Review Article

The Epidemiology and Economic Burden of Obesity and Related Cardiometabolic Disorders in the United Arab Emirates: A Systematic Review and Qualitative Synthesis

Table 1

Characteristics of included epidemiological studies

Author and yearStudied disease (criteria)Study typeParticipant characteristicsSampling

Obesity in childrenAl Hourani et al.. (2003) [21]At risk for overweight: BMI ≥ 85–95th percentiles for age and sex Overweight: ≥95th percentile for age and sex (NHANES reference data)Cross-sectional Period: October 1998–April 1999Emirate: Abu Dhabi (43.2%), Sharjah (19.2%), Dubai (16.3%), Ras Al Khaimah (16.1%), and Fujairah (5.2%) Nationality: Emirati Gender: female schoolchildren (public) aged 11–18 yearsUnclear Sample #: 898
Al Haddad et al. (2005) [22]Overweight: BMI ≥ 25 kg/m2 and <30 kg/m2 Obesity: BMI ≥30 kg/m2 (Cole et al. International Standards for overweight and obesity)Cross-sectional Period: October 1998–April 1999Emirate: All (national) Nationality: Emirati Schoolchildren aged 4–18 yearsMultistage stratified cluster sampling; stage 1: educational districts; stage 2: schools by PPS; stage 3: all Emirati students Sample #: 15,989
Malik and Bakir (2007) [15]Overweight: BMI >25 kg/m2 Obesity: BMI >30 kg/m2 (IOTF classification)Cross-sectional Period: October 1998–April 1999Emirate: All (national: Abu Dhabi: 47.2%; Abu Dhabi (Al Ain): 34.5%; others: 18.3%) Nationality: Emirati: 48%; others: 52% Gender: boys: 49.6%; girls: 50.4% Schoolchildren (public and private) aged 5–17 yearsTwo-stage PPS cluster random sampling: stage 1: schools (categorized according to size, gender, ethnic mix, type, and area of residence; randomization method not detailed); stage 2: one or more whole class per each school grade (25 children) Sample #: 4,381
Abdulrazzaq et al. (2011) [16]Overweight: (1) Under 5 years: ≥1 SD (equivalent to BMI 25 kg/m2 at 19 years) (WHO criteria) (2) 18 years old: IOTF guidelines (3) Other age groups (NR) Obesity: (1) Under 5 years: ≥2 SD (equivalent to BMI 30 kg/m2 at 19 years) (WHO criteria) (2) 18 years old: IOTF guidelines (3) Other age groups (NR)Cross-sectional Period: 1991-1992Emirate: All (national) Nationality: Emirati Age: 0–18 yearsMultistage stratified random sampling (not detailed) Sample #: 20,494
Al Haddad et al. (2000) [14]Overweight: BMI ≥85th and <95th percentiles for age and sex Obesity: BMI ≥95th percentile for age and sex or BMI ≥30 kg/m2, whichever is smaller (NHANES reference data)Cross-sectional Period: NREmirate: Ras Al Khaimah Nationality: Emirati Gender: girls: 56.1%; boys: 43.9% Schoolchildren aged 6–16 yearsUnclear Sample #: 4,075
Al Blooshi et al. (2016) [23]Overweight, obesity, and extreme obesity: IOTF (1) Overweight: BMI ≥25 kg/m2 equivalent and <30 kg/m2 equivalent (2) Obesity: BMI ≥30 kg/m2 equivalent WHO (1) Overweight: BMI for age ≥85th percentile and <95th percentile (2) Obesity: BMI for age ≥95th percentile CDC (1) Overweight: BMI for age ≥85th percentile and <95th percentile (2) Obesity: BMI for age ≥95th percentileCross-sectional Period: 2014-2015Emirate: Ras Al Khaimah Nationality: Emirati: 92%; others: 8% Gender: girls: 51%; boys: 49% Mean age: 10.4 (3.9) (range: 3–18 years) Schoolchildren (public)Exhaustive (all governmental schools in Ras Al Khaimah, with assigned nurses or where height/weight measurements are directly supervised) Sample #: 29,410
Bin Zaal et al. (2009) [24]Overweight: 85th to <95th BMI percentiles Obesity: ≥95th BMI percentile (WHO, 1995)Cross-sectional Period: NREmirate: Dubai Nationality: Emirati Gender: girls: 51%; boys: 49% Age range: 12–17 years Preparatory and secondary school studentsMultistage stratified random sampling (stratified by sex and school type: preparatory and secondary; randomization method not detailed) Sample #: 661
Al Junaibi et al. (2013) [25]Overweight: 85th < BMI <95th CDC percentile for age and sex Obesity: BMI ≥95th CDC percentile for age and sexCross-sectional Period: January–December 2011Emirate: Abu Dhabi Nationality: Emirati: 71.9%; others: 28.1% Gender: girls: 48.9%; boys: 51.1% Schoolchildren (public) aged 6–19 yearsTwo-stage stratified sampling by gender: stage 1: schools; stage 2: students by PPS Sample #: 1,440
Musaiger et al. (2012) [26]Overweight: IOTF reference standard Obesity: IOTF reference standardCross-sectional Period: March 2010–January 2011Emirate: Sharjah Nationality: NR Gender: boys: 51.9%; girls: 48.1% Mean age: boys: 16.41 (0.93); girls: 16.54 (0.99) (range: 15–18 years) Students in secondary schools (public)Multistage stratified random sampling: stage 1: administrative regions, stage 2: schools by PPS to administrative regions, and stage 3: classes (simple random method) Sample #: 505

