Regional prevalence of short stature in Saudi school-age children and adolescents.

OBJECTIVE: To assess the magnitude of regional difference in prevalence of short stature in Saudi children and adolescents. SUBJECTS AND METHODS: A representative sample from three different regions of the Kingdom of Saudi Arabia (KSA) (North, Southwest, and Center) was used to calculate the prevalence of short stature (standard deviation score less than -2) in children 5 to 17 years of age. RESULTS: There were 9018 children and adolescents from 5 to 17 years of age (3366, 2825, and 2827 in the Northern, Southwestern and Central regions, resp.) and 51% were boys. In both school-age children and adolescents, there was a significantly higher prevalence of short stature in the Southwestern than in the Northern or the Central region (P < 0.0001). CONCLUSION: The finding of significant regional variation between regions helps in planning priorities for research and preventive measures.

Blood pressure standards for pre-school children in Saudi Arabia.

The prevalence of hypertension (HTN) in children is increasing. Early detection of HTN in childhood may prevent the occurrence of complications in adult age. Blood pressure (BP) varies between populations according to ethnic and environmental factors. Based on these variations, reference norms developed for one particular population may not be applicable to others. Thus, this study aimed to provide age-, gender-, and height-related BP reference standards using oscillometric techniques for pre-school children in Saudi Arabia. A sub-sample of preschool children aged from 2 to 6 years was selected by multi-stage probability sampling of Saudi population. The samples represented Saudi children from the whole country. Data were collected through a house-to-house survey of all selected households in all 13 regions in the country. Oscillometric devices were used to measure the BP. Data were analyzed to study the distribution pattern of systolic (SBP) and diastolic BP (DBP) and to develop reference values based on age, gender, and height. The values for each age and height percentile were compared with the recent (2017) values of the North American children. A total of 2553 Saudi Arabian children (1299 boys and 1254 girls) aged 2-6 years with complete data on age, gender, height, SBP, and DBP were considered for analysis. Values for SBP and DBP were significantly higher in Saudi children than in the North American children. This study adds evidence to the BP variations between populations with influences such as genetic and environmental factors. The need of every population to define its normal BP standards is essential to avoid unnecessary investigations and anxiety in patients and their parents.

Blood pressure standards for Saudi children and adolescents.

BACKGROUND AND OBJECTIVES: Blood pressure levels may vary in children because of genetic, ethnic and socioeconomic factors. To date, there have been no large national studies in Saudi Arabia on blood pressure in children.Therefore, we sought to establish representative blood pressure reference centiles for Saudi Arabian children and adolescents. SUBJECTS AND METHODS: We selected a sample of children and adolescents aged from birth to 18 years by multi-stage probability sampling of the Saudi population. The selected sample represented Saudi children from the whole country. Data were collected through a house-to-house survey of all selected households in all 13 regions in the country. Data were analyzed to study the distribution pattern of systolic (SBP) and diastolic blood pressure (DBP) and to develop reference values. The 90th percentile of SBP and DBP values for each age were compared with values from a Turkish and an American study. RESULTS: A total of 16 226 Saudi children and adolescents from birth to 18 years were studied. Blood pressure rose steadily with age in both boys and girls. The average annual increase in SBP was 1.66 mm Hg for boys and 1.44 mm Hg for girls. The average annual increase in DBP was 0.83 mm Hg for boys and 0.77 mm Hg for girls. DBP rose sharply in boys at the age of 18 years. Values for the 90th percentile of both SBP and DBP varied in Saudi children from their Turkish and American counterparts for all age groups. CONCLUSION: Blood pressure values in this study differed from those from other studies in developing countries and in the United States, indicating that comparison across studies is difficult and from that every population should use their own normal standards to define measured blood pressure levels in children.

Pattern of celiac disease in infants and children.

