Physical activity is any movement produced by skeletal muscles resulting in energy expenditure.1 Based on the extensive benefits of physical activity, in 2020, the World Health Organization (WHO) updated its guidelines for regular aerobic activity and muscle strengthening for all age groups.2 For adults age 18–64 years, recommendations include at least 150 to 300 minutes per week of moderate-intensity, or at least 75 to 150 minutes per week of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate to vigorous physical activity (MVPA). Two or more days per week of muscle-strengthening activities at moderate or greater intensity are advised. For adults 65 years and older, muscle strengthening for 3 or more days per week and balance training are strongly recommended. Among 5–17 year olds, the recommendations advise at least 60 minutes per day of MVPA across the week and both vigorous-intensity aerobic activities and activities that strengthen muscles and bones at least 3 days per week. The 2020 WHO guidance2 also recommends people of all ages reduce their sedentary behaviors, defined as any waking time in a sitting, reclining, or lying position that requires 1.5 metabolic equivalents or less.3
Despite extensive evidence on the benefits of physical activity,4–6 a large proportion of the world’s population remains physically inactive.7 Estimates from 2012 indicated that physical inactivity, defined as not meeting physical activity recommendations, contributed to 9% of global premature mortality.8 These estimates were updated in 2022, with physical inactivity contributing to 4%, 7%, and 9% of mortality in low-, middle-, and high-income countries, respectively.9 Even so, this is likely an underestimate given the potentially detrimental impact of the COVID-19 pandemic on physical activity.10,11 In addition to the adverse effects on population health, physical inactivity results in an enormous economic burden.12 Worldwide data on children and adolescents indicate substantial actions will be needed to meet global goals to reduce lack of physical activity.13
Saudi Arabia is at an early stage in its demographic transition to an aging population, with concerning trends in noncommunicable diseases.5 For example, from 2009 to 2019, diabetes incidence increased by 94%; cardiovascular disease by 54%; and cancer by 50%, which may lead to higher health and economic burden.5,14 This is a unique time in the history of the country. A breadth of interventions have been introduced in the health, education, sport, environment, transportation, tourism, and urban design sectors, aiming to improve quality of living.15 In terms of health improvement, more streamlined efforts toward promoting physical activities and curtailing sedentary behaviors are essential.16 Realizing the importance of physical behaviors, the Quality of Life Program within Saudi Vision 2030 includes a goal of having at least 40% of the population exercise at least 1 days per week by the year 2030.15 Another national strategy recommends lowering the proportion of people with low physical activity to 20%.17 The 2021 Household Sports Practice Survey indicated that 48% of the country’s population engaged in at least 30 minutes per week of physical activity, which was higher than the 2019 prevalence of 45%.18
A total of 2 systematic reviews described physical activity and sedentary behavior in Saudi Arabia for adults16 and children/adolescents,16,19 with both searches conducted through early 2018. Regular surveillance of physical behaviors (ie, physical activity and sedentary behavior) assists in monitoring prevalence estimates over time, identifying population subgroups that might have the greatest need for intervention to reach national goals, and revealing gaps in the surveillance system.20 Centralized and recurring surveillance of physical behaviors is supplemented with other dispersed population-based assessments. These assessments are important, as they fill in gaps due to the irregular and fragmented data collection and provide more information on both physical activity and sedentary behavior for children, adolescents, and adults across regions.
Given the rapid changes occurring in Saudi Arabia that could impact physical behaviors,15 we sought to update the 2 prior reviews16,19 and focus specifically on studies utilizing population-based sampling. Thus, the purpose of this scoping review was to systematically summarize the population prevalence of physical activity and sedentary behavior in Saudi Arabia since 2018. Among the included studies, we also aimed to describe these behaviors by potential correlates (eg, age, gender, region, nationality, income, education, and body mass index [BMI]).
Methods
Search Methods
The systematic scoping review protocol was developed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews statement.21 Since this review focused on documenting levels of physical activity and sedentary behavior and was a scoping rather than a systematic review,22 the protocol was not required to be registered with any platforms. The completed Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews checklist can be found in Supplementary Material S1 (available online).21
We searched 6 databases (Cochrane Library, Global Health [EBSCO], PubMed, Scopus, SPORTDiscus [EBSCO], and WHO Global Index Medicus) on December 13, 2021, for articles published since 2018 using the search strategy detailed in Supplementary Material S2 (available online). After removing duplicate citations manually and using reference management software, 2 authors independently screened all titles/abstracts and full-text articles for inclusion using Covidence systematic review software (www.covidence.org; Veritas Health Innovation). Any discrepancies were resolved by consensus.
Inclusion Criteria
Observational studies that reported population prevalence (eg, municipal, regional, or national) of either physical activity or sedentary behavior in Saudi Arabia were included. Studies that used population-based sampling with a sampling frame delimited by no more than age, gender, and geographic area were considered. We included studies published in 2018 or later since a prior review was completed up to January 2018.16 We included studies published in either English or Arabic. Both self-reported and device-based measures of physical behaviors were included if ascertained from the entire sample.
Exclusion Criteria
We excluded studies that were not population-based or specific only to certain adverse health conditions (including obesity) or among hospitalized or institutionalized persons. We also excluded studies that only reported physical behaviors for a subset of their sample. Grey literature, dissertations, commentaries, and conference proceedings were omitted.
Abstraction and Analysis
Once the study inclusions were confirmed, one rater extracted the information and a second rater checked the information, with discrepancies resolved by consensus. The extraction tool included the following: study name, study purpose, data collection period, region, sampling methods, target population, inclusion and exclusion criteria, and sample size. Information extracted from the sample included physical activity and sedentary behavior assessments (eg, questionnaire and definitions used); age; gender; nationality; BMI; household income; and education. We classified the age group based on the predominant age included in the study, with children age 1 to 12 years, adolescents age 13–17 years, and adults age 18 years and older.23 If physical activity and sedentary behavior were cross-classified or stratified by age; gender; nationality; household income; education; or BMI (including the adult categories of underweight, normal weight, overweight, and obese), that information was extracted when available. If not directly reported, we calculated a pooled mean, SD, and percentage using the formulas in Supplementary Material S3 (available online). Classification of the 13 administrative regions in Saudi Arabia was based on the Saudi Health Interview Survey24: Al Riyadh, Makkah Al Moukarrama, Eastern Region, Northern Borders, Madinah, Jezan, Aseer, Najran, Qaseem, Tabuk, Hail, Al‐Jouf, and Al‐Baha.
