All relevant data are within the manuscript and its Supporting Information files.

Introduction {#sec005}
============

Obesity refers to the excessive accumulation of fat in the body, which leads to co-morbidities that negatively affect the obese person's health \[[@pone.0234244.ref001]\]. The Centers for Disease Control and Prevention (CDC) defined overweight as body mass index (BMI) over 85^th^ and below 95^th^ percentile and obesity as a BMI over 95^th^ percentile \[[@pone.0234244.ref002]\]. The most prevalent nutritional disorders in the United States (US) are childhood overweight and obesity. In recent years, the occurrence of childhood obesity has tripled in the US as stated by The Obesity Society \[[@pone.0234244.ref003]\]. In the United Arab Emirates (UAE), the prevalence of overweight and obesity varied across age, where below 9 years of age both sexes were below the international standards with an increase overweight and obesity occurring among both genders of 9 to 18 years \[[@pone.0234244.ref004]\]. A more recent study demonstrated that in UAE, obesity starts in toddlers and progresses linearly with age and pointed out an alarming high prevalence of extreme obesity, especially among boys \[[@pone.0234244.ref005]\].

The estimated worldwide prevalence of childhood overweight and obesity has increased from 4.2% in 1990 to 6.7% in 2010, and it is expected to rise more in the following years to reach up to 9.1% in 2020 \[[@pone.0234244.ref006]\].

A combination of various factors clearly contributes to the childhood obesity epidemic. Hence, knowledge of these causative factors will help in the prevention of obesity. Socioeconomic and psychological factors may also contribute to childhood obesity \[[@pone.0234244.ref007]\]. The consumption of high-calories food with no or limited physical activity is the main contributor to childhood obesity \[[@pone.0234244.ref008]\]. Additionally, psychological factors such as familial stress, anxiety, and social isolation may contribute to childhood obesity. Children tend to increase their consumption of food to deal with their emotions and problems \[[@pone.0234244.ref008]\]. In addition, some people have a genetic predisposition for being overweight or obese, but most do not become overweight or obese unless there is an imbalance between calories consumed in diet and calories burned \[[@pone.0234244.ref009]\]. Some studies found that children of lower socioeconomic status have lack of safe places for physical activity and limited access to healthy food thus they tend to consume food that does not spoil quickly such as frozen meals, in addition to high intake of fast and fried food \[[@pone.0234244.ref010]\]. Other studies mentioned that with the economic improvement, a greater demand for fat-rich diet results in an increase in energy consumption predisposing children to obesity and other diseases \[[@pone.0234244.ref011]\]. Moreover, obese children are at higher risk of developing cardiovascular diseases, type 2 diabetes and certain types of cancer such as endometrial, colon, and postmenopausal breast cancer \[[@pone.0234244.ref012]\]. Prevention is the key element for controlling childhood obesity. Strategies that can be followed including; the primary prevention of overweight or obesity itself and second is the prevention of weight regain after weight loss, plus prevention of weight gain in individuals unable to lose weight \[[@pone.0234244.ref007]\]. Several studies have explored childhood obesity \[[@pone.0234244.ref004], [@pone.0234244.ref012]\], and without doubt, the problem is an issue of public concern. There is also unanimous view emphasizing that the paramount increase in childhood as well as adulthood obesity requires continuous surveillance \[[@pone.0234244.ref013], [@pone.0234244.ref014]\]. Providing recent estimates of childhood obesity is essential to keep the focus on this matter as it has many consequences on the children health \[[@pone.0234244.ref007]\]. Based on this background, the aim of this study was to investigate the prevalence of childhood obesity in various schools in Sharjah, UAE, and to determine the influence of eating behavior and lifestyle of children on obesity.

Methods {#sec006}
=======

Study design {#sec007}
------------

The present study was conducted in Sharjah, UAE, based on a cross sectional survey over a period of four months (August to November 2017).

Ethical approval {#sec008}
----------------

This study received an ethical approval from the University of Sharjah Ethical Committee (REC-17-09-10-01-S). We informed parents, teachers, and the supervisors about the purpose and the nature of the study. The survey was coded, and the names were kept anonymous.

Questionnaire development {#sec009}
-------------------------

The development of questionnaire was based on the information needed for the study and it was written in both Arabic and English languages. The questionnaire was pre-piloted for face validity by distributing it to 12 parents of school children of the targeted age and their comments and recommendation were taken into consideration in the final version of the survey but their responses were included in results. The questionnaire included 20 items covered in two sections. The first section covered questions to collect information on socio-demographic and health related characteristics which included nine items (gender, age, ethnicity, weight, height, BMI percentile, family history of obesity, disease status and medication intake). The second section consisted of eleven items to collect information about child eating habits and lifestyle, and questions in this section addressed the child's eating patterns. These include the source of food consumed at school; frequency of consumption of fast food and candy, number of healthy meals, type and nature of food consumed as well as number of total meals per day. In addition, the section included questions on lifestyle (time interval between bedtime and the last meal, time spent using electronic devices, and physical activity). In this context we defined physical activity as any indoor or outdoor sport activity not including the use of smart devices or watching TV. On the other hand physical inactivity is defined as sedentary pleasurable activities such as watching cartoons on TV or using smart devices for gaming.

