Increasing prevalence of obesity

In the Eastern Mediterranean Region (EMR), there is a high burden of obesity and an increasing trend in the prevalence across all age groups. Differences have been noted between countries and between sexes. In adults, the prevalence of obesity is higher among women than among men, whereas in children, the prevalence of obesity is higher among boys than among girls in most countries in the region.

This increasing prevalence of obesity is potentially linked to an obesogenic environment, which includes cultural and social issues such as urbanization, increased wealth, and lower levels of physical activity, coupled with high consumption of energy-dense foods. Addressing these issues in a holistic manner could curb the escalating prevalence of obesity in these countries and relieve the health cost of management of noncommunicable diseases.

The prevalence of obesity among adults in selected low- and middle-income countries (LMICs) in the EMR ranges from 8.8% to 31.3% and approaches the prevalence of 34.9% observed in the USA (Fig. 8.1) [1–12]. Of greater concern is the increasing secular trend in the prevalence of obesity among adults in several countries in the region, with annual secular increases of +1.7 to +16% [5, 13–17].

Fig. 8.1

Prevalence (%) of obesity (body mass index [BMI] ≥ 30 kg/m²) among adults in selected low- and middle-income countries in the Eastern Mediterranean Region. * BMI > 30 kg/m² (WHO recommendations for the Asia-Pacific (more...)

In adolescents, the prevalence of obesity in LMICs in the EMR ranges between 1% and 8.9% (according to the 2007 World Health Organization [WHO] criteria), which is lower than the prevalence of 20.5% observed in the USA (according to the 2000 Centers for Disease Control and Prevention [CDC] criteria) [12, 17–32]. However, data on secular trends in the region are limited. In some countries where data at different time points were available, the average annual increase in the prevalence of obesity ranged from +2% to +13.5% [14, 26, 28, 33–38].

In children younger than 5 years, rates of overweight and obesity in selected LMICs in the EMR range from 2% to 22.4%; the lower figures are comparable to the estimates from developing countries (6.1%), and the highest figures are double the estimates from developed countries (11.7%) [17, 39–51]. Of greater concern is the increasing trend in the prevalence of overweight and obesity among children younger than 5 years in many countries in the EMR; the annual secular increases of +1.9 to +10.4% are extremely alarming. In contrast, a decrease in the prevalence of overweight and obesity among children younger than 5 years was reported in a few countries in the EMR, with annual decreases ranging from −1.1% to −7.7% [16, 17, 39, 40, 42, 44–59].

Cultural determinants of obesity: situation analysis and associations

The increase in the prevalence of obesity in Eastern Mediterranean populations has been associated with several sociocultural, behavioural, and environmental changes, such as the nutrition transition, changes in socioeconomic status, cultural and social factors, and urbanization, all of which have negatively affected the quality and the quantity of the food consumed and have encouraged sedentary behaviour.

Data from the Food and Agriculture Organization of the United Nations (FAO) food balance sheets and from food consumption surveys conducted in the EMR during the past four decades (between 1969–1971 and 2011) have shown a remarkable change in eating behaviour, marked by a shift away from the traditional diet, rich in fruits, vegetables, and whole grains, and towards a diet high in fat, sugar, and refined carbohydrates. Other factors, such as food marketing, body image, and early-life feeding practices, also appear to play an important role in the burden of obesity in the region. The interrelationships between the different sociocultural, behavioural, and environmental determinants of obesity in LMICs in the EMR are discussed in detail below.

The nutrition transition

Food availability and consumption

To understand the nutrition transition in LMICs in the EMR, is it important to analyse the changes that have occurred in food availability and food consumption, to properly address these changes. Data from the FAO food balance sheets and from food consumption surveys between 1969–1971 and 2011 highlight a shift towards an increasingly energy-dense diet and high intakes of fat and sugar, coupled with a parallel decrease in consumption of carbohydrates [60–65]. Data from FAO also show that sugar availability, which is reported to be a predisposing factor to obesity, increased considerably during the same period (1969–2011) in several LMICs in the EMR, such as Afghanistan, Sudan, Tunisia, and Yemen, and doubled in Egypt. However, a reduction was noted in Iraq and Pakistan (Fig. 8.2) [60].

Fig. 8.2

Change in sugar availability (kcal/capita/day) between 1969 and 2011 in selected low- and middle-income countries of the Eastern Mediterranean Region.

A strong association has been reported between high consumption of harmful food components (processed meat, red meat, trans-fatty acids, sugar-sweetened beverages, and sodium), low consumption of protective foods (fruits, vegetables and beans, nuts and seeds, whole grains, and omega-3 fatty acids [found in fish and seafood]), and increased risk of cardiometabolic diseases across all countries in the EMR; therefore, a food consumption pattern that is collectively high in harmful foods and low in protective foods is a strong predictor of risk of cardiometabolic diseases [66]. In addition, the dietary energy supply from the different food groups (harmful and protective) shows that the traditional diet has been modified, so that most of the countries have shown insufficient per capita consumption of protective foods, which fell well below recommended levels, as well as higher than recommended per capita consumption of harmful food components across all countries in the EMR [66].

The nutrition transition reflected in changes in food consumption patterns has been reported to be correlated with the prevalence of obesity in several countries in the EMR and across different age groups. High energy intake has been significantly associated with higher risk of obesity [15, 67]. The contribution of fat to energy intake was higher among obese individuals than among their non-obese counterparts, whereas the opposite was found for the contribution of carbohydrate to energy intake [68].

Countries have reported on the association of dietary patterns with obesity and metabolic diseases. In the Islamic Republic of Iran, a positive association was shown between an unhealthy dietary pattern and the risk of obesity in women, whereas the opposite was shown for a healthy dietary pattern [69]. A more recent cross-sectional study in a large cohort of Iranian adults found that adherence to a pattern of nutrient intake characterized by high consumption of thiamine, betaine, starch, folate, iron, selenium, niacin, calcium, and manganese was associated with a lower likelihood of general obesity (particularly in men), whereas a pattern of nutrient intake characterized by high consumption of glucose, fructose, sucrose, vitamin C, potassium, total dietary fibre, copper, and vitamin K was associated with a greater likelihood of general obesity in men [70]. In Lebanon, an unhealthy dietary pattern was also reported to be positively associated with high body mass index (BMI) and increased waist circumference, and tripled the risk of hyperglycaemia and metabolic syndrome among adults [71]. Table 8.1 summarizes the associations of different dietary and nutrient patterns in Lebanon and the Islamic Republic of Iran with obesity.