Quality Assessment
The quality of each study was assessed by 2 reviewers, and disagreements were resolved by consensus. We used the 9-item Joanna Briggs Institute Prevalence Critical Appraisal Tool to assess study quality,25 making minor modifications to fit the purposes of this review (Supplementary Material S4 [available online]). In recognition that objective quality assessment tools treat each threat to validity equally,26 we did not provide a total score for each study. Instead, we used the quality assessment results to focus on the specific threats to validity identified across included studies.
Results
Study Selection
A total of 1272 records were found; after removing 475 duplicates, 797 records were screened for inclusion (Preferred Reporting Items for Systematic Reviews and Meta-Analyses diagram27 in Figure 1). In the title and abstract stage, 756 records were excluded as irrelevant. After full-text review, 19 studies were included, all published in English. Overall, 9 studies included children/adolescents28–36 and 10 studies included adults.37–46 A total of 4 studies recruited participants age 15 years and older (without an upper age limit defined); we classified those as adult-focused.43–46 Other studies recruited participants age 15–17 years,33 15–18 years,31 and 15–19 years29; we classified those as child/adolescent-focused. A total of 2 adult studies utilized the Saudi Health Interview Survey data, with one reporting on physical activity44 and one reporting on sedentary behavior.43 In addition, 2 other adult studies reported on the Women in Saudi Arabia Health Examination Survey, with both reporting on physical activity (derived 2 different ways)39,40 and one reporting on sedentary behavior.40
—Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram of the search strategy and results for the scoping review (figure from Page et al, 2021).27
Citation: Journal of Physical Activity and Health 20, 6; 10.1123/jpah.2022-0537
All 19 studies were cross-sectional designs, and only one study42 included assessments at more than one point in time. Data collection ranged from 200929 to 202041,42 (Table 1). For the 2 studies with data collection in 2020 during the COVID-19 pandemic, one study42 included 4 repeated cross-sectional surveys over the year; we extracted results only for the first quarter, which were collected prior to COVID-19-related movement restrictions in Saudi Arabia.47 The second study41 collected data from June to July 2020, which occurred after movement restrictions were eased.47
Description of Each Included Study Listed in Alphabetical Order by the First Author’s Last Name (n = 19 Studies)
| First author, year | Study name | Years of data collection | Location in Saudi Arabia | Sampling procedure | Survey weights used | Analytic sample size | Age group | Age in years mean (SD) | Female percent | Nationality percent |
|---|---|---|---|---|---|---|---|---|---|---|
| Al-Hanawi43 | SHIS | 2013 | All 13 administrative regions | Multistage stratified probability sampling | No | 7746# | Adults | NR | 47.0 | 100% Saudi |
| Al-Hanawi44 | SHIS | 2013 | All 13 administrative regions | Multistage stratified probability sampling | No | 10,735 | Adults | NR | 51.1 | 100% Saudi |
| Al-Hazzaa and Albawardi29 | ATLS | 2009 | Three cities: Riyadh, Jeddah, and Al-Khobar | Multistage stratified cluster sampling | No | 2888 | Children | 16.6 (1.0) | 51.9 | 100% Saudi |
| Al-Hazzaa30 | NR | 2017 | Riyadh | Multistage stratified cluster random sampling | No | 1051 | Children | 9.2 (1.7) | 50.2 | 100% Saudi |
| Al-Raddadi37 | NR | 2011 to 2012 | Jeddah | Multistage stratified cluster sampling | No | 1419 | Adults | 36 (15.4) | 53.0 | 77.7% Arabian tribes, 6.9% Mediterranean countries, 5.6% Indian continent, 4.6% African tribes, 3.4% mid-Asia, and 1.8% Southeast Asia |
| Alasqah31 | NR | 2017 | Six cities in the Qassim Region (Buraydah, Onaiza, Alrass, Albukayriah, Albadea, and Almedhnab) | Multistage sampling | No | 1133 | Children | NR | 54.6 | 91.4% Saudi and 8.6% non-Saudi |
| Alhabib38 | PURE study | 2012–2015 | Riyadh and Alkharj | Randomly invited eligible candidates from primary health care center lists | No | 2047 | Adults | 46.5 (9.1) | 43.1 | NR |
| Alharbi35 | NR | 2018 | Riyadh | Multistage stratified sampling | No | 464 | Children | NR | 100.0 | NR |
| Aljuaid32 | NR | 2014–2015 | Taif | Two-stage random sampling | No | 2943 | Children | 15.4 (1.7) | 22.8 | NR |
| Alqahtani45 | Bulletin of Household Sports Practice National Survey | NR | All 13 administrative regions | Two-stage random sampling | No | 26,000 | Adults | NR | Saudi 56.2, non-Saudi 27.7 | NR |
| AlQuaiz39 | WISHES | 2014–2015 | Riyadh | For women: Randomly selected from PHCC and recruited from the general public; for men: Enrolled from 5 government institutions | No | 2997 | Adults | 43.6 (11.2) | 67.7 | NR |
| AlQuaiz40 | WISHES | 2014–2015 | Riyadh | For women: Randomly selected from PHCC and recruited from the general public; for men: Enrolled from 5 government institutions | No | 2997 | Adults | 43.6 (11.2) | 67.7 | NR |
| Althumiri41 | Saudi Mental Health Surveillance System | 2020 | All 13 administrative regions | Proportional quota sampling | No | 8333 | Adults | 36.5 (NR) | 50.3 | NR |
| Bahathig28 | NR | 2019 | Arar, Northern Borders | Multistage random sampling | No | 399 | Children | NR | 100.0 | 100% Saudi |
| Bandy33 | NR | 2018 | Sakaka City, Aljouf Region | Multistage sampling | No | 400 | Children | NR | 0.0 | NR |
| Baqal34 | Jeeluna (Arabic for “Our Generation”) | NR | All 13 administrative regions | Stratified cluster random sampling | No | 12,463 | Children | 15.8 (1.8) | 48.7 | Saudi 82.8% and non-Saudi 12.0% |
| BinDhim42 | NR | 2020 | All 13 administrative regions | Proportional quota sampling | Yes | 7050* | Adults | 36.5 (13.5) | 53.6* | NR |
| Osama36 | NR | NR | Northern Region | Random selection | No | 123 | Children | 13.6 (0.8) | 0.0 | NR |
| Thamer46 | SHIS | 2013 | All 13 administrative regions | Multistage stratified probability sampling | Yes | 10,821 | Adults | NR | 51.1 | 100% Saudi |
Abbreviations: ATLS, Arab Teens Lifestyle Study; NR, not reported; PHCC, primary health care centers; PURE, Prospective Urban Rural Epidemiology; SHIS, Saudi Health Interview Survey; WISHES, Women in Saudi Arabia Health Examination Survey.
