Metabolic health in the Middle East and north Africa

Review

Metabolic health in the Middle East and north Africa Fereidoun Azizi, Farzad Hadaegh, Farhad Hosseinpanah, Parvin Mirmiran, Atieh Amouzegar, Hengameh Abdi, Golaleh Asghari, Donna Parizadeh, Seyed Ali Montazeri, Mojtaba Lotfaliany, Farzin Takyar, Davood Khalili

The Middle East and north Africa are home to different populations with widely varying cultures, histories, and socioeconomic settings. Hence, their health status, health management, and access to appropriate health care differ accordingly. In this Review, we examine data on the historical and prospective status of metabolic diseases in this region including obesity, diabetes, hypertension, dyslipidaemia, and non-alcoholic fatty liver disease. Women in the Middle East and north Africa have the highest risk of metabolic diseases of all women globally, whereas men rank second of all men in this respect. Metabolic risk factors are responsible for more than 300 deaths per 100 000 individuals in this region, compared with a global mean of fewer than 250. Physical inactivity, especially in women, and an unhealthy diet (ie, low consumption of whole grains, nuts, and seafoods) stand out. More than one in every three women are obese in most countries of the region. Prevention programmes have not fully been achieved in most of these countries and the projected future is not optimistic. Comprehensive surveillance and monitoring of metabolic diseases, robust multisectoral systems that support primordial and primary preventions, continuous education of health-care providers, as well as collaboration between countries for joint projects in this region are urgently needed to overcome the paucity of data and to improve the metabolic health status of inhabitants in the Middle East and north Africa.

Introduction The Middle East and north Africa have characteristics that are specific to their geography, demography, social factors, economical patterns, and their overall ecosystems. On the basis of the super-regions proposed by the US Institute for Health Metrics and Evaluation (IHME) for calculation of the Global Burden of Disease (GBD), the following countries comprise the region of the Middle East and north Africa: Afghanistan, Algeria, Bahrain, Egypt, Iran, Iraq, Jordan, Kuwait, Lebanon, Libya, Morocco, the occupied Palestinian territory, Oman, Qatar, Saudi Arabia, Sudan, Syria, Tunisia, Turkey, United Arab Emirates, and Yemen.1 Three main religions (Islam, Christianity, and Judaism) are practiced in these countries, they have eight official languages, and their inhabitants have diverse cultures, historical backgrounds, and political, social, and economic contexts. Two-thirds of the countries in the Middle East and north Africa are low-income or middle-income and their Human Development Indices range between 0·47 and 0·85.2 Health status and accessibility to appropriate care in most of them have been adversely affected by political instability, social conflict, and war.3,4 Almost all countries of the Middle East and north Africa are in nutritional transition from a traditional to a modern diet, which is heavy in fast and processed foods, and their burden of disease has shifted from communicable to noncommunicable diseases.4,5 The Middle East and north Africa have had the highest burden of disability-adjusted life-years (DALYs) due to metabolic risk factors for women among different GBD super-regions, with men ranking second in this regard (figure 1). Breaking DALYs down into years lost to disability (YLDs) and years of life lost (YLLs) shows that during these decades, the Middle East and north Africa had one of the steepest decreases in the age-standardised YLLs due to metabolic risk factors and the steepest

increase in age-standardised YLDs. This trend shows that although mortality due to metabolic risk factors has decreased, the burden of metabolic diseases in survivors is increasing drastically, reflecting increased survival but with disability (appendix p 6). In 2017, around 23% of all-cause DALYs in the Middle East and north Africa were attributed to metabolic risk factors in both sexes, corresponding to 7921 years (95% CI 7216–8622) per 100 000 individuals in men and 6465 years (5856–7080) in women. These values were 6125 (6605–6652) for men and 4477 (4054–4929) for women globally. Considering major categories of risk factors, including metabolic, behavioural, and environmental, metabolic risk factors rank first in the Middle East and north Africa, with cumulative mortality of more than 300 deaths per 100 000 individuals. By contrast, metabolic risk factors rank second worldwide, with fewer than 250 deaths per 100 000.6 In this Review, we focus on the past, current, and predicted epidemiology of metabolic diseases including obesity, diabetes, hypertension, dyslipidaemia, and nonalcoholic fatty liver disease and the status of nutrition and physical activity in the Middle East and north Africa. Comprehensive and thorough coverage of all these aspects is challenging, as it is dependent on the availability of data on countries in the region.7 To provide results that can compare the Middle East and north African region with other parts of the world, as well as compare countries within the region, we reviewed and used five main databases that provide standardised and harmonised global data. These databases include the IHME and its 2017 GBD study,6 the Non-communicable Diseases Risk Factor Collaboration (NCD-RisC),8–10 the Food and Agriculture Organization of the UN (FAO), the World Health Organization (WHO),11 and the Inter­ national Diabetes Federation (IDF).12 The framework of

www.thelancet.com/diabetes-endocrinology Published online August 14, 2019 http://dx.doi.org/10.1016/S2213-8587(19)30179-2

