Review of the Nutrition Situation in Jordan: Trends and Way Forward

Deteriorating complementary feeding practices and dietary quality in Jordan: Trends and challenges

Quality complementary feeding (CF) of infants and young children is key to their growth and development. But in Jordan, providing appropriate CF remains a challenge. This study assesses trends in infant and young child feeding (IYCF) practices, and consumption by infants and young children aged 6-23 months of breast milk substitutes (BMSs), sugar-sweetened beverages (SSBs), and micronutrient-rich foods in Jordan from 1990 to 2017. We combined dietary data on infants and young children from six Demographic and Health Surveys (DHS) (n = 14,880 children) to compute IYCF indicators. The latter included minimum dietary diversity (MDD), minimum meal frequency (MMF), and minimum acceptable diet (MAD), as well as intake of micronutrient-rich foods and food groups, specific SSBs, and infant formula. We conducted trend analyses using logistic regression models adjusted for child's age in month, child age squared, governorates, urban/rural residence, mother's educational attainment, and household wealth quintiles. We found that the proportion of consumption of micronutrient-rich food groups declined significantly between 1990 and 2017, with fewer infants and young children consuming eggs (OR = 0.39, p ≤ 0.001, 2002 reference), meat, poultry, and fish (OR = 0.25, p ≤ 0.001, 2002 reference), dairy (OR = 0.59, p ≤ 0.001, 2002 reference) and Vitamin A-rich fruits and vegetables (OR = 0.66, p ≤ 0.001, 2002 reference). Conversely, there was increased use of BMSs and sugar-sweetened juices that paralleled a decline in the share of infants and young children meeting appropriate CF practices and consuming micronutrient-rich foods and food groups. By 2017, children aged 6-23 months were significantly less likely to meet MDD, MMF, and subsequently MAD; the odds of consuming BMSs were almost three times the reference (OR = 3.8, p ≤ 0.001, 1990 reference), as were the odds of consuming sugar sweetened juices  (OR = 3.63, p ≤ 0.001, 1990 reference). Food insecurity and undernutrition are low in Jordan; however, overweight and obesity rates are increasing concurrently as are micronutrient deficiencies. This highlights the need for policymakers to address factors at individual and household levels (behaviours and practices) as well as environmental issues (increasing access to unhealthy and ultraprocessed foods).

Knowledge, Awareness, and Practices toward Colorectal Cancer and Its Dietary and Lifestyle-Related Risk Factors among Jordanian University Students: A Cross-Sectional Study

Background

Globally, colorectal cancer (CRC) incidence is rising, and it is a leading cause of mortality, with greater death rates pronounced in developing countries, including Jordan. Understanding knowledge and awareness of etiologic factors, unhealthy lifestyles, and dietary patterns is crucial for combating ailments. Hence, this study is aimed at investigating the level of knowledge and awareness of CRC-related risk factors, practices, and possible associations of studied variables among young Jordanians. Methodology. A cross-sectional, observational study was conducted using an online self-reported assessment of anthropometrics, knowledge, awareness, and dietary and lifestyle practices toward CRC and its related risk factors.

Results

A study of 795 Jordanian university students found that 93.8% were Jordanians, 73.0% were female, aged 18-24, and single. Most participants were from medical and science schools (69.4%). The vast majority (about 84%) were found to have good knowledge and awareness of CRC and its risk factors, but this was not reflected in their dietary practices. There are significant differences in physical activity, smoking, vegetable consumption, and serving sizes of red meat and processed meats between the sexes. Academic study specialties significantly impact knowledge and awareness.

Conclusion

The study reveals that while young Jordanian university students have good knowledge and awareness about CRC and its risk factors, these levels are not reflected in their dietary behaviors and food choices for CRC prevention, highlighting the need for national programs to improve these practices, particularly in the younger population.

Community Pharmacists' Current Practice and Educational Needs in Breastfeeding Support in Jordan: A Cross-Sectional Study

BACKGROUND

Improving breastfeeding practices is a worldwide priority. Pharmacists have the opportunity to actively promote breastfeeding and educate parents as well as the general public about its benefits.