Table 8.1

Association of dietary and nutrient patterns in Lebanon and the Islamic Republic of Iran with obesity.

Food marketing

The contribution of food marketing to the rise in the prevalence of obesity in the EMR is governed by six major elements: availability, price, education and knowledge, labelling, food subsidy policies, and the impact of these policies.

LMICs in the EMR have been significantly affected by globalization, which has resulted in the wide spread of fast-food-chains as well as different food retail industries and markets, making energy-dense and processed foods more readily available than ever before and easily accessible by consumers of all ages. This trend has been further exacerbated by the convenient and affordable prices of energy-dense foods and snacks compared with healthy food items, which tend to be more expensive.

In the EMR, knowledge and education about healthy food products are largely influenced by the media. Exposure to television commercials for fast foods, soft drinks, sweets, and chocolates may markedly influence the food choices and dietary habits of the viewers, particularly children and adolescents. In Egypt, for example, television advertisements were found to be the main driver for the purchase of chocolate and sweets by school-age children [72]. Moreover, food labelling standards have not been mandatory in the EMR and have not been given enough consideration for public awareness and education about food content and portion sizes. As a result, consumers are either indifferent towards reading labels or find it challenging to understand the information on the label, especially consumers with low socioeconomic status.

Most countries in the EMR have opted to subsidize food items such as wheat, rice, vegetable oil, and sugar, hence possibly contributing to the high burden of obesity in the region by making consumers highly dependent on these energy-dense subsidized foods. In Egypt, mothers’ BMI was found to be inversely correlated with the price of subsidized baladi bread and subsidized sugar but directly correlated with the price of healthier foods such as fruits, milk, and eggs [73]. Hence, reducing the price of healthy food items may contribute to weight reduction among mothers by better promoting the consumption of healthier food items, reducing the consumption of energy-dense foods, or both [73]. The impact of such policies can be understood through more robust research in the EMR on the influence of food marketing policies on consumer behaviour and dietary intake, as well as obesity.

Early-life feeding practices

Inadequate feeding practices in the first years of life have been reported to be associated with an increased risk of adult obesity [74]. A longer duration of exclusive breastfeeding was suggested to reduce the risk of overweight and obesity in children [75]. In addition, very early introduction of complementary foods has been shown to increase the risk of obesity and cardiovascular disease later in life [76].

In the EMR, suboptimal breastfeeding is highly prevalent, coupled with untimely complementary feeding. This may have led to the double burden of child malnutrition in the region, manifested by concomitant high rates of stunting and obesity among children younger than 5 years.

The available studies highlight the low rates of exclusive breastfeeding in the first 6 months in most countries in the EMR. The rates range from 5.3% to 58.4%, falling below the World Health Assembly’s global nutrition target for 2025 of 50%, except in the Islamic Republic of Iran and Afghanistan [17, 41, 48–50, 58, 77–84].

Complementary feeding practices in the EMR are also suboptimal and fall short of global recommendations. In most countries in the region, solid foods are introduced before the recommended age of 4–6 months, a practice that may have contributed to the high prevalence of obesity [85–87].

Data on the association between early feeding practices and the risk of obesity are scarce in the EMR. In the Islamic Republic of Iran, for example, a longer duration of breastfeeding was found to be significantly associated with a lower prevalence of overweight among school-age children and adolescents [88, 89]. In Lebanon, a high likelihood of overweight and obesity were observed among children (0–2 years) who were exclusively breastfed for less than 4 months or less than 6 months, who received formula milk in the first 6 months, and who had high intakes of carbohydrates, sugars, and total fat (Nasreddine et al., unpublished data).

Socioeconomic status

Countries in the EMR are classified into three income groups: low-income countries, middle-income countries, and high-income countries. The prevalence of obesity in middle-income countries is high and similar to the prevalence in high-income countries, whereas the prevalence of obesity is lower in low-income countries [90].

Several studies in the countries in the EMR have shown a correlation between an individual’s socioeconomic status and the likelihood of obesity. In general, obesity is more prevalent in unemployed people and in married individuals of both sexes [67, 91–95]. In the Islamic Republic of Iran, living in an urban area and having a higher education level increased the likelihood of obesity among adults [96], whereas in Lebanon, obesity was found to be inversely associated with the socioeconomic status of women, and the likelihood of obesity decreased significantly with higher education level, greater household assets, and lower crowding index [67]. Socioeconomic indicators were also correlated with paediatric obesity. Risk of obesity increased among adolescents in the Syrian Arab Republic who reported a low crowding index and whose parents had attained a higher education level [65] and among children and adolescents in Pakistan who were in a higher school grade (grade 4 vs grade 1) and living in an urban area with higher socioeconomic status [97]. Table 8.2 summarizes the association of socioeconomic indicators with obesity in these four countries.

Table 8.2

Association of socioeconomic indicators with obesity in selected low- and middle-income countries in the Eastern Mediterranean Region.

Physical inactivity

Most of the available studies on physical activity in the EMR are hampered by the limited amount of reliable data, the varying methodology, and the different physical activity instruments used by different researchers [110]. WHO has provided crude estimates of the prevalence of insufficient physical activity among adults (≥ 18 years) and adolescents (11–17 years) in selected LMICs of the EMR where data are available. The prevalence of insufficient physical activity among adults differed across countries and ranged from 15.6% in Jordan to 49.3% in Iraq, whereas it reached alarming levels (> 75%) among adolescents, ranging from 76.7% in Lebanon to 91.9% in Sudan (Fig. 8.3) [111].

