Is Trans Fatty Acid Still an Issue for Policy Makers in Iran? A Technical Report

Unhealthy Dietary Habits and Obesity: The Major Risk Factors Beyond Non-Communicable Diseases in the Eastern Mediterranean Region

There are 22 countries in the Eastern Mediterranean Region (EMR) expanding from Morocco in the west to Pakistan and Afghanistan in the east, containing a population of 725,721 million in 2020. In the previous 30 years, the illness burden in the EMR has transmitted from communicable diseases to non-communicable diseases such as diabetes, cardiovascular diseases, and cancer. In 2019, cardiovascular mortality in the EMR was mostly attributed to ischemic heart disease, the first reason for mortality in 19 countries in the region. Stroke was the second reason for death in nine countries followed by diabetes, which was ranked as the second reason for death in two countries. The prominent nutrition-related NCDs risk factors in EMR include obesity, hypertension, high fasting plasma glucose, and upregulated unhealthy diet consumption. Most of the EMR population are unaware of their NCDs risk factor status. These risk factors, even if treated, are often poorly controlled, therefore, inhibiting their existence by changing the lifestyle to proper dietary habits and sufficient physical activity is mandatory. In this review, the epidemiology and nutrition-related risk factors of NCDs in the EMR will be discussed and illustrated, aiming to scale up action and support decision-makers in implementing cost effective strategies to address obesity and NCDs prevention and management in the region.

A Systematic Review of Trans Fat Reduction Initiatives in the Eastern Mediterranean Region

High intakes of trans fatty acids (TFA), particularly industrially-produced TFA, are implicated in the etiology of cardiovascular diseases, which represent the leading cause of mortality in the Eastern Mediterranean Region (EMR). This systematic review aims to document existing national TFA reduction strategies in the EMR, providing an overview of initiatives that are implemented by countries of the region, and tracking progress toward the elimination of industrially-produced TFA. A systematic review of published and gray literature was conducted using a predefined search strategy. A total of 136 peer-reviewed articles, gray literature documents, websites and references from country contacts were obtained, up until 2 August 2021. Randomized-control trials, case-control studies, and studies targeting unhealthy population groups were excluded. Only articles published after 1995, in English, Arabic or French, were included. Key characteristics of strategies were extracted and classified according to a pre-developed framework, which includes TFA intake assessment; determination of TFA levels in foods; strategic approach; implementation strategies (TFA bans/limits; consumer education, labeling, interventions in public institution settings, taxation), as well as monitoring and evaluation of program impact. Thirteen out of the 22 countries of the EMR (59%) have estimated TFA intake levels, 9 have determined TFA levels in foods (41%), and 14 (63.6%) have national TFA reduction initiatives. These initiatives were mainly led by governments, or by national multi-sectoral committees. The most common TFA reduction initiatives were based on TFA limits or bans (14/14 countries), with a mandatory approach being adopted by 8 countries (Bahrain, Iran, Jordan, KSA, Kuwait, Morocco, Oman and Palestine). Complementary approaches were implemented in several countries, including consumer education (10/14), food labeling (9/14) and interventions in specific settings (7/14). Monitoring activities were conducted by few countries (5/14), and impact evaluations were identified in only Iran and the UAE. The robustness of the studies, in terms of methodology and quality of assessment, as well as the lack of sufficient data in the EMR, remain a limitation that needs to be highlighted. Further action is needed to initiate TFA reduction programs in countries that are lagging behind, and to ensure rigorous implementation and evaluation of ongoing programs.

Analysis of fat, fatty acid profile, and salt content of Iranian restaurant foods during the COVID-19 pandemic: Strengths, weaknesses, opportunities, and threats analysis

