Risk factors of non-communicable diseases among female university students of the Health Colleges of Taif University

1 Department of Public Health and Community Medicine, College of Medicine and Applied Medical Sciences, Taif University, Saudi Arabia. 2 Department of Public Health and Community Medicine, Faculty of Medicine, Menoufyia University, Egypt. 3 Division of Biochemistry, Pharmacology and Toxicology Department, College of Pharmacy, Taif University, Al-Haweiah, Taif, Saudi Arabia. 4 Chemistry Department, Faculty of Science, Benha University, Benha, Qalyubia, Egypt. 5 Department of Pathology, college of medicine, Taif University, KSA. 6 Department of laboratory medicine, King Abdul Aziz Specialized Hospital, Taif, Saudi Arabia. 7 Department of laboratory medicine King Abdul Aziz Specialized Hospital, Taif, Saudi Arabia. 8 Department of Public Health and Community Medicine, College of Medicine and Applied Medical Sciences, Taif University, Saudi Arabia.


INTRODUCTION
Non-communicable diseases (NCDs) are a group of diseases accounting for millions of deaths globally each year (Zyl et al., 2010).Two-thirds of the 52•8 million deaths worldwide in 2010 were caused by these diseases, with ischaemic heart disease, stroke, chronic obstructive pulmonary disease, lung cancer, and diabetes ranking among the top ten causes (Lozano et al., 2010).
The most important risk factors for these diseases are high blood pressure, high concentration of cholesterol, inadequate intake of fruits and vegetables, overweight and obesity, physical inactivity and tobacco use (WHO, 2010 a).The World Health Organization (WHO) projected that by 2015, NCDs will account for over 70% of all deaths globally with 80% of these deaths occurring in developing countries (WHO, 2005).Studies have stated that the prevalence of risk factors for non-communicable diseases in adolescence results in a significant tendency towards development of disease in adulthood.Thus, adolescence is the appropriate period for proper intervention (Aboul Ell et al., 2011).In Saudi Arabia, there is a recent epidemic of noncommunicable diseases (Al-Nozha et al., 2004).The increase in the prevalence of these lifestyle-related diseases in Saudi Arabia is attributed to decreased physical activity and changes in dietary patterns (Al-Hazzaa, 2004).As at 2008, 26.6 per 1000 female population deaths and 46 per 1000 male population deaths in Saudi Arabia were attributed to NCDs (WHO, 2011).Prevention of NCDs has always been better than cure due to the slow manifestation of symptoms and the irreversibility of most of these diseases (Saudi Arabia Ministry of Health, 2005).In any community, this prevention depends on controlling the predisposing risk factors (Al-Nozha, 2007a), and identifying the risk-factor profile for that community (Zyl et al., 2010).Data about the magnitude of NCDs and its risk factors among young population in the KSA are scarce, that is why this study was carried out to assess the prevalence of risk factors of NCD among a sample of female university students.

METHODOLOGY Study design and sampling
This study was a cross sectional study carried out in Taif city, in the Kingdom of Saudi Arabia (KSA).The target population was all female university students of the three health colleges (Medicine, Pharmacy and Applied Medical Sciences) of Taif University.A total of 263 students were studying in different levels in these faculties during the study period.Total coverage was carried out and all students were invited to participate in the study.The study was in the context of time frame from March to June, 2012.The purpose of the study was explained to the students and verbal and written consents were soughed.The response rate was 86.31%, and a total of 227 students constituted the subjects of the study.Participants were consented to fill the questionnaire and only 119 of them agreed to donate blood samples for analysis.

Study tool
The Arabic version of the WHO STEPs approach was adopted.It uses three steps of chronic disease risk factors assessment (WHO STEPs instrument).
Step (1): Collecting information via a predesigned questionnaire on age, marital status, average household income, family history of chronic non-communicable diseases (diabetes, hypertension and obesity), pattern of physical activity and diet.Medical and health history component included questions on cigarette use, diabetes mellitus and hypertension.Step (2): Measurement of participants" blood pressure and anthropometrical measurements which included height, weight, hip and waist circumferences, and Step (3): the analysis of participant"s blood samples for fasting blood glucose, fasting total cholesterol and triglycerides levels.

