Extended healthy lifestyle index and colorectal cancer risk in the Moroccan population.

PURPOSE: Little is known about the combined effect of different lifestyle factors on CRC incidence among populations living in developing countries. In this study, we sought to create an Extended Healthy Lifestyle Index (EHLI) and to investigate its association with CRC risk in the Moroccan population. METHODS: A large case-control study including 1516 cases and 1516 controls, matched on age, sex and center were recruited in 5 Moroccan university hospital centers between 2009 and 2017. EHLI scores, including 9 modifiable factors (smoking, alcohol consumption, physical activity intensity, BMI, fruit and vegetables consumption, drinks that promote weight gain, red and processed meat, relatively unprocessed cereals and/or pulses, and dairy products consumption) were assigned to lifestyle information derived from the participants. We assessed the score based on the answers on each of the nine lifestyle components as unhealthy/un-compliant (0 point), healthy/compliant (1 point) and 0.5 for partial compliance to the recommendation. Conditional logistic regression models were used to assess the association between the EHLI and CRC risk and to estimate multivariate ORs and their 95% confidence intervals (CIs). All potential confounder variables were considered. RESULTS: After adjusting for potential confounding factors, a significant decrease in the risk of overall CRC was observed when comparing the highest EHLI category with the lowest index category (0.39, 95% CI: 0.33-0.47). These results did not differ by colon or rectum subsite. CONCLUSION: Combined healthy lifestyle factors are associated with a significantly lower incidence of CRC in Moroccan populations. Prevention strategies should consider targeting of multiple lifestyle factors.

Modified Mediterranean diet score adapted to a southern Mediterranean population and its relation to overweight and obesity risk.

OBJECTIVES: The current study aimed to develop a modified Mediterranean diet (MMD) score adjusted to the southern Mediterranean countries' cultural specificities and to evaluate associations between adherence to this modified score and overweight/obesity risk in Moroccan adults. DESIGN: Population-based cross-sectional study. SETTING: Rural and urban areas of the five greatest provinces of Morocco. PARTICIPANTS: In total, 1516 participants were recruited between September 2009 and February 2017. Dietary assessment was obtained using a validated Moroccan FFQ. We constructed a MMD score focusing on twelve components. The MMD score ranged from 0 (no adherence to the traditional southern Mediterranean diet (MD)) to 12 (maximal adherence) and was categorised as low (scores 0-4), moderate (scores 5-7) and high (scores 8-12). RESULTS: Among the whole population, 754 (50·5 %) were women and 738 (49·5 %) were men, and the mean age was about 55·60 ± 13·70. In total, 58 % of participants were moderately active. Regarding educational level, 50·7 % were illiterate. The prevalence of overweight and obesity was 43·3 and 8·6 %, respectively. In multivariate analyses, close adherence to MMD (scores 8-12) was associated with reduced overweight/obesity risk (OR 0·61, 95 % CI 0·44, 0·84). CONCLUSION: The prevalence of overweight and obesity was very high among Moroccan adults. Adherence to the traditional southern MD may help prevent overweight and obesity.

Consumption of meat, traditional and modern processed meat and colorectal cancer risk among the Moroccan population: A large-scale case-control study.

The current study aimed to investigate the relationship between red and white meat subtypes, processed meat (divided into traditional "Khlii, Kaddid" and industrially processed meat) and colorectal cancer (CRC) risk, considering CRC subsites, in Moroccan adults. A case-control study was conducted including 2,906 matched case-control pairs recruited from the five largest university hospitals in Morocco. Dietary data were collected through a validated Food Frequency Questionnaire (FFQ). Multivariable odds ratios (OR) and 95% confidence intervals (CI), for the association of CRC risk with meat consumption (high vs. low intake), were estimated using conditional logistic regression models, adjusted for relevant confounding variables. Overall, consumption of red meat was positively associated with colon cancer and CRC risk (OR = 1.23, 95% CI = 1.05-1.44; OR = 1.14, 95% CI = 1.02-1.27), respectively. In contrast, no significant association was observed between the consumption of red meat and rectal cancer risk (OR = 1.05, 95% = 0.90-1.23). Interestingly, while processed meat from industrial processes was positively associated with colon cancer, rectal cancer and CRC (OR = 1.61, 95% CI = 1.27-2.04; OR = 1.73, 95% CI = 1.34-2.23; OR = 1.67, 95% CI = 1.41-1.98), processed meat prepared using traditional methods was inversely associated with colon cancer and CRC risk (OR = 0.74, 95% CI = 0.57-0.98; OR = 0.77, 95% CI = 0.64-0.93), respectively. Furthermore, positive associations were observed between poultry intake and colon cancer risk among men (OR = 1.27, 95% CI = 1.01-1.59). Our study showed similar associations between the consumption of red meat and CRC risk in Morocco as in developed countries, while inverse associations were found for traditionally processed meat products. This is the first study to investigate the differential effects of traditional vs. westernized processed meat products in a developing country. Other studies are needed to confirm these findings and to understand the physiological pathways underlying these associations.

