Aspirin for Secondary Prevention of Cardiovascular Disease in 51 Low-, Middle-, and High-Income Countries.

Importance: Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD. Objective: To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries. Design, Setting, and Participants: Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years. Exposures: Countries' per capita income levels and world region; individuals' socioeconomic demographics. Main Outcomes and Measures: Self-reported use of aspirin for secondary prevention of CVD. Results: The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.1% [95% CI, 7.6%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries. Conclusion and Relevance: Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

Cardiovascular disease risk profile and management practices in 45 low-income and middle-income countries: A cross-sectional study of nationally representative individual-level survey data.

BACKGROUND: Global cardiovascular disease (CVD) burden is high and rising, especially in low-income and middle-income countries (LMICs). Focussing on 45 LMICs, we aimed to determine (1) the adult population's median 10-year predicted CVD risk, including its variation within countries by socio-demographic characteristics, and (2) the prevalence of self-reported blood pressure (BP) medication use among those with and without an indication for such medication as per World Health Organization (WHO) guidelines. METHODS AND FINDINGS: We conducted a cross-sectional analysis of nationally representative household surveys from 45 LMICs carried out between 2005 and 2017, with 32 surveys being WHO Stepwise Approach to Surveillance (STEPS) surveys. Country-specific median 10-year CVD risk was calculated using the 2019 WHO CVD Risk Chart Working Group non-laboratory-based equations. BP medication indications were based on the WHO Package of Essential Noncommunicable Disease Interventions guidelines. Regression models examined associations between CVD risk, BP medication use, and socio-demographic characteristics. Our complete case analysis included 600,484 adults from 45 countries. Median 10-year CVD risk (interquartile range [IQR]) for males and females was 2.7% (2.3%-4.2%) and 1.6% (1.3%-2.1%), respectively, with estimates indicating the lowest risk in sub-Saharan Africa and highest in Europe and the Eastern Mediterranean. Higher educational attainment and current employment were associated with lower CVD risk in most countries. Of those indicated for BP medication, the median (IQR) percentage taking medication was 24.2% (15.4%-37.2%) for males and 41.6% (23.9%-53.8%) for females. Conversely, a median (IQR) 47.1% (36.1%-58.6%) of all people taking a BP medication were not indicated for such based on CVD risk status. There was no association between BP medication use and socio-demographic characteristics in most of the 45 study countries. Study limitations include variation in country survey methods, most notably the sample age range and year of data collection, insufficient data to use the laboratory-based CVD risk equations, and an inability to determine past history of a CVD diagnosis. CONCLUSIONS: This study found underuse of guideline-indicated BP medication in people with elevated CVD risk and overuse by people with lower CVD risk. Country-specific targeted policies are needed to help improve the identification and management of those at highest CVD risk.

Validation of the Arabic Severe Respiratory Insufficiency Questionnaire.

BACKGROUND/OBJECTIVES: Assessment of Health-Related Quality of Life (HRQL) in patients with chronic respiratory insufficiency requiring Home Mechanical Ventilation (HMV) requires a valid measurement tool. The Severe Respiratory Insufficiency (SRI) questionnaire, originally developed in German, has been translated into different languages and tested in different contexts, but has so far not been in use in Arabic-speaking populations. The objective of this study is to validate the Arabic version of the SRI questionnaire in a sample of Arabic-speaking patients from Lebanon. METHODS: Following forward/backward translations, the finalized Arabic version was administered to 149 patients (53 males-96 females, age 69.80 ± 10 years) receiving HMV. Patients were recruited from outpatient clinics and visited at home. The Arabic SRI and the 36-Item Short-Form Health Survey (SF-36) were administered, in addition to questions on sociodemographics and medical history. Exploratory Factor Analysis (EFA) was used to explore dimensionality; internal consistency reliability of the unidimensional scale and its subscales was assessed using Cronbach's alpha. External nomological validity was examined by assessing the correlation between the SRI and SF-36 scores. RESULTS: The 49-item Arabic SRI scale showed a high internal consistency reliability (Cronbach alpha for the total scale was 0.897 and ranged between 0.73 and 0.87 for all subscales). Correlations between the SF-36-Mental Health Component MHC and SF-36-Physical Health Component with SRI-Summary Scale were 0.57 and 0.66, respectively, with higher correlations observed between the SF-36 and specific sub-scales such as the Physical Functioning and the Social Functioning subscales [r = 0.81 and r = 0.74 (P < 0.01), respectively]. CONCLUSION AND RECOMMENDATIONS: The Arabic SRI is a reliable and valid tool for assessing HRQL in patients with chronic respiratory insufficiency receiving home mechanical ventilation.