RESEARCH AIMS

The aims of this study are to investigate Jordanian pharmacists' present breastfeeding support practices and perceptions regarding their need for education and training in breastfeeding support.

METHODS

To examine sociodemographic characteristics of community pharmacists in Jordan and their current breastfeeding support practices and educational needs, a descriptive cross-sectional online (self-report) survey was conducted. Through social media, pharmacists working in community pharmacies in Jordan were recruited between August 2021 and February 2022. The level of breastfeeding support participants had been provided with was measured using eight items in a 5-point Likert scale ranging from 5 (Always) to 1 (Never). Each participant self-reported the frequency of advice/information given to breastfeeding women in each of these areas. Univariate and multivariable linear regression models were used to identify factors associated with the level of breastfeeding support.

RESULTS

Participants (N = 381) reported a high level of breastfeeding support, but expressed a need for training and education for further improvement. The breastfeeding support score of female participants was found to be 0.12 higher than that of males (Beta = 0.12, p = .02), 0.16 higher in married participants compared to non-married participants (Beta = 0.16, p = .03), and 0.10 higher in participants working in rural areas compared to those working in urban areas (Beta = 0.10, p = .04).

CONCLUSION

While community pharmacists generally report a high level of breastfeeding support, our findings revealed demographic differences. Attention to specific areas of need might enhance what pharmacists could offer; however, additional research would be required to guide the specific educational content.

Analysis of the nutritional status in the Palestinian territory: a review study

Background

Food insecurity, occupation, and poverty contribute to the poor nutritional status of Palestine. This review study aimed to analyze the nutritional status in the Palestinian Territory by analyzing published data from 2011 to 2023.

Method

Searching for relevant publications yielded 67 studies. Based on reviewing these studies, five major themes were identified: low birth weight, breastfeeding, obesity and overweight, protein-energy malnutrition, and micronutrient deficiency.

Results

Based on the review of these studies, five major themes were identified, namely, low birth weight, breastfeeding, obesity and overweight, protein-energy malnutrition, and micronutrient deficiency. Based on the literature, the prevalence rate of exclusive breastfeeding was 24.4% in the Gaza Strip, compared to a national rate of 39.9% in 2020. Smoking, anemia in mothers, diet during pregnancy, and indoor pollution were associated with low birth weight. One-fifth of the boys and girls were stunted by 2 years of age in the Gaza Strip, and girls were more stunted than boys. The prevalence rates of underweight, overweight, and obesity among school children in the West Bank were 7.3%, 14.5%, and 15.7%, respectively. Age, gender, and living area were significant predictors of being overweight among school children. The prevalence rates of overweight and obesity among adults in Palestine were 57.8% and 26.8%, respectively. Obesity is associated with a family history, chronic diseases, and low physical activity among adults. Exclusive breastfeeding was below the WHO recommendations, while significant rates of obesity and overweight were found among children and adults. Iron-deficiency anemia (IDA) among pregnant women and children remains a challenging public health issue, while other micronutrient deficiencies are high among children.

Conclusion

This review emphasizes the need for multi-sectoral interventions to address malnutrition and nutritional shifts. It identifies gaps and addresses nutrition-related issues in the Palestinian Territory, which can serve as a basis for guiding United Nations agencies and governments in formulating evidence-based policies and strategies for prioritizing nutritional interventions to meet sustainable development goals.

