Prevalence and age-related trends of overweight and obesity among Saudi children aged 2–14 years during the COVID-19 pandemic: A retrospective cross-sectional study

Abstract

Background

Childhood obesity is a growing public health crisis in Saudi Arabia, which was intensified by the COVID-19 pandemic. This study mapped the prevalence and trends among clinic-attending children to inform prevention strategies.

Methods

A retrospective cross-sectional analysis of electronic records for 28,275 Saudi children (aged 2–14 years) attending primary care clinics in Saudi Arabia’s Eastern Province (2018–2024). Body mass index (BMI) was classified according to the Centers for Disease Control criteria (overweight: 85th–95th percentile; obesity: ≥95th percentile), excluding secondary causes. Crude and age-standardized prevalence rates were calculated by age, sex, and year using R software.

Results

Mean age was 5.46 years (51% female). Overall, obesity prevalence was 12.3% (higher in males: 13.1% vs. 11.5% females), rising from 6.2% (ages 2–3 years) to 23.8% (ages 12–14 years). Overweight prevalence was 10.5% (7.3%–17.2% by age). Both reached their highest observed values in 2020 (obesity: 19.1%; overweight: 14.5%), with year-to-year variation thereafter.

Conclusion

Age-related increases underscore the obesogenic environments among Saudi youth, with COVID-19 amplifying these risks. Findings highlight the need for resilient, Vision 2030-aligned prevention strategies focusing on early intervention and equity.

Background

Over the past 30 years, the rates of overweight and obesity have doubled among adults and quadrupled among adolescents. ¹ The World Health Organization (WHO) estimates that 2.5 billion adults aged 18 years and older, 390 million children and adolescents aged 5–19 years, and 37 million children under five years of age are affected by overweight or obesity worldwide. ¹ The Kingdom of Saudi Arabia is not exempt, and obesity has become a significant public health concern and a leading cause of various non-communicable diseases, such as asthma, diabetes mellitus, and cardiovascular diseases. ² The General Authority for Statistics in Saudi Arabia announced that the prevalence of overweight and obesity among the adult population (≥15 years) is 45.1% and 23.1%, respectively. Meanwhile, the prevalence among children and adolescents (2 – 14 years) is 33.3% and 14.6%, respectively. ³ These alarming statistics underscore the gravity of the situation, indicating that the burdens associated with overweight and obesity have escalated from an epidemic to a pandemic level. ⁴

It often begins with maternal obesity, where excessive weight gain during pregnancy and the first two years of life is highly associated with obesity. ⁵ It is common knowledge that children of obese parents are more likely to become obese themselves, and childhood obesity persists into adulthood. Approximately one-third (26% males, 41% females) of Arabic-speaking preschoolers who were obese went on to become obese adults, as did half (42% males, 63% females) of obese school-age children. ⁶

However, childhood obesity arises from a multifactorial interplay of genetic predisposition, individual, familial, and environmental determinants. ⁷ At the individual level, factors such as birth weight, gestational age, and breastfeeding practices influence the risk of obesity. ⁸ Family-related factors, including socioeconomic status, parental education, family structure, and family history of obesity, further shape weight trajectories. ⁷ Environmental factors, such as residential location, dietary patterns, physical activity levels, and climatic conditions, also contribute to the development of these diseases. Recognizing this complexity is essential for developing targeted preventive strategies. ¹

Consequently, implementing foundational strategies to prevent overweight and obesity in early childhood, including environmental and societal changes and policy modifications, could significantly enhance the physical and mental well-being of future generations. Thus, it is crucial to recognize the prevalence of this condition and comprehend its trends to devise effective strategies for prevention and management.

Although national surveys exist, clinic-based trends in early childhood remain underexplored. This retrospective study examined the prevalence of overweight and obesity, defined as body mass index (BMI) ≥85th percentile, among 2–14-year-old Saudi children attending primary care, analyzing the first-recorded BMI by age, sex, and year (2018–2024).