Tobacco Research in the Eastern Mediterranean Region: A Scoping Review of Published Studies from Seven Countries.

While surveillance on a global scale has been showing a decline in tobacco smoking in the past decade, rates in the Eastern Mediterranean Region (EMR) remained stable with some countries showing rising trends. This study aimed to analyze the landscape of tobacco research in the EMR, present data on publication trends, and identify research gaps and opportunities to guide future tobacco research in the region. We conducted a scoping review of tobacco research in seven countries from January 2000 to December 2013. Three hundred and forty eight studies were identified, the majority of which were published in international journals and in English language. There was an increase in publications over time, with a significant positive linear trend (p = 0.03). Descriptive cross-sectional and case-control studies were the most common study designs (67.0%), and only 8% were longitudinal studies. Papers that reported, in part or solely, on waterpipe tobacco smoking (WTS) constituted 25.6% of the total publication pool. Tobacco consumption was treated as an exposure variable in half of the papers and mostly in relation to cancer and cardiovascular diseases, as an outcome measure in 37.7%, and as a confounding variable in 14.7% of the papers. Studies that examined associations of tobacco with other behaviors (5.3%) were lacking. The scarcity of high-evidence tobacco research in the EMR, together with the relatively deficient data on WTS and associations with other factors warrant the need for discussions on research priority setting and guidance on funding allocations in the region.

Association between country preparedness indicators and quality clinical care for cardiovascular disease risk factors in 44 lower- and middle-income countries: A multicountry analysis of survey data.

BACKGROUND: Cardiovascular diseases are leading causes of death, globally, and health systems that deliver quality clinical care are needed to manage an increasing number of people with risk factors for these diseases. Indicators of preparedness of countries to manage cardiovascular disease risk factors (CVDRFs) are regularly collected by ministries of health and global health agencies. We aimed to assess whether these indicators are associated with patient receipt of quality clinical care. METHODS AND FINDINGS: We did a secondary analysis of cross-sectional, nationally representative, individual-patient data from 187,552 people with hypertension (mean age 48.1 years, 53.5% female) living in 43 low- and middle-income countries (LMICs) and 40,795 people with diabetes (mean age 52.2 years, 57.7% female) living in 28 LMICs on progress through cascades of care (condition diagnosed, treated, or controlled) for diabetes or hypertension, to indicate outcomes of provision of quality clinical care. Data were extracted from national-level World Health Organization (WHO) Stepwise Approach to Surveillance (STEPS), or other similar household surveys, conducted between July 2005 and November 2016. We used mixed-effects logistic regression to estimate associations between each quality clinical care outcome and indicators of country development (gross domestic product [GDP] per capita or Human Development Index [HDI]); national capacity for the prevention and control of noncommunicable diseases ('NCD readiness indicators' from surveys done by WHO); health system finance (domestic government expenditure on health [as percentage of GDP], private, and out-of-pocket expenditure on health [both as percentage of current]); and health service readiness (number of physicians, nurses, or hospital beds per 1,000 people) and performance (neonatal mortality rate). All models were adjusted for individual-level predictors including age, sex, and education. In an exploratory analysis, we tested whether national-level data on facility preparedness for diabetes were positively associated with outcomes. Associations were inconsistent between indicators and quality clinical care outcomes. For hypertension, GDP and HDI were both positively associated with each outcome. Of the 33 relationships tested between NCD readiness indicators and outcomes, only two showed a significant positive association: presence of guidelines with being diagnosed (odds ratio [OR], 1.86 [95% CI 1.08-3.21], p = 0.03) and availability of funding with being controlled (OR, 2.26 [95% CI 1.09-4.69], p = 0.03). Hospital beds (OR, 1.14 [95% CI 1.02-1.27], p = 0.02), nurses/midwives (OR, 1.24 [95% CI 1.06-1.44], p = 0.006), and physicians (OR, 1.21 [95% CI 1.11-1.32], p < 0.001) per 1,000 people were positively associated with being diagnosed and, similarly, with being treated; and the number of physicians was additionally associated with being controlled (OR, 1.12 [95% CI 1.01-1.23], p = 0.03). For diabetes, no positive associations were seen between NCD readiness indicators and outcomes. There was no association between country development, health service finance, or health service performance and readiness indicators and any outcome, apart from GDP (OR, 1.70 [95% CI 1.12-2.59], p = 0.01), HDI (OR, 1.21 [95% CI 1.01-1.44], p = 0.04), and number of physicians per 1,000 people (OR, 1.28 [95% CI 1.09-1.51], p = 0.003), which were associated with being diagnosed. Six countries had data on cascades of care and nationwide-level data on facility preparedness. Of the 27 associations tested between facility preparedness indicators and outcomes, the only association that was significant was having metformin available, which was positively associated with treatment (OR, 1.35 [95% CI 1.01-1.81], p = 0.04). The main limitation was use of blood pressure measurement on a single occasion to diagnose hypertension and a single blood glucose measurement to diagnose diabetes. CONCLUSION: In this study, we observed that indicators of country preparedness to deal with CVDRFs are poor proxies for quality clinical care received by patients for hypertension and diabetes. The major implication is that assessments of countries' preparedness to manage CVDRFs should not rely on proxies; rather, it should involve direct assessment of quality clinical care.