The impact of weight loss diet programs on anemia, nutrient deficiencies, and organ dysfunction markers among university female students: A cross-sectional study

Practicing restricted weight loss diet programs (WLDPs) without proper supervision can result in nutritional deficiency, which can lead to the development of several nutritional disorders. The current cross-sectional study aimed to investigate the impact of WLDPs practiced by university female students on the prevalence of micronutrient deficiencies, anemia, and organs dysfunction, and to assess the association of identified anomalies with dieting practices and dietary habits of university female students. A total of 185 (105 dieting and 80 non-dieting) volunteers’ female students at Al-Hussein Bin Talal University participated in this study. After the participants answered a questionnaire, blood samples were collected for hematological and biochemical analysis, and the body mass index (BMI) was determined. The results show that there were no significant differences between dieting and non-dieting groups in biochemical markers of kidney and liver functions as well as serum levels of copper, zinc, and folate. On the other hand, dieting participants exhibited significantly lower level of hemoglobin, serum ferritin, iron, and vitamin B12 than encounter group (p<0.05). Attempting WLDPs significantly increased the prevalence of anemia (46.7%), iron deficiency (57.1%), and iron deficiency anemia (IDA) (41.9%), comparing to non-dieting students (28.7%, 33.8%, and 15.0%, respectively) (p<0.005). Chi-square test showed that the development of anemia among dieting girls was significantly dependence of several factors including BMI category, source and duration of the diet programs, and skipping breakfast (p<0.05). In conclusion, young girls attempting WLDPs without professional guidance are more prone to the risk of nutrients deficiencies and the development nutritional disorders like IDA. An educational program should be employed to teach young females on when and how to adopt healthy WLDPs.

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.

SLC26A4 Phenotypic Variability Influences Intra- and Inter-Familial Diagnosis and Management

SLC26A4 is one of the most common genes causing autosomal recessive non-syndromic sensorineural hearing loss (SNHL). It has been reported to cause Pendred Syndrome (PDS) and DFNB4 which is deafness with enlarged vestibular aqueduct (EVA). However, mutated SLC26A4 is not conclusive for having either DFNB4 or PDS. Three unrelated Jordanian families consisting of eight affected individuals with congenital bilateral hearing loss (HL) participated in this study. Whole-exome and Sanger sequencing were performed to investigate the underlying molecular etiology of HL. Further clinical investigations, including laboratory blood workup for the thyroid gland, CT scan for the temporal bone, and thyroid ultrasound were performed. Three disease-causing variants were identified in SLC26A4 in the three families, two of which were novel. Two families had a novel pathogenic homozygous splice-site accepter variant (c.165-1G>C), while the third family had compound heterozygous pathogenic variants (c.1446G>A; p.Trp482* and c.304G>A; p.Gly102Arg). Our approach helped in redirecting the diagnosis of several affected members of three different families from non-syndromic HL to syndromic HL. Two of the affected individuals had typical PDS, one had DFNB4, while the rest had atypical PDS. Our work emphasized the intra- and inter-familial variability of SLC26A4-related phenotypes. In addition, we highlighted the variable phenotypic impact of SLC26A4 on tailoring a personalized healthcare management.

Breastfeeding Practices, Infant Formula Use, Complementary Feeding and Childhood Malnutrition: An Updated Overview of the Eastern Mediterranean Landscape

BACKGROUND

With increasing global rates of overweight, obesity and non-communicable diseases (NCDs) along with undernutrition and micronutrient deficiencies, the Eastern Mediterranean Region (EMR) is no exception. This review focuses on specific nutrition parameters among under five years children, namely ever breastfed, exclusive breastfeeding, mixed milk feeding, continued breastfeeding, bottle feeding, introduction of solid, semi-solid, or soft foods and malnutrition.

METHODOLOGY

PubMed, Google Scholar, United Nations International Children's Emergency Fund (UNICEF) databases, World Health Organization (WHO) databases, the World Bank databases and the Global Nutrition Report databases were explored between 10 January and 6 June 2022, to review the nutrition situation among under five years children in the EMR.

RESULTS

The regional average prevalence of ever breastfed, exclusive breastfeeding, mixed milk feeding, continued breastfeeding, bottle feeding, introduction of solid, semi-solid, or soft foods was estimated at 84.3%, 30.9%, 42.9%, 41.5%, 32.1% and 69.3%, respectively. Iran, Iraq, Libya and Palestine have seen a decline over time in the prevalence of exclusive breastfeeding. Lebanon, Egypt, Kuwait and Saudi Arabia reported early introduction of infant formula. Moreover, Lebanon, Pakistan, Saudi Arabia and United Arab Emirates were seen to introduce food early to the child, at between 4-6 months of age. The estimated weighted regional averages for stunting, wasting and underweight were 20.3%, 8.9% and 13.1%, respectively. Of concern is the increasing prevalence of stunting in Libya. As for overweight and obesity, the average prevalence was reported to be 8.9% and 3%, respectively. Lebanon, Libya, Kuwait and Palestine showed an increased trend throughout this time.