The response options for participants to select from were variable. In questions on time intervals, we used a range of 30 minutes to more than two hours, for frequency (always, often, sometimes, rarely), and "Yes" and "No" answers. For other questions, the options were general for example, when the parents were asked about the ways of preparing foods for their children, the options were "boiled"," fried", "grilled" or "mixed", and for the nature of food consumed, the options were "carbohydrates", "fat", "protein" or "mixed". Additionally, we asked parents about the source of the food consumed by their children at school, and the options were "Bring his/her breakfast from home", "Buy a meal from cafeteria", "Just eat snacks", "Skip breakfast". The total number of surveys distributed was 932.

Study population {#sec010}
----------------

From a list provided by the Ministry of Education, we selected schools in the Emirate of Sharjah based on their accessibility and availability and applied the non- probability sampling method. The study population included both male and female pupils aged 6--11 years. The total representative sample was 678 pupils (299 boys and girls 379) in eight schools in Sharjah; UAE using the online sample size calculator was 248 with a confidence interval of 95% and 5% margin of error for a population of 65473 from 8 schools \[[@pone.0234244.ref015]--[@pone.0234244.ref017]\]. Within each selected school, pupils from Grade I to V were offered the opportunity to voluntarily and anonymously participate.

We based the selection of the pupils on the resubmission of questionnaire. The exclusion criteria included children with special needs of age below 6 and above 11 years, and parents who refused to participate in the study. Similar to the protocol employed in earlier studies \[[@pone.0234244.ref004]\], we trained members of the research team for three weeks on obesity, anthropometric measurements and how to conduct structured interviews of the participants.

Anthropometric measurements {#sec011}
---------------------------

Trained researchers measured student's height and weight in bare feet while wearing lightweight school uniform in the early morning before they start their daily classes. Weight (in kilograms) and height (in centimeters) were measured using Seca 799 scale. The BMI was calculated using Medscape online calculator. We defined obesity according to the CDC guidelines as a BMI ≥ 95th percentile and overweight as a BMI ≥ 85^th^---≤ 95^th^ percentile. The students were instructed to stand straight with their heads, backs and buttocks vertically aligned to the height gage, and then their heights were taken and rounded to the nearest 0.5 cm. Simultaneously, the students' weights were recorded from the digital screen and rounded to the nearest 0.5 kg. The three most important anthropometric measurements of clinical importance to be taken in paediatric practice are height or supine length, weight and head circumference. These measurements describe different body components and their changes have different biological significance. For other populations other than paediatrics the commonly obtained anthropometric measurements include height, weight, knee height, elbow breadth, triceps skinfold, subscapular skinfold, arm circumference, abdominal circumference and calf circumference. Obtained measurements are compared to standardized percentiles. Anthropometric measurements can be combined in the evaluation of nutritional status. For example, weight for height has been demonstrated as a strong predictor for 12-month mortality in haemodialysis patients. Mortality rate appears to decrease as patient's weight for height increase. BMI is also an important predictor. The use of correct body weight is essential for patient assessment and for determination of dietary needs. A variety of definitions of body weight have been used for nutritional assessment such as usual body weight, standard body weight, and ideal body weight \[[@pone.0234244.ref018]\]. Anthropometry involves the external measurement of morphologic traits of human beings. High quality anthropometric measurements are fundamental to clinical and epidemiological research. The measurements for each method have inherent variations, either due to biologic variation or due to error in measurement. Errors in measurement cannot be avoided completely but they can be minimized to a large extent. We define methods to estimate measurement error in anthropometry, offer guidelines for acceptable error, and suggest ways to minimize measurement error; thereby improving anthropometry quality in health assessments. We propose that special attention be paid to the following six key parameters for quality assurance of anthropometric measurements: (i) Identification of certified lead anthropometrist and trainer, (ii) manual of standard operating procedures, (iii) choice of robust equipment, (iv) equipment calibration, (v) standardization training and certification, and (vi) measurements resampling \[[@pone.0234244.ref019]\]. To abide by the above-mentioned parameters of quality assurance of anthropometric measurements, the researchers in this study were trained by certified professionals to take the measurements, and also measurement resampling was done. In addition to that the equipment used were standardized and calibrated before use. This is to improve anthropometric measurements quality and eliminate the error as much as possible. Finally, BMI measurements were calculated accordingly.

Statistical analysis {#sec012}
--------------------

We encoded the participants' responses and analyzed the data using Statistical Package for Social Sciences (IBM SPSS statistics for windows, version 20.0, IBM Corp., Armonk, NY, USA). We adopted descriptive analysis to calculate the response proportion of each group of respondents for each item in the questionnaire. We also used the Chi-square test to ascertain the association between the dependent variables and other independent selected variables considering the level of p\< 0.05 as the cut-off value of significance.

Results {#sec013}
=======

The total of surveys distributed was 932 and 678 surveys were completed and returned back giving a response rate of 72.8%. Throughout the process of distribution and collection of surveys, 46 samples were excluded including 4 participants who refused to participate, 9 were above 11 years, and 22 returned back unfilled surveys. We did not receive back additional 212 surveys, as the parents of the pupils were not interested to take a part in the study. Among the study pupils 299 (44.1%) were boys and 379 (55.9%) were girls. The average age of the pupils was 8.2±1.7 years, with an average height of 131±11.1 centimeters and weight of 30.5±10.8 kilograms. Less than one quarter (134; 19.8%) of the participants reported to have a family history of obesity. A total of 487 (59.4%) children showed normal range of BMI whereas 95 (14%) and 96 (14.2%) had an obese BMI and overweight respectively. [Table 1](#pone.0234244.t001){ref-type="table"} summarizes the socio-demographic and clinical characteristic of participants.