Lancet Diabetes Endocrinol 2019 Published Online August 14, 2019 http://dx.doi.org/10.1016/ S2213-8587(19)30179-2 Endocrine Research Center (F Azizi MD, A Amouzegar MD, H Abdi MD, F Takyar PhD), Prevention of Metabolic Disorders Research Center (F Hadaegh MD, D Parizadeh MD, M Lotfaliany MD, D Khalili PhD), Obesity Research Center (F Hosseinpanah MD, S A Montazeri MD), Nutrition and Endocrine Research Center (P Mirmiran PhD, G Asghari PhD), and Department of Biostatistics and Epidemiology (M Lotfaliany, D Khalili), Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran; and Faculty of Nutrition Sciences and Food Technology, National Nutrition and Food Technology Research Institute, Shahid Beheshti University of Medical Sciences, Tehran, Iran (P Mirmiran) Correspondence to: Dr Davood Khalili, Associate Professor of Epidemiology, Head of the Department of Biostatistics and Epidemiology, Research Institute for Endocrine Sciences, Shahid Beheshti University of Medical Sciences, Tehran, Iran [email protected] See Online for appendix

For the Food and Agriculture Organization see http://www. fao.org/faostat/en/#home

1

Review

A 700

Mortality per 100 000 people

600

500

Female

Male

Global North Africa and Middle East Southeast Asia, east Asia, and Oceania Central Europe, eastern Europe, and central Asia High-income countries Latin America and Caribbean South Asia Sub-Saharan Africa

400

300

200

100

B 14 000

DALYs per 100 000 people

12 000

10 000

8000

6000

4000

2000 1990

1994

1998

2002

2006

2010

2014

1990

1994

1998

Year

2002

2006

2010

2014

Year

Figure 1: Deaths and DALYs attributed to metabolic risk factors in different global regions of the world, according to the GBD 2017 study6

our Review covered: status of nutrition and physical activity in the region on the basis of reports from FAO, GBD 2017, and WHO; prevalence of each metabolic risk on the basis of data available from NCD-RisC or WHO reports; burden of diseases attributed to metabolic risks on the basis of IHME data (mortality, DALYs, YLLs, and YLDs); ranking countries in the region on the basis of observed-to-expected summary exposure values reported by IHME for a given metabolic risk; predicting the progression of metabolic risks on the basis of IHME and NCD-RisC projections; and prevention and control programmes based on WHO’s progress report on noncommunicable diseases of 2017. We also used PubMed to review references. Characteristics of the main sources of data and the definition of the metabolic health conditions based on these sources are summarised in the appendix (appendix p 3). All indices reported are age-adjusted, except if mentioned otherwise. 2

Nutritional status Food availability and calorie intake has increased during the period of nutritional transition in most countries in the Middle East and north Africa over 1993–2013, reaching approximately 3000 kcal per day in 2013 (appendix p 7). The highest increase was found in Kuwait, Oman, Saudi Arabia, and Morocco, where consumption increased by more than 500 kcal per day.13–15 Mean energy intake in most countries of the Middle-East and north African region was higher than the global average in 2013, the highest reported in Turkey and the lowest in Afghanistan and Yemen. A 2018 review16 emphasised that the contribution of fat in the diet also increased in most countries of the region. However, sex-specific calorie intake has not been adequately addressed in available sources. According to GBD data from 1990 to 2017,6 the average consumption of fruits and vegetables in the Middle

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Female

Global Bahrain Iraq Lebanon Occupied Palestinian territory Saudi Arabia Tunisia Yemen

Afghanistan Egypt Jordan Libya Oman Sudan Turkey

80 19 82 19 84 19 86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06 20 08 20 10 20 12 20 14

Female

19

86 19 88 19 90 19 92 19 94 19 96 19 98 20 00 20 02 20 04 20 06 20 08 20 10 20 12 20 14

19

82

84

19

19

80

19

Age-standardised prevalence of diabetes (%)

19 9 19 0 9 19 1 9 19 2 9 19 3 9 19 4 9 19 5 9 19 6 9 19 7 9 19 8 9 20 9 0 20 0 0 20 1 0 20 2 03 20 0 20 4 0 20 5 0 20 6 0 20 7 0 20 8 0 20 9 1 20 0 1 20 1 1 20 2 1 20 3 1 20 4 1 20 5 16

19 9 19 0 9 19 1 9 19 2 9 19 3 9 19 4 9 19 5 9 19 6 9 19 7 9 19 8 9 20 9 0 20 0 0 20 1 0 20 2 0 20 3 0 20 4 0 20 5 0 20 6 0 20 7 0 20 8 0 20 9 1 20 0 1 20 1 1 20 2 1 20 3 1 20 4 1 20 5 16

Age-standardised prevalence of obesity (%)

Female

19 75 19 77 19 79 19 8 19 1 83 19 85 19 87 19 89 19 91 19 93 19 95 19 97 19 99 20 01 20 03 20 05 20 07 20 09 20 11 20 13 20 15

19 75 19 77 19 79 19 8 19 1 83 19 85 19 87 19 89 19 91 19 93 19 95 19 97 19 99 20 01 20 03 20 05 20 07 20 09 20 11 20 13 20 15

Age-standardised prevalence of hypertension (%)

Review

50 Male

40 45

30 35

20 25

10 15

0 5

20 Male

16 18

14

10 12

6 8

4

2

0

50 Male

45

40

35

30

25

20

15

Year

Year

Algeria Iran Kuwait Morocco Qatar Syria United Arab Emirates

Figure 2: Prevalence of obesity, diabetes, and hypertension since 1975 by countries in the Middle East and north Africa, according to the 2016 data from NCD-RisC’s Country Profile database

NCD-RisC=Non-communicable Diseases Risk Factor Collaboration.

