Awareness of avian influenza (“bird flu”) among attendees of a primary healthcare clinic in Riyadh

To the Editor: I read with great interest the recently published article by Lafta and Kadhim1 in the Annals of Saudi Medicine and I appreciated the authors’ efforts and work. However, I would like to raise two points about viewing child obesity via a gender lens and interpreting the data of Table 2 in the manuscript. Both points are actually interrelated. The authors explained the sole significant association of BMI with >2 hours outdoor playing among boys aged 10-12 years by stating that “this may be due to the tribal custom that girls spend more time indoors”. I agree with the authors’ intention to discuss obesity and its risk factors from a gender perspective, especially in Arab countries. Even in nonArab cultures, Chen et al2 recommended the need for genderspecific approaches to prevent childhood obesity. However, the authors’ explanation was immaterial because they did not draw it from their data. The authors only found a significant association between longer outdoor exercise and BMI in the older cohort of the male sub-sample. Some studies in the Arab region proved that lack of exercise was associated significantly with obesity among children, whereas obesity in older adults is more prevalent among the least educated, nonsmokers, and those reporting a family history of obesity. For the authors to explain childhood obesity in a gender context, they have to prove that girls 10-12 years were more obese than boys, presumably because they spend fewer hours in outdoor playing than boys of the same age. On the contrary, the authors stated that “the difference [in obesity prevalence between boys and girls] was not statistically significant”. Moreover, the authors confused the reader in determining their reference category for the odds ratio (OR) of the risk factors in Table 2. They showed that the OR of first-born vs. lastborn child was 0.78, P=0.02, concluding in their result section that “first-born children [were] more frequently of normal weight than last-born children”. The same was mentioned for breast fed vs. bottle fed, as well as primary school vs. college educated parents, which implies that the second category, for the first three risk factors, was the reference category where OR=1. If the authors’ rule was applied for the remaining two variables in the table, outdoor playing and watching TV, then less than 2 hours of outdoor playing would be a protective factor for boys aged 10-12 years against overweight as OR was 0.47, P=0.004. Similarly, boys aged 7-9 years, who spend fewer hours watching TV, would be 2.98 times more likely to be overweight than others. Unfortunately, the reverse was stated in the results and such a discrepancy could be explained, in the best case scenario, by misplacing the categories in Table 2 for the last two variables. To conclude, the authors were imprecise and inaccurate in their interpretation and their gender approach as regards the last two variables in Table 2.