Salt Reduction Initiatives in the Eastern Mediterranean Region and Evaluation of Progress towards the 2025 Global Target: A Systematic Review

Knowledge, attitudes, and practices related to dietary salt among older adults in Abha, Saudi Arabia

The need to foster successful aging has intensified with the aging of the global population. This study aimed to assess the knowledge, attitudes, and practices (KAP) concerning dietary salt consumption and to investigate the correlations between sociodemographic variables and salt-related KAP. A structured interview was administered to a cohort of 200 older adults in Abha City, Saudi Arabia, recruited through a convenience sampling approach. The evaluation of salt-related KAP revealed widespread low knowledge (91.5%) as participants scored less than 3, negative attitudes (85.5%) scored less than 12, and predominantly unsatisfactory practices (69.5%) with scores less than 26. Noteworthy differences emerged between participants with poor overall KAP (81.5%) and those with good KAP (18.5%). Significantly weak negative correlations were found between age (r=-0.212), marital status (-0.236), and body mass index (-0.243) with overall KAP. Further examination revealed a significantly weak positive correlation between attitude and practice (r = 0.141). KAP scores show a highly significant positive correlation with overall KAP scores (r = 0.169, 0.352, 0.969). The uncovered correlations contribute to a valuable understanding of the complex dynamics surrounding salt-related KAP. This understanding guides the design of targeted interventions, such as health education programs, promoting successful aging and public health outcomes.

Multisectoral action to address noncommunicable diseases: lessons from three country case studies

Introduction

Multisectoral action is a central component of the global response to the rising prevalence of non-communicable diseases (NCDs). In this paper we aimed to unpack the definition of multisectoral action and provide an overview of the historical context, challenges, and recommendations alongside three country case studies: salt reduction in the UK, tobacco legislation in Nigeria, and regulation of edible oils in Iran.

Methods

We used an iterative review process to select three country case studies from a list of 20 potential cases previously identified by WHO. At our third round of review we unanimously agreed to focus on salt reduction in the UK, tobacco regulation in Nigeria, and edible oil regulation in Iran as these represented rich cases on diverse risk factors from three different world regions that we felt offered important lessons. We conducted literature reviews to identify further data for each case study.

Results

Across the three studies a number of important themes emerged. We found that multisectoral approaches demand the often difficult reconciliation of competing and conflicting values and priorities. Across our three chosen cases, commercial interests and free trade agreements were the most common obstacles to successful multisectoral strategies. We found that early consultative stakeholder engagement and strong political and bureaucratic leadership were necessary for success.

Discussion

The complex multi-rooted nature of NCDs requires a multisectoral approach, but the inevitable conflicts that this entails requires careful navigation.

Overview of hypertension in Saudi Arabia: A systematic review and meta-analysis

OBJECTIVES

To assess the prevalence, awareness, treatment, and control of hypertension in Saudi Arabia.

METHODS

We searched electronic databases and the references lists of found publications between 1990 and 2022. Original cross-sectional studies in English were included using PubMed, Google Scholar, and the Saudi Digital Library. A meta-analysis was performed to assess the combined prevalence, awareness, treatment, and control rates of hypertension.

RESULTS

Twenty-nine studies with 278873 individuals aged 14-100 were considered. The pooled prevalence of hypertension was 22.66% (95% CI:18.95-26.60), Cochran's Q=6221.98, dff=22, p<0.0001; I2=99.65%, Egger's test (p=0.0033) across 23 studies with 272378 people. The pooled hypertension awareness rate was 42.8% from 6 studies with 36046 participants (95% CI:35.66-50.01), Cochran's Q=781.86, dff=5, p<0.0001; I2=99.4% and Egger's test p=0.3772. The pooled proportion of hypertension patients treated in 6 studies involving 46075 samples was 59.4% (95% CI=38.14-79.02), Cochran's Q=9793.79 dff=5, p<0.0001; I2=99.95%, Egger's test p=0.8284. The pooled proportion of hypertension-controlled participants across 15 studies comprising 264817 subjects was 34.97% (95% CI: 27.62-42.68), Cochran's Q=11048.28, dff=14, p<0.0001; I2=99.87% and Egger's test p=0.9760.

CONCLUSION

The prevalence of hypertension was high, with low awareness, treatment, and control rates among Saudis. Therefore, policymakers and healthcare providers must work harmoniously to promote health and to prevent, detect, and control hypertension early.PROSPERO Reg. No.: CRD42023407978.