www.thelancet.com/diabetes-endocrinology Published online August 14, 2019 http://dx.doi.org/10.1016/S2213-8587(19)30179-2

3

Review

SDI Index value

High BMI Regional rank

O/E

High FPG Rank

O/E

High SBP Rank

O/E

High LDL cholesterol Rank

O/E

Rank

Kuwait

0·79

1

2·03

21

1·45

11

0·88

6

1·07

11

United Arab Emirates

0·79

1

1·62

15

1·72

15

0·96

10

1·06

10 4

Saudi Arabia

0·78

3

1·85

19

1·81

20

0·9

7

0·86

Qatar

0·77

4

1·95

20

1·44

10

0·96

10

0·82

3

Libya

0·76

5

1·45

13

1·76

19

1·38

17

0·94

5

Occupied Palestinian territory

0·74

6

1·63

16

1·53

13

0·81

2

1·3

20

Lebanon

0·73

7

1·55

14

1·73

17

1·02

13

1·18

18

Turkey

0·73

7

1·42

7

0·78

1

0·9

7

0·78

1

1·05

16

Bahrain

0·71

9

1·66

17

1·72

15

14

1·12

Algeria

0·7

10

1·43

8

1·36

7

0·7

1

0·81

2

Iran

0·7

10

1·15

2

1·3

6

0·86

3

1

8

Jordan

0·7

10

1·34

5

1·42

9

0·91

9

1·11

Tunisia

0·68

13

1·33

4

1·17

4

0·86

3

0·98

14 6

Syria

0·61

14

1·43

8

1·08

2

1·06

15

1·09

13

Egypt

0·6

15

1·74

18

1·75

18

1·07

16

0·99

7

Iraq

0·58

16

1·4

6

1·4

8

1·38

17

1·07

11

Morocco

0·58

16

1·44

11

1·45

11

1·38

17

1·11

14 17

Oman

0·54

18

1·43

8

1·63

14

1·5

21

1·13

Sudan

0·48

19

1·44

11

1·18

5

1·38

17

1·05

9

Yemen

0·43

20

0·94

1

1·09

3

0·87

5

1·21

19

Afghanistan

0·29

21

1·22

3

2·2

21

0·96

10

1·36

21

SDI rankings for each country are aggregate measures of total fertility, education, and income per capita. Rankings for metabolic risks are based on each country’s O/E summary exposure value of that risk factor in 2017. For each factor, the summary exposure value is a risk-weighted prevalence of exposure, an easily comparable single-number summary. The expected summary exposure value for a given risk factor is estimated on the basis of the SDI. An O/E ratio <1·0 indicates that observed exposures are better than expected, whereas O/E ratios >1·0 indicate the opposite.55,81 BMI=body-mass index. FPG=fasting plasma glucose. LDL=low-density lipoprotein. O/E=observed-to-expected. SBP=systolic blood pressure. SDI=sociodemographic index.

Table 1: O/E summary exposure of metabolic risk factors in the Middle East and north Africa by country for both sexes in 20176

East and north Africa is 1·5–2 times of that reported globally, although this statistic is still 2 to 2·5 times lower than the value recommended by WHO. During the past two decades, the mean daily intake of fruit, vegetables, and fibre increased in the Middle East and north Africa by a similar increment to that reported by GBD globally (appendix p 8). Nonetheless, these intakes decreased in Kuwait, Saudi Arabia, the United Arab Emirates, Iraq, Lebanon, and Libya (appendix pp 9–10). Other important components of a healthy diet are legumes and whole grains; legume intake has increased but the intake of whole grains was unchanged from 1990 to 2017 for each sex (appendix p 8). The consumption of whole grains in the Middle East and north Africa is one-third that of the global average. Mean sodium intake increased slightly between 1990 and 2017 in both sexes, although dietary sodium was lower for both sexes than the global average (appendix p 8). High cholesterol and omega-6, saturated, and trans fatty acids, which comprised 2·4% of the total energy intake (4·5 times higher than optimal), 4

might have predisposed residents in the Middle East and north Africa to increased incidence of noncommunicable diseases.17 Overall, considering the income status and nutritional illiteracy (even in highincome settings) of Middle Eastern and north African countries, practical suggestions for this region include focusing on whole-wheat bread production with desirable taste and quality, and providing subsidies for healthy dietary patterns, including the consumption of fruits, vegetables, legumes, nuts, and seeds to reduce the risk of non-communicable diseases.

Physical activity On the basis of data from WHO’s STEPwise approach to surveillance, the prevalence of physical inactivity in the Middle East and north Africa ranged from 21·6% to 86·8% before 2008, and from 24·1% to 71·1% after 2008. In Egypt, physical inactivity had been more prevalent before 2008 (50%) than after (25%). Uppermiddle-income countries show varying profiles of changes in physical activity, which has increased in some

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Review

High fasting plasma glucose (per 100 people)

8

Past Reference Worse Better Middle East and north Africa

6

4 Global 2

0

High body mass index (per 100 people)

30

25

20

Middle East and north Africa

15

10 Global 5

0 1990

1994

1998

2002

2006

2010

2014 Year

2018

2022

2026

2030

2034

2038

Figure 3: Projection for age-standardised prevalence of high BMI and high FPG (as summary exposure values) in the Middle East and north Africa compared with global estimates in different scenarios, according to the GBD 2017 Foresight BMI=body-mass index. FPG=fasting plasma glucose. GBD=Global Burden of Disease.

but decreased in others. In high-income countries, a slight decrease in physical activity is happening (appendix p 11). Although the presence of minor variations in the implementation of WHO’s STEPwise procedures cannot be ruled out, they are unlikely to cause major differences in reported values between countries. The Middle East and north Africa have one of the worst physical activity profiles globally. Average physical activity in almost all countries in the region is fewer than 2000 metabolic equivalent tasks per min per week in women and fewer than 2500 in men, which is substantially inferior to the global average of around 3000 in women and more than 3500 in men (appendix p 12). An unequal distribution was also reflected in a 2017 data analysis18 of 111 countries, suggesting that such inequality could be used as a predictor of obesity.