Concordance with the World Cancer Research Fund/American Institute for Cancer Research recommendations for cancer prevention and colorectal cancer risk in Morocco: A large, population-based case-control study.

The present study aimed to investigate associations between adherence to the recommendations on cancer prevention from the WCRF/AICR and colorectal cancer (CRC) risk in Morocco. Incident CRC cases (n = 1,516) and controls (n = 1,516) matched on age, sex and center, were recruited between September 2009 and February 2017 at five major hospitals located in Morocco. In-person interviews were conducted to assess habitual diet using a validated Food Frequency Questionnaire, physical activity and anthropometric measurements. Adherence to the WCRF/AIRC Recommendations was ranged from 0 (no adherence) to 6 (maximal adherence) and incorporating six WCRF/AICR components (food groups, physical activity and BMI). Multivariable odd ratios (ORA ) and 95% confidence intervals (CI) were calculated using conditional multivariate logistic regression models, with low adherence as referent, adjusting for potential confounding factors. Compared to those with the lowest adherence score, individuals in the highest WCRF/AICR score category had a statistically significant reduced risk for colon cancer (ORA = 0.63, 95% CI 0.53-0.76); rectal cancer (ORA = 0.52, 95% CI 0.43-0.63) and CRC overall (ORA = 0.58, 95% CI 0.51-0.66). For individual score components, when comparing the lowest with the highest adherence category, CRC risk was significantly lower in the highest adherence category for body fatness (ORA = 0.73; 95% CI 0.62-0.85), physical activity (ORA = 0.70; 95% CI 0.60-0.82), plant foods (ORA = 0.50; 95% CI 0.39-0.63) and red/processed meat (ORA = 0.81; 95% CI 0.71-0.92). Our analysis indicated that greater adherence to the WCRF/AICR recommendations for cancer prevention may lower CRC risk in Morocco.

Adaptation and validation of a food frequency questionnaire (FFQ) to assess dietary intake in Moroccan adults.

BACKGROUND: To date, no culture-specific food frequency questionnaires (FFQ) are available in North Africa. The aim of this study was to adapt and examine the reproducibility and validity of an FFQ or use in the Moroccan population. METHODS: The European Global Asthma and Allergy Network (GA2LEN) FFQ was used to assess its applicability in Morocco. The GA2LEN FFQ is comprised of 32 food sections and 200 food items. Using scientific published literature, as well as local resources, we identified and added foods that were representative of the Moroccan diet. Translation of the FFQ into Moroccan Arabic was carried out following the World Health Organization (WHO) standard operational procedure. To test the validity and the reproducibility of the FFQ, 105 healthy adults working at Hassan II University Hospital Center of Fez were invited to answer the adapted FFQ in two occasions, 1 month apart, and to complete three 24-h dietary recall questionnaires during this period. Pearson correlation, and Bland-Altman plots were used to assess validity of nutrient intakes. The reproducibility between nutrient intakes as reported from the first and second FFQ were calculated using intra-class correlation coefficient (ICC). All nutrients were log-transformed to improve normality and were adjusted using the residual method. RESULTS: The adapted FFQ was comprised of 255 items that included traditional Moroccan foods. Eighty-seven adults (mean age 27.3 ± 5.7 years) completed all the questionnaires. For energy and nutrients, the intakes reported in the FFQ1 were higher than the mean intakes reported by the 24-h recall questionnaires. The Pearson correlation coefficients between the first FFQ and the mean of three 24-h recall questionnaires were statistically significant. For validity, de-attenuated correlations were all positive, statistically significant and ranging from 0.24 (fiber) to 0.93 (total MUFA). For reproducibility, the ICCs were statistically significant and ranged between 0.69 for fat and 0.84 for Vitamin A. CONCLUSION: This adapted FFQ is an acceptable tool to assess usual dietary intake in Moroccan adults. Given its representativeness of local food intake, it can be used as an instrument to investigate the role of diet on health and disease outcomes.

