Journal of Adolescent Health xxx (2015) 1e11
www.jahonline.org Review article
Arab Adolescents: Health, Gender, and Social Context Carla Makhlouf Obermeyer, D.Sc. *, Sarah Bott, M.A, M.P.H., and Anniebelle J. Sassine, M.Sc. Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
Article history: Received August 15, 2014; Accepted January 2, 2015 Keywords: Adolescents; Arab countries; Burden of disease; Risk factors; Gender; Social factors; Violence; Mental health
A B S T R A C T
IMPLICATIONS AND CONTRIBUTION
This article reviews the evidence about adolescent health in the Arab world, against the background of social, economic, and political change in the region, and with a particular focus on gender. For the literature review, searches were conducted for relevant articles, and data were drawn from national population- and school-based surveys and from the Global Burden of Disease project. In some parts of the Arab world, adolescents experience a greater burden of ill health due to overweight/obesity, transport injuries, cardiovascular and metabolic conditions, and mental health disorders than those in other regions of the world. Poor diets, insufficient physical activity, tobacco use, road traffic injuries, and exposure to violence are major risk factors. Young men have higher risks of unsafe driving and tobacco use and young women have greater ill-health due to depression. Several features of the social context that affect adolescent health are discussed, including changing life trajectories and gender roles, the mismatch between education and job opportunities, and armed conflict and interpersonal violence. Policy makers need to address risk factors behind noncommunicable disease among adolescents in the Arab region, including tobacco use, unhealthy diets, sedentary lifestyles, unsafe driving, and exposure to violence. More broadly, adolescents need economic opportunity, safe communities, and a chance to have a voice in their future. Ó 2015 Society for Adolescent Health and Medicine. All rights reserved.
The 22 countries of the Arab League comprise a region with great socioeconomic diversity but important commonalities in language, culture, religion, and demographics. Although the “youth bulge” may have peaked around 2005 [1], a majority of the population are younger than 25 years, and population growth has resulted in unprecedented numbers of children and youth in the region, projected to number 217 million by 2050 [2]. Recent events highlight young people’s role in the rapid social, economic, and political changes underway in the region [3]. The Conflicts of Interest: The authors have no conflicts of interest or financial disclosures to report. * Address correspondence to: Carla Makhlouf Obermeyer, D.Sc., Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Beirut, Lebanon. E-mail address: [email protected] (C.M. Obermeyer). 1054-139X/Ó 2015 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2015.01.002
Examining the evidence on the health of Arab adolescents in light of the social context of their lives reveals distinctive features of the Arab region compared with the rest of the world in the burden of disease, gender differences, and the social forces that affect adolescent health.
health, well-being, and perspectives of Arab adolescents should therefore be of interest to those working in public health and for anyone interested in the generation on the cusp of adulthood in that region. There have been numerous recent global analyses of adolescent health [4e6] and efforts to estimate age-specific causes of death and disease by country and region [5,7,8]. There is also a large literature on adolescent health and development from the region, including multicountry surveys on economic, social, and health topics relevant to adolescents [1,9e16] and reviews of specific health issues including changing marriage patterns [17], sexual and reproductive health [18,19], and diet and physical activity [20]. There have been few attempts to provide a comprehensive overview of adolescent health in the region, however [21].