Association between Dietary Patterns and Cognitive Function among Qatari Adults: A Cross-Sectional Analysis of the Qatar Biobank Study

This study aimed to assess the association between dietary patterns and cognitive function among Qatari adults. In a cross-sectional analysis, data on 1000 Qatari adults attending the Qatar Biobank Study (QBB) aged ≥18 years were obtained. Using factor analysis, dietary patterns were constructed based on habitual dietary intake assessed by food frequency questionnaires (FFQs). The mean reaction time (MRT) derived from self-administered touch screen tests was used as an indicator of cognitive function. The association between dietary patterns and MRT was investigated using linear regression. The mean age of the participants was 35.8 (SD 10.3) years, and the mean MRT was 715.3 (SD 204.1) milliseconds. Three dietary patterns were identified. The "traditional" dietary pattern, characterized by high intakes of white rice, mixed dishes and soups/starters possibly high in saturated fat and sodium, was positively associated with MRT. In the multivariable model, comparing the highest to lowest quartiles of the traditional pattern, the regression coefficient for MRT was 50.0 (95% CI 16.9, 83.1; p for trend 0.001). There was an effect modification of diabetes and age on the association between the "modern" dietary pattern and MRT. The "convenient" dietary pattern was not associated with cognition. In conclusion, the traditional rice-based dietary pattern may be associated with poor cognitive function.

Nutrition Profile for Countries of the Eastern Mediterranean Region with Different Income Levels: An Analytical Review

The World Health Organization's (WHO) Eastern Mediterranean Region (EMR) is suffering from a double burden of malnutrition in which undernutrition coexists with rising rates of overweight and obesity. Although the countries of the EMR vary greatly in terms of income level, living conditions and health challenges, the nutrition status is often discussed only by using either regional or country-specific estimates. This analytical review studies the nutrition situation of the EMR during the past 20 years by dividing the region into four groups based on their income level-the low-income group (Afghanistan, Somalia, Sudan, Syria, and Yemen), the lower-middle-income group (Djibouti, Egypt, Iran, Morocco, Pakistan, Palestine, and Tunisia), the upper-middle-income group (Iraq, Jordan, Lebanon, and Libya) and the high-income group (Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates)-and by comparing and describing the estimates of the most important nutrition indicators, including stunting, wasting, overweight, obesity, anaemia, and early initiation and exclusive breastfeeding. The findings reveal that the trends of stunting and wasting were decreasing in all EMR income groups, while the percentages of overweight and obesity predominantly increased in all age groups across the income groups, with the only exception in the low-income group where a decreasing trend among children under five years existed. The income level was directly associated with the prevalence rates of overweight and obesity among other age groups except children under five, while an inverse association was observed regarding stunting and anaemia. Upper-middle-income country group showed the highest prevalence rate of overweight among children under five. Most countries of the EMR revealed below-desired rates of early initiation and exclusive breastfeeding. Changes in dietary patterns, nutrition transition, global and local crises, and nutrition policies are among the major explanatory factors for the findings. The scarcity of updated data remains a challenge in the region. Countries need support in filling the data gaps and implementing recommended policies and programmes to address the double burden of malnutrition.

Sugar Reduction Initiatives in the Eastern Mediterranean Region: A Systematic Review

This systematic review aims to identify and characterize existing national sugar reduction initiatives and strategies in the Eastern Mediterranean Region. For this purpose, a systematic review of published and grey literature was performed. A comprehensive list of search terms in the title/abstract/keyword fields was used to cover the four following concepts (1) sugar, (2) reduction OR intake, (3) policy and (4) EMR countries. A total of 162 peer-reviewed documents were identified, until the 2nd of August 2022. The key characteristics of the identified national strategies/initiatives included the average sugar intake of each country's population; sugar levels in food products/beverages; implementation strategies (taxation; elimination of subsidies; marketing regulation; reformulation; consumer education; labeling; interventions in public institution settings), as well as monitoring and evaluation of program impact. Twenty-one countries (95%) implemented at least one type of sugar reduction initiatives, the most common of which was consumer education (71%). The implemented fiscal policies included sugar subsidies' elimination (fourteen countries; 67%) and taxation (thirteen countries 62%). Thirteen countries (62%) have implemented interventions in public institution settings, compared to twelve and ten countries that implemented food product reformulation and marketing regulation initiatives, respectively. Food labeling was the least implemented sugar reduction initiative (nine countries). Monitoring activities were conducted by four countries only and impact evaluations were identified in only Iran and Kingdom of Saudi Arabia (KSA). Further action is needed to ensure that countries of the region strengthen their regulatory capacities and compliance monitoring of sugar reduction policy actions.

Using Digital Platform Approach to Reduce Salt Intake in a Sample of UAE Population: An Intervention Study

Background

Non-communicable diseases (NCDs) are the leading causes of mortality globally, accounting for more deaths than all other causes combined. World Health Organization launched its initiative in 2013 to reduce the intake of salt, the number of countries that have national sodium reduction strategies reached to 89 countries in 2017. In 2020, a study conducted in UAE showed more than 65% of the population exceeded WHO recommendations for salt intake. This study aimed to measure effectiveness of using digital platform approach to deliver educational materials to facilitate salt reduction in a sample of UAE population.