10.1371/journal.pone.0234244.t001

###### Socio-demographic and clinical characteristics of participants.

![](pone.0234244.t001){#pone.0234244.t001g}

  Characteristic                                             Frequency (%)
  ---------------------------------------------------------- ---------------
  **Child Gender**:                                          
  Female                                                     379 (55.9)
  Male                                                       299 (44.1)
  Total                                                      678 (100.0)
  **Family history of obesity**:                             
  Yes                                                        134 (19.8)
  No                                                         544 (80.2)
  Total                                                      678 (100)
  **Overweight and obesity in pupils with family history**   
  Overweight                                                 32 (4.8)
  Obese                                                      34 (5)
  Total                                                      66 (9.8)
  **BMI Percentile**:                                        
  Underweight                                                84 (12.4)
  Normal weight                                              403 (59.4)
  Overweight                                                 96 (14.2)
  Obese                                                      95 (14.0)
  Total                                                      684 (100.0)
  **Source of food services**:                               
  Bring his/her lunch from home                              456 (67.3)
  Buy a meal from school cafeteria                           67 (9.9)
  Just eat snacks.                                           143 (143.0)
  Skip lunch                                                 12 (1.8)
  Total                                                      678 (100.0)

Eating habits of participants {#sec014}
-----------------------------

In the present study, 456 (67.3%) of the pupils included in the study ate their in-home prepared food and 21.1% (143) reported that they buy their meals from the school cafeteria. An interval of 1 to 2 hours elapsing between the last meal consumed and bedtime was reported by 241 (35.5%) of participants. Slightly more than half (372; 54.9%) of the respondents reported their children to consume food of mixed nature (carbohydrates, fats and proteins). The majority (590; 87%) reported to consume food that was prepared by boiling, frying or grilling methods. Consumption of two healthy meals per day was reported by 292 (43.1%) of the participants. [Table 2](#pone.0234244.t002){ref-type="table"} summarizes the eating habits of children included in the study.

10.1371/journal.pone.0234244.t002

###### Eating habits of participants.

![](pone.0234244.t002){#pone.0234244.t002g}

  Eating Habits                                                Frequency (%)                                                      
  ------------------------------------------------------------ ------------------------------------------------------------------ ------------
  **Number of Meals During a Day**                             1 meal                                                             20 (2.9)
  2--5 meals                                                   646 (95.3)                                                         
  \> 5 meals                                                   12 (1.8)                                                           
  **Total**                                                    678 (100.0)                                                        
  **Time Interval Between Child Last Meal and Bed Time**       0-30minutes                                                        95 (14.0)
  30 minutes---1 hour                                          204 (30.1)                                                         
  1 hour---2 hour                                              241 (35.5)                                                         
  \> 2 hours                                                   138 (20.4)                                                         
  **Total**                                                    678 (100.0)                                                        
  **Type of Food That Child Eats**                             Boiled                                                             18 (2.7)
  Fried                                                        49 (7.2)                                                           
  Grilled                                                      21 (3.1)                                                           
  Mixed                                                        590 (87.0)                                                         
  **Total**                                                    678 (100.0)                                                        
  **Predominant food in child's diet**                         Carbohydrate (Rice, Bread, Milk, Yogurt, Corn, Potatoes, Fruits)   89 (13.1)
  Fats (Cheese, Dark Chocolate, Whole Eggs, Olive oil, Nuts)   11 (1.6)                                                           
  Proteins (Meat, Chicken, Fish, Eggs)                         206 (30.4)                                                         
  Mixed                                                        372 (54.9)                                                         
  **Total**                                                    678 (100.0)                                                        
  **Eating Fast Food**                                         Always                                                             42 (6.2)
  Often                                                        324 (47.8)                                                         
  Sometimes                                                    207 (30.5)                                                         
  Rare                                                         105 (15.5)                                                         
  **Total**                                                    678 (100.0)                                                        
  **Eating Candy**                                             Always                                                             370 (54.6)
  Often                                                        234 (34.5)                                                         
  Sometimes                                                    55 (8.1)                                                           
  Rare                                                         19 (2.8)                                                           
  **Total**                                                    678 (100.0)                                                        
  **Number of Daily Healthy Food (Fruits and Vegetables)**     0                                                                  12 (1.8)
  1                                                            197 (29.1)                                                         
  2                                                            292 (43.1)                                                         
  3                                                            136 (20.1)                                                         
  \> 4                                                         41 (6.0)                                                           
  **Total**                                                    678 (100.0)                                                        

Participants' leisure time {#sec015}
--------------------------

When the parents were asked about the time their children spend watching TV and using electronic devices, more than one quarter of those watching TV (237, 35%) and using electronic devices (203, 29.9%) reported spending 1--2 hours daily on such a leisure. Furthermore, almost one quarter (162; 23.9%) of the children reported low levels of physical activity. [Table 3](#pone.0234244.t003){ref-type="table"} summarizes the patterns of children's physical activity and leisure time.