2
C.M. Obermeyer et al. / Journal of Adolescent Health xxx (2015) 1e11
This article synthesizes evidence about adolescent health in the Arab region, with a particular focus on gender and the social context. Part one explores causes of death and disability among adolescents in the region compared with global statistics. Part two reviews evidence about the following four sets of risk factors or conditions that account for much ill-health among Arab adolescents: (1) malnutrition, overweight, and obesity; (2) transport injuries; (3) tobacco and other substance use; and (4) mental health conditions. Part three reviews the changing social, economic, and political context of adolescent health in Arab countries including the mismatch between education and employment opportunities, the pervasiveness of violence, and changing construction of gender. Methods We sought to summarize evidence about adolescent health from published sources, the gray literature, and open access databases. Searches were conducted in PubMed and Google Scholar using keywords adolescents, young people, youth, country names, and terms for key risk factors and conditions over the past 10 years. Searches for adolescents/ce in PubMed by country yielded between 50 (Djibouti) and nearly 5,000 (Egypt) sources for a total of more than 20,000 sources. Google Scholar often produced 10 times those numbers. Thus, a systematic review of each issue, factor, or health condition was not feasible. Our more limited goal was to identify issues of particular importance to the region and to highlight key themes for future research. We also searched for global and regional reviews, hand-searched bibliographies of key reports from the region, and extracted statistics from comparative survey reports. Searches were conducted in English, but some data from the Arabic literature were included in regional analyses, particularly those published by the United Nations. In this article, “Arab region” refers to the 22 member countries of the Arab League. Some data are provided for Middle East and North Africa (MENA), as defined in the Burden of Disease project; and for the Eastern Mediterranean region (EMRO), as defined by the World Health Organization (WHO)dsimilar but not identical groupings of countries (Supplementary Table 1). As per the United Nations definitions, adolescents are aged 10e19 years, youth are aged 15e24 years, and young people are aged 10e24 years [22]. Major Causes of Ill-Health Among Adolescents in Arab Countries According to 2010 Global Burden of Disease data, the top three causes of death among male adolescents aged 15e19 years in the Arab region are transport injuries, other unintentional injuries, and cardiovascular/circulatory disease [7]. Among female adolescents aged 15e19 years, the leading cause of death is infectious disease (diarrhea, lower respiratory infections and meningitis)dpart of the unfinished agenda of communicable disease that persists in the region. Second and third causes of death are cardiovascular/circulatory disease and unintentional injuries. The proportion of deaths due to cardiovascular and circulatory diseases is nearly three times higher among Arab adolescents (both male and female) than the global average. Diabetes and cancer also contribute a higher proportion than the global average (Table 1; Supplementary Table 2). Disability-adjusted life years (DALYs) represent the years of healthy life lost to premature mortality and disability. Mental
Table 1 Percent distribution of deaths by cause among male and female adolescents aged 15e19 years in the Arab region and globally, 2010a Causes of deathb
Transport injuries Unintentional injuries Cardiovascular and circulatory diseases Diarrhea, LRI, meningitis Intentional injuries Cancer NTD and Malaria Diabetes and other endocrine disorders Neurological disorders HIV and TB Nutritional deficiencies Other noncommunicable diseases Digestive diseases Chronic respiratory diseases War and disaster Other communicable disorders Liver cirrhosis Mental and behavioral disorders Musculoskeletal disorders Maternal disorders Death rate by all causes per 100,000
Arab region
Global
Male
Female
Male
Female
18.7 15.8 14.3 11.7 7.3 7.0 5.2 4.6 3.7 2.1 1.7 1.6 1.5 1.3 1.0 .8 .8 .7 .4 0.0 103.3
7.4 9.6 13.7 15.7 4.7 7.7 6.0 6.7 3.4 3.8 2.8 2.4 1.4 1.8 .7 1.4 1.2 .7 1.1 8.1 72.2
18.6 16.0 4.7 11.0 15.6 5.7 5.3 2.9 3.6 4.7 1.1 1.4 1.4 1.4 3.5 1.8 .6 .5 .2 0.0 132.7
7.7 13.0 4.9 12.8 13.5 5.3 6.3 4.1 3.2 7.7 2.6 1.5 1.8 1.3 2.0 2.5 .7 .4 .6 8.2 101.4
HIV ¼ human immunodeficiency virus; LRI ¼ lower respiratory infections; NCD ¼ non-communicable diseases; NTD ¼ neglected tropical diseases; TB ¼ tuberculosis. a Source: Global Burden of Disease database. b Causes are displayed in decreasing order, by the percentage of deaths among males in the Arab region.
Table 2 Percent distribution of Disability-adjusted life years (DALYs) by cause among male and female adolescents aged 15e19 years in the Arab region and globally, 2010a Causes of DALYsb
Mental and behavioral disorders Transport injuries Musculoskeletal disorders Unintentional injuries Other NCDs Cardiovascular and circulatory diseases Diarrhea, LRI, meningitis Neurological disorders Nutritional deficiencies Chronic and respiratory diseases NTD and malaria Diabetes and other endocrine disorders Intentional injuries Cancer HIV and TB Neonatal disorders Digestive diseases Other communicable diseases War and disaster Liver cirrhosis Maternal disorders DALYs lost from all causes per 100,000
Arab region
Global
Male
Male
Female
Female
19.2 10.2 9.7 8.3 7.2 7.1
24.9 3.5 10.7 3.9 8.0 5.4
16.0 11.0 7.8 9.5 6.0 2.9
18.3 4.3 9.2 6.4 6.8 2.7
6.6 4.4 4.1 4.0 3.7 3.6
6.5 5.3 7.0 4.3 3.5 5.2
7.1 4.8 2.8 4.0 4.6 2.7
6.9 6.0 5.8 4.0 4.5 4.2
3.6 3.3 1.4 1.1 1.0 .8 .5 .4 0.0 15,342.7
1.7 2.7 1.6 .8 .8 .7 .3 .4 2.9 14,524.1
8.6 3.1 2.9 1.1 1.2 1.3 2.1 .3 0.0 16,829.7
6.2 2.4 3.7 .8 1.3 1.4 1.0 .3 3.8 15,477.6
DALYs ¼ disability-adjusted life years; HIV ¼ human immunodeficiency virus; LRI ¼ lower respiratory infections; NCD ¼ non-communicable diseases; NTD ¼ neglected tropical diseases; TB ¼ tuberculosis. a Source: Global Burden of Disease database. b Causes are displayed in decreasing order, by the percentage of DALYs among males in the Arab region.