Association of Physical Activity and Sedentary Behavior with Colorectal Cancer Risk in Moroccan Adults: A Large-Scale, Population-Based Case-Control Study.

BACKGROUND: Physical activity has been associated with a lower risk of colorectal cancer in studies mainly conducted in high-income countries, while sedentary behavior has been suggested to increase CRC risk. In this study, we aimed to investigate the role of physical activity and sedentary behavior on CRC risk in the Moroccan population. METHODS: A case-control study was conducted involving 1516 case-control pairs, matched on age, sex and center in five university hospital centers. A structured questionnaire was used to collect information on socio-demographics, lifestyle habits, family history of CRC, and non-steroidal anti-inflammatory drug (NSAID) use. Information on physical activity and sedentary behavior were collected by the Global Physical Activity Questionnaire (GPAQ). For each activity (work, household, and recreational activities), a metabolic equivalent (MET) was calculated using GPAQ recommendations. Conditional logistic regression models were used to assess the association between physical activity, sedentary behavior and the risk of overall CRC, colon cancer, and rectal cancer taking into account other CRC risk factors. RESULTS: High level of physical activity was associated with lower risk of rectal cancer, colon cancer, and overall CRC, the adjusted odds ratios (ORa) for the highest versus the lowest level of activity were 0.67 (95% CI: 0.54-0.82), 0.77 (95% CI: 0.62-0.96), and 0.72 (95% CI: 0.62-0.83), respectively. In contrast, sedentary behavior was positively associated with rectal cancer risk (ORa=1.19, 95% CI: 1.01-1.40), but was unrelated to colon cancer risk (ORa=1.02, 95% CI: 0.87-1.20). CONCLUSION: We found an inverse association between physical activity and CRC risk in the Moroccan population, and a positive association between sedentary behavior and rectal cancer risk. Considering that one-third of the total population studied had a sedentary lifestyle, these results may be used to improve strategies of public health suitable for Moroccan population.

Association between obesity and chronic obstructive pulmonary disease in Moroccan adults: Evidence from the BOLD study.

OBJECTIVE: The Moroccan cross-sectional study aimed to investigate obesity in association to chronic obstructive pulmonary disease in Fez city. METHODS: A cross-sectional survey was carried out in Moroccan adults. Anthropometric and spirometry measurements were performed using standardized guidelines. RESULTS: Among the 744 participants, 53.9% of were women, with a mean age of 55.27 years (SD = 10.29). Nearly all women declared themselves to be never smokers, while 21% of men were current smokers. Overall, chronic obstructive pulmonary disease prevalence decreased with body mass index (p = 0.01) and waist circumference (p < 0.001). The same trends were also observed in women. The adjusted regression analysis showed a significant independent association between chronic obstructive pulmonary disease and decreasing overweight (ORa: 0.66; CI95% (0.40-0.98)), obesity (ORa: 0.66 CI95%: (0.36-0.89)), and a decreasing waist circumference-abdominal obesity (ORa: 0.58 CI95%: (0.34-0.99)) in the whole population. The same association remains significant in women for overweight (ORa: 0.18 CI95%: (0.06-0.54)) and for waist circumference-abdominal obesity (ORa: 0.40 CI95%: (0.19-0.85)). All these associations disappeared for men. CONCLUSION: Chronic obstructive pulmonary disease decreases with the increase in body mass index and waist circumference. The effect of waist circumference on the chronic obstructive pulmonary disease was greater among women, regardless of the tobacco factor. A multicenter study would help to confirm the accuracy of these findings in a larger sample of the Moroccan population. Developed lifestyle programs in patients with chronic obstructive pulmonary disease should be considered.

Prevalence of herbal medicine use among patients with kidney disease: A cross-sectional study from Morocco.