Obesity in university studentsAmine and Samy (1996) [27]Overweight: 110–120% of the reference value for standard weight for height tables issued by the Nutrition Institute in Cairo, Egypt Obesity: >120% of the reference value for standard weight for height tables issued by the Nutrition Institute in Cairo, EgyptCross-sectional Period: NREmirate: Abu Dhabi (Al Ain) Nationality: Emirati (Abu Dhabi: 40.3%, Dubai: 17.5%, Sharjah: 19.3%, Ras Al Khaimah: 14%, and others: 9%) Gender: female Students in UAE UniversityStratified (according to the number of students from each Emirate) random sampling (not detailed) Sample #: 566 included
Al Mukhtar (2000) [19]Overweight: BMI 25–29.0 kg/m2 Obesity: BMI ≥30 kg/m2Cross-sectional Period: NREmirate: Abu Dhabi (Al Ain) Nationality: NR Gender: female Age: mean: 19.8 (1.5); groups: <20 years: 38.5%; ≥20 years: 61.5% Student residing in hostels related to UAE UniversityUnclear Sample #: 200
Badr and El-Sabban (2008) [28]Overweight: BMI 25–29.9 kg/m2 Obesity: BMI ≥30 kg/m2Cross-sectional Period: 1996-1997Emirate: Abu Dhabi (Al Ain) Nationality: Emirati Gender: female: 63.3%; male: 36.7% Mean age: 20.4 (1.6) (female: 20.0 (1.6); male: 21.03 (1.5)) Students in UAE UniversityRandom sampling (not detailed) Sample #: 98
Musaiger et al. (2003) [29]Obesity: BMI ≥25 kg/m2Cross-sectional Period: NREmirate: Abu Dhabi (Al Ain) Nationality: NR Gender: male Age range: 18–24 years Student residing in hostels related to UAE UniversityTwo-stage random sampling: stage 1: hostels (simple random); stage 2: students (systematic random) Sample #: 300
Sheikh-Ismail et al. (2009) [30]Overweight: BMI 25–29.9 kg/m2 Obesity: BMI ≥30 kg/m2Cross-sectional Period: October 1999–April 2000Emirate: Abu Dhabi (Al Ain) Nationality: Emirati from all emirates Gender: female Age: 20–<30: 44.2%; 30–<60: 49.2%; >60: 6.6% Students in UAE UniversityFor students: stratified proportionately to emirate size and conveniently from university facilities, cafeteria, student hostels, sports center, library, and classes For their family members: random (not detailed) Sample #: 724
Kerkadi (2003) [31]Overweight: 25 < BMI > 29.9 kg/m2 Obesity: BMI ≥30 kg/m2 (WHO classification) Hypertension (NR) Diabetes (NR)Cross-sectional Period: NREmirate: Abu Dhabi (Al Ain) Nationality: NR Age range: 18–25 years Students in UAE UniversityConvenient sampling Sample #: 400
Musaiger and Radwan (1995) [32]Overweight: BMI 25–29.9 kg/m2 Obesity: BMI 30+Cross-sectional Period: 1993Emirate: Abu Dhabi (Al Ain) Nationality: Emirati: 91.6%; others: 8.4% Gender: female Mean age: 19.7 (1.3) (range: 18–30 years) Students in UAE UniversityConvenient sampling Sample #: 215
Papandreou et al. (2015) [33]Overweight (not defined) Obesity (not defined)Cross-sectional Period: 2014Emirate: NR Nationality: NR Gender: female Mean age: 20.55 (2.25) Students in 1 public universityConvenient sampling Sample #: 243