This study involved all children with celiac disease admitted and seen in the Paediatric Gastroenterology Clinic at King Khalid University Hospital (KKUH) over a 10-year period. In the first year, we identified 62 cases with celiac disease. Their mean age at presentation, introduction to cereals in the diet, and onset of symptoms were 6.5, 6 and 6 months, respectively, and most of the children belonged to the indigenous population. There were three Arabia families with more than one affected child and most families were of good social status. The main symptoms noted were diarrhoea in 34 (57%), growth failure in 47 (74.6%), abdominal distension in 21 (33%), and vomiting in 14 patients (14%). The significant physical signs at the time of presentation were short stature, seen in 44 patients (69.8%), pallor in 25 (40.3%) and abdominal distention in 21 (33%). The mean haemoglobin, serum feritin, serum folate, calcium, and serum albumin were 10.25 g/dL, 2.49 g/mL, 0.25 ng/mL, 8.86 mg/dL, and 3.7 g/dL. The mean anti-reticulin IgG, anti-endomyseal IgG, IgA and anti-gliadin IgG, IgA were one in 246, 332, 720, 121 and 300 units. There was total villous atrophy in each patient at the time of initial presentation; repeat small bowel biopsies were done in 12 patients of whom 6, 4 and 2 had normal villi, partial villous atrophy and subtotal villous atrophy, respectively. A third biopsy was performed in 2 patients while on gluten containing diet, which revealed villous atrophy. Most of the children improved on gluten-free diet.

Prevalence of type 1 diabetes mellitus in Saudi Arabian children and adolescents.

OBJECTIVE: To determine the prevalence of type 1 diabetes mellitus among 0-19 years old Saudi children and adolescents. METHODS: A nationwide Saudi Arabian project was conducted in the years 2001-2007 with the objective of establishing national growth charts, and defining the prevalence of some chronic childhood diseases such as diabetes mellitus. The 14,000 households were randomly selected based on a recent population statistic. The questionnaire used included demographic data and evidence of diabetes mellitus. The prevalence was estimated and expressed per 100,000. Breakdown of this figure per age and region was carried out. RESULTS: In the 11,874 out of the 14,000 84.9% selected households, 45,682 children and adolescents were surveyed. Fifty children and adolescents were identified to have type 1 diabetes mellitus with a prevalence rate of 109.5 per 100,000. The male to female ratio was almost equal (26 males and 24 females). The distribution of prevalence of type 1 diabetes mellitus by region shows that the highest was 162 in the central region, and the lowest was 48 in the eastern region. Children and adolescents were also grouped by age into 5-6 (prevalence 100), 7-12 (prevalence 109), 13-16 (prevalence 243), and 17-18 (prevalence 150). CONCLUSION: We conclude that the prevalence of type 1 diabetes mellitus in Saudi Arabian children and adolescents is 109.5 per 100,000.

The prevalence of sickle cell disease in Saudi children and adolescents. A community-based survey.

OBJECTIVE: To determine the prevalence and regional distribution of sickle cell disease in Saudi children. METHODS: A sample size of 45,682 children and adolescents from newborn to 19 years of age was selected by multistage random probability sampling of the Saudi households from each of the 13 regions of the country. The study is cross-sectional, community based, and conducted over 2 years from 2004 to 2005. Data, including history and clinical examination were collected with house-to-house survey of all selected households. Data management and analysis was carried out at King Saud University, Riyadh, Saudi Arabia. RESULTS: Sickle cell disease was detected in 108 of 45,682 children and adolescents with a prevalence of 24 per 10,000. The regional distribution of sickle cell disease showed eastern region dominance with a prevalence of 145 per 10,000, followed by the southern region with a prevalence of 24 per 10,000, western region 12 per 10,000, and central region with 6 per 10,000. No cases were found in the northern regions. The male to female ratio was approximately 1:1. CONCLUSION: The results of this national wide community-based survey show a high prevalence of sickle cell disease in the community and the disease is more common in eastern and southern regions of the country. National or regional newborn screening programs for sickle cell disease using hematological tests should be planed. This study shows that the population at risk has an uneven geographical distribution. For this reason, selective rather than universal neonatal screening is likely to be more appropriate in the country.

Consanguinity and major genetic disorders in Saudi children: a community-based cross-sectional study.