Ethical points
Official approvals were obtained from the ethics committee of the Taif University, and from the vice dean of the college of applied medical sciences.Verbal and written consents were obtained from all the respondent students before participating in the study.

Procedure
Participants were involved in the study for two settings: the first was for completing the questionnaire (conducted by the researchers), measuring blood pressure and anthropometric measurements (carried out by the nurse in the medical clinic of the college of applied medical sciences), and the second was for collection of blood samples.

Collected variables
Current daily smokers were defined as those who mentioned smoking at least one cigarette per day, and non-smokers were defined as those who currently do not smoke cigarettes or were never smokers (Centre for Disease Control and Prevention, 2010).Physical activity was measured by applying the section on leisuretime activity from the long version of the International Physical Activity Questionnaire (IPAQ) (International Physical Activity Questionnaire 1 (IPAQ) Research Committee, 2005).Students were asked questions to recall all physical activities they had performed during the previous week, where the student was classified as sedentary when she practiced less than 150 min of physical activity in a normal week (Craig et al., 2003).
Waist and hip circumferences were measured according to the WHO guidelines, where measurements were taken to the nearest 0.1 cm (WHO, 2008).The waist-to-hip ratio was estimated by dividing waist by hip measurements, and a value ≥ 0.8 was considered as central obesity (WHO, 2008).Weight and height were measured while the student was without shoes and wearing light clothes (which is the college uniform), the weight was measured to the nearest 10 g with a digital physician weighing scale, and a height measuring rod attached to the digital scale.The participant"s body mass index (BMI) was calculated as follows: (BMI = the weight in kilograms divided by the height in meters squared), and she was considered as underweight if her BMI is less than 18.5 kg/m 2 ; normal if BMI = 18.5 to 24.99 kg/m 2 ; overweight if BMI = 25 to 29.99 kg/m 2 ; having mild obesity if BMI = 30 to 34.99 kg/m 2 ; and having severe obesity if BMI > 35 kg/m 2 (Alberti et al., 2008).(Chobanianet al., 2004).BP was classified as follows: normal < 120 mm Hg systolic and < 80 mm Hg diastolic; prehypertension: 120 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic; hypertension if systolic blood pressure was at least 140 mm Hg, her diastolic blood pressure was at least 90 mm Hg, or if she was currently on anti-hypertension medication (Whitworth, 2003;Chobanian, 2003).Blood samples were taken for biochemical assessment.For blood samples the study respondents were asked to fast overnight and not consume any food except for clear water after supper/dinner until giving the blood samples in the college clinic in the morning of the following day.Blood samples were centrifuged and serum was obtained for the analysis of the different biochemical parameters.The lipid profile and fasting blood glucose were measured by automated chemistry analyzer (Cobas 6000/C501), with photometric principle.
Diagnosis of diabetes was based on the international criteria recommended by WHO and the Committee on the Diagnosis and Classification of Diabetes Mellitus: fasting blood glucose concentration ≥ 126 mg/dl (Alberti and Zimmet, 1998).The presence of dyslipidemia was defined as: total cholesterol (TC) ≥ 200 mg/dl or triglycerides (TG) ≥ 150 mg/dl (National Cholesterol Education Program (NCEP), 2001).After the reports of the blood analysis were obtained, the students were informed individually about their BP, BMI and laboratory results and advised accordingly.

Statistical analysis
Data were stored on a daily basis using statistical package for social sciences (SPSS), version 16.The qualitative data was expressed as numbers and percentages, and the Fisher"s exact test was applied to test the relationship between variables.Quantitative data was expressed as mean and standard deviation (Mean ± SD), and the Spearman correlation test was applied to test the relationship between variables.A p-value of < 0.05 was considered statistically significant.

RESULTS
Table 1 shows that 52.4% of the participant students were from the college of medicine, 26% were from the college of pharmacy and 21.6% were from the college of applied medical sciences.The mean age of the participant students was 19.8 ± 1.32 years, and all of them were unmarried.According to the smoking habits, Table 2 shows that 3.1% of the students were current smoker, of which 42.9% were daily smokers.The only reported type of smoke used was cigarette smoking and the mean number of cigarettes smoked daily was 2.71 ± 0.48 cigarette.About one third (31.7%) of the students reported to have a family member who is a smoker.Table 3 shows an observed high prevalence (61.7%) of physical inactivity among students.In addition, 43.6% were watching TV and 49.3% of the students were using the computer for more than 14 h per week.Only 25.1 and 40.5% of them consumed adequate amounts of fruits and vegetables per week.