CONCLUSIONS

In this review, the suboptimal infant and young child feeding patterns and the twofold incidence of malnutrition in the EMR are highlighted and we urge the prioritizing of measures to improve children's nutrition.

Correlates of Sub-Optimal Feeding Practices among under-5 Children amid Escalating Crises in Lebanon: A National Representative Cross-Sectional Study

Sub-optimal feeding practices among under-5 children are the major drivers of malnutrition. This study aims to assess the prevalence of malnutrition and the factors affecting exclusive breastfeeding, bottle feeding, and complementary feeding practices among under 5 children amid the COVID-19 pandemic as well as the economic and the political crises in Lebanon. A nationally representative stratified random sample of mother-child dyads (n = 511) was collected from households using a stratified cluster sampling design. The survey inquired about infant's feeding and complementary feeding practices using a valid questionnaire. Anthropometric measurements of the mother and child were collected. Multivariate logistic regression was conducted to explore the determinants associated with under-5 children's practices. The prevalence of underweight, stunting, wasting, overweight and obese children was 0.5%, 8.4%, 6.7%, 16.8% and 8.9%, respectively. In total, among under-5 children, the prevalence of ever breastfeeding, exclusive breastfeeding, and bottle feeding at birth was 95.1%, 59.1% and 25.8%, respectively. Half the children in this study started solid foods between 4 and 6 months. Regression analysis showed that supporting breastfeeding at hospital (aOR = 8.20, 95% CI (3.03-22.17)) and husband's support (aOR = 3.07, 95% CI (1.9-4.92)) were associated with increased breastfeeding odds. However, mother's occupation (aOR = 0.18, 95% CI (0.55-0.58)) was inversely associated with breastfeeding practices. Male children (aOR = 2.119, 95% CI (1.37-3.27), mothers diagnosed with COVID-19 (aOR = 0.58, 95% CI (0.35-0.95)), and bottle feeding at hospital (aOR = 0.5, 95% CI (0.32-0.77)) were more likely to induce early initiation of solid foods at 4 months of age. This study demonstrated non-negligible rates of malnutrition, low prevalence of exclusive breastfeeding, and high rates of early introduction of formula feeding and solid foods among Lebanese under-5-children amid escalating crises.

Iraq Is Moving Forward to Achieve Global Targets in Nutrition

From the 1990s and after 2003, Iraq suffered many difficulties which affected its population negatively in different ways; from embargo to political instabilities, conflicts, and wars, collectively leading to food insecurity especially among the internally displaced people. The Ministry of Health and International Organizations worked collectively to improve the nutritional situation among the most vulnerable groups: children under five, and women in reproductive age. This study aims to review the nutrition situation for Iraq in relation to the Global Nutrition Targets and for Sustainable Development Goals. The data used for comparison was obtained from nationally representative surveys conducted in Iraq from 1996 to 2018, including urban and rural areas for all 18 governorates. Results of these surveys showed a gradual decline in undernutrition indicators for children under five, and an emergence of overweight and obesity, indicating an urgent need for collective action from all sectors and related Ministries regarding malnutrition in its different forms. It also revealed a decline in the prevalence of anemia among the targeted women, but an increase of low birth weight in newborn infants. Exclusive breastfeeding though, is still staggering and in need of urgent action. Iraq is transferring from a generalized state of insecurity to a more secure one, emphasizing the need to strengthen systems for efficient monitoring and evaluation. There is also a need for more recent surveys representing Iraq, as the available data is scant, particularly dietary intake studies within the normal population and internally displaced families in camps or scattered shelters.