BACKGROUND AND OBJECTIVES: There is a high rate of consanguinity in Saudi Arabia; however, information on its relationship with genetic disorders is limited. The objective of this cross-sectional study was to explore the role of consanguinity in genetic disorders. SUBJECTS AND METHODS: The study sample was determined by a multistage probability random sampling procedure. Consanguinity status was obtained during household visits. Primary care physicians performed a history and physical examination of all children and adolescents younger than 19 years, and all cases of genetic diseases were recorded. The chi-square test was used to compare proportions. RESULTS: During the two-year study period (2004-2005), 11 554 of 11 874 (97%) mothers answered the question on consanguinity, and 6470 of 11 554 (56%) were consanguineous. There was no significant association between first-cousin consanguinity and Down syndrome (P=.55). Similarly, there was no significant association with either sickle cell disease (P=.97) or glucose-6-phosphate dehydrogenase deficiency (P=.67) for first-cousin consanguinity. A borderline statistical significance was found for major congenital malformations (P=.05). However, the most significant association with first-cousin consanguinity was congenital heart disease (CHD) (P=.01). Finally, no significant association was found for type 1 diabetes mellitus (P=.92). For all types of consanguinity, similar trends of association were found, with a definite statistically significant association only with CHD (P=.003). CONCLUSION: The data suggest a significant role of parental consanguinity in CHD. However, a relationship between consanguinity and other genetic diseases could not be established. The effect of consanguinity on genetic diseases is not uniform and this should be taken into consideration in genetic counseling.

Comparison of the 2005 growth charts for Saudi children and adolescents to the 2000 CDC growth charts.

BACKGROUND AND OBJECTIVES: The 2000 CDC growth charts for the United States, a revision of the National Center for Health Statistics/World Health Organization (NCHS/WHO) growth charts, were released in 2002 to replace the NCHS/WHO charts. We evaluated the differences between the CDC growth charts and the Saudi 2005 reference to determine the implications of using the 2000 CDC growth charts in Saudi children and adolescents. SUBJECTS AND METHODS: The Saudi reference was based on a cross-sectional representative sample of the Saudi population of healthy children and adolescents from birth to 19 years of age. Measurements of the length/stature, weight and head circumference were performed according to expert recommendations. The CDC charts from birth to 20 years were based on a cross-sectional representative national sample from five sources collected between 1963 and 1994. The data from the CDC study including the 3rd, 5th, 50th, 95th, and 97th percentiles were plotted against the corresponding percentiles on the Saudi charts for the weight for age, height for age, weight for height for children from 0 to 36 months and weight for age, stature for age and body mass index for children 2 to 19 years of age. RESULTS: There were major differences between the two growth charts. The main findings were the upward shift of the lower percentiles of the CDC curves and the overlap or downward shift of the upper percentiles, especially for weight, weight for height, and BMI. CONCLUSION: The use of the 2000 CDC growth charts for Saudi children and adolescents increases the prevalence of undernutrition, stunting, and wasting, potentially leading to unnecessary referrals, investigations and parental anxiety. The increased prevalence of overweight and obesity is alarming and needs further investigation.

Growth charts for Saudi children and adolescents.

OBJECTIVE: To establish reference growth charts for Saudi children and adolescents. METHODS: Multi-stage probability sampling of a cross-section of Saudi children and adolescents residing in all 13 regions of the Kingdom. Family interviews, and physical examinations of children and adolescents from birth to 19 years of age were conducted over a 2-year period (2004-2005). Only healthy children and adolescents were included for the measurement of length/stature, weight, and head circumference. All measurements were performed by trained physicians and nurses according to World Health Organization guidelines. Percentile construction and smoothing were performed using the LMS (lambda, mu, sigma) methodology. RESULTS: Determination of the standard measures for normal physical growth in a sample representing healthy Saudi children and adolescents from birth to 19 years of age. CONCLUSION: The results of this study present the most comprehensive and up-to-date reference growth charts for Saudi children and adolescents. Therefore, the authors recommend the use of these charts to replace older charts or those belonging to other countries.

Regional variations in the prevalence of consanguinity in Saudi Arabia.

OBJECTIVE: To report on the prevalence of consanguinity in each region of the Kingdom of Saudi Arabia including the variation in prevalence between urban and rural settlements. METHODS: The study was conducted over 2 years (2004-2005). A cross-sectional sample determined by multistage random probability sampling of Saudi households from each of the 13 regions of the Kingdom. As part of survey questionnaire, the mother of each household was asked on the relationship to her husband to choose one of 3 answers: first-degree cousin, more distant relationship, or no relation. RESULTS: The overall prevalence of consanguinity was 56% with the first-degree cousin (33.6%) being more common than all other relations (22.4%). The overall prevalence was significantly more common in rural (59.5%) than in urban settlements (54.7%) (p=0.000). There are regions with high prevalence of 67.2% such as Madina, and regions with significantly lower prevalence of 42.1% such as Al-Baha (p=0.000). CONCLUSION: The national prevalence of consanguinity in the Kingdom of Saudi Arabia remains high. In addition, there are significant variations in the prevalence of consanguinity between certain regions as well as between rural and urban settlements that should be taken into consideration in further studies.