*For information abstracted from BinDhim et al,42 the information is from quarter 1 of 2020. #This sample was reduced from 10,735 by excluding those with missing observations on relevant variables.
The location of each study by region is displayed in Figure 2A for adults and Figure 2B for children/adolescents. Studies were more commonly conducted in the Riyadh region, followed by the Makkah and Northern Borders regions. Procedures for sampling included random sampling using a database from a primary health care center38–40 or school36 and proportional quota sampling based on age and gender.41,42 The remaining studies used multiple stages to select the sample.28–35,37,43–46 For multistage sampling, the primary sampling units included schools or classrooms,28–35 regions of the country,43–46 or clusters within a city.37 Only 2 studies42,46 appeared to use sampling weights when reporting on physical behaviors.
—Map of the number of studies conducted in each of the 13 regions in Saudi Arabia from the scoping review for adults (panel A) and children/adolescents (panel B). Panel A: adults. Panel B: children/adolescents. Note. If the study was countrywide (n = 6 for adults and n = 1 for children/adolescents), then we assumed assignment to all 13 regions.
Citation: Journal of Physical Activity and Health 20, 6; 10.1123/jpah.2022-0537
Analytic sample sizes ranged from 12336 to 30,134.42 Descriptive information on age, gender, and nationality is given in Table 1. In total, 15 studies included a mix of males and females, while 2 studies sampled only females28,35 and 2 studies sampled only males.33,36 Participants from 6 studies were of Saudi nationality,28–30,43,44,46 3 studies reported a mix of nationalities residing within Saudi Arabia,31,34,37 and the remaining 10 studies did not report nationality.32,33,35,36,38–42,45
Physical Activity Among Children/Adolescents
Ages ranged from 1035 to 19 years29 among 8 child/adolescent studies that reported physical activity28,29,31–36 (Table 2). Physical activity was ascertained using accelerometry, parental reporting, and self-reporting. For the one accelerometry study, males age 12–14 years wore an ActiGraph accelerometer (ActiGraph, LLC) on their hip for 1 week.36 Using established cut points by Evenson et al,48 the authors reported an overall average time spent in MVPA of 50.6 minutes per day (defined as ≥2296 counts/min).
PA Results Among Children and Adolescents From the Scoping Review Listed in Order of Starting Age Range (n = 8 Studies)
| First author, year | Age range in years | Reported by whom | Assessment method | PA | Stratification reported | |
|---|---|---|---|---|---|---|
| Definitions used | Overall findings | |||||
| Alharbi35 | 10–15 | Self | PAQ-C | Continuous and categorized PAQ-C activity score as low (≤2.3), moderate (2.4–3.7), and high (≥3.8) | Activity score mean 2.6 (SD 0.6), range 1.3–4.2; low PA 22.4%, moderate PA 73.5%, and high PA 4.1% | 2, 6, 7 |
| Baqal34 | 10–19 | Self | Modified from the YRBS and the GSSHS | Continuous exercise; categorized as engaged in PA (≥1 d with >30 min PA) or not; categorized as engaged in sports at school | Mean number of days per week with >30 min exercise 1.9 (SD 2.4); proportion engaged in PA 53.4%; proportion engaged in sports at school 35.4% | 1, 2, 3, 4, 5 |
| Aljuaid32 | 12–18* | Self | Questionnaire | Categorized as <150, 150–300, >300 min/wk; percent of types of behaviors | Exercise <150 min/wk 32.6% and >300 min/wk 15.1%; 41.6% routine heavy lifting exercises; 43.4% routine group exercises; 33.1% routine walking; and 38.0% walk to/from school at least one time per week | 1 |
| Osama36 | 12–14 | Self | Accelerometer: ActiGraph wGT3X-BT | Continuous daily MVPA (≥2296 counts/min) computed for days with and without PE class; categorized children as active (≥50% of days had ≥60 min/d of MVPA) or inactive (<50% of days had ≥60 min/d of MVPA) | Overall MVPA mean 50.6 (SD 25.5) min/d; MVPA during PE class mean 9.9 (SD 3.6) min/d; and proportion of daily MVPA accumulated during PE mean 22.1% (SD 7.9%) | None |
| Bahathig28 | 13–14 | Self | PAQ-C | Categorized as meeting WHO/US Guidelines ≥60 min/d (equivalent to ≥420 min/wk of MVPA) | 7.3% meeting guidelines | None |
| Bandy33 | 15–17 | Parental proxy | Questionnaire | Categorized as 0, 1, 2–5, and ≥5 d/wk, 2–5 d/wk, 1 d/wk PA; PA was not defined | 0 d/wk 19.3%, 1 d/wk 20.5%, 2–5 d/wk 33.0%, and ≥5 d/wk 27.3% | None |
| Alasqah31 | 15–18 | Self | Questionnaire | Categorized as insufficient MVPA <60 min/d; and insufficient vigorous PA <3 times/wk | Insufficient MVPA 82.4% (95% CI, 80.1–84.6); insufficient vigorous PA 59.0% (56.0–61.8) | 3 |
| Al-Hazzaa29 | 15–19 | Self | ATLS | Continuous time spent in total, vigorous, and moderate PA | Mean MET-minutes per week: Total 2095.3 (SD 2269.4), vigorous 1320.9 (SD 1447.5), and moderate 873.1 (SD 809.4) | 1, 5 |
Abbreviations: ATLS, Arab Teens Lifestyle Study; CI, confidence interval; GSSHS, Global School-Based Student Health Survey; IPAQ, International Physical Activity Questionnaire; MET, metabolic equivalent; MVPA, moderate to vigorous PA; NR, not reported; PA, physical activity; PAQ-C, Physical Activity Questionnaire for Older Children; PE, physical education; YRBS, Youth Risk Behavior Survey. Note: WHO/US Guidelines refer to the WHO 2020 Guidelines on PA and Sedentary Behavior and the 2018 PA Guidelines for Americans, respectively. Stratification reported by (1) gender, (2) age, (3) region, (4) nationality, (5) body mass index, (6) income, and (7) education.