The state of hypertension care in 44 low-income and middle-income countries: a cross-sectional study of nationally representative individual-level data from 1·1 million adults.

BACKGROUND: Evidence from nationally representative studies in low-income and middle-income countries (LMICs) on where in the hypertension care continuum patients are lost to care is sparse. This information, however, is essential for effective targeting of interventions by health services and monitoring progress in improving hypertension care. We aimed to determine the cascade of hypertension care in 44 LMICs-and its variation between countries and population groups-by dividing the progression in the care process, from need of care to successful treatment, into discrete stages and measuring the losses at each stage. METHODS: In this cross-sectional study, we pooled individual-level population-based data from 44 LMICs. We first searched for nationally representative datasets from the WHO Stepwise Approach to Surveillance (STEPS) from 2005 or later. If a STEPS dataset was not available for a LMIC (or we could not gain access to it), we conducted a systematic search for survey datasets; the inclusion criteria in these searches were that the survey was done in 2005 or later, was nationally representative for at least three 10-year age groups older than 15 years, included measured blood pressure data, and contained data on at least two hypertension care cascade steps. Hypertension was defined as a systolic blood pressure of at least 140 mm Hg, diastolic blood pressure of at least 90 mm Hg, or reported use of medication for hypertension. Among those with hypertension, we calculated the proportion of individuals who had ever had their blood pressure measured; had been diagnosed with hypertension; had been treated for hypertension; and had achieved control of their hypertension. We weighted countries proportionally to their population size when determining this hypertension care cascade at the global and regional level. We disaggregated the hypertension care cascade by age, sex, education, household wealth quintile, body-mass index, smoking status, country, and region. We used linear regression to predict, separately for each cascade step, a country's performance based on gross domestic product (GDP) per capita, allowing us to identify countries whose performance fell outside of the 95% prediction interval. FINDINGS: Our pooled dataset included 1 100 507 participants, of whom 192 441 (17·5%) had hypertension. Among those with hypertension, 73·6% of participants (95% CI 72·9-74·3) had ever had their blood pressure measured, 39·2% of participants (38·2-40·3) had been diagnosed with hypertension, 29·9% of participants (28·6-31·3) received treatment, and 10·3% of participants (9·6-11·0) achieved control of their hypertension. Countries in Latin America and the Caribbean generally achieved the best performance relative to their predicted performance based on GDP per capita, whereas countries in sub-Saharan Africa performed worst. Bangladesh, Brazil, Costa Rica, Ecuador, Kyrgyzstan, and Peru performed significantly better on all care cascade steps than predicted based on GDP per capita. Being a woman, older, more educated, wealthier, and not being a current smoker were all positively associated with attaining each of the four steps of the care cascade. INTERPRETATION: Our study provides important evidence for the design and targeting of health policies and service interventions for hypertension in LMICs. We show at what steps and for whom there are gaps in the hypertension care process in each of the 44 countries in our study. We also identified countries in each world region that perform better than expected from their economic development, which can direct policy makers to important policy lessons. Given the high disease burden caused by hypertension in LMICs, nationally representative hypertension care cascades, as constructed in this study, are an important measure of progress towards achieving universal health coverage. FUNDING: Harvard McLennan Family Fund, Alexander von Humboldt Foundation.