The LMS and Z scale growth reference for Saudi school-age children and adolescents.

BACKGROUND/AIM: To establish L, M, and S parameters and z score reference for the assessment of nutrition and growth of Saudi school-age children and adolescents. SUBJECTS AND METHODS: Data from the original cross-sectional study were reanalyzed. The L, M, and S parameters and z scores were calculated for weight, height and body mass index for school-age children and adolescents. RESULTS: A total of 19,299 subjects from 5 to 18 years of age were included. All were Saudi nationals and 9,827 (50.9%) were boys. The L M S parameters and z scores for weight for age, height for age, and BMI for age for boys and girls are presented in detailed tables across the age of commonly used z scores (+3, +2, +1, 0, -1, -2, -3). Graphs corresponding to the same parameters (weight, height, and BMI) showing the main z scores across all ages from 5 to 18 years are illustrated. CONCLUSION: This report provides the first reference for nutritional status and growth of Saudi school-age children and adolescents. This tool is essential for more accurate assessment of growth and nutrition in various clinical conditions and research.

Diagnosis and management of growth disorders in Gulf Cooperation Council (GCC) countries: Current procedures and key recommendations for best practice.

Diagnosis and management of growth disorders comprises an important area of pediatric practice. Current procedures in the different stages of the identification, referral, investigation, and treatment of growth disorders in the Gulf Cooperation Council (GCC) countries have been summarized. Evidence-based procedures, relating specifically to height screening for identification of short stature, auxological criteria for patient referral from primary to secondary pediatric care, and general and endocrine investigations and diagnosis have been discussed and outlined. The management issues related to key disorders that are licensed for growth hormone (hGH) therapy, namely GH deficiency, Turner syndrome, short stature related to birth size small for gestational age (SGA), and idiopathic short stature are discussed with recommendations described for best practice. Finally, two key components of short stature management, namely transitional care for the transfer of patients from pediatric to adult endocrinology services and adherence to recommended therapy with hGH, have been addressed with current practice outlines and recommendations presented.

Standard penile size for normal full term newborns in the Saudi population.

OBJECTIVE: To establish norms for penile size for normal full term Saudi newborns. METHODS: The length between the pubic ramus and the tip of the glans was measured in 379 normal full term Saudi newborns. An unmarked spatula was used where its edge was placed against the pubic ramus and the shaft of the penis was stretched to the point of increased resistance. The penile circumference was measured using a non- stretchable plastic tube placed around the midshaft of the uncircumcised penis. The study was carried out in King Khalid University Hospital and King Fahad National Guard Hospital, Riyadh, Kingdom of Saudi Arabia for the period September 1998 to February 1999. RESULTS: The mean penile length was 3.55 cm (standard deviation 0.57) and the mean penile midshaft circumference was 3.96 cm (standard deviation 0.44 cm). CONCLUSION: The mean penile length of 3.55 cm in this study was similar to previously reported international data. The cut-off lower limit (-2.5 standard deviation) is calculated to be 2.13 cm. The cut-off upper limit (+2.5 standard deviation) is 4.98 cm. The mean penile circumference was 3.96 cm (standard deviation 0.44).

Nutritional rickets and osteomalacia in school children and adolescents.