This study aimed to analyze the fat, fatty acid profile, and salt content of restaurant foods (RFs) and find out strategies to lower them using the strengths, weaknesses, opportunities, and threats (SWOT). Five types of common foods (n = 70) were collected from restaurants in Tehran, Iran. The fat, fatty acid profile, and salt content of samples were analyzed by acid hydrolysis method, gas chromatography, and Charpentier Volhard methods, respectively. The quantitative data were analyzed by the SPSS using ANOVA and Spearman's correlation test. Then, a SWOT analysis was done. The laboratory results indicated that the highest amount of total fat was in Samosa (16.92% ± 6.27%), whereas saturated fatty acids (SFA) and trans fatty acids (TFA) were significantly higher in Koobideh kebab with rice (44.42% ± 5.07% and 2.86% ± 0.64%, respectively) as compared to other samples. In addition, the highest amount of salt was in the Falafel sandwich (2.87% ± 0.98%). The salt content in the majority of analyzed foods was about two times more than the daily recommendations of the World Health Organization (WHO). The SWOT analysis results showed the lack of standardization of recipes to measure accurate fat and salt content was the main weakness and food labeling in the menus was detected as an important opportunity. TFA and salt in RFs were alarmingly high and it is necessary to find strategies for reformulation of RFs to reduce their fat and salt content. Policymakers can use the SWOT analysis results of this study to offer directions for potential future strengthening actions of healthy foods in restaurants for public health.

Implementation of WHO Recommended Policies and Interventions on Healthy Diet in the Countries of the Eastern Mediterranean Region: From Policy to Action

Non-communicable diseases (NCDs) are responsible for almost two-thirds of the deaths in the 22 countries and territories of the WHO Eastern Mediterranean Region and unhealthy diets are a major contributor. Prevalence of overweight and obesity has increased among adults, adolescents and older children in recent decades. Among countries with the highest prevalence there are signs that the increase is slowing down or even that prevalence is declining. There has been no increase in the prevalence rate in younger children, although the absolute number of children under five years affected by overweight has increased. This review summarizes prevalence data and examines current implementation of regulatory, fiscal and voluntary measures to promote healthy diet across the Region. The last decade has seen a step up in such action. Ten of the Region's countries have policies relating to trans-fatty acids and they are increasingly implementing specific regulatory measures. Thirteen countries had fully or partially implemented national salt reduction policies by 2019. Only four countries had adopted policies relating to aspects of marketing food to children by 2019, and concrete action in this area is still lacking. Eight countries have introduced taxes-sometimes at a rate of 50%-on carbonated or sugar-sweetened beverages. In order to meet the agreed global and regional goals relating to nutrition and diet-related NCDs, countries will need to build on this progress and scale up action across the Region while intensifying efforts in areas where concrete action is lacking.

Assessment and prioritization of the WHO "best buys" and other recommended interventions for the prevention and control of non-communicable diseases in Iran

BACKGROUND

The WHO's "best buys" and other recommended interventions are a menu of policy options and cost-effective interventions for the prevention and control of major noncommunicable diseases (NCDs). The menu has six objectives, implementing which by member states is expected to promote the achievement of the nine NCD targets by 2025. In line with their context, countries can select from the menu of best buys and other recommended interventions. Iran adopted its national action plan on NCDs, 2015, including global as well as some specific goals and targets. This study had two objectives: analyzing the gaps to reach the national targets on NCDs; and prioritizing the best buys and other recommended interventions based on multi-criteria decision-making (MCDA) method for the context of Iran.

METHODS

This is a mixed-methods study. We used qualitative textual evidence (documentary content analysis) and MCDA for prioritization of interventions based on five criteria, including a number of people to be potentially affected by the intervention, cost-effectiveness of the intervention, attributable burden (DALY per 100,000), hospitalization and variations among income levels. Data related to five criteria for each intervention were extracted from national studies and relevant international organizations. The weight of each criterion determines based on the opinions of national experts.

RESULTS

Out of 105 actions and interventions recommended by WHO, only 12 of them were not on the national agenda in Iran, while the six missed interventions were related to objective number 4. Only one of the best buys Group's interventions was not targeted (vaccination against human papillomavirus, two doses of 9-13-year-old girls), for which arrangements are being made for the implementation. Encouraging and educating healthy dietary habits and increasing public awareness about the side effects of smoking and exposure to second-hand smoke, e.g., through mass media campaigns, are among the interventions in need of serious prioritization. The priority of interventions was independently calculated in the area of risk factors and clinical preventive interventions.

CONCLUSION

Due to limited resources, low and middle-income countries (LMICs) need to identify and prioritize more cost-effective and more equitable interventions to combat the NCD epidemic. Based on our findings, we advocate more investment in the mass and social media campaigns to promote a healthy diet, avoid tobacco use, as well as the inclusion of some effective clinical preventive interventions into the national action plan, along the long pathway to tackle NCDs and ultimately reach sustainable health development in Iran. The use of the MCDA approach assisted us in formulating a simultaneous use of efficiency and equity, and other indices for prioritizing the interventions.