Evaluating the Safety and Efficacy of a Non-Weight-Centric Approach to Obesity Prevention in Rural and Urban Female Adolescents: Quasi-Experimental Study.

Background: Obesity is rising among Saudi adolescents, with rural females particularly underserved due to limited health education and sociocultural barriers. Global guidelines promote non-weight-centric approaches to reduce stigma. The Green Apple program delivers school-based, weight-neutral education, with an added metabolic noncommunicable disease (MNCD) prevention unit. Although previously tested in urban settings, it has not yet been evaluated among rural female students. Objective: This study aimed to examine the effectiveness of the Green Apple intervention in improving MNCD knowledge and its safety, defined as no adverse psychological (body image discrepancy and disordered eating) or behavioral (sedentary behavior) outcomes. Methods: This quasi-experimental study included 105 participants from urban and rural schools in Saudi Arabia, with 4 classes assigned to either the intervention group (Green Apple) or the enhanced intervention group (Green Apple+MNCD). Both programs were implemented in female-only classrooms by trained facilitators during regular school hours. The intervention was delivered once per week over 2 consecutive weeks (2 sessions), while the enhanced intervention included an additional third session. Linear mixed-effects models assessed intervention effects across three time points: baseline, postintervention, and 1-month follow-up. Results: The mean age across participants was 16.42 (SD 0.66) years, with a significant difference between groups: 15.97 (SD 0.41) years in the enhanced intervention group and 17.00 (SD 0.42) years in the intervention group (P<.001). Both interventions significantly improved knowledge across schools. The enhanced intervention (Green Apple+MNCD) group demonstrated an increase of 1.65 (95% CI 0.61-2.70; P<.001) from baseline to follow-up, while the intervention (Green Apple) group showed an increase of 1.26 (95% CI 0.10-2.43; P=.02). However, no significant between-group differences were observed at baseline (mean difference 0.20, SE 0.46; P=.65), postintervention (mean difference 0.79, SE 0.45; P=.08), or follow-up (mean difference 0.73, SE 0.49; P=.13). Although sedentary behavior did not significantly decrease across all schools, a significant reduction was observed in rural schools receiving the Green Apple intervention (-3.12, 95% CI -5.67 to -0.56; P=.02). Regarding safety outcomes, no adverse effects on body image or disordered eating were observed. A significant reduction in disordered eating symptoms was found only in urban schools receiving the enhanced intervention (-0.94, 95% CI -1.61 to -0.26; P=.007). Conclusions: The Green Apple program is a culturally tailored, weight-neutral intervention that improves metabolic health literacy and reduces sedentary behavior among Saudi female adolescents without harming body image or eating behaviors. By focusing on an underserved subgroup, it addresses a key gap in health promotion and aligns with global calls for stigma-free approaches. Broader regional studies are needed to assess its long-term impact.