Smoking
Studies have shown that in addition to the physical consequences of adolescent tobacco use, there are also longer-term behavioral, social, educational and mental health effects.In the present study, only 3.1% of the students reported to be current smokers of which, 42.9% were daily smokers (Table 2).The smoking prevalence in this study is consistent with the prevalence observed in more than 12 cited articles on smoking among university students in Saudi Arabia (Al- Turki and Al-Rowais, 2008;Al-Mahmoudi and Amin, 2010), where the overall tobacco consumption among female students ranged from 1 to 16%.Low prevalence has also been observed in other studies conducted on female college students of different universities in Saudi Arabia, where the prevalence was (8.6 and 4.3%, respectively) (Koura et al., 2011;Al-Kaabba et al., 2011).The observed lower prevalence of smoking among female students in our study can be attributed to the ""social stigma"" that may force students to avoid reporting being a smoker, as smoking is considered a taboo in conservative communities such as Saudi Arabia, especially Taif which may be responsible for the underreporting among females (Mandil et al., 2011).

Physical activity
Physical inactivity is considered an independent risk factor of a number of chronic diseases such as coronary heart disease, diabetes and hypertension (US Department of health and human services, 1996).Studies also proved that participation in regular physical activity over time is associated with a decrease in all causes of mortality (Lollgen et al., 2009).In Saudi Arabia, the published reports on physical activity profile of Saudi population indicated that the majority of them are physically inactive (Al-Nozha, 2007b).
In the present study the majority of our students (61.7%) were physically inactive (Table 3).This result is in agreement with a previous study revealing high prevalence of physical inactivity among all Saudi females generally, and among university students particularly (Lollgen et al., 2009).This is in consistence with results from the WHO STEPwise approach to NCDs surveillance ).The high level of physical inactivity observed in this study could be attributed to the limited opportunities of Saudi females to engage in physical activity due to the absence of physical education programs for girls, in addition to cultural reasons where families may not encourage females to engage in physical activity.Moreover, most of Saudis rely on cars rather than walking for short-distance travel (Al-Hazzaa, 2006;Al-Hazzaa et al., 2011).The World Health Organization"s "Global Recommendations on Physical Activity for Health" has proposed more than 150 min of moderate-intensity physical activity (PA) per week to maintain body weight.
In the present study the mean value of metabolic equivalents of task (MET) minutes per week was (130.95) min, and this did not meet the (WHO"s) "Global Recommendations on Physical Activity for Health (WHO, 2010b).The sedentary behavior was defined as spending three or more hours per day sitting, watching television or playing computer games (Guthold et al., 2010).In the present study, 43.6 and 49.3% of the students were watching TV and using the computer for more than 14 h per week.These results are lower than those revealed from a study done on a sample of Saudi adolescents in Al-Khobar, Jeddah and Riyadh cities, where 84% of males and 91.2% of females spent more than 2 h on screen time daily (Al-Hazzaa et al., 2011).This can be attributed to the engagement of our students in medical education.A non-significant correlation was found between minutes of physical exercise (MET values) with other variables (fast food consumption, TV watching, computer usage, blood pressure, waist circumference and waist-hip ratio measurements) (Table 6).Similar results were revealed from another Saudi study on university students (Sabra et al., 2007).