C.M. Obermeyer et al. / Journal of Adolescent Health xxx (2015) 1e11
3
Figure 1. Percentage of girls and boys aged 13e15 years who were overweight or obese, most recent World Health Organization Global School-Based Health Surveys, 2007e2012. Countries displayed in alphabetical order.
and behavioral disorders account for more than 20% of DALYs lost among Arab adolescents, considerably higher than the global average (Table 2; Supplementary Table 3). Musculoskeletal disorders, other noncommunicable diseases, cardiovascular/circulatory disorders, nutritional deficiencies, and diabetes/endocrine disorders also account for a higher proportion of DALYs among Arab adolescents aged 15e19 years compared with global averages, while diarrhea/infections, unintentional injuries, maternal causes, HIV, tuberculosis, and intentional injuries contribute lower proportions. Causes of deaths vary widely by national income (Supplementary Table 4) [7]. Leading causes of death are cardiovascular/circulatory disease among older adolescents in middle-income countries, communicable diseases among adolescents in low-income Arab countries, and transport injuries among adolescents in high-income countries (accounting for more than 4 in 10 deaths among adolescents aged 15e19 years). Importantly, mental health and behavioral disorders are the leading cause of DALYs among adolescents aged 15e19 years across all income groups in the region (Supplementary Table 5). The 2010 Burden of Disease data predate some of the political upheaval of the “Arab Spring” and the Syrian crisis, and thus, may not capture recent mortality and morbidity associated with violence [23]. More recent WHO estimates suggest that collective violence contributes a substantial burden of ill-health among adolescents in Arab countries, particularly males [5].
Key Health Conditions and Risks Among Adolescents in Arab Countries Based on mortality and disability data, we focus on four conditions and determinants that account for considerable illhealth across Arab countries: overweight/obesity and tobacco use as key determinants of cardiovascular health; transport injuries as a top cause of death and disability; and mental illhealth, prominent across countries and income levels. Malnutrition, overweight, obesity, and physical activity Undernutrition and overnutrition are major risk factors for disease, mortality, healthy growth, and development [24,25]. Both are prominent in the Arab region, often within the same countries, sometimes within the same household [26e28]. Undernutrition among adolescents is widespread in low-income countries such as Djibouti and Yemen, in countries experiencing humanitarian crises such as Iraq, Somalia, and Sudan, and among underprivileged populations in affluent countries [29e33]. Overweight and obesity have become serious public health problems among Arab adolescents [34e38], linked to high levels of early metabolic syndrome [39e43] and high blood pressure [44]. As risk factors for cardiovascular/circulatory diseases, diabetes, and musculoskeletal disorders, they may account for the considerably higher proportion of DALYs for these conditions
4
C.M. Obermeyer et al. / Journal of Adolescent Health xxx (2015) 1e11
Boys 45
Girls
42 38
40
35
% Physical acƟvity
35
31
30 25
30
29
28 25 23
21
24
23
21
19
18
20
15
14
15 10
13 11
10
20
17
14
11
23
19
10
11
12
10
5 0
Figure 2. Percentage of boys and girls (13e15 years) who were physically active >60 minutes/day on 5 or more days during the past 7 days, WHO Global School-based Health Surveys. Countries displayed in alphabetical order.
