesity "is very alarming to us. We are sending a message to all officials that they have got to pay attention to this because it's going to affect us in the future."
Ms Birar said: "Parents don't limit what children eat. There is always chips or chocolates on the table. Rarely do they have fruit."
An even bigger problem is the lack of physical activity in government schools, physicians said. At most boys' schools, little emphasis is put on sport.
Dr al Qahtani said: "The teachers only bring them outside, tell them go after the ball and that's it." Fitness classes are needed "at least five times a week for weight reduction", he said.
The situation at girls' schools is worse: no organised physical activity at all - a concession to religious conservatives who view female sports as a step towards Saudi girls becoming "westernised" or "unfeminine", according to arguments put forth by some sheikhs.
Dr al Qahtani sees the ravages of childhood obesity first-hand at his clinic. It was opened two years ago to treat children 18 and under, and stresses a multidisciplinary approach that involves psychological counselling, fitness training, nutrition guidance, as well as physician consultations, he said.
Research has shown that without intervention, 80 per cent of pre-adolescent children become obese adults, and thus endure "suffering on several different levels", he said.
Apart from the diseases they are likely to contract and the societal discrimination they will face, "their self-esteem and self-image is not satisfying to them, so they avoid other people", Dr al Qahtani said. "That will initiate a vicious circle: they are isolated so they become depressed and then they eat more."
Salma al Nabulsi, the clinic's co-ordinator, said that "most of the patients who come here are really, really obese. It's really heart-breaking".
About 30 per cent are found to be genetically predisposed to obesity, but lifestyle also plays a big role, Dr al Qahtani said. If, for example, his unhappy 13-year-old patient had been born 50 years ago, he would probably grow into a large but not obese adult because he'd be doing manual labour every day and drinking water instead of soft drinks.
Between 30 and 40 per cent of the clinic's patients undergo bariatric surgery, the removal of part of their stomach and intestines, as a way to lose weight. They qualify for the operation if they already have a disease such as diabetes, or a strong genetic base for their obesity.
A year ago, Bashayer Alzubaidi, then 14, weighed 150kg, could not walk, was having seizures, and lost her vision because of pressure on her optical nerve, Dr al Qahtani said. Her obesity-inducing genes, and the severity of her condition, made surgery appropriate, he said.
Now she weighs 77kg, can walk and has regained partial eyesight. "I feel better now, thanks to God. I eat much less," she said.
Patients who do not have the surgery but follow the clinic's diet and exercise guidelines usually are able to maintain their weight, neither losing nor gaining.
Dr al Qahtani calls this "a good achievement" because as they grow taller into adulthood, their obesity decreases. And so, he hopes, does their suffering.