How Physically Active are University Students in Saudi Arabia?

Background: Physical activity is a very positive behavior that has many health benefits, so understanding current physical activity levels in specific populations is important for health policy planning. Objective(s): to estimate physical activity patterns in King Saud University students in Riyadh, Saudi Arabia. Methods: This cross-sectional study estimated physical activity patterns among King Saud University students. An online survey was distributed to all students attending King Saud University. The survey included questions on socio-demographic characteristics and the International Physical Activity Questionnaire Short Form (IPAQ-SF). Results : A total of 427 students were enrolled in the study (41% response rate of those clicking on the survey link). Three-quarters of respondents were females, and the majority were physically inactive (62.5%); no student reported being highly active. About half of them used their smartphones five hours or more per day, and the majority (65.1%) used applications to monitor physical activity. Bivariable analysis revealed a positive association between physical activity status and decreased hours of using a smartphone per day and using applications to monitor physical activity. Conclusion: Physical inactivity was prevalent among students at King Saud University. Targeted interventions are needed to enhance physical activity and prevent sedentary behaviors to prevent long-term adverse health consequences.


INTRODUCTION
hysical activity refers to any form of bodily movement performed by skeletal muscles that result in an increase in energy expenditure (1) .Most guidelines recommend 150 minutes of moderateto-vigorous-intensity physical activity each week (2) .There is high-quality evidence that physical activity prevents chronic illnesses, reduces deaths (2,3) , and improves quality of life (3) , and the World Health Organization guidelines for physical activity and sedentary behavior stress the need for physical activity for adults aged 18-64 years (average of 150-300 min of moderate-intensity physical activity or 75-150 min of vigorous-intensity physical activity) (4).Despite the overwhelming evidence emphasizing the benefits of physical activity, about a quarter of the global population take insufficient physical activity (5) , incurring a huge burden on individual health outcomes and the economy (6) .
Therefore, promoting physical activity is an important aspect of the wellness and health of society.The transition of young people from high school to university is an important life period when behaviors can be adopted and carried through to later adulthood.A systematic review reported that leaving high school was associated with a 7.04 min (95% CI, 2.82-11.26)decrease in moderate-to-vigorous physical activity each day (7) , suggesting that young adulthood represents a critical period to intervene to promote physical activity (7) .
In Saudi Arabia, anywhere between 50% and 95% of the population has low physical activity (8) , equating to 4 to 5 hours of sedentary behavior (sitting) per day (8)   .Approximately 58.0% and 62.7% of university students in southwestern Saudi Arabia (9) and Jazan (10) were reported to be physically inactive, respectively.However, there is no recent estimate of physical activity levels in university students in Riyadh, despite the need to quantify physical activity to develop targeted public health measures.Therefore, this study aimed to estimate physical activity patterns in King Saud University students in Riyadh, Saudi Arabia.

Study design
This was an online cross-sectional survey conducted

Original Article
between June and October 2023.Data were gathered from King Saud University undergraduate students.All 48914 university students enrolled in 2023, (11) were invited to participate in the study by e-mail.382 or more participants were needed to have a confidence level of 95% and a real value of ±5% of the measured value.

Data collection tool
Data were collected using the SURVS online survey tool (https://survs.com/).The questionnaire contained two sections: (i) sociodemographic variables (age, sex, college, specialty, medical illness or disease, weight, height, and information about the use of smartphones including history of using smartphones, time spent on smartphones, and history of using the smartphone for monitoring health and physical activity; and (ii) measuring physical activity.For the latter, the International Physical Activity Questionnaire Short Form (IPAQ-SF) (12) , a well validated tool used to assess physical activity in different contexts (13) , was used to measure physical activity.The Arabic version has previously been validated (14) and was used in this study.The IPAQ-SF records physical activity over the last seven days into days, hours, and minutes according to four activity levels: sitting, walking, moderate-intensity physical activity, and vigorousintensity physical activity.

Statistical analysis
Descriptive statistics including frequency and percentages were calculated for categorical variables.Body mass index (BMI) was calculated using the equation kg/m 2 and was categorized into <18.5, 18.5 to <25, 25 to <30, and ≥30.0 corresponding to underweight, healthy weight, overweight, and obese, respectively.Means and standard deviations (SD) were calculated for the physical activity IPAQ-SF items categorized as inactive, minimally active, and highly active, but the dependent variable was dichotomized as being inactive or not, since no one was highly active.Bivariate analysis was performed to determine associations between being active or not and the other dependent variables using Pearson chisquared tests.A P-value less than 0.05 was deemed statistically significant.Data was analyzed using SPSS software (IBM Statistics, Armonk, New York) (15) .

Ethical considerations:
The invitation for participation in the study included brief description of the research objective and the study link.Participation in the study was voluntary.In order to start the survey, the participant had to give his/ her consent.No identifiable data was requested such as name.This study has been reviewed by the King Saud University Ethics Committee (Reference no.KSU-HE-23-593).