*Obtained directly from authors.
One study of 15–17 year olds relied on parental reporting of physical activity.33 The 6 remaining studies relied on self-reporting, such as from the Arab Teens Lifestyle Study (ATLS) Questionnaire,29 the Physical Activity Questionnaire for Children,28,35 or other brief survey items modified from other questionnaires34 or not described.31,32
For studies using self-reporting, one conducted among 10- to 15-year-old girls categorized 22.4% in the low physical activity category, while 4.1% were assigned to the high physical activity category.35 Among 10–19 year olds, about half (53.4%) engaged in exercise at least 1 days per week, and 35.4% engaged in sports at school.34 Among 13- to 14-year-old females, only 7.3% met MVPA guidelines28 and among 15- to 17-year-old males, 27.3% engaged in physical activity at least 5 days per week.33 On average, they spent 1.9 days per week in at least 30 minutes per day in physical activity,34 while another study reported a mean of 2095 metabolic equivalent minutes per week in physical activity.29 Among 12–18 year olds, 32.6% exercised for <150 minutes per week, and 38.0% walked to and from school at least once a week.32 Among 15–18 year olds, 82.4% reported insufficient MVPA, defined as <60 minutes per day, and 59.0% reported insufficient vigorous activity, defined as <3 times per week.31
Correlates of Physical Activity Among Children/Adolescents
Any physical activity or exercise was reported more often among boys than girls,29,32,34 as was moderate activity,29 vigorous activity,29 walking to and from school,32 routine group exercise,32 and routine lifting of heavy weights.32 However, routine walking was higher in girls compared to boys age 12–18 years.32 Older girls age 13–15 years had lower physical activity scores (indicating lower physical activity) compared to younger girls age 10–12 years.35 Exercise participation was also lower among 15–19 year olds compared to 10–14 year olds.34
Children from urban areas reported more physical activity than children/adolescents from rural areas.34 The categorical distribution favored slightly more physical activity among participants living in the WHO Healthy Cities Program area compared to participants not living in those areas.31 One study reported similar participation in any physical activity among Saudi (54.9%) compared to non-Saudi (56.6%) children/adolescents.34
There were no significant differences in physical activity across the 4 BMI categories, ranging from 54.4% to 56.9%,34 while another study of 15–19 year olds found slightly higher levels of total and vigorous activity, but not moderate activity, among normal weight compared to those who were overweight or obese.29
Among girls age 10–15 years, total physical activity was higher, with each successively lower household income category and among those with unemployed fathers and mothers compared with employed fathers and mothers.35 However, total physical activity was not associated with the father’s or mother’s education.
Sedentary Behavior Among Children/Adolescents
Ages ranged from 630 to 19 years29 among 7 child/adolescent studies that reported on sedentary behavior28–32,34,35 (Table 3). One study of 6–13 year olds relied on parental reporting of total daily time spent viewing screens.30 The remaining studies relied on self-reporting, such as from the Adolescent Sedentary Activity Questionnaire,28 the ATLS Questionnaire,29 or other brief items that were modified from other questionnaires34 or not described in detail.30–32,35
Sedentary Behavior Results Among Children and Adolescents From the Scoping Review Listed in Order of Starting Age Range (n = 7 Studies)
| First author, year | Age range in years | Reported by whom | Sedentary behavior | Stratification reported | ||
|---|---|---|---|---|---|---|
| Assessment method | Definitions used | Overall findings | ||||
| Al-Hazzaa30 | 6–13 | Parental proxy | Questionnaire | Continuous daily screen time | Mean 3.2 (SD 1.7) h/d | 1 |
| Alharbi35 | 10–15 | Self | Questionnaire | Categorized as >2 or ≤2 h/d of screen time | Screen time >2 h/d 53.4%, and ≤2 h/d 46.6% | None |
| Baqal34 | 10–19 | Self | Modified from the YRBS and the GSSHS | Categorized as >2 or ≤2 h/d in sedentary behavior | Sedentary >2 h/d 65.5%, and ≤2 h/d 34.5% | None |
| Aljuaid32 | 12–18* | Self | Questionnaire | Continuous sedentary lifestyle not defined | Sedentary lifestyle 38.3% | 1 |
| Bahathig28 | 13–14 | Self | ASAQ | Continuous and categorized with high sedentary defined as ≥4 or not <4 h/wk | Mean weekday 357.6 (SD 86.3) min/d, 90% high; mean weekend days 470.5 (SD 147.6) min/d, 95% high | None |
| Alasqah31 | 15–18 | Self | Questionnaire | Categorized as excessive screen time >2 or not ≤2 h/d | Excessive screen time 84.6% (95% CI, 82.4–86.7) | 3 |
| Al-Hazzaa29 | 15–19 | Self | ATLS | Continuous total screen time; categorized as >3 or ≤3 h/d | Mean 6.0 (SD 3.4) h/d | 1, 5 |
Abbreviations: ASAQ, Adolescent Sedentary Activity Questionnaire; ATLS, Arab Teens Lifestyle Study; CI, confidence interval; GSSHS, Global School-Based Student Health Survey; YRBS, Youth Risk Behavior Survey. Note: Stratification reported by (1) gender, (2) age, (3) region, (4) nationality, (5) body mass index, (6) income, and (7) education.