10.1371/journal.pone.0234244.t003

###### Patterns of physical activity, daily leisure time and time spent using electronic devises.

![](pone.0234244.t003){#pone.0234244.t003g}

  Criteria                                                          Frequency (%)
  ----------------------------------------------- ----------------- ---------------
  **Physical Activity (classified per week)**     Always (7 days)   169 (24.9)
  Often (3--5 days)                               226 (33.3)        
  Sometimes (1--2 days)                           121 (17.8)        
  Rare (0--1 day)                                 162 (23.9)        
  **Total**                                       678 (100.0)       
  **Leisure Time (per day)**:                                       
  **Time Spent Watching TV**                      30 minutes        100 (14.7)
  30--60 minutes                                  160 (23.6)        
  60--120 minutes                                 237 (35.0)        
  \> 120 minutes                                  181 (26.7)        
  Total                                           678 (100.0)       
  **Time Spent on Phone, Tablet, and Computer**   None              21 (3.1)
  30 minutes                                      136 (20.1)        
  30--60 minutes                                  149 (22.0)        
  60--120 minutes                                 203 (29.9)        
  \> 120 minutes                                  169 (24.9)        
  **Total**                                       678 (100.0)       

Disease status and medications use by participants {#sec016}
--------------------------------------------------

Only 82 (12.1%) of the children were reported to have a disease and use medications. Iron deficiency anemia, allergy and asthma problems were among the most common diseases reported during the study period. Anti-allergic, anti-asthmatic, and iron supplements were among the most commonly medications used by the children.

Relationship between BMI percentile, pupil's habits and lifestyle {#sec017}
-----------------------------------------------------------------

Using chi-square test, we observed a number of statistically significant associations between BMI percentile, pupil's habits and lifestyle. The number of daily healthy food consumption and the predominant food in the child's diet were both significantly (p\< 0.002 and p\< 0.001 respectively) associated with BMI percentile of the participants. Furthermore, there was a significant association (p\<0.04) between time spent on television and BMI percentile of pupils included in the study (Tables [4](#pone.0234244.t004){ref-type="table"} and [5](#pone.0234244.t005){ref-type="table"}).

10.1371/journal.pone.0234244.t004

###### Association of food habits with BMI percentile.

![](pone.0234244.t004){#pone.0234244.t004g}

  -------------------------------------- ------------------------------------------------- ------------------- ---------------- ----------- -----------
                                         **BMI Percentile, Chi square test (p \<0.002)**                                                    
  **Number of daily healthy food**       **Underweight**                                   **Normal weight**   **Overweight**   **Obese**   **Total**
  **0**                                  **3**                                             **6**               **2**            **1**       **12**
  **1**                                  **30**                                            **109**             **27**           **31**      **197**
  **2**                                  **34**                                            **178**             **38**           **42**      **292**
  **3**                                  **13**                                            **91**              **13**           **19**      **136**
  **4 or more**                          **4**                                             **19**              **16**           **2**       **41**
  **Total**                              **84**                                            **403**             **96**           **95**      **678**
                                         **BMI Percentile, Chi square test (p \<0.001)**                                                    
  **Predominant food in child's diet**   **Underweight**                                   **Normal weight**   **Overweight**   **Obese**   **Total**
  **Carbohydrates**                      **14**                                            **51**              **12**           **12**      **89**
  **Fats**                               **1**                                             **3**               **1**            **6**       **11**
  **Proteins**                           **19**                                            **136**             **27**           **24**      **206**
  **Mixed**                              **50**                                            **213**             **56**           **53**      **372**
  **Total**                              **84**                                            **403**                                          
  -------------------------------------- ------------------------------------------------- ------------------- ---------------- ----------- -----------

10.1371/journal.pone.0234244.t005

###### Association of time spent on television with BMI Percentile.

![](pone.0234244.t005){#pone.0234244.t005g}

  Time spent on television/day   BMI Percentile, Chi square test (p \< 0.040)                   
  ------------------------------ ---------------------------------------------- ----- ---- ---- -----
  30 minutes                     10                                             65    16   9    100
  30 minutes---1 hour            16                                             113   14   17   160
  1--2 hours                     34                                             125   38   40   237
  More than 2 hours              24                                             100   28   29   181
  Total                          84                                             403   96   95   678

Discussion {#sec018}
==========

We carried out the present study to determine whether childhood obesity is predominant in the Emirate of Sharjah, UAE and to establish the association between obesity and the child's lifestyle and eating patterns. The global prevalence of overweight and obesity in 2010 was 6.7% \[[@pone.0234244.ref001]\]. Results of the present study revealed that the prevalence of overweight and obese children in UAE is 28.2%, which is around four times higher than the global prevalence described above for 2010. Our findings suggest that the increase in the prevalence of obesity in Sharjah-school pupils is in total agreement with the results of recent studies carried out in UAE on different population samples \[[@pone.0234244.ref004]\]. Over the last 5 decades, the economic enhancement in all countries of the Eastern Mediterranean Region (EMR) was associated with a greater demand on diet that is rich in fat. Such a tendency by increasing the intake of energy predisposes to obesity and diseases \[[@pone.0234244.ref014]\].

Similar to the results of an earlier study in UAE (17), we also identified a high prevalence (12.4%) among school children. About 27.5% of the underweight children were between 6--7 years old. These findings suggest that under nutrition is common among children in the UAE despite the high-income status of the country. We noticed that the lowest consumption of healthy diet was in children who were underweight, which might be an underlying factor. Poor knowledge of healthy dietary patterns may be a reason for under nutrition. However, the exact determinants for under nutrition among children in the UAE warrants further dedicated investigation.