RESULTS
During the study period, 1034 students viewed the survey link, of whom 427 agreed and completed the survey, a response rate among those who viewed the survey of 41%.Three-quarters (75.9%) of respondents were female, and a majority were from health-related colleges (55.4%) followed by humanity-related (22.6%) and sciences-related (19%) colleges.The age distribution was 22.7% 20 years, 20.7% 19 years, and 19.9% 21 years.Most respondents did not report a medical problem (87.8%).Forty-five percent of participants had normal BMIs, but 19.4% were overweight and 12.2% were obese.
The majority of respondents had used Apple smartphones (88.1%) for over five years (90.2%), and over half reported using their smartphones more than five hours daily (53.6%).Over half used smartphone applications to monitor their health, 65.1% used applications to monitor their physical activity, and 34.9% used wearable devices to monitor their physical activity (Table 1).
Nevertheless, most of the sample were not physically active (62.5%).Only 37.4% were minimally active and no participant was highly physically active.The mean vigorous physical activity was 0.91 ± 1.637 days, 0.40 ± 0.708 hours, and 17.99 ± 34.776 minutes.Participants practiced moderate physical activity for a mean of 1.08 ± 1.752 days, 0.56 ± 2.088 hours, and 17.37 ± 35.033 minutes.The mean walking period per week was 3.72 ± 2.630 days, 0.91 ± 1.248 hours, and 40.03 ± 52.726 minutes.The average sitting period per week was 7.13 ± 4.560 hours and 395.44 ± 350.055 minutes.
Sex, age, and BMI levels were not associated with physical activity, but there were differences according to their college, hours of using smartphones, and using applications to monitor their physical activity (Table 2).Minimal activity was most common in students from humanity-related colleges (50.5%) followed by science-related colleges (37%), health-related colleges (33.1%), and community-related colleges (23.1%).The percentage engagement in minimal physical activity decreased as hours of using smartphones increased: 66.7% in those who used their phones for two hours daily and 57.6% in those using their phones for three hours, 40% for four hours, 44% for five hours, and 30.6% for more than five hours daily.Using an application to monitor physical activity was significantly associated with physical activity, with 42.2% of students using applications to monitor their physical activity performing minimal activity (Table 2).

DISCUSSION
Universities should be an ideal place to support students' physical activity, mandating a greater understanding of determinants and motivation for physical activity in this environment (16) .University students are an interesting population undergoing a life transition, and the habits acquired during this period of early adulthood might influence their entire life.This study provides an estimate of the prevalence of physical activity in university students.Over half of the study sample was physically inactive, consistent with other studies of students in Saudi Arabia (9,10) , and none of the participants reported engaging in vigorous activity.Keating, Guan (17) reported a 40-50% prevalence of physical inactivity among university students, and a study from Saudi Arabia found that physical activity decreased after starting university in students attending different universities (18, 19) .Although the electronic link for the survey was sent to all university students, many more females responded than males, mirroring other studies of students attending other universities (18) .Reasons for physical inactivity include institutional, intrapersonal, and interpersonal barriers (20) .Walking seemed to be the most common type of physical activity, similar to Alkhateeb, Alkhameesi (18), probably because it is convenient, usually free, and easy to perform (18) .The largest barrier to physical activity is time constraints (18) , and it may be that students transitioning from high school find that they have more commitments at university, promoting sedentary behavior and weight gain (21) .We detected a signification association between smartphone use and physical activity, probably because screen time is often while sitting or during sedentary behavior (16) , which is problematic as prolonged sitting is associated with many health problems (22) .However, smartphones also had benefits: we found a significant association between using an application to monitor health and physical activity, consistent with a systematic review of the effectiveness of e-health interventions in promoting physical activity (23) .The positive effect of these applicationswhich use behavioral techniques that might assist in practicing physical activity such as self-monitoring, feedback on performance, and goalsetting (24) seems to be especially prominent over the short term (25), so applications must be designed that sustain user engagement over time (25) .Further studies are needed to examine the features and effects of using applications on university student physical activity.
This study is limited by its cross-sectional design, convenience sampling, and self-reporting of weight, height, and physical activity, which may be susceptible to recall bias.There may have also been selection bias given the self-selecting nature of recruitment.Using objective techniques such as accelerometers to measure physical activity and other parameters would increase the objectivity of the data.We did not assess the context of physical activity, and a robust understanding of the beliefs, barriers, and facilitators of physical activity using a theoretical framework, as noted in a systematic review of physical activity among women in the Gulf states (26) .
Despite the limitations of this study, a high proportion of students were physically inactive.A failure to meet recommended daily physical activity levels can have short-and long-term consequences (6) , for instance fatigue (27) .Given the generally sedentary profile of the student population and the fact that undertaking some physical activity is better than nothing (4) , interventions are urgently needed to motivate young adults to engage more in physical activity.

CONCLUSION AND RECOMMENDATIONS
Physical inactivity is prevalent among King Saud University students.Despite the emphasis placed by the government on physical activity as an important aspect of enhancing the nation's health and quality of life, efforts are needed to raise awareness about the magnitude of the problem with a specific focus on the needs, barriers, and facilitators to physical activity among university students.