Obesity in communityNg et al. (2011) [3]Adults: (1) Overweight: ≥25 BMI <30 kg/m2 (2) Obesity: BMI ≥30 kg/m2 (WHO, 2000) Children and adolescents (<19 years): IOTF cutoffsCross-sectional Period: 2009-2010Emirate: All (national) Nationality: Emirati Adult women: ≥19 years; adolescents: 11–18 years; children: 6–10 yearsMultistage random sampling: stage 1: census enumeration area in the urban areas or a village in the rural areas; stage 2: households (randomization method not detailed); participants (not detailed) Sample #: households: 628 (adult women: 478; adolescents: women: 143 and men: 133; children: women: 126 and men: 127)
Carter et al. (2004) [34]Overweight: BMI 25–29.9 kg/m2 Obesity: BMI ≥30 kg/m2 (NHLBI)Cross-sectional Period: September 2000–August 2001Emirate: Abu Dhabi (Al Ain) Nationality: Emirati citizen (by birth: 79%; by marriage: 21%) Gender: female Mean age: 34.3 (14.7) Community-dwellingStratified multistage random sampling: stage 1: living areas (randomization unclear); stage 2: houses (systematic randomization); stage 3: all women living in chosen houses Sample #: 535

Metabolic syndromeMehairi et al. (2013) [35]Metabolic syndrome (IDF definition) WC ≥90th percentile or ≥94th percentile; cut points for youth aged ≥16, TG ≥150 mg/dL (1.7 mmol/L), HDL-C <40 mg/dL (1.03 mmol/L) or <50 mg/dL (1.29 mmol/L) for female adolescents aged ≥16, FBG >100 mg/dL (5.6 mmol/L), and BP ≥130/80 mmHgCross-sectional Period: March–April 2010Emirate: Abu Dhabi (Al Ain) Nationality: Emirati: 52%; others: 48% Gender: male: 51.6%; female: 48.4% Mean age: 15.4 (1.8) (range 12–18 years) Schoolchildren (public and private)Two-stage PPS random sampling: stage 1: schools (randomly selected by using SPSS Software); stage 2: students sampled proportional to the enrollment size of each school (self-weighting) Sample #: 1,018
Al Dhaheri et al. (2016) [36]Metabolic syndrome ≥3 of the following: (1) elevated WC (≥80 cm); (2) hypertriglyceridemia (TG ≥150 mg/dL or drug treatment for elevated TG); (3) reduced HDL-C (<50 mg/dL or drug treatment for reduced HDL-C); (4) elevated BP (SBP >130 mmHg and/or DBP >85 mmHg or use of antihypertensive drugs); (5) elevated FBG (≥100 mg/dL or use of hypoglycemic medication) (IDF and AHA/NHLBI)Cross-sectional Period: 2013-2014Emirate: Abu Dhabi (Al Ain) Nationality: Emirati Gender: Female Mean age: 20.4 (1.7) (range 17–25 years) Students in UAE UniversityStratified random sampling: stratification by college, followed by random subsample of 10% of each college (unclear randomization) Sample #: 555
Malik and Razig (2008) [17]Metabolic syndrome: NCEP and IDF definition (ethnicity-specific cutoff levels of WC to define central obesity ≥90 cm for South Asian men and ≥94 cm for men from other nationalities; for women, irrespective of ethnicity: ≥ 80 cm; high WHR: ≥0.95 for men and ≥0.90 for women)Cross-sectional Period: October 1999–June 2000Emirate: All (national) Nationality: Emirati: 42%; others: 58% Gender: male: 41.3%; female: 58.7% Mean age: 41.45 (11.7)Participants recruited from the 2000 Emirates National Diabetes study and screening for risk factors for Coronary Artery Disease Study Multistage, stratified, cluster random sampling (not detailed) Sample #: 4,097

DyslipidemiaAgarwal et al. (1995) [37]Dyslipidemia (elevated total cholesterol) Borderline high: 200–239 mg/dL High: 240 mg/dL (NCEP guidelines)Cross-sectional Period: NREmirate: NR Nationality: UAE nationals: 26.6%; Arabs (non-UAE): 45.9%; non-Arabs: 27.5% Gender: female: 24.6%; male: 75.4% Age: <51 years: 85.1%; >51 years: 14.9%Convenient sampling (recruitment from urban public sites, e.g., shopping malls, mosques, etc.) Sample #: 834