We also observed that 19.8% of the participants had a family history of obesity, and 9.8% of them were overweight and obese. This is consistent with the findings of a similar study conducted in the Emirate of Abu Dhabi \[[@pone.0234244.ref020]\]. These results taken together, strongly supports the link that is widely documented in literature between family history of obesity and the development of obesity in children. A family history of obesity may promote childhood obesity through environmental and biological mechanisms. With regard to the environmental risk, mother's personal eating habits are likely to influence children's dietary patterns. Biologically, children whose both parents are overweight are predisposed to have a high BMI \[[@pone.0234244.ref021]\]. However, although genetic factors may contribute to the development of obesity, some researchers suggested that genetic factors only account for up to 5% of childhood obesity cases \[[@pone.0234244.ref022]\]. A significant association between child's age and BMI percentile (p-value = 0.01) was found. The prevalence of obesity and overweight was the highest (14.2%) in children aged 11 years and lowest (3%) at the age of 7 years. This is consistent with the results of a large cross-sectional study among UAE school children in both the Emirates of Abu Dhabi and Ras Al Khaimah \[[@pone.0234244.ref004], [@pone.0234244.ref005]\]. When taken together, these results reveal a trend of a progressive increase in the prevalence of overweight and obesity with age across the population of schoolchildren in the UAE that reflects global trends \[[@pone.0234244.ref023], [@pone.0234244.ref024]\]. The onset of puberty that occurs in children in this age group may contribute to the increase in the prevalence of obesity. Puberty is associated with the accumulation of adipose tissue and decreased physical activity; particularly among children who experience early puberty. These findings indicate that early interventions targeting children aged 6--7 years may be more likely to achieve better outcomes in minimizing or preventing the development of obesity in children.

Results of the present study also revealed that the time spent watching TV and using smart devices was relatively high. About 35% of the total participants spend 1--2 hour per day watching TV and of those 11.5% were obese and overweight. This is consistent with results of the study carried out at the University of Texas Health Science Center and Baylor in Houston, which reported that 67% of their participants watched TV with an average of 1.84 hours per day \[[@pone.0234244.ref023]\]. Other studies suggested that watching TV has several effects that may lead to obesity including decreased metabolic rate, and increased snacking while watching TV in addition to the influence of food advertisements. Moreover, it has been documented that increasing the time spent on watching TV will increase the prevalence of obesity \[[@pone.0234244.ref024]\], a finding that parallels results of the present study but contrasts with those of another study that failed to show a link between BMI and watching TV \[[@pone.0234244.ref025]\].

Additionally, 29.9% of children spent 1--2 hours of their time on smart phones, tablets, and computers but we observed no significant association between the BMI percentile and time spent on these electronic devices. However, there is a correlation between the child's gender and time spent on smart phones and computers where 61.9% of the total male participants spent more than 1 hour on electronic devices as compared to 49.3% of the total female participants. Within the age pool of our study, the fact that boys were more interested in such instruments than girls may explain such results. There was no relationship between physical activity and BMI percentile (p value = 0.443), which is consistent with the findings of other studies that failed to demonstrate a significant effect of physical activity on BMI \[[@pone.0234244.ref024]\]. Although there is no difference in the obesity predominance between the two genders, we observed a significant association between the physical activity and child's gender in which the number of girls (15.5%) of the total population that rarely exercise is twice that of boys (8.4%). Traditional, cultural, and religious beliefs, as well as the inadequate sport facilities for females in schools are contributing factors for the reduced physical activity and sedentary lifestyle in females. The strict supervision by the parents over their children may also be a reason. The reason behind this strict supervision is that parents prefer to keep their children under their scrutiny at home rather than allowing them to play outdoors \[[@pone.0234244.ref007]\]. Another factor that pertains to UAE in particular is the hot weather that persists throughout the year. Extreme heat and conditions that can cause heat strokes and dehydration in children prevent parents from sending them outside to get any physical activity. Irrespective to gender differences, it is essential to emphasize the importance of physical activity in young children and to increase awareness of parents regarding its importance. Establishing adequate physical activity at a young age will help children maintain this habit throughout their life.

In the present study, more than half (54.9%) of the participants tend to have food of a mixed nature (carbohydrates, fats, and proteins). The majority of participants (87%) reported consuming food with a mixed preparation pattern (boiled, fried, and grilled). It has been noted that a minor percentage of the population consume either fats (1.6%) or carbohydrates (13.1%). Furthermore, more than one quarter (30.4%) of the participants reported consuming protein as their main food with 7.5% of this group being obese and overweight.

A study in the US found a correlation between BMI and dietary protein intake in children up to the age of 5 years \[[@pone.0234244.ref025]\]. High protein intake may result in a higher than normal BMI, this can be explained by the \"Early Protein Hypothesis\" which assumes that the high protein consumption will lead to high insulin-releasing amino acids in the plasma which will trigger insulin secretion and insulin like growth factor I (IGF-I) and leads to fat deposition and weight gain. It is worth noting that skipping breakfast is common among both adults and children, and this practice has a negative impact on BMI \[[@pone.0234244.ref014]\]. A study preformed in Al Ain, UAE reinforced that children who skipped breakfast are more likely to be obese \[[@pone.0234244.ref016]\]. According to the present results, about one quarter (21.1%) of the participants preferred eating snacks as their breakfast meal, which is mostly full of carbohydrates and with no beneficial nutritional value, and 1.8% of the participants skip breakfast. Collectively 13.6% of girls and 9.2% of boys of the total population have a habit of skipping a proper healthy breakfast meal. A systemic review carried out in Europe showed that individuals who eat breakfast are less likely to become obese or overweight \[[@pone.0234244.ref026]\]. In harmony with results of the present study, an earlier study in UAE reported that skipping breakfast is more common in girls (37%) as compared to boys (28%) in UAE \[[@pone.0234244.ref016]\].