OBJECTIVE: To review experiences of nutritional rickets and osteomalacia in school children and adolescents at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia. METHODS: Records of children and adolescents aged 6-18 years, seen at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia, during the period January 1994 through to December 1999, who were diagnosed to have rickets or osteomalacia were reviewed. The diagnosis was based on clinical, biochemical and radiological data. Data extracted and analyzed included age, sex, presenting symptoms and signs, dietary history and sun exposure, blood count, bone profiles, renal and liver profile, and 25-hydroxy vitamin D3 and 1, 25 dihydroxy vitamin D3. Hand and wrist x-rays were carried out for all patients while bone density of lumbar spine and 3 femoral sites and bone scan were performed on the majority of patients. RESULTS: Forty-two children and adolescents (25 females and 17 males) were diagnosed. Their age ranged between 6-18 years with a mean of 13.5. Non specific symptoms, such as bone pain and fatigue were the most presenting symptoms, while skeletal deformities and fractures were the presenting symptoms in only 5 and 3 patients. Lack of direct sun exposure and poor calcium intake was evident. Bone profiles at the time of diagnosis revealed mean serum calcium of 2.1 mmol/L, range 1.5 2.3 (Normal=2.2-2.7), phosphorus 1.1 mmol/L, range 0.7 1.9 (Normal=1.4 2.1) and alkaline phosphatase activities of 1,480 U/L, range 834-2,590 (N=<600). Serum concentrations of 25-hydroxy Vitamin D were low (<10 mg/L) while that of 1, 25 Dihydroxy Vitamin D varied between low to normal (<10-45 ng/L). Bone density of the lumbar spine and 3 femoral sites were performed in 26 patients and showed markedly reduced values, while bone scan demonstrated a high uptake of tracer throughout the skeleton "super scan". Multiple stress fractures were evident in 8 children. CONCLUSION: Although a community-based study to assess the magnitude of the problem is needed, it seems that rickets and osteomalacia of nutritional origin are not that uncommon and deserves special attention from all pediatricians and practicing physicians. They also suggested that further studies are needed to help understand the pathophysiology, and identify the contributing factors for the development of the disorder.

Growth hormone therapy and treatment outcomes: current clinical practice of the Gulf Cooperation Council.

Over the last 20 years, recombinant human growth hormone (somatropin) has been the cornerstone of managing children with growth hormone deficiency (GHD). Although both international and national guidelines for growth hormone (GH) therapy exist, there is currently no consensus on the optimal use of GH therapy in Gulf Cooperation Council (GCC) countries. The goals of GH therapy are to normalize height during childhood, attain normal adult height and correct metabolic abnormalities related to GHD. However, extended use of GH >50 µg/kg/day may increase frequency of adverse events. Here, we report the proceedings from a meeting of nine GCC pediatric endocrinology experts, which took place in Beirut in November 2011. The meeting was also attended by three European counterparts and aimed to provide consensus on best practice in the management of children with GHD in the GCC based on current local medical and regulatory environments.

Regional variation in prevalence of overweight and obesity in Saudi children and adolescents.

BACKGROUND/AIMS: There are limited data on regional variation of overweight and obesity in the Kingdom of Saudi Arabia. Therefore, the aim of this report is to explore the magnitude of these variation in order to focus preventive programs to regional needs. SETTING AND DESIGN: Community-based multistage random sample of representative cohort from each region. PATIENTS AND METHODS: the study sample was cross-sectional, representative of healthy children and adolescents from 2 to 17 years of age. Body mass index (BMI) was calculated according to the formula (weight/height²). The 2000 center for disease control reference was used for the calculation of prevalence of overweight and obesity defined as the proportion of children and adolescents whose BMI for age was above 85 th and 95 th percentiles respectively, for Northern, Southwestern and Central regions of the Kingdom. Chi-square test was used to assess the difference in prevalence between regions and a P value of <0.05 was considered significant. RESULTS: The sample size was 3525, 3413 and 4174 from 2-17 years of age in the Central, Southwestern and Northern regions respectively. The overall prevalence of overweight was 21%, 13.4% and 20.1%, that of obesity was 9.3%, 6% and 9.1% in the Central, Southwestern and Northern regions respectively indicating a significantly-lower prevalence in the Southwestern compared to other regions (P<0.0001). CONCLUSIONS: This report revealed significant regional variations important to consider in planning preventive and therapeutic programs tailored to the needs of each region.

The prevalence of neurological disorders in Saudi children: a community-based study.

There are limited data on the pattern and prevalence of pediatric chronic neurologic conditions in the region. Therefore, the objective of this study was to establish the prevalence of these disorders in the Kingdom of Saudi Arabia. A multistage probability sampling design was used to select a random sample of Saudi households representative of the Saudi population. A total of 45 682 Saudi children were screened. Of these children, 313 had a chronic major neurologic disorder indicating a prevalence of 68.5 per 10 000 children, which was the highest among all chronic diseases in children. Mental retardation and cerebral palsy were the most common neurologic disorders among Saudi children with a prevalence rate of 26.3/10 000 and 23.4/10 000, respectively. The finding that major neurologic disorders are the most common pediatric chronic disorders in the Kingdom of Saudi Arabia indicates that priority should be given to research and education as well as health care planning.

