Association between Physical Activity, Sedentary Behaviors, and Sleep and Cardiometabolic Health among Adults in the Kingdom of Saudi Arabia: Establishment of the Saudi ProPASS Prospective Cohort Study

Abstract

Background: Physical behaviors such as physical activity (PA), sedentary behavior (SB), andsleep are crucial indicators of health, with insufficient PA, excessive SB, and poor sleep being linked to higher incidences of non-communicable diseases (NCDs) like cardiovascular disease and diabetes. Globally, many adults do not meet recommended PA levels, and most countries are unlikely to meet global PA targets by 2030. This issue is particularly severe in Saudi Arabia, where urbanization has led to lifestyle changes characterized by low PA, increased SB, and a rising prevalence of NCDs. Despite the significance of these behaviors, there is a lack of comprehensive data on PA, SB, and sleep among Saudi adults. The World Health Organization has flagged in particular the expansion of device-based data to under-represented counties as an urgent research need to enhance understanding of the health impacts of these behaviors. In response, the Prospective Physical Activity, Sitting, and Sleep Consortium (ProPASS) was established as an international research platform to spearhead the expansion of the evidence base and transition to wearables data based global guidelines. Initially, ProPASS focused on thigh-worn and recently ProPASS has expanded to wrist-worn accelerometry devices to collect detailed data on PA, SB,sleep, and their connections to health outcomes. Based on ProPASS methodologies, this Ph.D.study seeks to address this gap by establishing a cohort in Saudi Arabia, thereby providing crucialdata to guide public health strategies in line with Saudi Vision 2030.

Objectives: This thesis aimed to establish a prospective cohort that will investigative theassociations between device measured lifestyle behavior (physical activity, sedentary behavior,and sleep time) and cardiometabolic health in a sample of Saudi adults. This thesis seeks to provide preliminary evidence of feasibility and validity of ProPASS methods within Saudi Arabia context as well as initial evidence of associations between 24-hour physical behaviors and cardiometabolichealth in this population.

Method: The aims were investigated in three cross-sectional studies with adults in Saudi Arabia.The study I aimed to translated and culture adaptation for three questionnaires which were Sedentary Behavior Questionnaire (SBQ), Dietary Habits Questionnaire adapted from the Surveyof Health, Aging and Retirement in Europe (SHARE), and Preclinical Mobility Limitation questionnaire. The study II aimed to assess the feasibility and acceptability of ProPASS method in Saudi Arabia, where recruitment, acceptability, suitability, of study procedures, and Resources and ability to manage and implement the study were assessed. Lastly, study III investigated the association between physical behaviors and cardiometabolic health markers.

Result: The Sedentary Behavior, Dietary Habits SHARE, and Preclinical Mobility Limitation questionnaires are ready to be used in Arabic-speaking countries (Paper I). The ProPASS protocols have a requirement rate of approximately 65% and a high completion rate of about 88%, indicating they are feasible to administer in Saudi Arabia (Paper II). Preliminary results from Study III(n=845) showed that Saudi adults spend 13.07 hours sitting, 2.01 hours standing, 1.08 hour in LIPA, 0.98 hours in MVPA, and 6.85 hours sleeping (Paper III).

Conclusion:This thesis successfully established a foundational understanding of physical behaviors, includingPA, SB, and sleep, within a Saudi Arabian context. The translation and cultural adaptation of key questionnaires (SBQ, SHARE Dietary Habits, and Preclinical Mobility Limitation) have made them suitable for use in Arabic-speaking populations, filling a critical gap in tools available forthis region. The feasibility study demonstrated that the ProPASS protocols, which incorporate advanced device-based measurements, are both viable and well-received among Saudi adults, withhigh completion rates. Preliminary findings from the cohort reveal significant patterns of physical behavior, such as prolonged sitting times and limited engagement in MVPA, which are concerning given their associations with cardiometabolic health risks.

These results underscore the urgent need for targeted public health strategies to address the sedentary lifestyles prevalent in Saudi Arabia, in alignment with Saudi Vision 2030. The data gathered from this research not only enriches the global understanding of physical behaviors in underrepresented regions but also provides a robust foundation for future studies aimed at mitigating the rising burden of non-communicable diseases in the Kingdom.