Non-communicable diseases research output in the Eastern Mediterranean region: an overview of systematic reviews.

BACKGROUND: Rates of non-communicable diseases (NCDs) are rapidly rising in the Eastern Mediterranean Region (EMR). Systematic reviews satisfy the demand from practitioners and policy makers for prompt comprehensive evidence. The aim of this study is to review trends in NCD systematic reviews research output and quality by time and place, describe design and focus, and examine gaps in knowledge produced. METHODS: Using the Montori et al. systematic reviews filter, MeSH and keywords were applied to search Medline Ovid, Cochrane Central and Epistemonikos for publications from 1996 until 2015 in the 22 countries of the EMR. The 'Measurement Tool to Assess Systematic Reviews', AMSTAR, was used to assess the methodological quality of the papers. RESULTS: Our search yielded 2439 papers for abstract and title screening, and 89 papers for full text screening. A total of 39 (43.8%) studies included meta-analysis. Most of the papers were judged as being of low AMSTAR quality (83.2%), and only one paper was judged as being of high AMSTAR quality. Whilst annual number of papers increased over the years, the growth was mainly attributed to an increase in low-quality publications approaching in 2015 over four times the number of medium-quality publications. Reviews were significantly more likely to be characterized by higher AMSTAR scores (±SD) when meta-analysis was performed compared to when meta-analysis was not performed (3.4 ± 1.5 vs 2.6 ± 2.0; p-value = 0.034); and when critical appraisal of the included studies was conducted (4.3 ± 2.3 vs 2.5 ± 1.5; p-value = 0.004). Most of the reviews focused on cancer and diabetes as an outcome (25.8% and 24.7%, respectively), and on smoking, dietary habits and physical activity as exposures (15.7%, 12.4%, 9.0%, respectively). There was a blatant deficit in reviews examining associations between behaviors and physiologic factors, notably metabolic conditions. CONCLUSIONS: Systematic reviews research in the EMR region are overwhelmingly of low quality, with gaps in the literature for studies on cardiovascular disease and on associations between behavioral factors and intermediary physiologic parameters. This study raises awareness of the need for high-quality evidence guided by locally driven research agenda responsive to emerging needs in countries of the EMR.

Sex disparities in dietary intake across the lifespan: the case of Lebanon.

BACKGROUND: Little is known about sex-based dietary differences in middle-income countries, particularly those undergoing the nutrition transition. This study aims at examining sex disparities in energy and macronutrients' intakes, food consumption patterns, and micronutrients' adequacy in Lebanon, while adopting a life course approach. METHODS: Data were derived from a national cross-sectional survey conducted in Lebanon in 2008/2009. The study sample consisted of 3636 subjects: 956 children and adolescents aged 6-19.9 years; 2239 adults aged 20-59.9 years and 441 older adults aged above 60 years. At the households, trained nutritionists conducted face-to-face interviews with participants to complete a sociodemographic questionnaire and one 24-h diet recall. Food items were categorized into 25 food groups. The Nutritionist Pro software was used for the analysis of dietary intake data and the estimation of energy, macronutrients', and micronutrients' intakes. RESULTS: In all age groups, males had significantly higher energy intakes, while females had significantly higher fiber intakes. In addition, in adolescents aged 12-19.9 years, females had higher fat intakes as compared to males (37.02 ± 0.6% vs 35.03 ± 0.61%), and in adults aged 20-59.9 years, females had significantly higher total fat (37.73 ± 0.33% vs 36.45 ± 0.38%) and saturated fat intakes (11.24 ± 0.15% vs 10.45 ± 0.18%). These differences in macronutrient intakes were not observed in younger children nor in older adults. Sex-based differences in food groups' intakes were also observed: men and boys had significantly higher intakes of red and processed meat, bread, fast food, soft drinks, and alcohol, while girls and women had higher intakes of fruits, vegetables, milk, and sweets. In all age groups, females had lower micronutrient intakes compared to males, including calcium, iron, and zinc. CONCLUSIONS: This study identified sex-specific priorities that ought to be tackled by context-specific interventions to promote healthier diets in Lebanon. The fact that sex-based differences in nutrient intakes and food consumption patterns were the most noticeable in the adolescent and adult years, hence women's reproductive years call for concerted efforts to improve nutrition for women and girls as this would lay the foundation not only for their future education, productivity, and economic empowerment, but also for the health of future generations.