Prevalence of short stature in Saudi children and adolescents.

BACKGROUND AND OBJECTIVE: Data on stature in Saudi children and adolescents are limited. The objective of this report was to establish the national prevalence of short stature in Saudi children and adolescents. DESIGN AND SETTING: Community-based, cross-sectional study conducted over 2 years (2004, 2005) PATIENTS AND METHODS: The national data set of the Saudi reference was used to calculate the stature for age for children and adolescents 5 to 18 years of age. Using the 2007 World Health Organization (WHO) reference, the prevalence of moderate and severe short stature was defined as the proportion of children whose standard deviation score for stature for age was less than -2 and -3, respectively. In addition, the 2000 Center for Disease Control (CDC) and the older 1978 National Center for Health Statistics (NCHS)/WHO references were used for comparison. RESULTS: Using the 2007 WHO reference, sample size in the Saudi reference was 19 372 healthy children and adolescents 5 to 17 years of age, with 50.8% being boys. The overall prevalence of moderate and severe short stature in boys was 11.3% and 1.8%, respectively; and in girls, 10.5% and 1.2%, respectively. The prevalence of moderate short stature was 12.1%, 11% and 11.3% in boys and 10.9%, 11.3% and 10.5% in girls when the 1978 WHO, the 2000 CDC and the 2007 WHO references were used, respectively. CONCLUSIONS: The national prevalence of short stature in Saudi children and adolescents is intermediate compared with the international level. Improvement in the socioeconomic and health status of children and adolescents should lead to a reduction in the prevalence of short stature.

Effects of education of the head of the household on the prevalence of malnutrition in children.

OBJECTIVE: To explore the effect of the educational level of the head of household on the prevalence of malnutrition in Saudi children. METHODS: The study was conducted over 2 years in 2004 and 2005 in all regions of the Kingdom of Saudi Arabia (KSA). The design consisted of a stratified multistage probability random sampling of the population of the KSA. The educational level of the heads of the household, and measurements of weight and height of the children were obtained during house visits. Nutritional indicators in the form of weight for age, height for age, and weight for height for children below 5 years of age were determined, and the prevalence of each indicator below -2 standard deviations (SD) was calculated for each level of education. RESULTS: The sample size was 7390 in the weight for age, 7275 height for age, and 7335 for weight for height. The prevalence of underweight (weight for age below -2 SD) increased from 7.4% for the university level to 15.2% in the children of illiterate heads of household. Similar patterns were found for the prevalence of stunting (height for age below -2 SD) and wasting (weight for height below -2 SD). CONCLUSION: This study demonstrates that the higher the education level of the heads of the household, the lower the prevalence of malnutrition in their children, suggesting that completing at least 9-12 years of education (intermediate and secondary school) is needed for better improvement in the nutritional status of the children.

Prevalence of overweight and obesity in Saudi children and adolescents.

BACKGROUND AND OBJECTIVE: There is limited information on overweight and obesity in Saudi children and adolescents. The objective of this study was to establish the national prevalence of overweight and obesity in Saudi children and adolescents. METHODS: The 2005 Saudi reference data set was used to calculate the body mass index (BMI) for children aged 5 to 18 years. Using the 2007 WHO reference, the prevalence of overweight, obesity and severe obesity were defined as the proportion of children with a BMI standard deviation score more than +1, +2 and +3, respectively. The 2000 CDC reference was also used for comparison. RESULTS: There were 19 317 healthy children and adolescents from 5 to 18 years of age, 50.8% of whom were boys. The overall prevalence of overweight, obesity and severe obesity in all age groups was 23.1%, 9.3% and 2%, respectively. A significantly lower prevalence of overweight (23.8 vs 20.4; P<.001) and obesity (9.5 vs 5.7; P<.001) was found when the CDC reference was used. CONCLUSIONS: This report establishes baseline national prevalence rates for overweight, obesity and severe obesity in Saudi children and adolescents, indicating intermediate levels between developing and industrialized countries. Measures should be implemented to prevent further increases in the numbers of overweight school-age children and adolescents and the associated health hazards.