Fig. 8.3

Prevalence (%) of insufficient physical activity among adults and adolescents in selected low- and middle-income countries of the Eastern Mediterranean Region. * < 150 minutes per week of moderate-intensity physical activity, or < 75 (more...)

According to the Global School-based Student Health Survey from 2003–2007, the proportion of students who spent 3 hours or more per day on sedentary activities (sitting and watching television, playing computer games, talking with friends, or doing other seated activities) reported for schoolchildren (13–15 years) in some countries in the EMR was relatively high, ranging from 22.4% in Egypt to 42.0% in Jordan [112].

In most countries in the EMR, labour-saving changes in occupations, a high dependence on cars and buses for transportation, massive urbanization, satellite television, and increased reliance on computers and telecommunication technology may all have contributed to an increase in the burden of obesity [113]. Outdoor activities are hampered by the overall lack of public parks and walking and bicycle lanes, and by the hot climate [114]. In the region, women face more barriers to participating in physical activity compared with men. This is because men, in general, have more freedom and more places to practise sport and other recreational activities, whereas women are often restricted due to cultural and religious beliefs, which make them unable to publicly and freely participate in physical activity [115].

Conclusions

LMICs in the EMR have been undergoing a nutrition transition, with a parallel increase in obesity rates across all age groups and among both sexes, which can be attributed to socioeconomic, cultural, and social factors, as well as urbanization. Many factors may have contributed to the escalating burden of obesity in the region, including an unhealthy dietary pattern, low breastfeeding rates coupled with untimely and faulty complementary feeding practices, unemployment, low education levels, physical inactivity, perceptions of beauty and a preference for plumpness in women, and cultural habits such as plate sharing and traditional clothing (abaya).

Intervention strategies to combat obesity should adopt a holistic approach in addressing the obesogenic factors comprehensively. A single intervention alone may not be viable and economically efficient for a multifaceted problem like obesity, which involves complex interactions. Therefore, adopting a model as suggested by Amarasinghe and D’Souza [116], which is adapted to Eastern Mediterranean populations and which encompasses economic, environmental, social, and individual elements, would constitute a promising approach to curb the rising burden of obesity in the region.

Key points

•

There is a high burden of obesity and an increasing trend in the prevalence across all age groups in LMICs in the EMR.

•

Obesity in LMICs in the EMR is associated with sociocultural, behavioural, and environmental determinants (e.g. the nutrition transition, socioeconomic status, cultural and social factors, and urbanization) that are closely interrelated.

•

An unhealthy dietary pattern, food marketing that promotes consumption of energy-dense foods, faulty and untimely early feeding practices, unemployment, low education levels, physical inactivity, perceptions of beauty and a preference for plumpness in women, as well as plate sharing and traditional clothing are all factors implicated in the escalating burden of obesity in LMICs in the EMR.

Research needs

•

Adequate research data are needed on sociocultural determinants of obesity in LMICs in the EMR.

•

There is a need for the development of intervention strategies and the assessment of their impact in addressing obesity prevention in LMICs in the EMR.

•

Cohort studies are needed to adequately investigate culturally related early-life infant and young child feeding practices and their future impact on obesity in LMICs in the EMR.

References

1.

Gunaid AA (2012). Obesity, overweight and underweight among adults in an urban community in Yemen. East Mediterr Health J. 18(12):1187–93. 10.26719/2012.18.12.1187 [PubMed: 23301392] [CrossRef]

2.

STEPS (2009). WHO STEPS chronic disease risk factor surveillance: Iran STEPS Survey 2009 Fact Sheet 1388. Available from: https://www​.who.int/chp​/steps/Iran_2009_STEPS_FactSheet​.pdf?ua=1

3.

STEPS (2003). WHO STEPS noncommunicable disease risk factor surveillance: Syrian Arab Republic 2003 STEPS Survey Fact Sheet [in Arabic]. Available from: https://www​.who.int/chp​/steps/SyrianArabRepublicSTEPSReport​.PDF?ua=1

4.

STEPS (2006). WHO STEPS chronic disease risk factor surveillance: Khartoum State/Sudan STEPS Survey 2005–2006 Fact Sheet. Available from: https://www​.who.int/chp​/steps/STEPS_FactSheet_Sudan.pdf?ua=1

5.

El Ati J, Traissac P, Delpeuch F, Aounallah-Skhiri H, Béji C, Eymard-Duvernay S, et al. (2012). Gender obesity inequities are huge but differ greatly according to environment and socio-economics in a North African setting: a national cross-sectional study in Tunisia. PLoS One. 7(10):e48153. 10.1371/journal.pone.0048153 [PMC free article: PMC3485235] [PubMed: 23118943] [CrossRef]

6.

STEPS (2011). WHO STEPS chronic disease risk factor surveillance (6–3C-1): Palestine STEPS Survey 2010–2011 Fact Sheet. Available from: https://www​.who.int/chp​/steps/Palestine_FactSheet_2010-11​.pdf?ua=1

7.

Saeed KMI (2015). Prevalence and associated risk factors for obesity in Jalalabad city – Afghanistan. Alex J Med. 51(4):347–52. 10.1016/j.ajme.2014.12.004 [CrossRef]

8.

Sibai A, Hwalla N (2010). WHO STEPS chronic disease risk factor surveillance: data book for Lebanon. Available from: https://www​.who.int/chp​/steps/2008_STEPS_Lebanon.pdf?ua=1

9.

Aslam M, Saeed A, Pasha GR, Altaf S (2010). Gender differences of body mass index in adults of Pakistan: a case study of Multan city. Pak J Nutr. 9(2):162–6. 10.3923/pjn.2010.162.166 [CrossRef]

10.

STEPS (2009). WHO STEPS noncommunicable disease risk factor surveillance: Libya 2009 STEPS Survey Report [in Arabic]. Available from: https://www​.who.int/chp​/steps/2009_STEPS_Libya.pdf?ua=1

11.