For the GBD Foresight database see https://vizhub. healthdata.org/gbd-foresight/

Obesity and overweight Compared with the global average, the prevalence of obesity has been higher in the Middle East and north Africa since 1990 (figure 2). In 2016, the prevalence of obesity was more than 30% in women and more than 20% in men in all countries of this region, except for Afghanistan, Sudan, and Yemen, whereas the worldwide prevalence of obesity was 15·7% for women and 11·6% for men (appendix p 13). People in almost all countries in the Middle East and north Africa have the lowest levels of physical activity worldwide and their prevalence of obesity has been increasing in both sexes during the past three decades. Industrialisation and urbanisation are among the main factors contributing to this increase. Hallal and colleagues19 reported that the prevalence of physical inactivity in countries of the Eastern Mediterranean was

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For the STEPwise approach to surveillance see https://www. who.int/ncds/surveillance/steps/ en/

5

Review

Men

Women

Estimated prevalence Projection for 2025 in 2010 Afghanistan Algeria

Probability of meeting global target

Estimated prevalence Projection for 2025 in 2010

Probability of meeting global target

2·3% (1·0–4·6)

6·0% (2·2–12·3)

0%

6·0% (3·4–9·6)

12·6% (6·5–20·9)

0%

16·5% (11·4–22·2)

29·3% (18·8–42·0)

0%

32·1% (25·9–38·5)

43·4% (32·6–54·6)

0% 4%

Bahrain

23·0% (17·1–29·1)

32·9% (21·7–44·8)

1%

35·6% (29·3–42·0)

42·3% (31·3–53·4)

Egypt

19·4% (14·9–24·4)

31·4% (21·3–42·8)

0%

38·3% (33·1–43·5)

49·4% (39·3–59·5)

0%

Iran

16·1% (13·5–18·9)

27·6% (19·1–37·3)

0%

29·9% (26·4–33·3)

39·7% (30·6–49·1)

0%

Iraq

20·5% (15·0–26·2)

31·7% (21·6–43·6)

0%

35·0% (28·6–41·3)

43·9% (33·4–54·5)

1%

Jordan

25·1% (20·2–30·4)

36·7% (26·7–47·2)

0%

41·4% (36·5–46·4)

49·7% (40·2–59·1)

1%

Kuwait

30·4% (25·5–35·3)

41·2% (30·8–52·2)

0%

44·6% (39·5–49·8)

51·0% (41·2–60·8)

4%

Lebanon

24·6% (18·6–30·8)

35·4% (24·2–47·4)

0%

35·6% (29·4–42·3)

43·1% (32·4–54·5)

2%

Libya

22·0% (16·3–28·2)

33·1% (22·3–45·5)

0%

37·8% (30·9–44·6)

46·4% (35·2–57·5)

1%

Morocco

16·1% (10·9–22·0)

28·4% (17·7–40·6)

0%

29·3% (23·2–35·5)

40·6% (29·8–52·0)

0%

Occupied Palestinian territory

23·2% (17·6–29·3)

34·8% (23·6–47·2)

0%

36·9% (31·0–42·7)

45·7% (34·9–56·4)

1%

Oman

19·3% (14·4–24·4)

32·5% (21·8–44·9)

0%

31·0% (25·0–37·0)

41·6% (30·5–53·0)

0%

Qatar

29·3% (23·1–35·8)

41·2% (29·8–53·2)

0%

41·8% (35·3–48·2)

49·2% (38·3–60·0)

2%

Saudi Arabia

27·2% (22·7–32·0)

40·0% (29·7–50·9)

0%

40·5% (35·6–45·3)

49·1% (39·3–58·7)

1%

3·0% (1·5–5·4)

6·2% (2·4–12·8)

1%

10·5% (6·7–15·4)

17·8% (10·4–27·5)

0% 0%

Sudan Syria

17·5% (12·0–23·9)

29·9% (18·8–42·8)

0%

32·0% (25·0–39·2)

43·0% (31·6–54·8)

Tunisia

16·2% (11·6–21·4)

27·2% (17·3–38·7)

0%

32·1% (26·1–38·1)

41·6% (31·1–52·8)

1%

Turkey

21·0% (17·4–24·9)

33·7% (24·1–43·9)

0%

36·8% (32·8–41·0)

47·3% (38·2–56·9)

0%

United Arab Emirates

24·3% (18·4–30·6)

36·3% (25·0–48·5)

0%

39·2% (32·9–45·6)

47·8% (37·1–58·9)

1%

9·1% (5·8–13·2)

20·2% (11·2–31·8)

0%

18·8% (14·0–23·9)

31·0% (21·2–41·8)

0%

Yemen

Data are % (UI) of age-standardised estimates for adults aged 20 years and older. NCD-RisC=Non-communicable Diseases Risk Factor Collaboration. UI=uncertainty interval.

