INTRODUCTION {#sec1-1}
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Lifestyle in any society is a reflection of the prevailing culture,\[[@ref1]\] which can influence expatriates to adopt to enhance their social integration.  This is especially of importance in the current scenario of increased global migration.  Many studies suggests that expatriates do not develop healthy adult lifestyles that include regular exercise due to various barriers such as lack of role models, social support, time, transportation, finance, social norms, and adequate information.  This is of further of concern among women in conservative Saudi Arabian society, which makes it unacceptable for females to participate in sports or other physical activities outdoors.  There are also indications of disordered eating being the result of conflicts between traditional lifestyle and liberalization.\[[@ref2]\] Several studies have also documented the impact of the content of TV and the Internet on children\'s lifestyle choices; these range from the effect of popular TV characters poor eating habits\[[@ref3]\] to consumption of high calorie food which are extensively advertised in the media.\[[@ref4][@ref5][@ref6][@ref7]\] In addition to these direct consequences of TV and Internet, it by default promotes a sedentary lifestyle habits among children\'s, which ultimately leads to the development of obesity.\[[@ref8][@ref9][@ref10][@ref11][@ref12]\] It is indeed not surprising that among children and adolescents, most published research has linked increased television viewing hours with being overweight or obese,\[[@ref13][@ref14][@ref15][@ref16][@ref17][@ref18][@ref19][@ref20][@ref21][@ref22]\] however, a few studies suggests that such associations are very weak and not of clinical concern,\[[@ref26]\] while a few studies are not consistent with these findings\[[@ref23][@ref24][@ref25]\] and some studies refute these conclusions.\[[@ref27][@ref28]\]

Body mass index (BMI) with some exceptions is the most acceptable and universal method of measuring overweight and obesity.\[[@ref29]\] BMI (kg/m^2^) is defined as weight (kg) divided by height squared (m^2^).  It is recommended by the WHO and is an economical method for assessing obesity in large epidemiological studies.\[[@ref30]\] Here, we examined the relationships between sociodemographic, behavioral, and psychosocial lifestyle factors with overweight and obesity among expatriates living in Abha, Kingdom of Saudi Arabia.  We also assessed the self-image and opinions about overweight and obesity in this population. 

MATERIALS AND METHODS {#sec1-2}
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The study was conducted in Abha, Kingdom of Saudi Arabia from September 1, 2013 to February 15, 2014 and involved 550 expatriates.  The study was approved by the King Khalid University Ethical Committee.  The aim of this study was to identify known risk factors for obesity, self-image, and opinions about overweight and obesity in a cohort of expatriates in Abha city of Kingdom of Saudi Arabia and to establish various levels of obesity in this population.  To achieve our aim, a cross-sectional survey with a self-administered paper-based questionnaire was developed \[[Table 1](#T1){ref-type="table"}\].  The survey collected information on lifestyle choices and the risk factors that contribute to obesity.  Height, weight, and waist circumference (WC) were measured.  Questions were designed to get information on hours spent on watching TV, working with computer, idle sitting time, and walking and leisure activities.  Perceptions of obesity and beliefs about overweight were also asked.  Respondents were also asked if they would like to lose weight and how they believed the overweight could be treated.  The questionnaire was acceptable and within the cultural norms for all the expatriates. 

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Questionnaire

![]( JNSBM-6-329-g001)

Data management and analysis {#sec2-1}
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The data collected from each expatriate in each location were recorded every day and packed in a big A4 envelope.  All the envelopes were labeled with the date of survey, venue, and number of participants.  The questionnaires were stored securely to maintain the confidentiality of information and ensure data security.  A spreadsheet, Microsoft Excel™ ((Microsoft Corporation, New Mexico, USA) was used for the data compilation and analysis.  The data were analyzed using GraphPad Prisim (GraphPad Software Inc., San Diego CA, USA). 

RESULTS {#sec1-3}
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The features of the lifestyle patterns observed in our study population are presented in [Table 2](#T2){ref-type="table"}.  19.1% of the participants watched TV for 4 or more h/day while 51.64% watched TV for 2-3 h/day.  A number (29.27%) of the participants watched TV for \<1 h/day.  Eighteen percent of our study population used a computer for 4 or more h/day, and 50% used it for 2-3 h/day.  Over 50% (51.45%) of the participants reported that they sat idle for 2-3 h during the 7 days preceding the study. 

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Features of lifestyle patterns

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The study subjects were categorized as normal weight or overweight based on their BMI and WHO criteria.  The correlation of BMI with the lifestyle patterns of the study subjects is summarized in [Table 3](#T3){ref-type="table"}.  Statistically significant relationship was observed between participants BMI status and time spent sitting idle (*P* = 9.40 × 10^−15^), time spent on the computer (*P* = 6.34 × 10^−27^), and time spent watching TV (*P* = 3.43 × 10^−9^).  Regarding idle sitting time, 34.2% of overweight and obese participants sat idle for 4 or more h/day.  Forty percent of overweight or obese participants reported watching TV for 4 or more h/day.  Respondents who were overweight or obese reported a steady increase in the TV time and idle sitting time.  Interestingly, study subjects who spent \>2 h of idle time or watched TV for \>2 h/day or spent time on internet for over 2 h had a higher BMI and were categorized as overweight \[[Table 3](#T3){ref-type="table"}\]. 

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Lifestyle of respondents and BMI status

![]( JNSBM-6-329-g003)

The study subject\'s beliefs about the treatments for overweight/obesity are summarized in [Table 4](#T4){ref-type="table"}.  A substantial number (68.55%) of respondents believed that the obesity might best be treated by the individual\'s effort to change the diet and exercise regime.  In terms of the dietitian\'s methods to treat obesity, approximately 8.73% believed that a dietitian could help in the treatment of obesity.  Interestingly, the least common treatment option selected was surgery (3.27%). 