STEPS (2012). WHO STEPS chronic disease risk factor surveillance (6–3C-1): Egypt STEPS Survey 2011–12 Fact Sheet. Available from: https://www​.who.int/chp​/steps/2011-2012_Egypt_FactSheet​.pdf?ua=1

12.

Ogden CL, Carroll MD, Kit BK, Flegal KM (2014). Prevalence of childhood and adult obesity in the United States, 2011-2012. JAMA. 311(8):806–14. 10.1001/jama.2014.732 [PMC free article: PMC4770258] [PubMed: 24570244] [CrossRef]

13.

Khader Y, Batieha A, Ajlouni H, El-Khateeb M, Ajlouni K (2008). Obesity in Jordan: prevalence, associated factors, comorbidities, and change in prevalence over ten years. Metab Syndr Relat Disord. 6(2):113–20. 10.1089/met.2007.0030 [PubMed: 18510436] [CrossRef]

14.

Nasreddine L, Naja F, Chamieh MC, Adra N, Sibai A-M, Hwalla N (2012). Trends in overweight and obesity in Lebanon: evidence from two national cross-sectional surveys (1997 and 2009). BMC Public Health. 12(1):798. 10.1186/1471-2458-12-798 [PMC free article: PMC3527186] [PubMed: 22984791] [CrossRef]

15.

Mokhtar N, Elati J, Chabir R, Bour A, Elkari K, Schlossman NP, et al. (2001). Diet culture and obesity in northern Africa. J Nutr. 131(3):887S–92S. 10.1093/jn/131.3.887S [PubMed: 11238780] [CrossRef]

16.

MOPH (2005). Summary Report of the National Nutrition Survey, Afghanistan, 2004. Kabul: Ministry of Public Health of the Islamic Republic of Afghanistan, UNICEF, Centers for Disease Control and Prevention, National Institute for Research on Food and Nutrition-Italy, and Tufts University.

17.

MOPH (2013). National Nutrition Survey, Afghanistan (2013): survey report. Kabul: Ministry of Public Health of the Islamic Republic of Afghanistan and UNICEF. Available from: http://reliefweb.int/sites/reliefweb.int/files/resources/Report NNS Afghanistan 2013 (July 26-14).pdf

18.

WHO (2007). The WHO child growth standards. Geneva, Switzerland: World Health Organization. Available from: https://www​.who.int/childgrowth/en/

19.

Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z, et al. (2002). 2000 CDC growth charts for the United States: methods and development. National Center for Health Statistics. Vital Health Stat. 11(246). Available from: https://www​.cdc.gov/nchs​/data/series/sr_11/sr11_246.pdf [PubMed: 12043359]

20.

GSHS (2009). Global School-based Student Health Survey (GSHS): Pakistan 2009 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/Pakistan_2009_FS.pdf?ua=1

21.

GSHS (2010). Global School-based Student Health Survey (GSHS): Morocco 2010 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/Morocco_2010_GSHS_FS.pdf?ua=1

22.

GSHS (2012). Global School-based Student Health Survey (GSHS): Sudan 2012 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/2012_Sudan_GSHS_FS.pdf?ua=1

23.

GSHS (2008). Global School-based Student Health Survey (GSHS): Yemen 2008 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/2008_Yemen_fact_sheet.pdf?ua=1

24.

GSHS (2007). Global school-based student health survey (GSHS): Djibouti 2007 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/Djibouti_2007_Fact_Sheet​.pdf?ua=1

25.

GSHS (2007). Global School-based Student Health Survey (GSHS): Jordan 2007 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/gshs_fs_jordan_2007.pdf?ua=1

26.

Aounallah-Skhiri H, El Ati J, Traissac P, Ben Romdhane H, Eymard-Duvernay S, Delpeuch F, et al. (2012). Blood pressure and associated factors in a North African adolescent population. a national cross-sectional study in Tunisia. BMC Public Health. 12(1):98. 10.1186/1471-2458-12-98 [PMC free article: PMC3331812] [PubMed: 22305045] [CrossRef]

27.

GSHS (2010). Global School-based Student Health Survey (GSHS): Syria 2010 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/Syria_2010_GSHS_FS.pdf?ua=1

28.

GSHS (2011). Global School-based Student Health Survey (GSHS): Lebanon 2011 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/2011_GSHS_FS_Lebanon.pdf?ua=1

29.

GSHS (2011). Global School-based Student Health Survey (GSHS): Egypt 2011 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/Egypt_GSHS_FS_2011.pdf?ua=1

30.

GSHS (2012). Global School-based Student Health Survey (GSHS): Iraq 2012 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/2012_Iraq_GSHS_FS.pdf?ua=1

31.

GSHS (2007). Global School-based Student Health Survey (GSHS): Libya 2007 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/Libya_2007_fact_sheet.pdf?ua=1

32.

Bahreynian M, Motlagh ME, Qorbani M, Heshmat R, Ardalan G, Kelishadi R (2015). Prevalence of growth disorders in a nationally representative sample of Iranian adolescents according to socioeconomic status: the CASPIAN-III study. Pediatr Neonatol. 56(4):242–7. 10.1016/j.pedneo.2014.12.001 [PubMed: 25603727] [CrossRef]

33.

Kelishadi R, Haghdoost A-A, Sadeghirad B, Khajehkazemi R (2014). Trend in the prevalence of obesity and overweight among Iranian children and adolescents: a systematic review and meta-analysis. Nutrition. 30(4):393–400. 10.1016/j.nut.2013.08.011 [PubMed: 24332523] [CrossRef]

34.

Kelishadi R, Ardalan G, Gheiratmand R, Majdzadeh R, Hosseini M, Gouya MM, et al.; Caspian Study Group (2008). Thinness, overweight and obesity in a national sample of Iranian children and adolescents: CASPIAN Study. Child Care Health Dev. 34(1):44–54. [PubMed: 18171443]

35.

Mirmohammadi S-J, Hafezi R, Mehrparvar AH, Rezaeian B, Akbari H (2011). Prevalence of overweight and obesity among Iranian school children in different ethnicities. Iran J Pediatr. 21(4):514–20. [PMC free article: PMC3446144] [PubMed: 23056841]

36.