Table 2: Projection of obesity prevalence in 2025 and the probability of meeting the global target according to NCD-RisC’s Country Profile database

43%, which is higher than the global average of 31%. Additionally, the nutritional transition from traditional to westernised food means that energy intake and the contribution of fat in the diet have increased in most of these countries.16 Finally, much attention has been focused on a possible role of ambient air pollution as an emergent risk factor for the development of obesity, an issue of crucial significance in the Middle East and north Africa, which has some of the highest levels of ambient air pollution worldwide.20 Compared with the world average, and especially with developed countries, the difference in prevalence of obesity between sexes is more pronounced in the Middle East and north Africa.21 A population-based cohort study in Iran22 has also reported that the cumulative incidence of adult obesity was 38·1% in women and 23·4% in men for a period of 8 years. However, it is important to note that waist circumference is higher in men than in women in the Middle East and north Africa.22–24 This sex difference in obesity could partly result from increased prevalence of physical inactivity in women and girls in the region. A national surveillance report of risk factors of non-communicable diseases in Iran25 6

showed that, in 2011, 49·7% of women had low levels of physical activity, but only 28·7% of men did so, and that the levels of inactivity in women rose more in 2007–11 than in men. Various factors discourage women from being physically active in the Middle East and north Africa, such as personal issues (no motivation, enjoyment, or skills in sport), lack of social support, environmental barriers (not enough free time or access to sports facilities), and cultural stigma.26 Moreover, parity rate is associated with increased risk of obesity and overweight27–29 and the Middle East and north Africa has had one of the highest parity rates worldwide.13 Air pollution, which is linked to obesity, probably affects women more than men,30 as sex-related and behaviour-related effects of air pollution have been documented.31 Biological differences between men and women include lung volume, airway reactivity, and hormonal influence on systemic inflammation. Behavioural factors, such as smoking habits, work-related and indoor air pollution, and psychosocial stressors, might differ between male and female individuals.32 In the Middle East and north Africa, exposure to household air pollution and associated DALYs in 2017 were slightly higher in women than in men.33

www.thelancet.com/diabetes-endocrinology Published online August 14, 2019 http://dx.doi.org/10.1016/S2213-8587(19)30179-2

Review

Men

Women

Estimated prevalence Projection for 2025 in 2010

Probability of meeting global target

Estimated prevalence Projection for 2025 in 2010

Probability of meeting global target 12%

Afghanistan

10·5% (6·8–15·1)

16·8% (5·7–37·2)

12%

11·1% (7·2–15·8)

17·8% (6·1–38·7)

Algeria

11·2% (7·8–15·5)

17·8% (6·9–38·3)

10%

11·6% (8·3–15·8)

17·5% (6·9–36·5)

13%

Bahrain

11·6% (8·0–16)

14·1% (5·3–29·8)

35%

10·4% (7·1–14·4)

12·0% (4·3–26·1)

43%

Egypt

14·2% (10·0–19·1)

23·2% (9·5–46·9)

8%

17·6% (13–23·2)

29·0% (13·0–57·0)

5%

Iran

10·2% (7·5–13·4)

17·7% (7·2–37·9)

6%

11·5% (8·8–14·9)

19·5% (8·7–40·7)

5%

Iraq

15·2% (10·7–20·7)

25·2% (10·2–51·0)

6%

15·7% (11·3–21)

24·4% (10·3–48·6)

9%

Jordan

15·1% (11·0–20·1)

22·6% (9·6–45·5)

11%

16·2% (12·3–20·9)

21·3% (9·6–40·6)

22%

Kuwait

18·4% (13·4–24·4)

25·4% (11·6–48·1)

14%

18·3% (13·4–24·2)

24·9% (11·3–46·8)

15%

Lebanon

12·5% (8·3–17·5)

23·2% (8·6–49·1)

5%

10·8% (7·3–15·2)

17·9% (6·7–38·0)

10% 10%

Libya

14·0% (10·3–18·7)

21·8% (9·0–45·2)

10%

15·4% (11·6–20·1)

22·8% (9·7–44·8)

Morocco

12·5% (8·5–17·2)

21·8% (8·3–46·1)

6%

12·1% (8·3–16·8)

19·6% (7·7–41·5)

9%

Occupied Palestinian territory

14·7% (10·6–19·6)

25·5% (10·6–52·7)

5%

15·6% (11·6–20·3)

25·5% (11·1–51·1)

6%

Oman

13·1% (9·4–17·6)

20·1% (7·7–42·2)

11%

11·6% (8·3–15·6)

15·7% (6·0–32·3)

21%

Qatar

17·3% (12·6–22·9)

26·0% (11·2–50·0)

10%

17·3% (12·9–22·8)

24·9% (11·0–48·7)

12%

Saudi Arabia

16·1% (12·0–21·3)

23·5% (10·3–45·7)

12%

15·7% (11·7–20·6)

22·1% (9·8–43·6)

14%

7·9% (4·8–11·8)

11·2% (3·3–26·4)

25%

9·0% (5·5–13·4)

12·3% (3·8–28·5)

27%

Sudan Syria

12·7% (9·1–17·1)

20·0% (7·8–42·8)

11%

13·9% (10·2–18·5)

21·5% (8·7–44·5)

10%

Tunisia

11·0% (7·9–14·9)

17·8% (7·0–37·5)

9%

11·9% (8·7–15·6)

17·2% (6·9–35·3)

15%

Turkey

11·8% (8·9–15·1)

19·9% (9·1–38·5)

4%

13·0% (9·9–16·3)

20·0% (9·5–37·0)

7%

United Arab Emirates

14·7% (10·7–19·6)

19·9% (8·0–41·1)

21%

14·9% (11·1–19·7)

19·9% (8·0–40·4)

22%

Yemen

11·0% (6·7–16·6)

21·6% (6·8–50·9)

5%

8·9% (5·2–13·7)

17·0% (5·4–40·3)

6%

Data are % (UI) of age-standardised estimates for adults aged 18 years and older. NCD-RisC=Non-communicable Diseases Risk Factor Collaboration. UI=uncertainty interval.