among Arab adolescents, consistent with findings among adults in the region [23]. Global school-based student health surveys (GSHS) find levels of overweight/obesity among adolescents of nearly 50% in countries of the Gulf, low levels (
www.jahonline.org Review article
Arab Adolescents: Health, Gender, and Social Context Carla Makhlouf Obermeyer, D.Sc. *, Sarah Bott, M.A, M.P.H., and Anniebelle J. Sassine, M.Sc. Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon
Article history: Received August 15, 2014; Accepted January 2, 2015 Keywords: Adolescents; Arab countries; Burden of disease; Risk factors; Gender; Social factors; Violence; Mental health
A B S T R A C T
IMPLICATIONS AND CONTRIBUTION
This article reviews the evidence about adolescent health in the Arab world, against the background of social, economic, and political change in the region, and with a particular focus on gender. For the literature review, searches were conducted for relevant articles, and data were drawn from national population- and school-based surveys and from the Global Burden of Disease project. In some parts of the Arab world, adolescents experience a greater burden of ill health due to overweight/obesity, transport injuries, cardiovascular and metabolic conditions, and mental health disorders than those in other regions of the world. Poor diets, insufficient physical activity, tobacco use, road traffic injuries, and exposure to violence are major risk factors. Young men have higher risks of unsafe driving and tobacco use and young women have greater ill-health due to depression. Several features of the social context that affect adolescent health are discussed, including changing life trajectories and gender roles, the mismatch between education and job opportunities, and armed conflict and interpersonal violence. Policy makers need to address risk factors behind noncommunicable disease among adolescents in the Arab region, including tobacco use, unhealthy diets, sedentary lifestyles, unsafe driving, and exposure to violence. More broadly, adolescents need economic opportunity, safe communities, and a chance to have a voice in their future. Ó 2015 Society for Adolescent Health and Medicine. All rights reserved.
The 22 countries of the Arab League comprise a region with great socioeconomic diversity but important commonalities in language, culture, religion, and demographics. Although the “youth bulge” may have peaked around 2005 [1], a majority of the population are younger than 25 years, and population growth has resulted in unprecedented numbers of children and youth in the region, projected to number 217 million by 2050 [2]. Recent events highlight young people’s role in the rapid social, economic, and political changes underway in the region [3]. The Conflicts of Interest: The authors have no conflicts of interest or financial disclosures to report. * Address correspondence to: Carla Makhlouf Obermeyer, D.Sc., Center for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, PO Box 11-0236, Beirut, Lebanon. E-mail address: [email protected] (C.M. Obermeyer). 1054-139X/Ó 2015 Society for Adolescent Health and Medicine. All rights reserved. http://dx.doi.org/10.1016/j.jadohealth.2015.01.002
Examining the evidence on the health of Arab adolescents in light of the social context of their lives reveals distinctive features of the Arab region compared with the rest of the world in the burden of disease, gender differences, and the social forces that affect adolescent health.
health, well-being, and perspectives of Arab adolescents should therefore be of interest to those working in public health and for anyone interested in the generation on the cusp of adulthood in that region. There have been numerous recent global analyses of adolescent health [4e6] and efforts to estimate age-specific causes of death and disease by country and region [5,7,8]. There is also a large literature on adolescent health and development from the region, including multicountry surveys on economic, social, and health topics relevant to adolescents [1,9e16] and reviews of specific health issues including changing marriage patterns [17], sexual and reproductive health [18,19], and diet and physical activity [20]. There have been few attempts to provide a comprehensive overview of adolescent health in the region, however [21].