Obesity has lately been associated with high consumption of fast food. Children often prefer fast food restaurants; and consumption of fast food has increased due to its convenience and affordability particularly in children of working parents. Regular consumption of fast food has shown bad influence on health as it contains a large number of calories with very low nutritional value, especially for children, who require nutrients for their growth and development. Despite the fact that numerous studies have showed that consumption of fast food causes weight gain, a relationship between the two factors is difficult to establish \[[@pone.0234244.ref004]\].

We pinpoint two methodological limitations that should be considered when interpreting the findings of the present study. First, we assessed dietary patterns by asking broad questions about food groups consumed and their quantity and sources of food. Hence, responses of participants may be subject to recall bias and personal interpretation than the use of a food diary that enables objective and detailed documentation of types and quantity of foods consumed within a specified period. Second, the UAE population is highly diverse, with the majority of people being expatriates from various Arabic-speaking, and South- and East-Asian countries, with Emirati citizens representing a minority. The marked differences in income, dietary practices, and cultural identities of the various ethnic groups in UAE can influence the development of obesity in children. In addition, Emirati children largely attend governmental schools while children of expatriates attend private schools. We did not specifically measure these factors in the present study and thus they require further investigation in large cross-sectional studies in the future.

Conclusion {#sec019}
==========

The percentage of overweight and obesity is high in both genders and across all ages of the studied population. However, we observed that the highest percentage of overweight is among children at the age of 11years and this may be a consequence of their sedentary lifestyle, consumption of unhealthy food and family history. Further investigation regarding this topic is required, and increasing awareness of the public towards childhood obesity is to be achieved in the near future as an essential task to limit further progression of obesity in UAE and to protect against non-communicable diseases that may be associated with obesity.

Supporting information {#sec020}
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10.1371/journal.pone.0234244.r001

Decision Letter 0

Siegel

Robert

Academic Editor

© 2020 Robert Siegel

2020

Robert Siegel

This is an open access article distributed under the terms of the

Creative Commons Attribution License

, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

6 Apr 2020

PONE-D-19-26655

Obesity and its associated risk factors among school-aged children in Sharjah, UAE

PLOS ONE

Dear Dr Abduelkarem,

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To enhance the reproducibility of your results, we recommend that if applicable you deposit your laboratory protocols in protocols.io, where a protocol can be assigned its own identifier (DOI) such that it can be cited independently in the future. For instructions see: <http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols>

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). This letter should be uploaded as separate file and labeled \'Response to Reviewers\'.A marked-up copy of your manuscript that highlights changes made to the original version. This file should be uploaded as separate file and labeled \'Revised Manuscript with Track Changes\'.An unmarked version of your revised paper without tracked changes. This file should be uploaded as separate file and labeled \'Manuscript\'.

Please note while forming your response, if your article is accepted, you may have the opportunity to make the peer review history publicly available. The record will include editor decision letters (with reviews) and your responses to reviewer comments. If eligible, we will contact you to opt in or out.

We look forward to receiving your revised manuscript.

Kind regards,

Robert Siegel

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements:

1.    Please ensure that your manuscript meets PLOS ONE\'s style requirements, including those for file naming. The PLOS ONE style templates can be found at <http://www.plosone.org/attachments/PLOSOne_formatting_sample_main_body.pdf> and <http://www.plosone.org/attachments/PLOSOne_formatting_sample_title_authors_affiliations.pdf>

2\. Please include additional information regarding the survey or questionnaire used in the study and ensure that you have provided sufficient details that others could replicate the analyses. For instance, if you developed a questionnaire as part of this study and it is not under a copyright more restrictive than CC-BY, please include a copy, in both the original language and English, as Supporting Information. Moreover, please include more details on how the questionnaire was pre-tested, and whether it was validated.

3\. We suggest you thoroughly copyedit your manuscript for language usage, spelling, and grammar. If you do not know anyone who can help you do this, you may wish to consider employing a professional scientific editing service.  

Whilst you may use any professional scientific editing service of your choice, PLOS has partnered with both American Journal Experts (AJE) and Editage to provide discounted services to PLOS authors. Both organizations have experience helping authors meet PLOS guidelines and can provide language editing, translation, manuscript formatting, and figure formatting to ensure your manuscript meets our submission guidelines. To take advantage of our partnership with AJE, visit the AJE website ([http://learn.aje.com/plos/](about:blank)) for a 15% discount off AJE services. To take advantage of our partnership with Editage, visit the Editage website ([www.editage.com](http://www.editage.com)) and enter referral code PLOSEDIT for a 15% discount off Editage services.  If the PLOS editorial team finds any language issues in text that either AJE or Editage has edited, the service provider will re-edit the text for free.

Upon resubmission, please provide the following:

●      The name of the colleague or the details of the professional service that edited your manuscript

●      A copy of your manuscript showing your changes by either highlighting them or using track changes (uploaded as a \*supporting information\* file)

●      A clean copy of the edited manuscript (uploaded as the new \*manuscript\* file)

4.  We note that you have indicated that data from this study are available upon request. PLOS only allows data to be available upon request if there are legal or ethical restrictions on sharing data publicly. For information on unacceptable data access restrictions, please see <http://journals.plos.org/plosone/s/data-availability#loc-unacceptable-data-access-restrictions>.