*Obtained directly from authors.
Among 6–13 year olds, the mean screen time was 3.2 hours per day.30 In contrast, females age 13–14 years reported a mean sedentary time of 6.0 hours per day on weekdays and 7.8 hours per day on weekends,28 and another study of 15–19 year olds reported a mean screen time of 6.0 h/d.29
Several studies grouped children/adolescents into 2 categories: above and below 2 hours of screen time or sedentary behavior. Overall, 34.5%,34 46.6%,35 and 84.6%31 reported <2 or ≤2 hours per day of screen time or sedentary behavior. Among 12–18 year olds, 38.3% were considered sedentary.32
Correlates of Sedentary Behavior Among Children/Adolescents
Average screen time was higher for 6- to 13-year-old boys (3.5 h/d) compared with girls (3.0 h/d).30 However, in another study of 15–19 year olds, screen time was higher in girls (6.6 h/d) than in boys (5.3 h/d),29 and a generally defined “sedentary lifestyle” was also higher in girls compared with boys in a study with a mean age of 15.4 years.32
One study reported on sedentary behavior by city location. The categorical distribution favored more excessive screen time (88.2%) among those living in the WHO Healthy Cities Program area compared with those not living in those areas (83.0%).31 Only one study reported sedentary behavior by weight status. They found that screen time was similar among 15–19 year olds of participants who were normal weight compared with participants who were overweight or obese.29 The studies included in the review did not report on sedentary behavior by age, nationality, income, or education.
Physical Activity Among Adults
A total of 9 studies reported physical activity among adults, self-reported using the International Physical Activity Questionnaire (IPAQ),38–40,44,46 a brief assessment tool,41 or other brief items that were modified from other questionnaires or not described in detail37,42,45 (Table 4). Of the 5 studies that used the IPAQ, one reported that 94.9% did not meet physical activity recommendations,44 while other studies reported that 48.2%,39 66.7%,40 and 69.4%38 were classified as having low physical activity. Overall, walking was reported by 59.0% of the sample, compared to 10.8% participating in sports and 2.1% participating in work activity.46 Using other questionnaires, 16.5% of the sample reported at least 150 minutes per week of MVPA,41 while another study reported 21.7%.37 In contrast, a study reported that 41.0% met physical activity guidelines.42
PA Results Among Adults From the Scoping Review Listed in Order of Starting Age Range (n = 9 Studies)
| First author, year | Age range in years | PA | Stratification reported | ||
|---|---|---|---|---|---|
| Assessment method | Definitions used | Overall findings | |||
| Al-Hanawi44 | ≥15 | IPAQ | WHO Guidelines: ≥150 min/wk MVPA or ≥60 min/wk VPA, or the equivalent combination | 94.9% did not meet guidelines | 1, 2, 6, 7 |
| Thamer46 | ≥15 | IPAQ | Categorized as to whether or not they participated in any activity within each domain | Participated in: Work PA 2.1%; sport PA 10.8%; walking 59.0% | None |
| Alqahtani45 | ≥15 | Questionnaire | Categorized as ≥150 or <150 min/wk engagement in PA | NR | 1, 3, 4 |
| Al-Raddadi37 | ≥18 | Questionnaire | Categorized as <60, 60 to <150, and ≥150 min/wk MVPA | MVPA mean <60 min/wk 67.0%, 60 to <150 min/wk 11.3%, ≥150 min/wk 21.7% | 5 |
| Althumiri41 | ≥18 | Brief assessment tool | Categorized using WHO/US Guidelines: ≥75 min/wk VPA; ≥150 min/wk MPA | MPA ≥150 min/wk mean 16.5%; VPA ≥75 min/wk 12.1% | None |
| BinDhim42 | ≥18 | Questionnaire | WHO/US Guidelines: ≥150 min/wk MPA and/or ≥75 min/wk of VPA or equivalent combination of the 2 | Acceptable PA level before COVID-19 restrictions (Q1) mean 41.0% | None |
| Alhabib38 | 35–70 | IPAQ | Low PA: ≤600 MET-min/wk | Low PA: 69.4% | 1, 2 |
| AlQuaiz39 | 30–75 | IPAQ-short | Continuous (MET-minutes per week) based on walking (3.3 METs), MPA (4.0 METs), VPA (8.0 METs); criteria for “unhealthy lifestyle” (<1200 MET-min/wk) | Total PA in MET-minutes per week median 1928 (IQR 3065); low PA 48.2% | 1, 2 |
| AlQuaiz40 | 30–75 | IPAQ-short | Total MET-minutes per week based on walking (2.2 METs), MPA (4.0 METs), VPA (8.0 METs); categorized as low/inactive, moderately/minimally active, or high active | Low PA 66.7% | 1 |
Abbreviations: IPAQ, International Physical Activity Questionnaire; MET, metabolic equivalent; MPA, moderate PA; MVPA, moderate to vigorous PA; NR, not reported; PA, physical activity; VPA, vigorous PA; WHO, World Health Organization. Note: WHO/US Guidelines refer to the WHO 2020 Guidelines on PA and Sedentary Behavior and the 2018 PA Guidelines for Americans, respectively. Stratification reported by (1) gender, (2) age, (3) region, (4) nationality, (5) body mass index, (6) income, and (7) education.