GSHS (2005). Global School-based Student Health Survey (GSHS): Lebanon 2005 Fact Sheet. Available from: https://www​.who.int/chp​/gshs/2005_Lebanon_Fact_Sheet​.pdf?ua=1

37.

Nasreddine L, Naja F, Akl C, Chamieh MC, Karam S, Sibai AM, et al. (2014). Dietary, lifestyle and socio-economic correlates of overweight, obesity and central adiposity in Lebanese children and adolescents. Nutrients. 6(3):1038–62. 10.3390/nu6031038 [PMC free article: PMC3967177] [PubMed: 24618510] [CrossRef]

38.

Aounallah-Skhiri H, El Ati J, Traissac P, Ben Romdhane H, Bougatef S, Béji C, et al. (2009). Evolution de la consommation alimentaire et de la corpulence des adolescents tunisiens entre 1996 et 2005. 4ème Congrès de la Société Française de Nutrition, Montpellier (France), 10–12 décembre 2009.

39.

Republic of Yemen Ministry of Public Health and Population and Central Statistical Organization (2015).Yemen National Health and Demographic Survey 2013. Sana’a, Yemen: Ministry of Public Health and Population and Central Statistical Organization; Cairo, Egypt: Pan Arab Project for Family Health (PAPFAM); Rockville (MD), USA: The Demographic and Health Surveys (DHS) Program, ICF International. Available from: https://dhsprogram​.com​/pubs/pdf/FR296/FR296.pdf

40.

Government of Sudan Federal Ministry of Health and Central Bureau of Statistics (2012). Sudan Household Health Survey – Round 2, 2010: national report. Khartoum, Sudan: Federal Ministry of Health and Central Bureau of Statistics. Available from: https:​//mics-surveys-prod​.s3.amazonaws.com​/MICS4/Middle%20East​%20and%20North%20Africa​/Sudan/2010/Final​/Sudan%202010%20MICS_English.pdf

41.

Jordan Department of Statistics (2013). Jordan Population and Family Health Survey, 2012. Amman, Jordan: Department of Statistics; Calverton (MD), USA: ICF International. Available from: https://dhsprogram​.com​/pubs/pdf/FR282/FR282.pdf

42.

de Onis M, Blössner M, Borghi E (2010). Global prevalence and trends of overweight and obesity among preschool children. Am J Clin Nutr. 92(5):1257–64. 10.3945/ajcn.2010.29786 [PubMed: 20861173] [CrossRef]

43.

Palestinian Central Bureau of Statistics (2013). Palestinian Family Survey, 2010: final report. Ramallah, Palestine: Palestinian Central Bureau of Statistics, UNICEF, and UNFPA. Available from: www​.pcbs.gov.ps/Portals​/_PCBS/Downloads/book1941.pdf

44.

Aga Khan University (2012). National Nutrition Survey Pakistan, 2011. Islamabad, Pakistan: Aga Khan University, Pakistan Medical Research Council (PMRC), Government of Pakistan, and UNICEF Pakistan. Available from: https://www.humanitarianresponse.info/system/files/documents/files/59_National Nutrition Survey-2011.pdf

45.

Ministère de la Santé Maroc (2012). Enquête Nationale sur la Population et la Santé Familiale (ENPSF) 2011: rapport préliminaire. Rabat, Morocco: Ministère de la Santé, Direction de la Planification et des Ressources Financières, Division de la Planification et des Etudes, Service des Etudes et de l’Information Sanitaire. Available from: http://www.sante.gov.ma/Publications/Etudes_enquete/Documents/Rapport synthese_ENPSF-2011.pdf

46.

WHO (2015). Global database on child growth and malnutrition. Countries and territories. Geneva, Switzerland: World Health Organization. Available from: https://www​.who.int/nutgrowthdb​/database/countries/en/

47.

Iraq Central Statistics Organization and Kurdistan Regional Statistics Office (2012). Iraq Multiple Indicator Cluster Survey (MICS) 2011: final report. Baghdad, Iraq: Central Statistical Organization (CSO) and Kurdistan Regional Statistics Office (KRSO).

48.

Tunisia Ministry of Development and International Cooperation (2013). Monitoring the situation of children and women in Tunisia, MICS 2011–2012: final report [in French]. Tunis, Tunisia: Ministry of Development and International Cooperation, National Institute of Statistics, and UNICEF. Available from: https:​//mics-surveys-prod​.s3.amazonaws.com​/MICS4/Middle%20East​%20and%20North%20Africa​/Tunisia/2011-2012​/Final/Tunisia%202011-12​%20MICS_French.pdf

49.

Egypt Ministry of Health and Population (2014). Egypt Demographic and Health Survey (EDHS) 2014: main findings. Cairo, Egypt: Ministry of Health and Population; Rockville (MD), USA: The DHS Program, ICF International. Available from: https://dhsprogram​.com​/pubs/pdf/PR54/PR54.pdf

50.

League of Arab States and Syrian Arab Republic (2011). Family Health Survey of the Arab Republic of Syria, 2009: principal report (PAPFAM). Cairo, Egypt: League of Arab States.

51.

Libyan National Center for Infectious and Chronic Disease Control and Pan Arab Project for Family Health (2008). Libyan National Survey of Family Health (PAPFAM), 2007. Cairo, Egypt: League of Arab States.

52.

General Committee for Health and Social Security (1996). Libya Maternal and Child Health Survey 1995: preliminary report. Tripoli, Libya: General Committee for Health and Social Security; Cairo, Egypt: League of Arab States (PAPCHILD).

53.

Ministère de la Santé Publique (2008). Enquête sur la santé et le bien être de la mère et l’enfant: MICS 3. Tunis, Tunisia: Ministère de la Santé Publique, Office National de la Famille et de la Population, and UNICEF.

54.