Table 3: Projection of diabetes prevalence in 2025 and the probability of meeting the global target according to NCD-RisC’s Country Profile database

Compared with other GBD super-regions, the Middle East and north Africa ranked first in 2017 for DALYs and mortality due to high body-mass index (BMI).6 This prevalence could be explained by increased agestandardised prevalence, and poor management and control of, obesity and other non-communicable disease risk factors (appendix pp 17, 21).

Diabetes and prediabetes The Middle East and north Africa had the second-highest prevalence of type 2 diabetes (10·8%) in 2017 globally.12 Among countries of the region, in 2014, prevalent diabetes (including both types 1 and 2, but predominantly related to type 2) ranged from 8·3% in Sudan to 19·7% in Kuwait in men, and from 9·5% in Sudan to 19·8% in Egypt in women.34 During the past three decades, diabetes has increased in all Middle Eastern and north African countries (figure 2, appendix p 15).34 The disease increased by 1·5–2 times even in high-income countries of this region, whereas in European high-income countries, the prevalence of type 2 diabetes remained steady throughout this period.34 Alarmingly, in line with the hidden global epidemic of type 2 diabetes,12 about 50% of diabetes cases in 2017

were undiagnosed in the Middle East and north Africa, ranging from 17% in Kuwait to about 70% in Tunisia and Afghanistan.12 Additionally, a high proportion of adults in the region were at increased risk of diabetes type 2 due to prediabetes, and national age-standardised results from the region showed high prevalence of impaired fasting glucose in adults in Saudi Arabia35 (25·5% in 2015) and Iran36 (16·8% in 2007). In 2017, the overall DALYs attributed to high fasting plasma glucose (FPG) in the Middle East and north Africa were considerably more than the global estimates (appendix pp 18, 22).6 In 1990–2017, the age-standardised DALYs due to high FPG in the Middle East and north Africa decreased by 9%, whereas the corresponding all-age DALYs increased by 25%, reflecting the rising burden of high FPG in the ageing population in the region.33,37 The risk of DALYs due to type 2 diabetes was attributed to a combination of metabolic, environmental, and behavioural risk factors, of which high BMI, low consumption of whole grains, and ambient particulate matter (air pollution) were most prominent (appendix p 25). Besides obesity, ambient air pollution has been linked to insulin resistance and diabetes, possibly through activating inflammatory processes and changing glucose and lipid metabolism.38,39

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For NCD-RisC’s Country Profile database see http:// ncdrisc.org/country-profile.html

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Despite the increased prevalence of general adiposity in women in the Middle East and north Africa compared with men, the 2017 GBD did not report any significant sex differences in the prevalence of, and DALYs attributed to, type 2 diabetes.33 The prevalence of DALYs due to type 2 diabetes in women was considerably higher than in men during the past three decades; however, this difference has since attenuated, mostly because these DALYs have also been increasing in men (appendix p 26). Important risk factors other than obesity, such as increased prevalence of smoking in men, might have contributed to the course of the type 2 diabetes burden in the Middle East and north Africa during this period.40 Indeed, smoking was associated with higher risk of DALYs due to type 2 diabetes than low physical activity in men and high consumption of sweetened beverages in both sexes in the region (appendix p 25). Alarmingly, although the prevalence of smoking in women in the region is overall much lower than in men, an increase has been reported in both women with and without diabetes in the past decade.41 According to population-based studies from the Middle East and north Africa,42,43 only about half of patients with known type 2 diabetes received antihyperglycaemic treatment. However, clinic-based studies showed that treatment prevalence (about 90% of patients with type 2 diabetes and its comorbidities) was remarkably higher than estimated by the populationbased studies, which might indicate selection bias in clinic-based studies.44,45 Yet, achieving target blood glucose, blood pressure, and lipids with treatment was successful in fewer than 50% of patients.44–48 Nonadherence to medication is a major challenge for controlling type 2 diabetes because patients might be distrustful of their prescribed medication and concerned about its possible adverse effects.49,50 Suboptimal control is reflected in the high frequency of vascular complications due to diabetes in the Middle East and north Africa.48 In fact, the greatest proportion of the direct cost of treating patients with diabetes in the region is attributed to disease complications.51,52 Hence, because care for patients with diabetes is poorly funded in the region, the focus of health expenditure needs to be on primary prevention and optimal disease manage­ment.49,52,53