Correlates of Physical Activity Among Adults
Self-reporting of low physical activity was similar between males and females in 2 studies,38,44 but in the Women in Saudi Arabia Health Examination Survey study almost twice the prevalence of low physical activity occurred among males (90.9%) compared with females (55.2%).40 Also, in the Women in Saudi Arabia Health Examination Survey study, males compared with females reported lower physical activity at the age of 30 to 44 years, but higher physical activity at the age of 45–59 years.39 At 60–75 years of age, the observed level of physical activity was much lower and similar between males and females. In 2 other studies, self-reported physical activity was higher among males than females.39,45
Self-reporting of low physical activity was high across age groups, ranging from 96.6% among 15–24 year olds to 92.0% among those 65 years and older.44 In another study, low physical activity was higher among 60–70 year olds (75.2%), compared with 50–59 year olds (73.9%) and 35–49 year olds (66.8%),38 and the same trend was observed in another study (60–75 y: 63.2%, 45–59 y: 49.7%, and 30–44 y: 44.5%).39
Reporting at least 150 minutes per week of physical activity was presented by region and nationality in one study.45 They reported consistently higher physical activity among Saudi compared with non-Saudi adults living across the 13 regions of the country. Participation in at least 150 minutes per week of physical activity varied remarkably by region (Saudi: 5.2%–48.5% and non-Saudi: 4.2%–69.0%), with the highest prevalence in Madinah for both Saudi and non-Saudi adults. One study did not find differences in self-reported physical activity across BMI categories after adjusting for gender.37 Self-reports of “low physical activity” did not vary by categories of monthly income, ranging from 93.4% to 96.4%, and were lower among those with greater than high school education (91.7%) compared with those with high school (94.5%) or less than high school (range: 94.2%–94.3%).44
Sedentary Behavior Among Adults
Only 3 studies of adults reported on sedentary behavior, all relying on self-reporting (Table 5).40,43,46 In one study, adults reported a mean of 25.1 hours per week spent in front of a television or computer.43 In another study, 40.7% watched television at least 4 hours per day, and 43.3% reported sitting at least 5 hours per day.46 In the last study, the mean sitting time was 6.0 hours per day, and 43.5% reported at least 6 hours per weekday of sitting.40 Weekday sitting time was higher in males (8.0 h/d) than in females (5.0 h/d), and the proportion of sitting for at least 6.0 hours each weekday was more than twice as high among males (69.3%) than females (31.3%). The studies included in the review did not report on sedentary behavior by age, region, nationality, BMI, income, or education.
Sedentary Behavior Results Among Adults From the Scoping Review Listed in Order of Starting Age Range (n = 3 Studies)
| First author, year | Age range in years | Sedentary behavior | Stratification reported | ||
|---|---|---|---|---|---|
| Assessment method | Definitions used | Overall findings | |||
| Al-Hanawi43 | ≥15 | One-item question | Continuous time spent in front of a TV or a computer in a typical week | Mean 25.1, median 19, range 2–71 h/wk | None |
| Thamer46 | ≥15 | Questionnaire asking about weekly TV time and weekly sitting time | TV viewing time categorized as ≥4 or <4 h/d: sitting time categorized as ≥5 or <5 h/d | TV viewing time ≥4 h/d: 40.7%; sitting time ≥5 h/d 43.3% | None |
| AlQuaiz40 | 30–75 | One-item question from IPAQ | Continuous time and categorized as >6 or ≤6 h/d spent sitting | Weekday sitting time mean 360 (SD 218) min/d; sitting time >6 h/weekday mean 43.5% | 1 |
Abbreviations: IPAQ, International Physical Activity Questionnaire; TV, television. Note: Stratification reported by (1) gender, (2) age, (3) region, (4) nationality, (5) body mass index, (6) income, and (7) education.
Quality Assessment
The quality assessment tool, consisting of 9 questions, is provided in Table 6 with the corresponding questions itemized in Supplementary Material S4 (available online). About half of the studies provided a sample size justification (n = 10, question 3) or either ensured an adequate response rate or managed the low response rate appropriately (n = 10, question 9). The management of low response rate was hard to discern, with 8 studies receiving an “unclear” assignment due to not reporting their response rate. Slightly more than half of the studies provided detail to ensure valid methods were used to assess the total volume of physical activity or sedentary behavior (n = 11, question 6). Most studies described the participants and setting in detail (n = 14, question 4), created an appropriate sampling frame for the target population (n = 15, question 1), and sampled participants appropriately (n = 14, question 2). Almost all studies measured physical activity and sedentary behavior in a standard way for all participants (n = 16, question 7) and conducted data analysis with sufficient coverage of the identified sample (n = 17, question 5).