League of Arab States (PAPFAM) and Syrian Arab Republic Central Bureau of Statistics (2002). The Family Health Survey in the Syrian Arab Republic: principal report. Cairo, Egypt: League of Arab States (PAPFAM) and Syrian Arab Republic, Office of the Prime Minister, Central Bureau of Statistics. Available from: s3​.amazonaws.com/zanran_storage/www​.un.org​.sy/ContentPages/47530865.pdf

55.

Ministère de la Santé Maroc (2005). Enquête sur la Population et la Santé Familiale (EPSF) 2003–2004. Rabat, Morocco: Ministère de la Santé; Calverton (MD), USA: ORC Macro. Available from: https://dhsprogram​.com​/pubs/pdf/FR155/FR155.pdf

56.

Arab League and Republic of Lebanon (2006). Lebanon Family Health Survey 2004: principal report. Tutelian M, Khayyat M, Monem AA, editors. Arab League, Lebanon Central Administration of Statistics, and Pan Arab Project for Family Health (PAPFAM). Available from: http://s3​.amazonaws.com​/zanran_storage/www​.pdslebanon.org/ContentPages​/2504898874.pdf

57.

El-Zanaty F, Way A (2009). Egypt Demographic and Health Survey 2008. Cairo, Egypt: Ministry of Health; Available from: Available from https://dhsprogram​.com​/pubs/pdf/fr220/fr220.pdf

58.

Yemen Ministry of Health and Population (2004). Yemen Family Health Survey: principal report. Cairo, Egypt: Yemen Ministry of Health and Population, Central Statistical Organization, and League of Arab States (PAPFAM).

59.

Government of National Unity and Government of South Sudan (2007). Sudan Household Health Survey (SHHS), 2006. Khartoum, Sudan: Government of National Unity; Juba, South Sudan: Government of South Sudan (additional analysis conducted by PAPFAM, June 2013).

60.

FAO (2015). FAOSTAT: Food and agriculture data. Food and Agriculture Organization of the United Nations. Available from: http://faostat3​.fao.org/home/E

61.

Nasreddine L, Naja FA, Sibai AM, Helou K, Adra N, Hwalla N (2014). Trends in nutritional intakes and nutrition-related cardiovascular disease risk factors in Lebanon: the need for immediate action. J Med Liban. 62(2):83–91. 10.12816/0004102 [PubMed: 25011369] [CrossRef]

62.

Kelishadi R, Gheisari A, Zare N, Farajian S, Shariatinejad K (2013). Salt intake and the association with blood pressure in young Iranian children: first report from the middle East and north Africa. Int J Prev Med. 4(4):475–83. [PMC free article: PMC3650601] [PubMed: 23671781]

63.

Ahmadi A, Moazen M, Mosallaei Z, Mohammadbeigi A, Amin-Iari F (2014). Nutrient intake and growth indices for children at kindergartens in Shiraz, Iran. J Pak Med Assoc. 64(3):316–21. [PubMed: 24864607]

64.

Shab-Bidar S, Hosseini-Esfahani F, Mirmiran P, Hosseinpour-Niazi S, Azizi F (2014). Metabolic syndrome profiles, obesity measures and intake of dietary fatty acids in adults: Tehran Lipid and Glucose Study. J Hum Nutr Diet. 27 Suppl 2:98–108. 10.1111/jhn.12117 [PubMed: 23731333] [CrossRef]

65.

Nasreddine L, Mehio-Sibai A, Mrayati M, Adra N, Hwalla N (2010). Adolescent obesity in Syria: prevalence and associated factors. Child Care Health Dev. 36(3):404–13. 10.1111/j.1365-2214.2009.01042.x [PubMed: 19961497] [CrossRef]

66.

Afshin A, Micha R, Khatibzadeh S, Fahimi S, Shi P, Powles J, et al.; 2010 Global Burden of Diseases, Injuries, and Risk Factors Study: NUTRItrition and ChrOnic Diseases Expert Group (NUTRICODE), and Metabolic Risk Factors of ChrOnic Diseases Collaborating Group (2015). The impact of dietary habits and metabolic risk factors on cardiovascular and diabetes mortality in countries of the Middle East and North Africa in 2010: a comparative risk assessment analysis. BMJ Open. 5(5):e006385. 10.1136/bmjopen-2014-006385 [PMC free article: PMC4442236] [PubMed: 25995236] [CrossRef]

67.

Chamieh MC, Moore HJ, Summerbell C, Tamim H, Sibai AM, Hwalla N (2015). Diet, physical activity and socio-economic disparities of obesity in Lebanese adults: findings from a national study. BMC Public Health. 15(1):279. 10.1186/s12889-015-1605-9 [PMC free article: PMC4373105] [PubMed: 25880751] [CrossRef]

68.

Musaiger AO (2007). Overweight and obesity in the Arab countries: the need for action. Bahrain: Arab Center for Nutrition; Available from: Available from www​.acnut.com/v/images​/stories/pdf/overweight​_and_obesity_in_arab_countries.pdf

69.

Esmaillzadeh A, Azadbakht L (2008). Major dietary patterns in relation to general obesity and central adiposity among Iranian women. J Nutr. 138(2):358–63. 10.1093/jn/138.2.358 [PubMed: 18203904] [CrossRef]

70.

Salehi-Abargouei A, Esmaillzadeh A, Azadbakht L, Keshteli AH, Feizi A, Feinle-Bisset C, et al. (2015). Nutrient patterns and their relation to general and abdominal obesity in Iranian adults: findings from the SEPAHAN study. Eur J Nutr. 10.1007/s00394-015-0867-4 [PubMed: 25733164] [CrossRef]

71.

Naja F, Nasreddine L, Itani L, Dimassi H, Sibai AM, Hwalla N (2014). Dietary patterns in cardiovascular diseases prevention and management: review of the evidence and recommendations for primary care physicians in Lebanon. J Med Liban. 62(2):92–9. 10.12816/0004103 [PubMed: 25011370] [CrossRef]

72.

Jaweesh KS (2002). Television advertisements as a factor influencing children food habits. Arab Journal of Food and Nutrition. 3(6):392–408.

73.