Lessons learned in the provision NCD primary care to Syrian refugee and host communities in Lebanon: the need to 'act locally and think globally'.

BACKGROUND: Prevention and control of non-communicable diseases (NCDs) remain inadequate in resource-scarce countries, particularly in conflict situations. This paper describes a multicomponent intervention for management of hypertension and diabetes among older adult Syrian refugees and the Lebanese host community and reflects on challenges for scaling up NCD integration into primary care in humanitarian situations. METHODS: Using a mixed method approach, the study focused on monitoring and evaluation of the three components of the intervention: healthcare physical facilities and documentation processes, provider knowledge and guideline-concordant performance, and refugee and host community awareness. RESULTS: Findings revealed overall high compliance of healthcare workers with completing data collection forms. Their knowledge of basic aspects of hypertension/diabetes management was adequate, but diagnosis knowledge was low. Patients and healthcare providers voiced satisfaction with the program. Yet, interruptions in medicines' supplies and lapses in care were perceived by all study groups alike as the most problematic aspect of the program. CONCLUSIONS: Our intervention program was aligned with internationally agreed-upon practices, yet, our experiences in the field point to the need for more 'local testing' of modified interventions within such contexts. This can then inform 'thinking globally' on guidelines for the delivery of NCD care in crisis settings.

Consumption of Fruits and Vegetables Among Individuals 15 Years and Older in 28 Low- and Middle-Income Countries.

BACKGROUND: The WHO recommends 400 g/d of fruits and vegetables (the equivalent of ∼5 servings/d) for the prevention of noncommunicable diseases (NCDs). However, there is limited evidence regarding individual-level correlates of meeting these recommendations in low- and middle-income countries (LMICs). In order to target policies and interventions aimed at improving intake, global monitoring of fruit and vegetable consumption by socio-demographic subpopulations is required. OBJECTIVES: The aims of this study were to 1) assess the proportion of individuals meeting the WHO recommendation and 2) evaluate socio-demographic predictors (age, sex, and educational attainment) of meeting the WHO recommendation. METHODS: Data were collected from 193,606 individuals aged ≥15 y in 28 LMICs between 2005 and 2016. The prevalence of meeting the WHO recommendation took into account the complex survey designs, and countries were weighted according to their World Bank population estimates in 2015. Poisson regression was used to estimate associations with socio-demographic characteristics. RESULTS: The proportion (95% CI) of individuals aged ≥15 y who met the WHO recommendation was 18.0% (16.6-19.4%). Mean intake of fruits was 1.15 (1.10-1.20) servings per day and for vegetables, 2.46 (2.40-2.51) servings/d. The proportion of individuals meeting the recommendation increased with increasing country gross domestic product (GDP) class (P < 0.0001) and with decreasing country FAO food price index (FPI; indicating greater stability of food prices; P < 0.0001). At the individual level, those with secondary education or greater were more likely to achieve the recommendation compared with individuals with no formal education: risk ratio (95% CI), 1.61 (1.24-2.09). CONCLUSIONS: Over 80% of individuals aged ≥15 y living in these 28 LMICs consumed lower amounts of fruits and vegetables than recommended by the WHO. Policies to promote fruit and vegetable consumption in LMICs are urgently needed to address the observed inequities in intake and prevent NCDs.

Obesity/overweight and asthma control in LEBANESE adults: a cross-sectional study.

BACKGROUND: Studies exploring the association between weight and asthma are not conclusive. Both obesity and asthma have been increasing in Lebanon, their association is not yet documented. The aim of this study is to explore the effect of weight on asthma control in adults. METHODS: This is a cross-sectional study, involving all consecutive asthma patients presenting to the outpatient allergy clinic at the Hotel-Dieu de France (HDF) University Hospital between January 1, 2014 and December 30, 2016. Patients included were those who consented to fill the Asthma Control Test (ACT) after 3 months of therapy. BMI was reported at the same time of the questionnaire. RESULTS: A total of 183 records of diagnosed asthma cases in adults were included. Sixty-three (34.4%) were males and 120 (65.6%) females, with a mean age of 38.5 (SD = 14.3). Ninety patients (49.2%) were of normal weight, 65 (35.5%) overweight and 28 (15.3%) obese. Seventy-one percent had an ACT score ≤ 19, which corresponds to poor asthma control. Patients who were overweight or obese were more likely to have poor asthma control compared to patients who had a normal weight at the time of evaluation. CONCLUSION: In conclusion, our study showed a significant association between asthma control as assessed by the ACT and high BMI defining overweight or obesity. This is the first national study exploring the association between asthma and overweight/obesity in Lebanon. A larger study with sampling from different specialists' sites is needed to draw more conclusions about this association.