2
C.M. Obermeyer et al. / Journal of Adolescent Health xxx (2015) 1e11
This article synthesizes evidence about adolescent health in the Arab region, with a particular focus on gender and the social context. Part one explores causes of death and disability among adolescents in the region compared with global statistics. Part two reviews evidence about the following four sets of risk factors or conditions that account for much ill-health among Arab adolescents: (1) malnutrition, overweight, and obesity; (2) transport injuries; (3) tobacco and other substance use; and (4) mental health conditions. Part three reviews the changing social, economic, and political context of adolescent health in Arab countries including the mismatch between education and employment opportunities, the pervasiveness of violence, and changing construction of gender. Methods We sought to summarize evidence about adolescent health from published sources, the gray literature, and open access databases. Searches were conducted in PubMed and Google Scholar using keywords adolescents, young people, youth, country names, and terms for key risk factors and conditions over the past 10 years. Searches for adolescents/ce in PubMed by country yielded between 50 (Djibouti) and nearly 5,000 (Egypt) sources for a total of more than 20,000 sources. Google Scholar often produced 10 times those numbers. Thus, a systematic review of each issue, factor, or health condition was not feasible. Our more limited goal was to identify issues of particular importance to the region and to highlight key themes for future research. We also searched for global and regional reviews, hand-searched bibliographies of key reports from the region, and extracted statistics from comparative survey reports. Searches were conducted in English, but some data from the Arabic literature were included in regional analyses, particularly those published by the United Nations. In this article, “Arab region” refers to the 22 member countries of the Arab League. Some data are provided for Middle East and North Africa (MENA), as defined in the Burden of Disease project; and for the Eastern Mediterranean region (EMRO), as defined by the World Health Organization (WHO)dsimilar but not identical groupings of countries (Supplementary Table 1). As per the United Nations definitions, adolescents are aged 10e19 years, youth are aged 15e24 years, and young people are aged 10e24 years [22]. Major Causes of Ill-Health Among Adolescents in Arab Countries According to 2010 Global Burden of Disease data, the top three causes of death among male adolescents aged 15e19 years in the Arab region are transport injuries, other unintentional injuries, and cardiovascular/circulatory disease [7]. Among female adolescents aged 15e19 years, the leading cause of death is infectious disease (diarrhea, lower respiratory infections and meningitis)dpart of the unfinished agenda of communicable disease that persists in the region. Second and third causes of death are cardiovascular/circulatory disease and unintentional injuries. The proportion of deaths due to cardiovascular and circulatory diseases is nearly three times higher among Arab adolescents (both male and female) than the global average. Diabetes and cancer also contribute a higher proportion than the global average (Table 1; Supplementary Table 2). Disability-adjusted life years (DALYs) represent the years of healthy life lost to premature mortality and disability. Mental
Table 1 Percent distribution of deaths by cause among male and female adolescents aged 15e19 years in the Arab region and globally, 2010a Causes of deathb
Transport injuries Unintentional injuries Cardiovascular and circulatory diseases Diarrhea, LRI, meningitis Intentional injuries Cancer NTD and Malaria Diabetes and other endocrine disorders Neurological disorders HIV and TB Nutritional deficiencies Other noncommunicable diseases Digestive diseases Chronic respiratory diseases War and disaster Other communicable disorders Liver cirrhosis Mental and behavioral disorders Musculoskeletal disorders Maternal disorders Death rate by all causes per 100,000
Arab region
Global
Male
Female
Male
Female
18.7 15.8 14.3 11.7 7.3 7.0 5.2 4.6 3.7 2.1 1.7 1.6 1.5 1.3 1.0 .8 .8 .7 .4 0.0 103.3
7.4 9.6 13.7 15.7 4.7 7.7 6.0 6.7 3.4 3.8 2.8 2.4 1.4 1.8 .7 1.4 1.2 .7 1.1 8.1 72.2
18.6 16.0 4.7 11.0 15.6 5.7 5.3 2.9 3.6 4.7 1.1 1.4 1.4 1.4 3.5 1.8 .6 .5 .2 0.0 132.7
7.7 13.0 4.9 12.8 13.5 5.3 6.3 4.1 3.2 7.7 2.6 1.5 1.8 1.3 2.0 2.5 .7 .4 .6 8.2 101.4
HIV ¼ human immunodeficiency virus; LRI ¼ lower respiratory infections; NCD ¼ non-communicable diseases; NTD ¼ neglected tropical diseases; TB ¼ tuberculosis. a Source: Global Burden of Disease database. b Causes are displayed in decreasing order, by the percentage of deaths among males in the Arab region.