Asfaw A (2007). Do government food price policies affect the prevalence of obesity? Empirical evidence from Egypt. World Dev. 35(4):687–701. 10.1016/j.worlddev.2006.05.005 [CrossRef]

74.

Caulfield LE, de Onis M, Blössner M, Black RE (2004). Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria, and measles. Am J Clin Nutr. 80(1):193–8. 10.1093/ajcn/80.1.193 [PubMed: 15213048] [CrossRef]

75.

Horta BL, Victora CG (2013). Long-term effects of breastfeeding: a systematic review. Geneva, Switzerland: World Health Organization; Available from: Available from https://apps​.who.int​/iris/bitstream/10665​/79198/1/9789241505307_eng.pdf

76.

Wilson AC, Forsyth JS, Greene SA, Irvine L, Hau C, Howie PW (1998). Relation of infant diet to childhood health: seven year follow up of cohort of children in Dundee infant feeding study. BMJ. 316(7124):21–5. 10.1136/bmj.316.7124.21 [PMC free article: PMC2665344] [PubMed: 9451261] [CrossRef]

77.

Kassim IAR, Seal A, Moloney G, Erhardt J, Jooste P, et al. (2010). National Micronutrient and Anthropometric Nutrition Survey, Somalia 2009. Food Security and Nutrition Analysis Unit (FSNAU), Food and Agriculture Organization of the United Nations. Available from: https://www​.humanitarianresponse​.info/system​/files/Somalia-National-Micronutrient-Study.pdf

78.

FAO (2014). Food and nutrition in numbers 2014. Food and Agriculture Organization of the United Nations. Available from: http://www​.fao.org/3/a-i4175e.pdf

79.

Lebanon Central Administration of Statistics in and UNICEF Beirut (2009). Multiple Indicators Cluster Survey, round 3 (MICS3). Lebanon: Lebanon Central Administration of Statistics.

80.

WHO (2014). Global Health Observatory data repository. Exclusive breastfeeding under 6 months: data by country. Geneva, Switzerland: World Health Organization. Available from: https://apps​.who.int/gho/data/view​.main.NUT1730?lang=eng

81.

Geneva Infant Feeding Association (IBFAN-GIFA) IBFAN Global Liaison Office (2014). The Convention on the Rights of the Child, Session 67/September 2014: Report on the situation of infant and young child feeding in Morocco. International Baby Food Action Network (IBFAN). Available from: http://tbinternet.ohchr.org/Treaties/CRC/Shared Documents/MAR/INT_CRC_NGO_MAR_17890_E.pdf

82.

Palestinian Central Bureau of Statistics (2015). Palestinian Multiple Indicator Cluster Survey (MICS) 2014: key findings. Ramallah, Palestine: Palestinian Central Bureau of Statistics. Available from: www​.pcbs.gov.ps/Downloads/book2099.pdf

83.

UNICEF (2013). UNICEF Annual Report 2013 – Djibouti. Available from: https://www​.unicef.org​/about/annualreport​/files/Djibouti_COAR_2013.pdf

84.

Kalantari N, Roudsari AH (2013). Breastfeeding promotion in Iran: opportunities and challenges. J Compr Pediatr. 3(5):165–6. 10.17795/compreped-12327 [CrossRef]

85.

Abdul Ameer AJ, Al-Hadi AH, Abdulla MM (2008). Knowledge, attitudes and practices of Iraqi mothers and family child-caring women regarding breastfeeding. East Mediterr Health J. 14(5):1003–14. [PubMed: 19161071]

86.

Batal M, Boulghourjian C, Akik C (2010). Complementary feeding patterns in a developing country: a cross-sectional study across Lebanon. East Mediterr Health J. 16(2):180–6. 10.26719/2010.16.2.180 [PubMed: 20799572] [CrossRef]

87.

Shembesh NM, Balo NNM, Singh R. Breast-feeding and weaning patterns in Benghazi, Libyan Arab Jamahiriya. East Mediterr Health J 1997;3(2):251e7.

88.

Kelishadi R, Pour MH, Sarraf-Zadegan N, Sadry GH, Ansari R, Alikhassy H, et al. (2003). Obesity and associated modifiable environmental factors in Iranian adolescents: Isfahan Healthy Heart Program - Heart Health Promotion from Childhood. Pediatr Int. 45(4):435–42. 10.1046/j.1442-200X.2003.01738.x [PubMed: 12911481] [CrossRef]

89.

Fallahzadeh H, Golestan M, Rezvanian T, Ghasemian Z (2009). Breast-feeding history and overweight in 11 to 13-year-old children in Iran. World J Pediatr. 5(1):36–41. 10.1007/s12519-009-0006-5 [PubMed: 19172330] [CrossRef]

90.

Musaiger AO (2011). Overweight and obesity in eastern mediterranean region: prevalence and possible causes. J Obes. 2011:407237. 10.1155/2011/407237 [PMC free article: PMC3175401] [PubMed: 21941635] [CrossRef]

91.

Ahmad MN, Tukan SK, Takruri HR (2006). Obesity and overweight in young adult females of Northern Badia of Jordan. Malays J Nutr. 12(2):157–66.

92.

Ainy E, Azizi F (2007). Women, occupation and cardiovascular risk factors: findings from the Tehran Lipid and Glucose Study. Public Health. 121(12):950–3. 10.1016/j.puhe.2006.12.016 [PubMed: 17645903] [CrossRef]

93.

Janghorbani M, Amini M, Willett WC, Mehdi Gouya M, Delavari A, Alikhani S, et al. (2007). First nationwide survey of prevalence of overweight, underweight, and abdominal obesity in Iranian adults. Obesity (Silver Spring). 15(11):2797–808. 10.1038/oby.2007.332 [PubMed: 18070771] [CrossRef]

94.

Batnitzky A (2008). Obesity and household roles: gender and social class in Morocco. Sociol Health Illn. 30(3):445–62. 10.1111/j.1467-9566.2007.01067.x [PubMed: 18373507] [CrossRef]

95.