Environmental footprints of food consumption and dietary patterns among Lebanese adults: a cross-sectional study.

BACKGROUND: Following the release of the Sustainable Development Goals, dietary patterns and guidelines are being revised for their effect on the environment in addition to their health implications. The objective of this study was to evaluate and compare the Environmental Footprints (EFPs) of food consumption patterns among Lebanese adults. METHODS: For this study, data for adults aged > 18 years (n = 337) were drawn from a previous national survey conducted in Lebanon (2008-2009), where dietary intake was assessed using a 61-item Food Frequency Questionnaire. Dietary patterns previously derived in the study sample included: Western, Lebanese-Mediterranean and High-Protein. In this study, food consumption and dietary patterns were examined for their EFPs including water use, energy use, and greenhouse gas (GHG) emissions, using review of life cycle analyses. RESULTS: In the study population, the EFPs of food consumption were: water use: 2571.62 ± 1259.45 L/day; energy use: 37.34 ± 19.98 MJ/day and GHGs: 4.06 ± 1.93 kg CO2 eq / day. Among the three dietary patterns prevalent in the study population, the Lebanese-Mediterranean diet had the lowest water use and GHG per 1000 Kcal (Water (L/Kg): 443.61 ± 197.15, 243.35 ± 112.0, 264.72 ± 161.67; GHG (KG CO2 eq/day) 0.58 ± 0.32, 0.38 ± 0.24, 0.57 ± 0.37, for the Western, Lebanese-Mediterranean and High- Protein, respectively). The scores of the High-Protein dietary pattern were associated with higher odds of the three EFPs, whereas the Lebanese-Mediterranean dietary pattern was associated with lower odds of energy use. Furthermore, scores of the Western pattern were associated with higher water use. CONCLUSIONS: The findings of this study showed that, among Lebanese adults, the Western and High-Protein dietary patterns had high EFPs, whereas the Lebanese-Mediterranean dietary pattern had lower water use and GHG emissions. Coupled to our earlier findings of the Lebanese-Mediterranean pattern's beneficial effects on health, the findings of this study lend evidence for the notion that what is healthy for people may also be healthy for ecosystems and highlight the need for nutrition recommendations to take into consideration the nexus of water, food, energy, in addition to health.

A scoping review of reporting 'Ethical Research Practices' in research conducted among refugees and war-affected populations in the Arab world.

BACKGROUND: Ethical research conduct is a cornerstone of research practice particularly when research participants include vulnerable populations. This study mapped the extent of reporting ethical research practices in studies conducted among refugees and war-affected populations in the Arab World, and assessed variations by time, country of study, and study characteristics. METHODS: An electronic search of eight databases resulted in 5668 unique records published between 2000 and 2013. Scoping review yielded 164 eligible articles for analyses. RESULTS: Ethical research practices, including obtaining institutional approval, access to the community/research site, and informed consent/assent from the research participants, were reported in 48.2, 54.9, and 53.7% of the publications, respectively. Institutional approval was significantly more likely to be reported when the research was biomedical in nature compared to public health and social (91.7% vs. 54.4 and 32.4%), when the study employed quantitative compared to qualitative or mixed methodologies (61.7% vs. 26.8 and 42.9%), and when the journal required a statement on ethical declarations (57.4% vs. 27.1%). Institutional approval was least likely to be reported in papers that were sole-authored (9.5%), when these did not mention a funding source (29.6%), or when published in national journals (0%). Similar results were obtained for access to the community site and for seeking informed consent/assent from study participants. CONCLUSIONS: The responsibility of inadequacies in adherence to ethical research conduct in crisis settings is born by a multitude of stakeholders including funding agencies, institutional research boards, researchers and international relief organizations involved in research, as well as journal editors, all of whom need to play a more proactive role for enhancing the practice of ethical research conduct in conflict settings.

The integration and management of noncommunicable diseases in primary health care (Guest Editorial).