Methods

Study design

This retrospective cross-sectional study included patients who attended a pediatric primary care clinic at a tertiary hospital in the Eastern Province of Saudi Arabia. Data were extracted from the electronic medical record system (EPIC) for the period 2018–2024.

Inclusion/exclusion criteria

This study included patients who attended pediatric primary care clinics across four main districts in the Eastern Province of Saudi Arabia. The inclusion criteria required participants to be (1) aged between 2 and 14 years. In accordance with these CDC standards, a BMI between the 85th and 95th percentiles was classified as overweight, and a BMI at or above the 95th percentile was classified as obese. ⁹ Exclusion criteria were applied to focus on primary obesity, excluding participants with (1) known genetic, syndromic, or endocrine disorders linked to weight gain (e.g., Prader-Willi syndrome, hypothyroidism); (2) chronic use of medications that significantly affect weight (e.g., systemic corticosteroids, antipsychotics); or (3) incomplete anthropometric data required for classification.

Sample derivation

A total of 133,353 records were extracted from the EPIC system for the period 2018-2024. Records were excluded sequentially as follows: 9,093 records were excluded for age ≥ 15 years (remaining: 124,260); 3,008 records were excluded for incomplete anthropometric data (remaining: 121,252); and 92,977 subsequent visit records were removed, retaining only each patient’s first recorded visit across the study period, yielding the final analytic sample of 28,275 children. A flow diagram is presented in Figure 1.

Figure 1.

Flow diagram of study sample derivation. A total of 133,353 electronic medical records of children aged 2–14 years attending primary care clinics at Johns Hopkins Aramco Healthcare in the Eastern Province of Saudi Arabia (2018–2024) were initially extracted. Records were sequentially excluded as follows: 9,093 for age ≥15 years, 3,008 for incomplete anthropometric data, and 92,977 for representing subsequent visits (retaining only each patient’s first recorded visit). The final analytic sample comprised 28,275 unique children.

Data collection

Data for this study were retrospectively collected from the EPIC electronic health record system. A system-generated report included the patient’s date of birth, date of first recorded BMI, age at first recorded BMI, sex, weight, height, BMI value, BMI percentile, and BMI category. The dataset was exported to Microsoft Excel for data management and analysis.

Data analysis

Descriptive statistics were used to summarize the data, with categorical variables presented as frequencies and percentages and continuous variables as means and standard deviations (SD). Data were analyzed using R (version 2023.06.0+421). BMI percentiles and z-scores were calculated using the CDC Anthro R package (version 0.1.3), using the 2000 CDC Growth Charts for non-obese children and the extended method for obese children. ¹⁰

Crude prevalence rates for obesity and overweight were calculated for age groups (2–3, 4–5, 6–11, and 12–14) from 2018–2024 data. Age-standardized rates were calculated using the 2022 Saudi Arabia age proportions (GASTAT for Statistics) through direct standardization. ¹¹ To formally assess temporal trends, Cochran-Armitage trend tests were applied to the underlying binary outcome data (obese/non-obese and overweight/non-overweight) across ordered calendar years. To formally assess age-related trends, Cochran-Armitage trend tests were applied to age-specific prevalence across ordered age groups. Sex-stratified analyses were conducted using age-standardized rates and chi-square tests. Logistic regression models with year as a continuous predictor were fitted to assess temporal trends, both unadjusted and age-group-adjusted. Bar charts of the standardized rates were created using ggplot2.

Results

Study population

The study population of 28,275 children (51.22% female, 48.78% male; mean age 5.46 years, SD 3.59) was predominantly young, with 42.37% toddlers (2–3 years) and 33.12% in middle childhood (6–11 years old). Preschoolers (4–5 years) and young teens (12–14 years) comprised 17.00% and 7.51% of the sample, respectively. Visits reached their highest volume in 2018 (35.14%) and lowest in 2020 (7.00%), likely due to COVID-19-related quarantine (Table 1). Crude prevalence rates showed higher obesity in males (13.12%) than in females (11.54%), while overweight rates were slightly higher in females (11.19%) than in males (9.82%) (Figure 2). After age-standardization, males had significantly higher obesity prevalence than females (18.5%, 95% CI: 17.5–19.5% vs 15.3%, 95% CI: 14.5–16.2%; χ²=16.312, p<0.001). Conversely, females had a significantly higher prevalence of overweight than males (13.8%, 95% CI: 13.0–14.6% vs 12.2%, 95% CI: 11.4–13.0%; χ²=13.755, p<0.001). The age-related increase in prevalence was statistically significant in both sexes for both obesity and overweight (Cochran-Armitage, all p<0.001).

