Screen-time eating linked to double burden of malnutrition in Saudi middle schoolers

A cross-sectional study of 268 middle school students in Saudi Arabia has found that underweight and overweight or obesity coexist at nearly identical levels in the same school population, a pattern researchers describe as a population-level double burden of malnutrition. Using survey-weighted estimates that account for the complex sampling design, the research team reported that 49.8 percent of the represented population had an abnormal BMI-for-age classification, with 25.3 percent classified as underweight and 24.5 percent as overweight or obese. The findings, published in Frontiers in Nutrition, come from four schools selected through stratified cluster sampling, and they show that malnutrition in adolescence is not a single-direction problem but one that can pull in two opposing directions at once.

The study, led by researchers at the University of Hail, set out to assess the double burden of malnutrition among middle school students and to examine how selected lifestyle behaviors relate to nutritional status. Data on dietary habits, physical activity, and screen-related behaviors were collected through a structured self-administered questionnaire, while the research team directly obtained anthropometric measurements, including height and weight. Nutritional status was classified using the World Health Organization BMI-for-age reference, a standard that accounts for age and sex when determining whether a child or adolescent falls into the underweight, healthy weight, or overweight and obese categories.

What distinguishes this analysis from many school-based nutrition surveys is its statistical treatment. The researchers incorporated sampling weights and the complex survey design into their analyses, meaning the results are intended to reflect the broader represented population rather than only the 268 students who were measured. Associations between behaviors and BMI category were examined using the Rao–Scott design-adjusted chi-square test, a method that corrects for the clustering of students within schools and the unequal probabilities introduced by weighted sampling.

Across the full set of behaviors examined, only one emerged as significantly associated with BMI category in the design-adjusted bivariate analyses: eating while using screens. The association reached statistical significance at p = 0.046. The weighted prevalence of overweight or obesity rose from 12.1 percent among students who never ate while using screens to 32.9 percent among those who always did so, a nearly threefold difference across the frequency spectrum of this single habit. The pattern suggests that the context in which food is consumed, not merely what is eaten, may be relevant to adolescent weight status, although the cross-sectional design of the study means the direction of the relationship cannot be established from these data alone.

Notably, the remaining measured factors did not show statistically significant associations. Demographic characteristics, dietary behaviors, physical-activity frequency, screen-time duration, mobile-phone use, and eating while using a mobile phone were all reported as not statistically significant in relation to BMI category. This pattern is instructive in itself: total hours spent in front of screens did not distinguish students by weight category, yet the specific behavior of combining eating with screen use did. The findings hint that distracted eating, in which attention is divided between food and a device, may operate differently from screen exposure alone, though the study’s design limits any causal interpretation of this distinction.

The coexistence of underweight and overweight or obesity at similar levels, 25.3 percent and 24.5 percent respectively, underscores why the double burden of malnutrition is considered an important public health concern among adolescents. In a single classroom, students at opposite ends of the nutritional spectrum may sit side by side, each facing distinct health risks. Interventions that address only one side of the burden risk overlooking the other, which is why population-level assessments that capture both extremes are valuable for planning school-health strategies.

The study’s authors connect their findings to practical implications for schools. The results support school-health strategies addressing both forms of malnutrition and promoting balanced dietary practices, regular physical activity, and reduced screen-related eating. Because the data were collected in a school setting with direct anthropometric measurement rather than self-reported height and weight, the nutritional classifications rest on objective measurements, a strength in a research area where self-reported body size is known to be unreliable. The structured questionnaire approach also allowed the team to capture multiple lifestyle domains, from dietary habits to physical activity to screen-related behaviors, within a single assessment.

At the same time, the authors are explicit about the limits of their conclusions. The cross-sectional design means that associations observed at a single point in time cannot establish whether eating while using screens contributes to higher weight status or whether the relationship runs in some other direction. The limited number of sampled schools, four in total, also requires cautious interpretation, since findings from a small number of clusters may not generalize broadly even when sampling weights are applied. The researchers state that these considerations demand careful interpretation of the observed association between screen-related eating and BMI category, and they frame their results as evidence to inform strategies rather than as proof of causal effects.

As adolescent nutrition research increasingly recognizes that underweight and excess weight can coexist within the same communities, studies that measure both burdens simultaneously with design-appropriate statistics offer a clearer picture of where interventions may be needed. For the represented middle-school population in this Saudi Arabian sample, the message is twofold: malnutrition in both directions is present at meaningful levels, and the everyday habit of eating while looking at a screen is the one lifestyle factor that, in this analysis, stood out as significantly associated with where students fell on the BMI-for-age scale.

Subject of Research: Cross-sectional study of the double burden of malnutrition and lifestyle behaviors among middle school students in Saudi Arabia

Article Title: Lifestyle behaviors associated with the population-level double burden of malnutrition among middle school students in Saudi Arabia: a cross-sectional study

Article References: Marzouk, S. A., AlAbd, A. M. A., Elalem, O. M., Alrashidi, N. A., Alenizi, S. F., Othman, A. F., & Balawi, A. M. (2026). Lifestyle behaviors associated with the population-level double burden of malnutrition among middle school students in Saudi Arabia: a cross-sectional study. Frontiers in Nutrition, 13, 1930134. https://doi.org/10.3389/fnut.2026.1930134

Image Credits: AI Generated

DOI: 10.3389/fnut.2026.1930134

Keywords: double burden of malnutrition, adolescent nutrition, BMI-for-age, screen-based eating, Saudi Arabia, cross-sectional study, school health, overweight and obesity, underweight, physical activity, nutritional epidemiology, survey weighting