INTRODUCTION: The objectives of this study were to determine the prevalence of herbal medicine use by patients hospitalized or consultant in the nephrology department of University Hospital center Hassan II Fez, the reasons of this use, to identify socio-demographic characteristics, and the etiology of kidney disease related to herbal medicine use, also the most used plants. METHOD: Cross-sectional study on the use of herbal medicine conducted at the nephrology department of University Hospital Center Hassan II Fez, Morocco. During 6 months between August 2015 and February 2016. Patients older than 15 years (n=471) with varying degrees of kidney disease were included. The questionnaire contained questions related to socio-demographic data, the use of plants, knowledge about herbal medicine toxicity, and etiology of KD. Descriptive statistics were used to analyze socio-demographic characteristics related to herbal medicine use. RESULTS: A total of 471 patients responded; the prevalence of herbal medicine use was 50.7%. Herbal medicine users were more likely to be males (OR 0.43; 95%CI 0.25-0.74); unemployed (OR 0.51; 95%CI 0.29-0.89), with unknown etiology (OR 0.43; 95%CI 0.22-0.84). Reasons of use were: belief in its efficacy (74%), easy access to medicinal herbal medicine (70%), and lower cost (48%). The most commonly used herbal medicine were Rosmarinus officinalis L.; Origanum compactum Benth; Artemisia herba-alba Asso and Mentha pulegium L. Potentially harmful herbal medicine included Aristolochia longa. CONCLUSIONS: The prevalence of herbal medicine use is high among patients with kidney disease in nephrology department.

Behavioral, Nutritional, and Genetic Risk Factors of Colorectal Cancers in Morocco: Protocol for a Multicenter Case-Control Study.

BACKGROUND: Colorectal cancer (CRC) has been reported as the third most commonly diagnosed cancer worldwide and is currently considered as a major public health concern. A peak increase in incidence has been noted in economically transitioning countries like Morocco where industrialization started shifting from a traditional lifestyle and diet toward a more westernized diet and lifestyle. OBJECTIVE: This paper aims to present the protocol of a large-scale Moroccan case-control study that aims at investigating associations of diet, other lifestyle factors, and genetic traits with CRC risk in Morocco. METHODS: A case-control study was conducted between 2009 and 2017, including 3032 case-control pairs (1516 cases and 1516 controls) matched on sex, age, and center in 5 major public health hospitals in Morocco. Questionnaires on sociodemographic data, lifestyle, family history of CRC, and nonsteroidal anti-inflammatory drugs (NSAIDs) were completed by trained investigators during face-to-face interviews. In addition, participants completed a semiquantitative food-frequency questionnaire, developed to assess food intake in the Moroccan population. Information regarding genetic factors was recorded for cases, and paraffin blocks (with embedded tumor tissues) are available in 3 collaborating hospitals. Conditional logistic regression analysis is planned to assess associations between diet and CRC risk. Binary logistic regression is considered to predict associations between mutations and nutritional risk factors including only CRC case series. RESULTS: Altogether, 2966 cases-control pairs (1483 cases and 1483 controls) were considered eligible and included in this study. Both cases and controls did not differ significantly with respect to age (P=.36), sex (P=.51), center (P>.99), marital status (P=.30), and NSAID use (P=.08). However, participants in the control group were significantly more likely to have a high income level and live in urban areas and to have a high level of education than cases. CONCLUSIONS: This is the first study investigating potential risk factors of CRC such as lifestyle, diet, and genetic factors, originating from a southern Mediterranean country with low but increasing CRC prevalence. Identified risk factors allow the establishment of evidence-based preventive actions regarding nutrition and other lifestyle habits adapted to the Moroccan context. In brief, this study will promote cancer research and prevention in Morocco. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/13998.

Hypertension and type 2 diabetes: a cross-sectional study in Morocco (EPIDIAM Study).

BACKGROUND: In Morocco, there are no studies that focused on the hypertension and its associated risk factors through patients with type 2 diabetes. Different findings show that the frequency of type 2 diabetes has risen rapidly in Morocco. The main objective of this study was to assess the prevalence of hypertension and its associated risk factors among a group of patients with type 2 diabetes and to examine the level of control of hypertension among type 2 diabetic patients with hypertension. METHODS: A cross-sectional study was carried out on 525 type 2 diabetics in three Moroccan regions. The structured questionnaire was used to gather information on sociodemographic variables, history of hypertension, use of anti-hypertensive medications and duration of diabetes. Anthropometric measurements including weight and height were measured by trained staff. Blood pressure was measured using standardized sphygmomanometers. RESULTS: The prevalence of hypertension was 70.4%. The logistic regression indicated that hypertension was positively associated with age (p<10-4), BMI (p<0.0002) and duration of diabetes (p) CONCLUSION: Hypertension is a common co-morbidity among Moroccan diabetic patients with high rate of ignorance of hypertension among study subjects. The focus must be on patients and family education, counseling and behavioral interventions designed to modify lifestyle such as increasing physical activity and adopting recommended dietary changes, as well as compliance with medications.