Noncommunicable diseases (NCDs) are a great burden in the Eastern Mediterranean Region (EMR) and, if no strategic intervention is taken, the burden is forecast to become even heavier, particularly with the additional impact of ageing populations. Currently, 62% of deaths in the EMR are due to NCDs. However, by 2030 this proportion is projected to increase to nearly 70%. The EMR is disproportionately affected by NCDs as a result of the Region's rapid urbanization and the globalization of unhealthy behaviours. Moreover, many of the EMR countries have health systems whose structures are not designed for the prevention, early detection and management of NCDs.

Self-rated health disparities among disadvantaged older adults in ethnically diverse urban neighborhoods in a Middle Eastern country.

OBJECTIVES: This paper examines differentials in self-rated health (SRH) among older adults (aged 60+ years) across three impoverished and ethnically diverse neighborhoods in post-conflict Lebanon and assesses whether variations are explained by social and economic factors. DESIGN: Data were drawn from the Older Adult Component (n = 740) of the Urban Health Survey, a population-based cross-sectional study conducted in 2003 in a formal community (Nabaa), an informal settlement (Hey El-Sellom), and a refugee camp for Palestinians (Burj El-Barajneh) in Beirut, Lebanon. The role of the social capital and economic security constructs in offsetting poor SRH was assessed using multivariate ordinal logistic regression analyses. RESULTS: Older adults in Nabaa fared better in SRH compared to those in Hey El-Sellom and Burj El-Barajneh, with a prevalence of good, average, and poor SRH being respectively, 41.5%, 37.0%, and 21.5% in Nabaa, 33.3%, 23.9%, and 42.7% in Hey El-Sellom, and 25.2%, 31.3%, and 43.5% in Burj El-Barajneh. The economic security construct attenuated the odds of poorer SRH in Burj El-Barajneh as compared to Nabaa from 2.57 (95% confidence interval, CI: 1.89-3.79) to 1.42 (95% CI: 0.96-2.08), but had no impact on this association in Hey El-Sellom (odds ratio, OR: 2.12, 95% CI: 1.39-3.24). The incorporation of the social capital construct in the fully adjusted model rendered this association insignificant in Hey El-Sellom (OR: 1.49, 95% CI: 0.96-2.32), and led to further reductions in the magnitude of the association in Burj El-Barajneh camp (OR: 1.18, 95% CI: 0.80-1.76). CONCLUSIONS: The social context in which older adults live and their financial security are key in explaining disparities in SRH in marginalized communities. Social capital and economic security, often overlooked in policy and public health interventions, need to be integrated in dimensions of well-being of older adults, especially in post-conflict settings.

Role of inflammation in the association between the western dietary pattern and metabolic syndrome among Lebanese adults.

The aim of this study was to investigate whether inflammation mediates the previously observed direct association between the western dietary pattern (WDP) and metabolic syndrome (MetS) among Lebanese adults. Sociodemographic, lifestyle, dietary pattern scores, anthropometric and biochemical data of 331 adults were used in this study. Inflammation indicators considered were: serum C-reactive protein (CRP) and the dietary inflammatory index (DII). The scores of the WDP were significantly associated with DII (r = .64) but not with serum CRP. Higher CRP levels increased the odds of MetS and four out of five of its components, while no association was found between the DII and MetS. CONCLUSION: The findings of this study confirmed the association of serum CRP with MetS but did not support mediation effect of inflammation on the association between the WDP and MetS. These findings are important to direct future investigations on diet, inflammation and association with diseases risk.

Potential use of telephone surveys for non-communicable disease surveillance in developing countries: evidence from a national household survey in Lebanon.

BACKGROUND: Given the worldwide proliferation of cellphones, this paper examines their potential use for the surveillance of non-communicable disease (NCD) risk factors in a Middle Eastern country. METHODS: Data were derived from a national household survey of 2,656 adults (aged 18 years or older) in Lebanon in 2009. Responses to questions on phone ownership yielded two subsamples, the 'cell phone sample' (n = 1,404) and the 'any phone sample' (n = 2,158). Prevalence estimates of various socio-demographics and 11 key NCD risk factors and comorbidities were compared between each subsample and the overall household sample. RESULTS: Adjusting for baseline age and sex distribution, no differences were observed for all NCD indicators when comparing either of subsamples to the overall household sample, except for binge drinking [(OR = 1.55, 95 % CI: 1.33-1.81) and (OR = 1.48, 95 % CI: 1.18-1.85) for 'cell phone subsample' and 'any phone subsample', respectively] and self-rated health (OR = 1.23, 95 % CI: 1.10-1.36) and (OR = 1.16, 95 % CI: 1.02-1.32), respectively). Differences in the odds of hyperlipidemia (OR = 1.27, 95 % CI: 1.06-1.51) was also found in the subsample of 'any phone' carriers. CONCLUSIONS: Multi-mode telephone surveillance techniques provide viable alternative to face-to-face surveys in developing countries. Cell phones may also be useful for personalized public health and medical care interventions in young populations.