Veghari G, Sedaghat M, Joshaghani H, Hoseini A, Niknezhad F, Angizeh A, et al. (2010). The prevalence of obesity and its related risk factor in the north of iran in 2006. J Res Health Sci. 10(2):116–21. [PubMed: 22911934]

96.

Tavassoli AA, Gharipour M, Khosravi A, Kelishadi R, Siadat ZD, Bahonar A, et al. (2010). Gender differences in obesogenic behaviour, socioeconomic and metabolic factors in a population-based sample of Iranians: the IHHP study. J Health Popul Nutr. 28(6):602–9. 10.3329/jhpn.v28i6.6609 [PMC free article: PMC2995029] [PubMed: 21261206] [CrossRef]

97.

Mushtaq MU, Gull S, Abdullah HM, Shahid U, Shad MA, Akram J (2011). Prevalence and socioeconomic correlates of overweight and obesity among Pakistani primary school children. BMC Public Health. 11(1):724. 10.1186/1471-2458-11-724 [PMC free article: PMC3195095] [PubMed: 21943029] [CrossRef]

98.

Al-Tawil NG, Abdulla MM, Abdul Ameer AJ (2007). Prevalence of and factors associated with overweight and obesity among a group of Iraqi women. East Mediterr Health J. 13(2):420–9. [PubMed: 17684862]

99.

Musaiger AO, Shahbeek NE, Al-Mannai M (2004). The role of social factors and weight status in ideal body-shape preferences as perceived by Arab women. J Biosoc Sci. 36(6):699–707. 10.1017/S0021932003006412 [PubMed: 15535459] [CrossRef]

100.

Rguibi M, Belahsen R (2004). Overweight and obesity among urban Sahraoui women of South Morocco. Ethn Dis. 14(4):542–7. [PubMed: 15724774]

101.

Musaiger AO, Qashqari K (2005). The relation between dressing and obesity among women in Saudi Arabia. Arab J Food Nutr. 6:292–302.

102.

Abdollahi P, Mann T (2001). Eating disorder symptoms and body image concerns in Iran: comparisons between Iranian women in Iran and in America. Int J Eat Disord. 30(3):259–68. 10.1002/eat.1083 [PubMed: 11746285] [CrossRef]

103.

Mirkin B (2010). Population levels, trends and policies in the Arab region: challenges and opportunities. Arab Human Development Report research paper series. United Nations Development Programme, Regional Bureau for Arab States. Available from: www​.undp.org/content​/dam/rbas/report/Population​%20Levels,Trends.pdf

104.

Misra A, Khurana L (2008). Obesity and the metabolic syndrome in developing countries. J Clin Endocrinol Metab. 93(11) Suppl 1:S9–30. 10.1210/jc.2008-1595 [PubMed: 18987276] [CrossRef]

105.

Monteiro CA, Moura EC, Conde WL, Popkin BM (2004). Socioeconomic status and obesity in adult populations of developing countries: a review. Bull World Health Organ. 82(12):940–6. [PMC free article: PMC2623095] [PubMed: 15654409]

106.

Galal OM (2002). The nutrition transition in Egypt: obesity, undernutrition and the food consumption context. Public Health Nutr. 5(1a) 1A:141–8. 10.1079/PHN2001286 [PubMed: 12027277] [CrossRef]

107.

Benjelloun S (2002). Nutrition transition in Morocco. Public Health Nutr. 5(1a) 1A:135–40. 10.1079/PHN2001285 [PubMed: 12027276] [CrossRef]

108.

Abdul-Rahim HF, Holmboe-Ottesen G, Stene LCM, Husseini A, Giacaman R, Jervell J, et al. (2003). Obesity in a rural and an urban Palestinian West Bank population. Int J Obes Relat Metab Disord. 27(1):140–6. 10.1038/sj.ijo.0802160 [PubMed: 12532166] [CrossRef]

109.

Esmaeily H, Azimi-Nezhad M, Ghayour-Mobarhan M, Parizadeh M-R, Safarian M, Parizadeh M-J, et al. (2009). Association between socioeconomic factors and obesity in Iran. Pak J Nutr. 8(1):53–6. 10.3923/pjn.2009.53.56 [CrossRef]

110.

Al-Hazzaa HM (2004). The public health burden of physical inactivity in saudi arabia. J Family Community Med. 11(2):45–51. [PMC free article: PMC3410089] [PubMed: 23012048]

111.

WHO (2010). Global Health Observatory (GHO) data. Prevalence of insufficient physical activity: by country. Geneva, Switzerland: World Health Organization. Available from: https://www​.who.int/gho​/ncd/risk_factors​/physical_activity/en/

112.

Guthold R, Cowan MJ, Autenrieth CS, Kann L, Riley LM (2010). Physical activity and sedentary behavior among schoolchildren: a 34-country comparison. J Pediatr. 157(1):43–49.e1. 10.1016/j.jpeds.2010.01.019 [PubMed: 20304415] [CrossRef]

113.

Musaiger AO, Al-Hazzaa HM (2012). Prevalence and risk factors associated with nutrition-related noncommunicable diseases in the Eastern Mediterranean region. Int J Gen Med. 5:199–217. 10.2147/IJGM.S29663 [PMC free article: PMC3295618] [PubMed: 22399864] [CrossRef]

114.

Yount KM, Sibai AM (2009). The demography of aging in Arab societies. In: Uhlenberg P, editor. International handbook of the demography of aging. 9th ed. Dordrecht, Netherlands: Springer; 10.1007/978-1-4020-8356-3_13 [CrossRef]

115.

Musaiger AO, Al-Ansari MS (2000). Barriers to practicing physical activity in the Arab countries. In: Musaiger AO, Meladi SS, editors. Nutrition and physical activity in the Arab countries of the Near East. Cairo, Egypt: FAO Regional Office.

116.

Amarasinghe A, D’Souza G (2012). Individual, social, economic, and environmental model: a paradigm shift for obesity prevention. ISRN Public Health. 571803:1–10. 10.5402/2012/571803 [CrossRef]