Table 1.

Demographic characteristics of study population (n = 28,275).

Characteristic	n (%)
Mean Age, years (SD)	5.46 (3.59)
Sex
Female	14,483 (51.22%)
Male	13,792 (48.78%)
Age Group
Toddlers (2–3 years)	11,981 (42.37%)
Preschoolers (4–5 years)	4,806 (17.00%)
Middle Childhood (6–11 years)	9,365 (33.12%)
Young Teens (12–14 years)	2,123 (7.51%)
BMI Category
Underweight (<5th percentile)	3,244 (11.47%)
Healthy Weight (5th–84th percentile)	18,575 (65.69%)
Overweight (85th–94th percentile)	2,975 (10.52%)
Obese (≥95th percentile)	3,481 (12.31%)
Year of Visit
2018	9,937 (35.14%)
2019	4,664 (16.50%)
2020	1,978 (7.00%)
2021	2,920 (10.33%)
2022	2,620 (9.27%)
2023	3,132 (11.08%)
2024	3,024 (10.69%)

Figure 2.

Crude prevalence of overweight and obesity by sex among Saudi children aged 2–14 years attending primary care clinics (n = 28,275). Overweight was defined as body mass index (BMI) between the 85th and 94th percentiles, and obesity as BMI ≥95th percentile, according to the Centers for Disease Control and Prevention (CDC) 2000 growth charts. Data represent the first recorded BMI for each child between 2018 and 2024.

Prevalence of obesity and overweight

The crude prevalence of obesity among Saudi Arabian youth increased with age, from 6.16% in toddlers (2–3 years) to 24.35% in young teens (12–14 years), with age-adjusted rates closely aligned (6.20% to 23.78%). The prevalence of overweight followed a similar trend, increasing from 7.44% in toddlers to 17.57% in young teens (adjusted: 7.27% to 17.16%) (Tables 2 and 3). Cochran-Armitage trend tests applied to age-specific prevalence across ordered age groups confirmed statistically significant increases in both obesity (Z=33.618, p<0.001) and overweight (Z=19.464, p<0.001).

Table 2.

Crude and age-adjusted obesity prevalence by age group.

Age group	Crude %	Adjusted %	95% CI
Toddlers (2–3 years)	6.16%	6.20%	5.73–6.59%
Preschoolers (4–5 years)	8.30%	8.33%	7.52–9.08%
Middle Childhood (6–11 years)	19.51%	19.66%	18.70–20.31%
Young Teens (12–14 years)	24.35%	23.78%	22.54–26.16%

Table 3.

Crude and age-adjusted overweight prevalence by age group.

Age group	Crude %	Adjusted %	95% CI
Toddlers (2–3 years)	7.44%	7.27%	6.97–7.90%
Preschoolers (4–5 years)	7.80%	7.81%	7.04–8.56%
Middle Childhood (6–11 years)	14.27%	14.30%	13.56–14.97%
Young Teens (12–14 years)	17.57%	17.16%	15.97–19.17%