Diet
College students are highly exposed to unhealthy eating habits leading to body weight gain (Huang et al., 2003).In this study, based on the Center of Disease Control and Prevention (CDC) recommendations of current daily fruit and vegetable intake (CDC, 2013), only 25.1 and 40.5% of the students consumed adequate amounts of fruits and vegetables per week, respectively (Table 3).The same results were observed from a study done in Al-Khobar, Jeddah and Riyadh cities (Al-Hazzaa et al., 2011), and from a study done on male university students in Dammam and Qassim Cities (Sabra et al., 2007;Al-Rethaiaa et al., 2010).Low intake of vegetables and fruits observed among the studied students could be attributed to the low content of vegetables in most of the traditional Saudi meals (for example, Kabsa, Margog, Mandy) (Al-Rethaiaa et al., 2010).Other causes are the increasing consumption of animal products and refined foods in Saudi diet at the expense of vegetables and fruits, and the uncommon intake of raw vegetables and fruits in the course of meals among Saudi population (Al-Rethaiaa et al., 2010;Amin et al., 2008).Similar results of low fruit and vegetable consumption were reported from studies done on adolescents and university students in Iran, Syria and United Arab Emerates (UAE) (Kelishadi et al., 2007;Mahmood et al., 2012;Kerkadi, 2003).
About seventy percent (70.9%) of the students reported consumption of fast food in breakfast, lunch or dinner 1 to 5 times per week.This high consumption was also revealed from a study on female university students in Dammam city (Koura et al., 2012), and from studies done on adolescents and university students in UAE and Syria (Kerkadi, 2003;Bashour, 2004).About fifty percent of our students (51.1%) reported using saturated fatty acids in family cooking.This was also revealed from a previous Saudi study (Koura et al., 2012), and from other studies in the Middle East (Musaiger, 2002).This observed bad dietary habits could be attributed to the rapid improvement in the economy which makes people to consume diets high in saturated fat, cholesterol, salt, and refined carbohydrates, and low in polyunsaturated fats and fiber (Galal, 2003).

Body mass index
In Saudi Arabia, the dietary changes were accused for increasing the prevalence of both overweight and obesity (El-Hazmi and Warsy 2002).In an earlier study done in Taif city in 1996, the prevalence of underweight and overweight or obese was 14.7 and 16.3%, respectively (Madani et al., 1996).In the present work, 28.6% of the students were overweight, 18.1% had mild to severe obesity and 6.6% were underweight and 46.7% had normal weight (Table 4).Nearby results were observed from a study done on university students in Riyadh, where 31% of the sample were overweight, 23.3% was obese and 45.8% had normal body weight (Al Turki, 2007).These findings were also close to data from studies done on Saudi female university students, Saudi females in the childbearing age (AL Qauhiz, 2010;Al-Malki et al., 2003), and Saudi female adolescents (Al-Hazzaa et al., 2012).These high figures of overweight and obesity in our study can be explained in view of the predominance of unhealthy dietary behaviors of participants.Our figures are higher than that observed in other Arab and Eastern countries.This may be attributed to better education and modern dress of female university students in these countries which outlines their body contours as compared to the traditional dressings in KSA (Suleiman et al., 2009).
In the present work, 15% of the students had unacceptable waist circumference (WC) (more than 80 cm), and according to the waist hip ratio indicating central obesity, 11.9% of them had unacceptable waist hip ratio (WHR) (more than 0.85) (Table 4).This high prevalence of unacceptable WC and WHR was also observed in another two studies conducted on Saudi female university students and healthy young Saudi females (Al Kadi and Alissa, 2011;Koura et al., 2012).In addition, the mean value of waist circumference observed in this study is comparable to data observed in a previous study on Saudi adolescents (Al-Hazzaa et al., 2012).A significant negative correlation was found between actual MET minutes of physical exercises and the BMI categories (Table 6).This finding is consistent with studies which proved that physical inactivity is a leading factor of obesity during adolescence (Kelishadi et al., 2007).The same findings were revealed from studies done in USA and other 34 countries (Janssen et al., 2005), and from other Saudi studies (Mahfouz et al., 2008;Al-Hazzaa et al., 2012).