HypertensionAbdulle et al. (2014) [38]Prehypertension: BP ≥90th and <95th CDC percentiles for age and sex Hypertension: BP ≥95th CDC percentile for age and sexCross-sectional Period: January 2011–December 2011Emirate: Abu Dhabi Nationality: Emirati Gender: female: 47.3%; male: 52.7% Mean age: female: 11.0 (3.4); male: 11.7 (3.5) (range 6–17 years)  Schoolchildren (public)Two-stage random sampling: stage 1: public schools (stratified to collect a similar number of boys and girls); stage 2: students (proportional to school size)  Sample #: 999 (405 non-Emirati and 36 Emirati adults were excluded)
El Shahat et al. (1999) [39]Hypertension: SBP >140 mmHg and/or DBP >90 mmHg, and/or self-reported treatment with antihypertensive medications (JNC-VI on detection, evaluation, and treatment of high blood pressure)Cross-sectional Period: 1997Emirate: Sharjah Nationality: Emirati Gender: female: 53%; male: 47% Age: 17–30: 26%; 31–50: 46%; >50: 28% (range: 18–75 years)Stratified (unclear) systematic random sampling (PHC) and census of governmental departments’ employees Sample #: 3,150

DiabetesEl Mugamer et al. (1995) [40]Diabetes: random BG (taken 2–4 hours after a meal) ≥11.1 mmol/L (WHO) Hypertension: SBP >140 mmHg and/or DBP >90 mmHg Obesity: BMI ≥30 kg/m2Cross-sectional Period: 1989-1990Emirate: Abu Dhabi (Al Ain) (Zakher (urban) and Al Hayer and Wagan (rural) areas) Nationality: Emirati Gender: female: 61.8%; male: 38.2% Age: >19 yearsPurposive for the locations (to increase the Bedouin-derived population); unclear for participants Sample #: 322
Saadi et al. (2007) [41]Prediabetes: impaired fasting glucose (venous blood glucose: 5.6–6.9 mmol/L) or impaired glucose tolerance (2 h post-OGTT venous blood glucose: 7.8–11.0 mmol/L) Diabetes: fasting venous blood glucose concentration ≥7.0 mmol/L and/or 2 h post-OGTT venous blood glucose concentration ≥11.1 mmol/L (WHO expert group)Cross-sectional Period: December 2005–November 2006Emirate: Abu Dhabi (Al Ain) Nationality: Emirati Gender: female: 50.9%; male: 49.1% Age: ≥18 yearsTwo-stage sample: stage 1: houses (simple random sample of houses listed in the electricity department); stage 2: all men and nonpregnant women living in chosen houses Sample #: 452 houses (2455 adults, including 2396 for whom diabetes status was available)

Multiple risk factorsMalik et al. (2005) [18]Abnormal glucose tolerance: WHO expert group recommendation Diabetes: FBG ≥7.0 mmol/L and/or 2 h BG ≥11.1 mmol/L Impaired fasting glycemia: FBG: 6.1–6.9 mmol/L IGT: 2 h venous BG: 7.8–11.0 mmol/L on the OGTT Hypertension: SBP ≥140 mmHg and/or DBP ≥90 mmHg Central obesity: WHR ≥0.95 for men and ≥0.90 for women Preobesity: BMI 25–29.9 kg/m2 Obesity: BMI ≥30 kg/m2Cross-sectional Period: 1999-2000Emirate: All (national) Nationality: Emirati: 40%; others: 60% Gender: male: 43%; female: 57% Age: ≥20 yearsParticipants recruited from the 2000 Emirates National Diabetes study and screening for risk factors for Coronary Artery Disease Study Multistage, stratified, cluster random sampling (not detailed) Sample #: 5,844
Yusufali et al. (2015) [42]Dyslipidemia: history of known or treated dyslipidemia (receiving cholesterol-lowering medication) or total cholesterol ≥200 mg/dl or HDL-C <40 mg/dl Hypertension: history of known and treated hypertension (receiving antihypertensive medication) or SBP ≥140 mm Hg or DBP ≥90 mm Hg Obesity: BMI ≥30.0 kg/m2 Diabetes: history of known and treated diabetes (receiving antihyperglycemic medication) or HbA1c ≥6.5% Central obesity: WC ≥102 cm in male and ≥88 cm in femaleCross-sectional Period: September-October 2012Emirate: Dubai, Abu Dhabi, Sharjah, Fujairah, and Ras Al Khaimah Nationality: Emirati: 6.7%; other Arabs: 9.9%; South Asians: 73.7%; other Asians: 4.6%; others: 5.1% Mean age: 38 (11) Gender: male: 75%; female: 25%Opportunistic sampling (convenient recruitment from shopping malls, outpatient health care facilities, and labor camps) Sample #: 4,128
Baynouna et al. (2008) [43]Diabetes: FBG >125 mg/dL, use of diabetes medications, or self-reported diabetes (ADA) Prehypertension: BP ≥120/80 mm Hg on more than 2 occasions Hypertension: BP>140/90 mm Hg on both visits (JNC criteria) Obesity: BMI ≥30 kg/m2 Metabolic syndrome: ≥3 of the following: central obesity, high TG, low HDL-C, high BP, or IFG (ATP III criteria) Central obesity (not defined) Dyslipidemia (not defined)Cross-sectional Period: February 2004–February 2005Emirate: Abu Dhabi Nationality: Emirati Gender: female: 51.8%; male: 48.2% Mean age: 44.1 (range: 25–68)Two-stage sampling: stage 1: selection of PHCs stratified by geography (choose the busiest if more than 1); stage 2: random selection from lists of possession of a health card, stratified by gender (randomization method not detailed) Sample #: 817
Hajat and Harrison (2010) [44]Overweight (not defined) Obesity (not defined) Central obesity: elevated WC with ethnicity-specific values Prediabetes: HbA1c 5.7%–6.4% (ADA classification) Diabetes: HbA1c ≥6.5% or random glucose >11.1 mmol/L or self-reported history of diabetes warranting treatment Framingham Risk ScoreCross-sectional Period: April 2008–April 2010Emirate: Abu Dhabi Nationality: Emirati Mean age: 35.2 (13.8)All individuals included in the WEQAYA screening program Sample #: 173,501
Hajat et al. (2012) [20]Overweight: BMI 25 to 29.9 kg/m2 Obesity: BMI ≥30 kg/m2 Central obesity: WHR ≥0.85 for women and ≥0.9 for men Hypertension: self-reported past history of high BP requiring medication or a single elevated clinical BP reading (SBP ≥140 mmHg or DBP ≥90 mmHg) Dyslipidemia: self-reported past history of abnormal cholesterol levels requiring medication or a measured LDL-C ≥4.1 mmol/L or HDL-C ≤1.0 mmol/LCross-sectional Period: April 2009–June 2010Emirate: Abu Dhabi Nationality: Emirati Gender: female: 57%; male: 43% Mean age: 36.82 (14.3)All individuals included in the WEQAYA screening program Sample #: 50,138