Trends over time

From 2018 to 2024, the age-adjusted obesity prevalence among Saudi Arabian youth showed fluctuations. In 2018, it was 15.11% (95% CI: 14.41%–15.81%), rising to 17.14% (95% CI: 16.06%–18.22%) in 2019. The peak was observed in 2020 at 19.07% (95% CI: 17.34%–20.80%). Subsequently, the rates varied yearly: 17.94% (95% CI: 16.55%–19.33%) in 2021, 16.05% (95% CI: 14.65%–17.46%) in 2022, 16.70% (95% CI: 15.40%–18.01%) in 2023, and 16.52% (95% CI: 15.19%–17.84%) in 2024. Similarly, the age-adjusted overweight prevalence ranged from 12.23% (95% CI: 11.59%–12.88%) in 2018 to 13.52% (95% CI: 12.30%–14.74%) in 2024, with a peak of 14.46% (95% CI: 12.91%–16.01%) in 2020. Cochran-Armitage trend tests applied to the binary outcome data across ordered calendar years indicated no significant temporal trend for obesity (Z=1.222, p=0.222) or overweight (Z=−0.286, p=0.775) throughout the study period, suggesting that the observed changes were temporal variations rather than directional trends. Logistic regression analysis, adjusted for age group, confirmed the lack of significance of temporal trends in both obesity (p=0.361) and overweight (p=0.952), suggesting that changes in crude rates were mainly due to shifts in the age composition of clinic visitors over time. The increase in 2020 for both conditions coincided with the onset of the COVID-19 pandemic. Figures 3 and 4 illustrate the crude and age-adjusted prevalence of obesity and overweight, respectively, across the study period (2018–2024).

Figure 3.

Prevalence of obesity among Saudi children aged 2–14 years attending primary care clinics, 2018–2024 (n = 28,275). The figure displays both crude and age-standardized prevalence rates of obesity (BMI ≥95th percentile) by calendar year. Age standardization was performed using the 2022 Saudi Arabia population age proportions from the General Authority for Statistics (GASTAT). Error bars represent 95% confidence intervals.

Figure 4.

Prevalence of overweight among Saudi children aged 2–14 years attending primary care clinics, 2018–2024 (n = 28,275). The figure displays both crude and age-standardized prevalence rates of overweight (BMI 85th–94th percentile) by calendar year. Age standardization was performed using the 2022 Saudi Arabia population age proportions from the General Authority for Statistics (GASTAT). Error bars represent 95% confidence intervals.

Discussion

The present study, a retrospective analysis of 28,275 Saudi children and adolescents from primary healthcare centers between 2018 and 2024, revealed a marked age-related increase in obesity and overweight, confirmed by Cochran-Armitage trend testing (obesity: Z=33.618, p<0.001; overweight: Z=19.464, p<0.001). Age-adjusted obesity peaked at 19.07% (95% CI: 17.34%–20.80%) in 2020, during the COVID-19 pandemic. However, formal trend testing showed no statistically significant temporal trend in age-adjusted rates, so this finding should be interpreted cautiously as temporal variation consistent with, but not causally attributable to, pandemic-related lifestyle changes.

These findings are consistent with international evidence, including a U.S. cohort study reporting higher childhood obesity and overweight during and after the COVID-19 lockdowns in 2020 and 2021 than in the pre-pandemic period, likely reflecting pandemic-related lifestyle disruptions. ¹² The increase during this period may be linked to reduced physical activity due to lockdowns and closure of recreational facilities, shifts toward comfort foods, ¹³ elevated psychological stress, disruption of daily routines, and limited access to healthcare and wellness resources. ¹³ The decline in 2021 and variability in later years may reflect adaptation to new routines, reopening of public spaces, and greater public health awareness as restrictions eased. Studies have shown that pandemic-induced lifestyle changes increased overweight and obesity among children and adolescents. A systematic review reported decreased physical activity and increased sedentary time during lockdowns, linked to higher BMI and obesity rates in this age group during the pandemic. ¹³ Evidence from Qatar showed decreased physical activity and increased screen time during school closures, correlating with higher BMI-for-age Z-scores (BAZ) in students. ¹⁴ Further analysis indicated that chronic stress, unhealthy eating behaviors, and reduced physical activity during COVID-19 contributed to excessive weight gain. ¹⁵ A broad literature review concluded that routine disruptions, sedentary lifestyles, and changes in diet and sleep patterns collectively increased the risk of childhood obesity during the COVID era. ¹⁶