Methods

A controlled parallel intervention study was conducted in 2020. A sample of 121 participants completed the study and fulfilled the inclusion criteria with female to male ratio of (0.95:1.05). Participants were distributed randomly into three groups Control group, WhatsApp group, and Electronic Brochures group. Educational materials were distributed among participants of WhatsApp and Electronic brochures groups for 6-weeks. 24-h urinary excretion for sodium, potassium and creatinine, were measured in addition to KAP questionnaire and physical activity on two occasions at baseline and endpoint after 10-weeks (6-weeks of educational intervention).

Results

Both intervention groups showed a reduction in sodium with 278 mg (p < 0.001) for WhatsApp group (n = 41) and 169 mg (p < 0.018) for Electronic brochures group (n = 41), while Control group didn't show any significant change. Moreover, the percentage of participants exceeding WHO recommendation of sodium intake was significantly reduced at the end of intervention, (p = 0.004). WhatsApp group was more efficient in the percentage of reduction of participants exceeding WHO recommendation compared with baseline, with p = 0.023. A significant reduction in the practice toward adding salt during cooking, use of table salt, adding salt before tasting the foods and use of chicken stocks for both intervention groups was noted with p < 0.05. Intervention groups showed a significant improvement (p < 0.001) in Food and Health related knowledge after 6-weeks of intervention.

Conclusion

The digital platform approach such as WhatsApp and Electronic Brochure were effective in salt reduction. This study proves that UAE population is ready to reduce salt intake with appropriate education materials and easy delivery approach.

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.

The Sweet and Salty Dietary Face of Hypertension and Cardiovascular Disease in Lebanon

According to the World Health Organization (WHO), an estimated 1.28 billion adults aged 30–79 years worldwide have hypertension; and every year, hypertension takes 7.6 million lives. High intakes of salt and sugar (mainly fructose from added sugars) have been linked to the etiology of hypertension, and this may be particularly true for countries undergoing the nutrition transition, such as Lebanon. Salt-induced hypertension and fructose-induced hypertension are manifested in different mechanisms, including Inflammation, aldosterone-mineralocorticoid receptor pathway, aldosterone independent mineralocorticoid receptor pathway, renin-angiotensin system (RAS), sympathetic nervous system (SNS) activity, and genetic mechanisms. This review describes the evolution of hypertension and cardiovascular diseases (CVDs) in Lebanon and aims to elucidate potential mechanisms where salt and fructose work together to induce hypertension. These mechanisms increase salt absorption, decrease salt excretion, induce endogenous fructose production, activate fructose-insulin-salt interaction, and trigger oxidative stress, thus leading to hypertension. The review also provides an up-to-date appraisal of current intake levels of salt and fructose in Lebanon and their main food contributors. It identifies ongoing salt and sugar intake reduction strategies in Lebanon while acknowledging the country’s limited scope of regulation and legislation. Finally, the review concludes with proposed public health strategies and suggestions for future research, which can reduce the intake levels of salt and fructose levels and contribute to curbing the CVD epidemic in the country.

Shifting to a Sustainable Dietary Pattern in Iranian Population: Current Evidence and Future Directions

The need for a shift in diet toward a more sustainable one has reached an urgency in certain regions, including Iran, due to more rapid climate change and a higher level of vulnerability. This study was undertaken to identify and summarize available data on changes required in the current Iranian diet to make it more sustainable and the extent to which current policies in the country have addressed such a shift. In this study, PubMed, Scopus, and Web of science, as well as Iranian scientific search engines, including Scientific Information Database and Magiran, were systematically searched from January 1990 to July 2021. A total of 11 studies and policy analyses were included in this study. Based on the findings, moving Iranian diet toward sustainability will require increase in consumption of dairy, fruits, vegetables, cereals, poultry, and legumes and decrease in consumption of bread, rice, pasta, red meat, eggs, fats, sugars, and sweets. There has been a great deal of effort and investment on policies and strategies to decrease the amount of sugar, salt, and fat (specifically trans-fatty acids) in the Iranian diet, which makes it more sustainable healthwise. Several policies and programs have been implemented to tackle non-communicable diseases (NCDs) by reducing access to unhealthy foods, which is in line with health dimension of a sustainable diet. However, there is almost no direct address to ecological aspect of sustainable diet in the food and nutrition policy documents in the ccountry. Development of an enabling environment to a sustainable diet will require policy and actions to improve public awareness, support study to provide evidence and identify possible alternatives, and plan and implement interventions/programs to promote and facilitate healthy and sustainable diets.