Table 2 Percent distribution of Disability-adjusted life years (DALYs) by cause among male and female adolescents aged 15e19 years in the Arab region and globally, 2010a Causes of DALYsb
Mental and behavioral disorders Transport injuries Musculoskeletal disorders Unintentional injuries Other NCDs Cardiovascular and circulatory diseases Diarrhea, LRI, meningitis Neurological disorders Nutritional deficiencies Chronic and respiratory diseases NTD and malaria Diabetes and other endocrine disorders Intentional injuries Cancer HIV and TB Neonatal disorders Digestive diseases Other communicable diseases War and disaster Liver cirrhosis Maternal disorders DALYs lost from all causes per 100,000
Arab region
Global
Male
Male
Female
Female
19.2 10.2 9.7 8.3 7.2 7.1
24.9 3.5 10.7 3.9 8.0 5.4
16.0 11.0 7.8 9.5 6.0 2.9
18.3 4.3 9.2 6.4 6.8 2.7
6.6 4.4 4.1 4.0 3.7 3.6
6.5 5.3 7.0 4.3 3.5 5.2
7.1 4.8 2.8 4.0 4.6 2.7
6.9 6.0 5.8 4.0 4.5 4.2
3.6 3.3 1.4 1.1 1.0 .8 .5 .4 0.0 15,342.7
1.7 2.7 1.6 .8 .8 .7 .3 .4 2.9 14,524.1
8.6 3.1 2.9 1.1 1.2 1.3 2.1 .3 0.0 16,829.7
6.2 2.4 3.7 .8 1.3 1.4 1.0 .3 3.8 15,477.6
DALYs ¼ disability-adjusted life years; HIV ¼ human immunodeficiency virus; LRI ¼ lower respiratory infections; NCD ¼ non-communicable diseases; NTD ¼ neglected tropical diseases; TB ¼ tuberculosis. a Source: Global Burden of Disease database. b Causes are displayed in decreasing order, by the percentage of DALYs among males in the Arab region.
C.M. Obermeyer et al. / Journal of Adolescent Health xxx (2015) 1e11
3
Figure 1. Percentage of girls and boys aged 13e15 years who were overweight or obese, most recent World Health Organization Global School-Based Health Surveys, 2007e2012. Countries displayed in alphabetical order.
and behavioral disorders account for more than 20% of DALYs lost among Arab adolescents, considerably higher than the global average (Table 2; Supplementary Table 3). Musculoskeletal disorders, other noncommunicable diseases, cardiovascular/circulatory disorders, nutritional deficiencies, and diabetes/endocrine disorders also account for a higher proportion of DALYs among Arab adolescents aged 15e19 years compared with global averages, while diarrhea/infections, unintentional injuries, maternal causes, HIV, tuberculosis, and intentional injuries contribute lower proportions. Causes of deaths vary widely by national income (Supplementary Table 4) [7]. Leading causes of death are cardiovascular/circulatory disease among older adolescents in middle-income countries, communicable diseases among adolescents in low-income Arab countries, and transport injuries among adolescents in high-income countries (accounting for more than 4 in 10 deaths among adolescents aged 15e19 years). Importantly, mental health and behavioral disorders are the leading cause of DALYs among adolescents aged 15e19 years across all income groups in the region (Supplementary Table 5). The 2010 Burden of Disease data predate some of the political upheaval of the “Arab Spring” and the Syrian crisis, and thus, may not capture recent mortality and morbidity associated with violence [23]. More recent WHO estimates suggest that collective violence contributes a substantial burden of ill-health among adolescents in Arab countries, particularly males [5].
Key Health Conditions and Risks Among Adolescents in Arab Countries Based on mortality and disability data, we focus on four conditions and determinants that account for considerable illhealth across Arab countries: overweight/obesity and tobacco use as key determinants of cardiovascular health; transport injuries as a top cause of death and disability; and mental illhealth, prominent across countries and income levels. Malnutrition, overweight, obesity, and physical activity Undernutrition and overnutrition are major risk factors for disease, mortality, healthy growth, and development [24,25]. Both are prominent in the Arab region, often within the same countries, sometimes within the same household [26e28]. Undernutrition among adolescents is widespread in low-income countries such as Djibouti and Yemen, in countries experiencing humanitarian crises such as Iraq, Somalia, and Sudan, and among underprivileged populations in affluent countries [29e33]. Overweight and obesity have become serious public health problems among Arab adolescents [34e38], linked to high levels of early metabolic syndrome [39e43] and high blood pressure [44]. As risk factors for cardiovascular/circulatory diseases, diabetes, and musculoskeletal disorders, they may account for the considerably higher proportion of DALYs for these conditions
4
C.M. Obermeyer et al. / Journal of Adolescent Health xxx (2015) 1e11
Boys 45
Girls
42 38
40
35
% Physical acƟvity
35
31
30 25
30
29
28 25 23
21
24
23
21
19
18
20
15
14
15 10
13 11
10
20
17
14
11
23
19
10
11
12
10
5 0
Figure 2. Percentage of boys and girls (13e15 years) who were physically active >60 minutes/day on 5 or more days during the past 7 days, WHO Global School-based Health Surveys. Countries displayed in alphabetical order.
among Arab adolescents, consistent with findings among adults in the region [23]. Global school-based student health surveys (GSHS) find levels of overweight/obesity among adolescents of nearly 50% in countries of the Gulf, low levels (