The present cross-sectional study demonstrates a statistically significant age-related increase in the prevalence of overweight and obesity among Saudi children (Cochran-Armitage trend testing, p<0.001 for both conditions), rising from approximately 6% obesity and 7% overweight in toddlers (2–3 years) to over 23% obesity and 17% overweight in early adolescents (12–14 years). These findings align with earlier national data indicating a progressive increase in adiposity across childhood and adolescence in Saudi Arabia and reflect the cumulative effects of prolonged exposure to obesogenic environments characterized by sedentary lifestyles and diets high in processed and calorie-dense foods, particularly in urban settings. ¹⁷

Urbanization, processed and calorie-dense diets, and sedentary behavior drive childhood obesity in Saudi Arabia.^18,19 National surveillance shows increasing consumption of ultra-processed, energy-dense foods and sugar-sweetened beverages, with declining physical activity among youth, reflecting an obesogenic environment. ¹⁹ Genetic susceptibility, combined with high consanguinity, may increase metabolic risk and predispose to obesity. Consanguinity increases homozygosity, unmasking recessive variants linked to obesity and cardiometabolic disorders; these factors explain age-progressive increases in obesity.^20–22

Our findings align with regional and global epidemiological trends. The 2025 Lancet Global Burden of Disease analysis reported that 93.1 million children aged 5–14 years worldwide were obese in 2022, nearly tripling since 1990, with the highest prevalence in North Africa and the Middle East. ²³ Saudi Arabia was identified as one of the fastest-rising countries, with a 2.5-fold increase in childhood obesity since 1990, attributed to urbanization and dietary shifts. ²³ Our age-adjusted estimates, including 19.7% obesity among 6–11-year-olds, mirror the Lancet’s Saudi-specific modeled projections, though slightly higher in middle childhood, likely reflecting inclusion of children under five years and routine primary care screening. Regionally, Saudi Arabia ranks in the top quartile for adolescent obesity prevalence in the Middle East and North Africa, reinforcing the urgency of addressing Saudi-specific drivers, including oil-dependent affluence, cultural dietary norms, and limited opportunities for physical activity.

The parallel increase in the prevalence of overweight and obesity highlights their interconnected nature and sensitivity to environmental and societal stressors. Importantly, fluctuations in the prevalence of overweight individuals may serve as early indicators of shifts in obesity trends, suggesting that prevention strategies should target both conditions simultaneously. Therefore, integrated public health approaches are warranted, emphasizing nutrition security, physical activity promotion, and psychosocial resilience, particularly during periods of societal disruption.

The COVID-19 pandemic is a salient example of such disruptions. International and regional studies have consistently reported reduced physical activity, increased sedentary behavior, emotional eating, and weight gain among children and adolescents during lockdowns and social restrictions.^12–16 The patterns observed in our population align with those in the literature, underscoring the role of environmental stressors and constrained mobility in accelerating unhealthy weight gain during crises. These findings emphasize the need for targeted interventions during public health emergencies, such as home-based physical activity programs, digital health engagement, and accessible mental health support systems.

From a public health standpoint, the observed prevalence—approaching 1 in 4 young adolescents being obese—portends substantial future morbidity, including elevated risks of type 2 diabetes, cardiovascular disease, orthopedic complications and psychosocial distress. ¹⁷ Given that our data originate from primary care settings, routine anthropometric assessments are a feasible and effective strategy for early detection, particularly among younger children (mean age 5.5 years), an age group that is less emphasized in global surveillance frameworks, such as the Lancet’s 5–19-year focus. ²³

Policy responses to childhood obesity in Saudi Arabia should prioritize culturally adapted, system-level interventions addressing environmental and behavioral determinants. Gender-equitable physical activity promotion in schools and communities, alongside dietary initiatives, can increase energy expenditure, improve nutrition, and support weight trajectories. Such interventions align with evidence of rising obesity among Saudi youth and the national agenda to reduce obesity-related morbidity. ²⁴