Lipid profile (Cholesterol and TG)
According to the WHO"s STEPwise approach to Surveillance (STEPS) of Non-Communicable Diseases (NCD) conducted in Saudi Arabia in 2005 (Saudi Arabia Ministry of Health, 2005), the overall prevalence of dyslipidemia ranged from 20 to 40%.In this study, 31.1% of the students had unacceptable fasting blood cholesterol level and 33.6% had unacceptable fasting blood triglycerides (TG) level (Table 4).Similar results of presence of dyslipidemia among young Saudi population were revealed from a large population-based study conducted in Riyadh city, where the prevalence of low HDL-C was 85% among the age group between 18 to 29 years (Al-Daghri et al., 2010).Results revealed from this study are in agreement with a recent study done on healthy young Saudi females which showed remarkable hyperlipidemia (Al Kadi and Alissa, 2011).However, our results are lower than that witnessed in other Arabian and Western countries (Shawar et al., 2012;Palomo et al., 2006).This difference could be attributed to the variations in lifestyles and demographic features and to the high carbohydrate intake which was reported in the Saudi youth (Amin et al., 2008).A significant positive correlation was found between BMI categories and the levels of blood lipids (cholesterol and triglycerides) (Table 5).This result was also revealed from studies done on Saudi male university students (Al-Ajlan, 2011; Hegazi et al., 2011), and it is consistent with studies done in other countries (Humayun et al., 2009).

Hypertention
In KSA, previous studies on the prevalence of hypertension attributed the high prevalence to lifestyle changes towards urbanization and dietary eating habits (Al-Nozha et al., 2007).In the present study, 23.8% of the students had systolic pre-hypertension, 13.2% had diastolic pre-hypertension (Table 4).The mean value of systolic and diastolic blood pressure observed in our study is comparable to those observed in a study on female university students of King Saud University in 2011 (Abdel-Megeid et al., 2011).According to the prevalence of pre-hypertension, our results are in consistence with those observed from another study on female university students in Dammam city, where 13.5% of them were pre-hypertensive (Koura et al., 2012).However a higher prevalence was observed in another study on male students in the same region (Sabra, 2007).
In the present study, 11.9% of the students were diagnosed to have systolic hypertension, and only 0.9% of the students were diagnosed to have diastolic hypertension type 1.This result is much lower than that observed in a national survey in Saudi Arabia, where 7.8% of population aged 15 to 24 years were hypertensive (Saeed et al., 2011).

Diabetes
Previous studies from Saudi Arabia suggested that the rapid socioeconomic changes in the country over the last thirty years have contributed to the high prevalence rate of diabetes (Madani et al., 2000).In the present work, 2.5% of the students had high fasting blood glucose level (Table 4).This result is in consistence with results revealed from the WHO STEP wise survey conducted in KSA in 2005, where 2.4% of women aged 15 to 24 years were diagnosed to have diabetes (Saudi Arabia Ministry of Health, 2005).In comparison to other Arabian countries, higher figure was observed from a Lebanese study, where 3.5% of adolescents were diagnosed to have diabetes (Salameh and Barbour, 2011).

Study limitations
This study has some limitations including the small sample size, and the inclusion of young educated females which may limit the generalizability of our results.
In addition, risk factors were assessed using a questionnaire, a form of assessment that could be subjected to recall bias.In a conservative community as Saudi Arabia, women may feel ashamed to admit certain habits as smoking.That is why longitudinal studies on large samples of young population including both sexes should be carried out.

CONCLUSION AND RECOMMENDATIONS
The aim of this study was to assess the prevalence of risk factors of NCDs among female university students.

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Results of the study revealed a high prevalence of these risk factors among the participants.The study calls for the importance of implementation of educational and awareness programs on NCDs risk factors to Saudi young population.These programs should focus on the importance of adoption of healthy life styles in this young age, to avoid the occurrence of NCDs in adulthood.
Further studies should be done to assess knowledge and attitudes of young Saudis to healthy lifestyles, and to address barriers towards adopting it.

Table 1 .
Distribution of the health colleges"s students according to their socio-demographic characteristics.

Table 2 .
Distribution of the female health colleges"s students according to their smoking habits.

Table 3 .
Distribution of the female health colleges"s students according to their physical activity and nutritional habits.
(Kelishadi et al., 2007;Suleiman et al., 76.2% of females aged 15 to 24 years were physically inactive (Saudi Arabia Ministry of Health, 2005).When compared with similar studies, the results of our study are in agreement with those revealed from other Iranian and Jordanian studies(Kelishadi et al., 2007;Suleiman et al.,

Table 4 .
Distribution of the participant students according to their physical measurements.

Table 5 .
Correlation between BMI categories and other variables.

Table 6 .
Correlation between MET minutes of physical activity and other variables.