EmployeesHossain and Malik (1998) [45]IGT: FBG <7.8 mmol/L and 2-hour BG: 7.8–11.1 mmol/L Diabetes: FBG >7.8 mmol/L or 2-hour BG >11.1 mmol/L Elevated blood cholesterol: fasting total cholesterol >200 mg/dl Obesity: BMI ≥24.99 kg/m2 and WHR >1.0Cross-sectional Period: May 1995–January 1996Emirate: Abu Dhabi Gender: male Age range: 35–49 years Other characteristics: office based in a group of petroleum companiesConvenient sampling Sample #: 358
Newson-Smith (2010) [46]Obesity: ≥30 kg/m2 Diabetes (not defined) Hypertension (not defined)Cross-sectional Period: 2005/2008Nationality: Emirati: 13.3%; Indians: 43.1%; Egyptians: 15.1%; Filipinos: 7.3%; others: 21.2% Gender: male Mean age: 37.3 (range: 19–64 years)  Other characteristics: oil and gas company workersUnclear Sample #: 1,037
IncidenceSreedharan et al. (2015) [13]Diabetes: FBG ≥126 mg/dL or previous first diagnosis of diabetes or documented diabetes by a physician Impaired fasting glucose: FBG 110–126 mg/dL or documented impaired fasting glucose by a physicianRetrospective cohort Period: January 2010–December 2010Emirati and non-Emirati in AjmanExhaustive (all cases treated in 5 PHCs and 2 general hospitals where most of the diabetic patients are presumed to be managed) Sample #: NR

BMI: body mass index; NHANES: National Health and Nutrition Examination Survey; PPS: probability proportional to size; IOTF: International Obesity Task Force; SD: standard deviation; WHO: World Health Organization; CDC: Centers for Disease Control and Prevention; NR: not reported; UAE: United Arab Emirates; NHLBI: National Heart, Lung, and Blood Institute; IDF: International Diabetes Federation; WC: waist circumference; HDL-C: high-density lipoprotein cholesterol; FBG: fasting blood glucose; BP: blood pressure; TG: triglycerides; SBP: systolic blood pressure; DBP: diastolic blood pressure; AHA: American Heart Association; NCEP: National Cholesterol Education Program; WHR: waist-to-hip ratio; JNC: Joint National Committee; OGTT: oral glucose tolerance test; HbA1c: hemoglobin A1c; ADA: American Diabetes Association; ATP: Adult Treatment Panel; LDL-C: low-density lipoprotein cholesterol; BG: blood glucose; PHC: primary health care center.