Hypertension and prehypertension The prevalence of hypertension in the Middle East and north Africa was higher than the rest of the world between 1975 and 2015 according to NCD-RisC estimates, with no differences between men and women (figure 2, appendix p 16). During this period, consumption of fruits and vegetables in the region was consistently higher and sodium intake was lower, yet increasing, than global estimates, but slightly more sugar-sweetened beverages were consumed overall54 and physical activity was also less.18,19 The prevalence of hypertension decreased in both sexes, except in Sudan, Afghanistan, and Yemen, where it increased. These 8

findings contrast with those showing increases in obesity in the Middle East and north Africa in both sexes. Compared with worldwide data, Turkish men always had reduced prevalence of hypertension during the period 1975–2015. Of note, increased blood pressure is a metabolic risk factor, and its measurement heavily depends on the observer, the measurement setting, and the measurement device. A possible explanation for the reduction in hypertension, despite the unfavourable trends in sodium intake, obesity, and physical activity in the Middle East and north Africa, needs to focus on other probably unmeasured factors influencing blood pressure,9 although the increased use of antihypertensive drugs over the period might be a contributing factor. High systolic blood pressure is the leading risk factor of DALYs in the Middle East and north Africa.55 In 2017, the lowest prevalence of DALYs due to high systolic blood pressure was reported from Kuwait and the highest from Afghanistan.6 Overall, throughout 1990–2017, DALYs and mortality attributed to high systolic blood pressure decreased in all countries of the region (appendix pp 19, 23). On the basis of several population-based studies from Iran,56,57 Saudi Arabia,58 Tunisia,59 and Oman,60 prehypertension (ie, systolic blood pressure 120–139 mm Hg, diastolic blood pressure 80–89 mm Hg, or both) has a crude prevalence from 40% to 66%, affecting more men than women. According to community-based studies from Egypt61 and Saudi Arabia,62 the prevalence of undiagnosed hypertension was 62·5% and that of controlled hypertension was 8·0% in Egypt, and in Saudi Arabia it was 33% and 25%. Findings of reports from Iran (2005–11)57 and Turkey (2003–12)63 indicate increased awareness, treatment, and proportion of patients with controlled hypertension throughout these periods. Nevertheless, a substantial proportion of patients with hypertension remained undiagnosed, and many treated patients had poorly controlled hypertension.

Dyslipidaemia Among countries in the Middle East and north Africa, only few have done regular national STEPwise surveys on metabolic risk factors including dyslipidaemia (Iran, Egypt, Iraq, Lebanon, and Kuwait). In Egypt, the prevalence of hypercholesterolaemia (locally defined as ≥5·0 mmol/L) steeply declined from 36·8% in 2011–2012 to 19·2% in 2017.11 The prevalence of hypercholesterolaemia (≥5·2 mmol/L) in Iran also declined from 32·8% in 2007 to 28% in 2011,11 which is in accordance with populationbased studies from the country.64 Overall, scarcity of systematic data on the trends in prevalence of dyslipidaemia makes it difficult to determine the status of people in the region. Nevertheless, in a country like Iran, for which data are available, the favourable decline of serum cholesterol might be attributable to widespread prescribing of statins by general practitioners. Additionally, restrictions by the

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Review

ministry of health on the content of trans fatty acids in edible oils and increased public awareness about dyslipidaemia also seem to contribute to its decline.65 However, local surveys available from some Arab countries, Turkey, and Iran, generally indicate that people in the region have high lipid serum concen­trations.65–67 Low HDL was reported as the main component of dyslipidaemia in Iranian adults, with a prevalence of about 70%,65 and 42% in Turkish adults.67 The high prevalence of dyslipidaemia is predictable for the region, considering the high consumption of dietary fats, obesity, and physical inactivity. Moreover, increasing consumption of carbohydrate-rich food such as refined grains, which are generally low-cost and readily available, could further contribute to low concentrations of HDL.68 According to GBD estimates, DALYs due to high LDL in the region decreased during 1990–2017,6 similarly to global trends, but were still considerably higher than the rest of the world (appendix p 20). The high prevalence of DALYs could be attributed to poor control of dyslipidaemia despite increased medical therapy, probably because either patients or physicians do not adhere to prescription and treatment guidelines, statins are not optimally dosed, or combination therapies are not used when necessary.69 Results from the Dyslipidaemia International Study70 done in the United Arab Emirates, Saudi Arabia, Lebanon, and Jordan showed that after more than 3 months of treatment with statins, about two-thirds of patients still had uncontrolled LDL concentrations and about half of them had low HDL cholesterol and high triglyceride concentrations.70 When done in Egypt, the same study69 reported that the prevalence of uncontrolled LDL cholesterol was about 70%, that of low HDL cholesterol was 47%, and that of high triglycerides was 37%. Similarly, in a population-based study from Iran,41 although the use of lipid-lowering medication increased and more patients had improved control of LDL cholesterol during the past decade, abnormal lipid concentrations remained high in the population, including about 30–50% of study participants without diabetes and 50–60% of patients with diabetes. DALYs attributed to high LDL were considerably more in low-income countries in the Middle East and north Africa than in higher-income countries. In 2017, Afghanistan, Egypt, and Yemen had the highest DALYs and mortality attributed to high LDL, and Bahrain, Qatar, and Turkey had the lowest (appendix pp 20, 24).