A Lebanese dietary pattern promotes better diet quality among older adults: findings from a national cross-sectional study.

BACKGROUND: Proper nutrition is critical for healthy aging and maintaining functional independence. Limited research has been done on the assessment of dietary patterns of older adults and their association with diet quality indices. This study was conducted to identify, characterize, and evaluate the dietary patterns and diet quality of older adults in Lebanon, a middle-income country undergoing nutrition transition. METHODS: A cross-sectional population-based study was conducted on a nationally representative sample of community-dwelling older adults aged >50 years (n = 525). Socio-demographic, anthropometric, and lifestyle variables were collected through interviews, and dietary intake was assessed using a semi-quantitative food frequency questionnaire (FFQ). Five commonly used diet quality indices (DQIs) were calculated, including the Alternative Healthy Eating Index (AHEI), the alternate Mediterranean diet score (aMed), the Dietary Approach to Stop Hypertension (DASH) style diet score, and the Lebanese Mediterranean Diet index. Dietary patterns (DPs) were derived using exploratory factor analysis. Associations of identified DPs with energy, energy-adjusted nutrients, and DQIs were evaluated by Pearson's correlations. Multiple linear regression analyses were used to examine correlates of DPs. RESULTS: Three DPs were derived: Lebanese, Western, and High Protein/Alcohol patterns. The Lebanese pattern had highest correlations with fiber, folate, vitamin C, and all five DQIs. The Western was positively associated with energy and sodium and was inversely correlated with fiber, most vitamins, and a number of DQIs, namely AHEI, aMED, and DASH-style diet score. Highest correlations with intakes of proteins and fat were observed for the High Protein/Alcohol pattern. The Lebanese pattern was associated with female gender, education, nonsmoking and physical activity, whereas the Western pattern was associated with adverse health behaviors, including smoking, skipping breakfast, and physical inactivity. CONCLUSIONS: Of the three identified patterns, the Lebanese DP was associated with better diet quality and healthier lifestyle behaviors while the Western pattern implicated a lower quality diet. Public health programs promoting prudent diets, including the Mediterranean and Lebanese DPs, are needed to improve the diet quality of middle-aged and older adults in an attempt to improve their functionality and quality of life.

Mapping genetic research in non-communicable disease publications in selected Arab countries: first step towards a guided research agenda.

BACKGROUND: In the Arab world, intervention and policy response to non-communicable diseases (NCD) has been weak despite extensive epidemiological evidence highlighting the alarmingly increased prevalence of chronic diseases. Generating genetic information is one key component to promote efficient disease management strategies. This study undertook a scoping review to generate the profile of the undertaken research on genetics of NCD publications in selected Arab countries. An analysis of the research produced examined the extent, range, nature, topic and methods of published research. The study aimed at identifying the gaps in genetic NCD research to inform policy action for NCD prevention and control. METHODS: The scoping review was conducted based on the five-stage methodological framework and included countries in Arab region selected to represent various economies and epidemiological transitions. RESULTS: The search identified 555 articles that focus on genetics-NCD research in the selected Arab countries over the duration of this study (January 2000 to December 2013). The most commonly conducted research was descriptive and clinically focused, rather than etiologically focused. Country-specific carrier and risk screening studies were not among the top research designs. The genetic component of certain highly heritable diseases, as well as diabetes, obesity, hypertension, chronic lung dysfunction and metabolic syndrome were all under investigated. CONCLUSIONS: This scoping review identified gaps for further research in the context of bioinformatics and genome-wide association studies. Genetic research in the Arab region has to be redirected towards NCDs with the highest morbidity, heritability and health burden within each country. A focused research plan to include community genetics is required for its proper integration in the Arab community.