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Beliefs about treatment of overweight and obesity

![]( JNSBM-6-329-g004)

The study subject\'s beliefs about BMI and obesity status are summarized in [Table 5](#T5){ref-type="table"}.  The perception of heredity as a cause of obesity significantly (*P* = 5.09 × 10^−9^) differed between normal weight and overweight subjects, with significantly more number of obese individuals associating obesity with heredity factors.  Over 37% of respondents who reported that heredity was not at all important were overweight or obese, while only 40.87% of normal weight subjects indicated heredity as not being important in obesity.  19.57% of normal weight subjects reported that the heredity was only slightly important in being overweight while 38.13% of obese subjects mentioned heredity as a slightly important cause of overweight.  18.13% who were overweight or obese and 37.83% who were not overweight reported that heredity was somewhat important for obesity.  6.25% of overweight subjects and 1.74% normal weight subjects indicated heredity as a very important cause of obesity. 

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Beliefs about obesity and BMI status

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The perception of the study subjects about the various obesity treatment and BMI status is listed in [Table 6](#T6){ref-type="table"}.  The variables of treatment by hospital, clinics or specialists, treatment general practitioners, treatment by dieticians, treatment by social workers, treatment by individual effort, and treatment by surgery were statistically significant (*P* = 8.47 × 10^−26^) with the BMI status.  It is, however, interesting to note that significantly greater number of overweight subjects (73.75%) believed dietary factors and exercise as a valuable treatment in reducing obesity. 

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Beliefs about obesity treatment and BMI status

![]( JNSBM-6-329-g006)

Almost 27.83% subjects who believed in the treatment by dietitians as the best option were not overweight.  25.65% who believed individual effort is the best treatments for obesity were not overweight.  It is also interesting to note that prescription medication and surgery were least preferred option by both normal weight and overweight subjects.  It was also surprising to note general practitioners bring least preferred by the overweight subjects, which indicate the need to enhance confidence among overweight subject to consult their general practitioners, who could be valuable source of information in planning diet and exercise regimen tailored to individual\'s needs.  Interestingly, social works were also one of the least preferred options by both normal weight and overweight subjects, which is indeed disappointing considering the role social workers can play in counseling and guiding overweight subjects.  Nevertheless, it is indeed interesting to know the high degree of variability in perception of treatment options among normal weight and overweight expats in our study subjects. 

DISCUSSIONS {#sec1-4}
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The mechanisms most commonly proposed to explain the link between television viewing and obesity are reduced leisure-time physical activity and increased energy intake.\[[@ref31]\] Television viewing is hypothesized to supplant physical activity and/or increase caloric intake through snacking in response to the numerous cues in advertisements for energy dense foods of poor nutritional content.\[[@ref32][@ref33][@ref34]\] Our study provides some support for both mechanisms.  Men and women who were frequent television viewers were more likely to be inactive in their leisure time.  Low consumption of fruit and vegetables, which is contrasted with a diet high in fat,\[[@ref35]\] was also associated with high levels of television viewing.  A third possible explanation of the link between television time and obesity is the low metabolic rate associated with television viewing.  It is evident that prolonged excessive internet use and TV viewing takes away valuable time from certain necessary activities that children should engage in.\[[@ref36][@ref37]\] Excessive internet use and TV viewing not only result in the lack of sleep but also affect concentration levels.  Indeed in our study overwhelming majority of children received \<9 h of sleep; more specifically most of the overweight and obese children received \<7 h of sleep (data not shown).  This is particularly significant since numerous studies have reported that link of lack of sleep with becoming obese among both children and adults.\[[@ref38][@ref39][@ref40][@ref41]\] In a European study, the EPIC-PANACEA survey, which was conducted in nine European countries, physical activity at work and leisure-time physical activity were inversely correlated with BMI and WC.\[[@ref42][@ref43]\] TV watching leads to harmful habits such as passive snacking and lust for sugar-sweetened soft drinks and energy-dense foods.\[[@ref44]\] Which leads to lower metabolic rate in comparison with other sedentary activities like sewing, playing board games, driving a car, reading, and writing.\[[@ref45]\] Finally, the relation between TV watching and metabolic diseases could be partly attributed to the psychological stress induced by TV, which enhances insulin resistance, sympathetic system activation, visceral adiposity, and metabolic syndrome.  Notably, the aforementioned associations between physical activity, sedentary lifestyle patterns, and cardiometabolic risk factors were observed almost exclusively among males rather than females.\[[@ref46][@ref47]\] Intervention studies specifically targeted at reducing television viewing have yielded encouraging results in reducing obesity levels among children and adolescents.\[[@ref48]\] Furthermore, some evidence indicates that recommendations aimed at reducing sedentary behaviors may be more effective than those targeted at promoting physical activity.\[[@ref49]\] Studies have found that sedentary behaviors, particularly television viewing, adopted in childhood track into adulthood, and some even suggest that sedentary behaviors track more strongly than physical activity.\[[@ref50][@ref51][@ref52][@ref53]\]

CONCLUSIONS {#sec1-5}
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Overweight and obesity among expatriates within Saudi Arabia poses an important public health problem.  Embracing Western influences due to its global consumerism culture, changes in diets, attitudes, and lifestyle due to the economic boom and sudden transition have had a profound impact on the health of the people.  This research provides the singular important information concerning attitudes and body image concerns among expatriates in the Kingdom of Saudi Arabia.  Hence, there is a need for more public health educational programs by health professionals as well as effective interventions on health awareness and education for the population.  Social ties and social networks, to which an individual belongs, have a great influence on the beliefs and attitudes of the individual toward overweight and obesity. 

**Source of Support:** Nil. 

**Conflict of Interest:** None declared.