In your revised cover letter, please address the following prompts:

a\) If there are ethical or legal restrictions on sharing a de-identified data set, please explain them in detail (e.g., data contain potentially identifying or sensitive patient information) and who has imposed them (e.g., an ethics committee). Please also provide contact information for a data access committee, ethics committee, or other institutional body to which data requests may be sent.

b\) If there are no restrictions, please upload the minimal anonymized data set necessary to replicate your study findings as either Supporting Information files or to a stable, public repository and provide us with the relevant URLs, DOIs, or accession numbers. Please see <http://www.bmj.com/content/340/bmj.c181.long> for guidelines on how to de-identify and prepare clinical data for publication. For a list of acceptable repositories, please see <http://journals.plos.org/plosone/s/data-availability#loc-recommended-repositories>.

We will update your Data Availability statement on your behalf to reflect the information you provide.

 

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Reviewers\' comments:

Reviewer\'s Responses to Questions

**Comments to the Author**

1\. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer \#1: Partly

Reviewer \#2: Partly

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2\. Has the statistical analysis been performed appropriately and rigorously?

Reviewer \#1: N/A

Reviewer \#2: I Don\'t Know

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3\. Have the authors made all data underlying the findings in their manuscript fully available?

The [PLOS Data policy](http://www.plosone.org/static/policies.action#sharing) requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data---e.g. participant privacy or use of data from a third party---those must be specified.

Reviewer \#1: Yes

Reviewer \#2: Yes

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4\. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer \#1: Yes

Reviewer \#2: Yes

\*\*\*\*\*\*\*\*\*\*

5\. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer \#1: Comments to the Author

This Study aimed to assess "obesity and its associated risk factors among school-aged children in sharjah"

1- In the introduction section the authors refer to the prevalence of childhood overweight and obesity in the US and worldwide, but they did not provide any description about the prevalence of childhood overweight and obesity in the UAE. Please add this data in the introduction.

2- Anthropometric measurements: Quality assurance for anthropocentric measurements should be described in details.

3- Is the questionnaire of dietary habit reliable or valid for this population study? Please provide more information about reliability and validity of this questionnaire.

4- The author did not provide any information about the physical activity in children. Please add this information in the methods section (questionnaire development section).

5- Based on method section you select population between native and non-native students, but in the results you did not refer to this. How many of the subjects were non-native? Are there any differences in the prevalence of childhood overweight and obesity between the native and non-native students?

6- What is the definition of physical inactivity that you reported in the result section?

7- In the statistical analysis the author used the chi-square test to ascertain the association between the dependent and independent variables, how you can use Chi-square test for ascertain an association? Please check the type of statistical tests with a statistician.

8- Table section: The author must mention that the type of statistical tests was used for assessing the difference of various socio-demographic, lifestyle, anthropometric, in across BMI percentile.

9- In the table you did not refer that what type of data was used, number or percent?

Reviewer \#2: I commend the authors on taking on an important project. This type of research is needed in order to reverse the obesity epidemic that threatens all nations. I have multiple concerns about this manuscript. The methods section is missing pertinent details about how the sample was created (how many schools, every child in the age range within the school or certain grades, etc.; what are the demographics of the schools included -- similar, different). Additionally, some of the questions in the survey are hard to follow (see line corrections below). The descriptive results in table 1 are not presented by BMI category, which makes it harder for the reader to understand the sample. There is insufficient text supporting the findings in table 4 & 5. Additionally, the discussion is too long. The authors should seek to identify the take home findings and what adds to the literature, rather than discussing every result. Also, a re-review of the grammar would be helpful, as there are multiple errors throughout. Lastly, some of the links provided within the references are outdated and need to be revisited and reinserted. Please see some additional line suggestions below.

Line suggestions

Abstract:

1\. Line 36: Should read "...and determine" rather than determining

2\. Line 38: insert "was" before the word based

3\. Line 43: Recommend person-first language. Would recommend from "were obese or overweight" to "had obesity or overweight."

Introduction:

4\. Line 65-66: The consumption of high calories food with no or limited physical activity is the main contributor to childhood obesity. This statement needs a citation.

5\. Line 73: Run on sentence, needs appropriate punctuation.

6\. Line 80: Two strategies can be followed including; the primary prevention of overweight

or obesity itself and second is the prevention of weight regain after weight loss, plus prevention of weight gain in individuals unable to lose weight \[5\]. This statement is confusing. Initially talks about two strategies, but introduces a third.

7\. Line 100: Add "the" before the word questionnaire.

Methods:

8\. The survey question asking the Nature of food consumed to parents is very confusing. Why were fruit and vegetables not included as an answer choice for the question: predominant food in child's diet? What does mixed mean -- 2 categories, 3 categories? Would be better to have had families give percentages. Was fruit included in carbohydrate? Was the any ascertainment of baseline knowledge level -- were families clear on what food groups fell into each of these categories?

9\. I am concerned about selection bias. The parents/child that returned the survey could be inherently different that the ones that didn't. Did you have any data to say that your sample population is representative? Do you have any data on the parents/children that chose not to participate or the data on the schools as a whole?

Study Population

10\. How many schools were participants recruited from? Were the schools the same in terms of demographics of students?

11\. Were the surveys sent to every child in a specific grade. Need to expand on how the sample was put together in more detail.

Results:

12\. Line 153: Person first language recommended. (E.g. Had an obese BMI, rather than were obese.)

13\. Descriptive characteristics should be presented by BMI category.

14\. It is unclear how disease status and medication use were related to the aims of the study.

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6\. PLOS authors have the option to publish the peer review history of their article ([what does this mean?](https://journals.plos.org/plosone/s/editorial-and-peer-review-process#loc-peer-review-history)). If published, this will include your full peer review and any attached files.