Limitations

This study has several limitations. First, the clinic-based sample from primary care clinics in the Eastern Province may introduce selection bias, as families accessing routine pediatric services at Johns Hopkins Aramco Healthcare (JHAH) likely represent urban, higher socioeconomic, or health-aware groups, potentially overestimating prevalence relative to community-wide rates. This restricts the generalizability of the findings to the broader Saudi population, particularly rural or non-oil-affiliated communities. Second, the retrospective design limits causal inference; observed temporal patterns, such as the 2020 COVID-19 elevation, capture ecological associations rather than individual-level mechanisms, with unmeasured confounders (e.g., socioeconomic status and precise dietary or physical activity data) possibly influencing outcomes. Third, reliance on the first-recorded BMI introduces measurement variability, such as potential inconsistencies in height/weight protocols before the full EPIC implementation in 2020, although electronic standardization and complete-case analysis (excluding <2.5% incomplete records) minimized this. Fourth, the cross-sectional approach provides snapshots of prevalence and trends but cannot track longitudinal changes, limiting insights into obesity persistence, remission, or age-related progression at the individual level. Fifth, the low visit volume in 2020 (7.0% of total visits) may have introduced selection bias in that year’s estimates, as attendance patterns during the COVID-19 lockdown may not have been representative of the full pediatric population. The age-standardized estimate for 2020 should therefore be interpreted with caution. Finally, as this was a retrospective census of all available records meeting the inclusion criteria, a priori sample size calculation was not performed. However, post-hoc power for the primary age-trend analysis exceeded 99% (Cochran-Armitage Z=33.618), and confidence intervals are reported throughout to convey statistical precision. Despite these constraints, the strengths of this study — a large sample size (n=28,275), standardized CDC growth chart metrics, and age-adjustment using national proportions — offer robust, localized evidence to inform Saudi public health strategies.

These limitations highlight the opportunities for future research to build on our findings. Longitudinal cohort studies incorporating serial BMI assessments and behavioral metrics (e.g., via validated food frequency questionnaires or accelerometers) would clarify causal pathways and long-term trajectories, particularly the persistence of early obesity into adulthood. Broader, multicenter, or national surveys—potentially in collaboration with the General Authority for Statistics (GASTAT)—could enhance generalizability by including diverse regions (e.g., rural Western Province) and addressing urban bias. Additionally, prospective studies integrating genetic markers and environmental factors should be conducted to refine risk modeling in the Saudi context. Finally, randomized controlled trials of Vision 2030-aligned interventions, such as school-based physical activity programs or family-centered nutrition education, could evaluate their efficacy in reducing prevalence, with built-in economic analyses to quantify benefits relative to the substantial non-communicable disease burden.

Conclusion

In conclusion, this study documents a statistically significant fourfold increase in obesity prevalence from toddlers (6.2%) to young teens (23.8%), confirmed by Cochran-Armitage trend testing (Z=33.618, p<0.001), highlighting the early childhood window as a critical period for intervention. The congruence between our findings and international evidence validates the strength of our data. It underscores the urgent need for comprehensive, culturally sensitive, and resilient public health strategies to curb the rising tide of childhood overweight and obesity in Saudi Arabia in the future.

Appendix.

List of abbreviations

BAZ

BMI-for-age Z-scores

BMI

Body mass index

CDC

Centers for Disease Control and Prevention

SD

Standard deviation

WHO

World Health Organization

ORCID iDs

Hayat Mushcab https://orcid.org/0000-0003-4398-7020

Anwar Alotaibi https://orcid.org/0000-0003-4827-0731

Ethical considerations

This study was conducted in accordance with the Declaration of Helsinki. The study was approved by the Johns Hopkins Aramco Healthcare Institutional Review Board (IRB# 23-24).

Consent to participate

The requirement for written informed consent was waived because of the retrospective nature of the data collection and the use of de-identified records.

Data Availability Statement

The datasets generated and analyzed in this study are not publicly available, and de-identified datasets may be available from the corresponding author upon reasonable request.*