Quality Assessment Results Listed in Alphabetical Order by the First Author’s Last Name (n = 19 Studies)
| First author, year | Q1 | Q2 | Q3 | Q4 | Q5 | Q6 | Q7 | Q8 | Q9 |
|---|---|---|---|---|---|---|---|---|---|
| Al-Hanawi43 | Y | Y | N | Y | N | U | U | Y | Y |
| Al-Hanawi44 | Y | Y | N | Y | Y | Y | Y | Y | Y |
| Al-Hazzaa29 | Y | Y | Y | Y | Y | Y | Y | Y | U |
| Al-Hazzaa30 | Y | Y | Y | Y | Y | N | Y | Y | Y |
| Al-Raddadi37 | Y | Y | Y | Y | Y | U | U | Y | Y |
| Alasqah31 | N | Y | Y | N | Y | U | Y | Y | U |
| Alhabib38 | N | Y | N | Y | Y | Y | Y | N | U |
| Alharbi35 | Y | Y | Y | N | Y | Y | Y | Y | Y |
| Aljuaid32 | Y | Y | N | Y | Y | U | U | N | U |
| Alqahtani45 | Y | N | N | N | Y | Y | Y | Y | U |
| AlQuaiz39 | N | N | N | Y | Y | Y | Y | Y | Y |
| AlQuaiz40 | N | N | N | Y | Y | Y | Y | N | Y |
| Althumiri41 | Y | Y | Y | N | Y | N | Y | N | Y |
| Bahathig28 | Y | U | Y | Y | Y | Y | Y | Y | Y |
| Bandy33 | Y | Y | Y | Y | Y | N | Y | Y | U |
| Baqal34 | Y | Y | Y | Y | Y | N | Y | Y | U |
| BinDhim42 | Y | Y | Y | N | Y | Y | Y | Y | N |
| Osama36 | Y | U | N | Y | U | Y | Y | Y | U |
| Thamer46 | Y | Y | N | Y | Y | Y | Y | U | Y |
| Total Yes | 15 | 14 | 10 | 14 | 17 | 11 | 16 | 14 | 10 |
| Total Unclear | 0 | 2 | 0 | 0 | 1 | 4 | 3 | 1 | 8 |
| Total No | 4 | 3 | 9 | 5 | 1 | 4 | 0 | 4 | 1 |
Abbreviations: N, no; Q, question; U, unclear; Y, yes. Note: The questionnaire is available in Supplementary Material S4 (available online) of this paper.
Discussion
Through this scoping review, we found that a large proportion of children, adolescents, and adults did not meet either the WHO guidelines2 or the Saudi Arabian guidelines49 for physical activity and sedentary behavior. Several studies included in our review indicated that the prevalence of low physical activity exceeded the recommended guidelines for both children/adolescents35 and adults.38–40 Among children/adolescents, approximately 80% to 90% did not attain at least 60 minutes per day of MVPA,28,31 and about 50% to 80% engaged in 2 hours per day or more of screen or sedentary time.31,34,35 Among adults, approximately 50% to 95% had low or insufficient physical activity,37–40,42,44 and approximately 45% sat for ≥5 or >6 hours per day.40,46 This is in line with prior reviews that indicated that the prevalence of physical inactivity ranged from 73% to 91% among female adults, 50% to 85% among male adults, and 55% to 96% among children/adolescents.16,19
Correlates
The proportion of the population engaging in physical activity was higher among younger compared to older children/adolescents34,35 and generally higher among males than females,29,32,34 except for walking among 12–18 year-olds, wherein girls reported more than boys.32 Other reviews identified similar results for both age and gender.16,19 From our review, it was also found that physical activity may be higher among children/adolescents from urban compared to rural areas.34
We found in one study that average screen time was higher among 6- to 13-year-old boys compared to girls,30 but in another study screen time among 15–19 year olds, the screen time was higher among girls compared to boys.29 A “sedentary lifestyle,” not defined by the authors, was also higher in girls than in boys.32 Reporting of other correlates of sedentary behavior was limited. Other reviews indicated that screen time is greater in children/adolescents, with higher time among girls than boys.5 Our findings indicate a potential need for physical behavior interventions targeting children/adolescents who are older or living in rural areas. For physical activity and sedentary behavior, there were no studies of children <10 years of age, indicating an urgent need to include them in future surveillance studies. A prior review also found a lack of studies among the youngest age group.50
Our review found that the association differed between adult males and females across studies. However, earlier reviews have found males to report higher levels of physical activity than females.51 It may be that the more recent studies are capturing a shift in the prevalence of physical activity among women as they participate in more leisure-time physical activity.52 Our review also found that the older age groups reported the lowest physical activity levels, which is also consistent with other reviews.51 While our review identified few other consistent correlates, another review of the Arabian Peninsula indicated that higher physical activity was directly associated with being married or employed and inversely related to years of education and lack of time and motivation.51 Our review found that sitting time was higher among males than females, with few other correlates explored. In summary, these findings indicate a need for interventions targeting older adults and adults with lower educational attainment. Surveillance of physical behaviors among older adults is also needed, as this group was often excluded from studies of adults.
Measurement of Physical Behaviors
In this review, only one of 19 studies utilized an accelerometer to measure physical activity and did not report on sedentary behavior.36 The remaining studies relied on parental reporting30,33 or self-reporting.28,29,31,32,34,35,37–46 Accelerometry has several advantages to self-reporting; in the former, it provides high-quality and detailed data without participant effort or recall bias.53 Accelerometry also allows for easier comparisons within and across populations and can be used for the entire age spectrum. This is especially advantageous for young children who cannot provide sufficient recall, as parental recall has low validity and reliability.54 Other countries around the world, such as Canada,55 South Korea,56 Portugal,57 Sweden,58 and the United States,59 utilize accelerometry as part of their national surveillance system. This should be a consideration for Saudi Arabia, as integrating accelerometry into regular surveillance could greatly enhance monitoring efforts, facilitating monitoring trends over time, planning research and interventions, and evaluating policy and environmental changes.
Child/adolescent-focused questionnaires used by the studies included the ATLS Questionnaire,60,61 the Physical Activity Questionnaire for Children,62–64 the Adolescent Sedentary Activity Questionnaire,65 and items modified from the Youth Risk Behavior Surveillance System survey66 combined with the Global School-Based Student Health Survey.67 Adult-focused questionnaires used by the studies included the IPAQ68 and a brief assessment tool.69 These questionnaires were similar to those identified from a review of physical activity tools used by studies in the Gulf region.70 Physical activity assessed by self-report provides the advantage of describing the mode of physical activity, but this was often not reported in the reviewed studies except in studies that used, for example, the ATLS Questionnaire.60,61 In fact, most studies only published broad categorical results from disparate questionnaires, making it difficult to compare across studies with different data categorization. Among adults, the IPAQ was used in 5 studies, yet even these results were difficult to harmonize due to differences in analytic methods and reporting. The IPAQ also includes one (short form) or 2 (long form) questions on sitting, but only 2 of 5 studies reported results related to sedentary behavior.