If you choose "no", your identity will remain anonymous but your review may still be made public.

**Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our [Privacy Policy](https://www.plos.org/privacy-policy).

Reviewer \#1: No

Reviewer \#2: No

\[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link \"View Attachments\". If this link does not appear, there are no attachment files to be viewed.\]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, <https://pacev2.apexcovantage.com/>. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email us at <figures@plos.org>. Please note that Supporting Information files do not need this step.

###### 

Submitted filename: comments to authors.docx

###### 

Click here for additional data file.

10.1371/journal.pone.0234244.r002

Author response to Decision Letter 0

7 May 2020

All the invaluable comments of the respected reviewers and the journal additional comments were considered and our responses are attached as "our responses to reviewer's comments" and "our responses to additional journal comments" two separate file.

As per your request, a copy of the survey, in both the original language (Arabic) and English, will be attached for you as Supporting Information.

To answer your request regarding "copyedit your manuscript for language usage, spelling, and grammar", the manuscript was thoroughly revised by one of us namely Prof. Suleiman I. Sharif, College of Pharmacy, University of Sharjah, Sharjah, UAE.

A copy of our manuscript showing our changes by either highlighting them or using track changes will be attached for you as revised version and clean copy of the edited manuscript and it will be uploaded as a "supporting information" file.

We would like to clearly indicate that there are no ethical or legal restrictions on sharing the data. It must be noted that in our study the identity of the participants was disguised.

###### 

Submitted filename: 3-Our Response to Reviewers Comments.docx

###### 

Click here for additional data file.

10.1371/journal.pone.0234244.r003

Decision Letter 1

Siegel

Robert

Academic Editor

© 2020 Robert Siegel

2020

Robert Siegel

This is an open access article distributed under the terms of the

Creative Commons Attribution License

, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

22 May 2020

Obesity and its associated risk factors among school-aged children in Sharjah, UAE

PONE-D-19-26655R1

Dear Dr. Abduelkarem,

We are pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it complies with all outstanding technical requirements.

Within one week, you will receive an e-mail containing information on the amendments required prior to publication. When all required modifications have been addressed, you will receive a formal acceptance letter and your manuscript will proceed to our production department and be scheduled for publication.

Shortly after the formal acceptance letter is sent, an invoice for payment will follow. To ensure an efficient production and billing process, please log into Editorial Manager at <https://www.editorialmanager.com/pone/>, click the \"Update My Information\" link at the top of the page, and update your user information. If you have any billing related questions, please contact our Author Billing department directly at <authorbilling@plos.org>.

If your institution or institutions have a press office, please notify them about your upcoming paper to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, you must inform our press team as soon as possible and no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact <onepress@plos.org>.

With kind regards,

Robert Siegel

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors have addressed all the reviewer concerns.

Reviewers\' comments:

Reviewer\'s Responses to Questions

**Comments to the Author**

1\. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the "Comments to the Author" section, enter your conflict of interest statement in the "Confidential to Editor" section, and submit your \"Accept\" recommendation.

Reviewer \#1: All comments have been addressed

Reviewer \#2: All comments have been addressed

\*\*\*\*\*\*\*\*\*\*

2\. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer \#1: Yes

Reviewer \#2: (No Response)

\*\*\*\*\*\*\*\*\*\*

3\. Has the statistical analysis been performed appropriately and rigorously?

Reviewer \#1: Yes

Reviewer \#2: (No Response)

\*\*\*\*\*\*\*\*\*\*

4\. Have the authors made all data underlying the findings in their manuscript fully available?

The [PLOS Data policy](http://www.plosone.org/static/policies.action#sharing) requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data---e.g. participant privacy or use of data from a third party---those must be specified.

Reviewer \#1: Yes

Reviewer \#2: (No Response)

\*\*\*\*\*\*\*\*\*\*

5\. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer \#1: Yes

Reviewer \#2: (No Response)

\*\*\*\*\*\*\*\*\*\*

6\. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer \#1: this manuscript accepted without revision

Reviewer \#2: (No Response)

\*\*\*\*\*\*\*\*\*\*

7\. PLOS authors have the option to publish the peer review history of their article ([what does this mean?](https://journals.plos.org/plosone/s/editorial-and-peer-review-process#loc-peer-review-history)). If published, this will include your full peer review and any attached files.

If you choose "no", your identity will remain anonymous but your review may still be made public.

**Do you want your identity to be public for this peer review?** For information about this choice, including consent withdrawal, please see our [Privacy Policy](https://www.plos.org/privacy-policy).

Reviewer \#1: No

Reviewer \#2: No

10.1371/journal.pone.0234244.r004

Acceptance letter

Siegel

Robert

Academic Editor

© 2020 Robert Siegel

2020

Robert Siegel

This is an open access article distributed under the terms of the

Creative Commons Attribution License

, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

28 May 2020

PONE-D-19-26655R1

Obesity and its associated risk factors among school-aged children in Sharjah, UAE

Dear Dr. Abduelkarem:

I am pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please notify them about your upcoming paper at this point, to enable them to help maximize its impact. If they will be preparing press materials for this manuscript, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact <onepress@plos.org>.

For any other questions or concerns, please email <plosone@plos.org>.

Thank you for submitting your work to PLOS ONE.

With kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Robert Siegel

Academic Editor

PLOS ONE

[^1]: **Competing Interests:**The authors have declared that no competing interests exist.