In addition, as evidenced by the quality assessment results, several studies did not adequately describe the measures used or reference any validity or reliability of the items. This is in line with what other authors have found; in a review on adult physical activity in the Gulf region, the authors called for the adoption of valid and reliable measures at both the country and regional levels.70 Simple questionnaires such as the IPAQ68 and the Global Physical Activity Questionnaire71 were developed and translated into many languages to provide standardized, accessible, and validated methods for assessing and reporting physical behaviors and could be considered in future work to enhance harmonization across studies.72 Arabic versions exist for both the IPAQ73 and Global Physical Activity Questionnaire.74 This would spare researchers the effort of developing and validating a questionnaire, provide a solid basis for comparing and pooling across study results, and ensure data are summarized appropriately per the questionnaire’s scoring guidelines.
Gaps
In Saudi Arabia, dispersed population-based assessments supplement regular, centralized surveillance of physical activity and sedentary behavior. The reliance on independently collected supplemental data leads to inconsistencies in sampling, measurement approaches, and analytic methods, making harmonizing results difficult. It also misses certain regions of the country and does not consistently provide data on important sociodemographic and health characteristics. This was evidenced through a wide range of sampling techniques; disparate measurement approaches mainly focused on self-reporting and diverse ways of categorizing summary measures. Metrics varied for physical activity and sedentary behavior; few correlates were reported for sedentary behavior, particularly among adults, and data were not updated for the youngest and oldest populations. Without a standardized surveillance system, the variation over time will impede distinguishing relationships between interventions and population effects.75 Researchers working together could identify a smaller range of instruments to measure physical behavior and derive standardized metrics that align with national goals.
Although guidance on muscle strength and balance is also part of the WHO guidelines,2 muscle strengthening was reported in only one study,32 and no studies reported on balance in this review. This is not surprising given the limited and discrepant number of tools to assess these domains and the lower frequency with which these are assessed worldwide.76,77
Our review focused on studies that used population-based sampling. However, only 2 studies42,46 appeared to use sampling weights. Other studies did not provide adequate detail on their sampling plan and analytic approach to account for the sampling, although they did meet our inclusion criteria. The lack of sampling weights is particularly concerning, considering that about half of the studies did not report or had low response rates. Estimating prevalence statistics using sample weights to account for the methods used to recruit participants and nonresponse would provide a population-based metric that matches the target population and that enhances generalizability. In addition, authors should report the response rate for their study to facilitate transparency and an understanding of its external validity.
Physical activity and sedentary behavior of children, adolescents, and adults have been impacted by the COVID-19 pandemic, as reported in studies worldwide10,11 and in Saudi Arabia.78 Among the 19 studies included in this review, data collection ranged from 2009 to 2020. There were 2 studies with data collected in 2020. One study included data collected from June to July 2020 during a movement restriction period in Saudi Arabia, so the results for this single study should be interpreted with this in mind.41 The second study collected 4 repeated cross-sectional surveys over the year; we extracted the first quarter to avoid the confounding introduced by the pandemic lockdown.42 A review on the impact of the COVID-19 pandemic on physical behaviors in Saudi Arabia found that physical activity declined while sedentary behavior increased for children, adolescents, and adults.78 It will be important to continue monitoring physical behaviors to assess the long-term impact of the COVID-19 pandemic across the population in Saudi Arabia and worldwide. For example, 2 population-based cross-sectional surveys of Riyadh adolescents (grades 10–12), conducted in 2009–2010 and 2019–2020, found moderate and total activity increased, while vigorous activity and screen time decreased.52 The latter measures were completed before the lockdown period, so it would be of interest to ascertain whether these changes were sustained through the pandemic.
Strengths and Limitations
This review provided a comprehensive assessment of recent studies reporting on physical activity and sedentary behavior, and the correlates of those behaviors, in Saudi Arabia. The review included 6 databases and focused on higher-quality studies by including only those using population-based sampling. Consequently, our results on the prevalence and correlates of physical behaviors are more generalizable.
However, several limitations of this review should be acknowledged. First, the literature is highly diverse, using various self-reported instruments to describe physical behaviors. In addition, at times the studies did not distinguish “physical activity” from “exercise.” We abstracted terminology published by each study. Second, many of the studies’ primary aims were not directly related to the surveillance of physical behaviors. Thus, many studies did not report results stratified by sociodemographic (eg, age, gender, and urbanicity) and health factors. Related to this, our summary of correlates were secondary to our review and were not searched for specifically. Therefore, our review may have missed studies that describe potential correlates from research that were not population based.
Conclusions
The findings of this scoping review agree with prior reviews16,19,50 in that a high proportion of the Saudi Arabian population does not meet physical activity recommendations and spends many hours daily in sedentary behavior. Factors related to these physical behaviors can be used to identify priority populations for interventions in children, adolescents, and adults. We identified a lack of population-based studies among children <10 years of age and older adults. Saudi Arabia’s national strategy on physical activity and diet for 2014–2025 recommends changes to policies, environments, programs, and evaluation.17 Matching surveillance efforts to these metrics would provide feedback on the results of ongoing efforts in the country. Public health surveillance of physical activity and sedentary behavior is critical to monitoring trends over time, assessing national strategies, planning research and interventions, and evaluating policy and environmental changes,79 particularly in light of the widespread proposed and ongoing policy and environmental changes in the country.
Acknowledgments
Rekha Menon, practice manager at the World Bank, and Issam Abousleiman, regional director for the Gulf Cooperation Council Countries at the World Bank, provided input and support on the manuscript. Funding: This work was supported by the King Faisal Specialist Hospital and Research Center and the World Bank. Financing for the analysis was provided by the King Faisal Specialist Hospital and Research Center and the Health, Nutrition and Population Reimbursable Advisory Services Program between the World Bank and the Ministry of Finance in Saudi Arabia (P172148 and P179873). The content is solely the responsibility of the authors and does not necessarily represent the official views of the King Faisal Specialist Hospital and Research Center or the World Bank.
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