Cirrhosis due to non-alcoholic steatohepatitis has been included as a cause of chronic liver disease in GBD studies, and liver cancer due to non-alcoholic fatty liver disease has been added as a new outcome of high BMI.55 Country-specific prevalence of cirrhosis due to non-alcoholic steatohepatitis based on GBD 2017 data in the Middle East and north Africa is shown in the appendix (p 28). In 2017, men in Kuwait and Qatar had the highest prevalence of cirrhosis, more than two times the global estimates. GBD data related to non-alcoholic fatty liver disease are unadjusted for exclusions of other related liver diseases, which might also result in misleading findings because of high prevalence of viral hepatitis in the Middle East and north Africa.80 Accordingly, compared with the global average, the prevalence and burden of chronic kidney disease as a sequence of metabolic risk factors, including high BMI, blood glucose, and blood pressure, are substantially increased in the region as well (appendix pp 29–33).

Non-alcoholic fatty liver disease

Using IHME estimates, we compared the potential trajectories for BMI and FPG for the Middle East and north Africa with global averages, on the basis of agestandardised summary exposure values (figure 3). On the basis of these results, if Middle Eastern and north African countries follow their optimum scenario (ie, better health; along the 85th percentile of the annualised rate of change observed in previous years), they would still be far from the global average estimates of FPG and BMI.

There are scarce data from few studies with different definitions and substantial design shortcomings on the epidemiology of non-alcoholic fatty liver disease in the Middle East and north Africa. Most reports are from Iran with a prevalence range of 3–44% (appendix p 27).71–78 It has been projected that by 2030 the prevalence of this disease will increase from 25·7% to 31·7% in Saudi Arabia and from 25·0% to 30·2% in the United Arab Emirates.79

Observed-to-expected summary exposure value of metabolic risks Middle Eastern and north African countries with different sociodemographic indices have different profiles of metabolic risk factors and their index ranks do not match with their ranks of observed-to-expected summary exposure of metabolic risk factors (table 1). Kuwait has the best sociodemographic index in the region but has the highest unexpected prevalence of high BMI, followed by Qatar and Saudi Arabia. Afghanistan has the lowest sociodemographic index, despite its superior status regarding high BMI, and has the worst unexpected prevalence of both high FPG and LDL. Yemen is the only country in which the prevalence of high BMI is as expected on the basis of its sociodemographic index. Overall, the countries’ ranks show that those with high sociodemographic indices have the highest unexpected prevalence of high BMI and high FPG. The prevalence of metabolic risk factors in Tunisia, Turkey, and Iran is as expected, which is not the case for the prevalence of obesity in Tunisia, and in Turkey and Iran for diabetes. Therefore, the distribution of metabolic risk factors among countries is not the same and none can be considered superior or inferior in this regard.

Forecasting metabolic risks in different scenarios

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Governance

Prevention and reduction of risk factors

National National targets strategy plan

Salt policies

Saturated fatty acids and trans-fats policies

Physical activity policies

Monitoring and evaluation

Primary health care

Mortality data

National guidelines on non-communicable diseases

STEPS survey

Total score Provision of drug therapy, including glycaemic control

Countries Afghanistan

0

1

0·5

1

0

0

0·5

0

0

3

Algeria

1

0·5

1

0

1

0

0·5

0·5

0

4·5

Bahrain

1

1

0·5

1

1

0·5

0·5

0

1

6·5

Egypt

1

0·5

0·5

0

0

0·5

0·5

0·5

0

3·5

Iran

1

1

1

1

1

0·5

1

1

1

8·5

Iraq

1

1

0·5

1

1

0·5

0·5

1

0

6·5

Jordan

0·5

0·5

1

1

1

0·5

0·5

0·5

1

6·5

Kuwait

1

1

0·5

1

1

0·5

0·5

1

1

7·5

Lebanon

0

0·5

0

0

1

0

0·5

1

1

4

Libya

0

0

0

0

0

0

0·5

0

0

0·5

Morocco

1

0·5

1

1

1

0·5

0·5

0·5

0

6

Occupied Palestinian territory

1

0·5

1

0

0

0·5

0·5

0·5

1

5

Oman

1

0

1

1

1

0·5

0·5

1

1

7

Qatar

1

1

0·5

1

1

0·5

0·5

1

0

6·5

Saudi Arabia

1

1

1

1

1

0·5

1

1

1

8·5

Sudan

1

0

0

0

0

0

1

1

0

3

Syria

0

0

0

0

0

0·5

0

0·5

0·5

1·5

Tunisia

0

0

1

1

1

0·5

0·5

0·5

0

4·5

Turkey

1

0

1

1

1

1

0·5

0·5

0

6

United Arab Emirates

1

1

1

1

1

0·5

0·5

1

1

8

Yemen

0

0

0

0

0

0

0

0

0

0

Target achievement Fully achieved Partially achieved

66·7%

38·1%

47·6%

61·9%

66·7%

4·8%

28·6%

28·6%

0%

0%

4·8%

14·3%

42·9%

42·9%

··

66·7%

76·2%

38·1%

4·8%

··

Target achievement refers to the proportion of fully or partially achieved goals in each area of the national preventive programmes by all countries in the region. The score for each indicator is 1 if fully achieved, 0·5 if partially achieved, or 0 if not achieved. The maximum total score for each country is 9. STEPS=STEPwise approach to surveillance.

Table 4: Achievement scores from WHO’s 2017 Non-communicable Diseases Progress Monitor report84 for different areas of national preventive programmes by country in the Middle East and north Africa

The wide range of different scenarios shows that current health policy can have a substantial effect on future disease prevalence.82 On the basis of WHO’s global action plan for the prevention and control of NCDs 2013–20,83 by 2025 the global target for obesity and diabetes will stop their increase in prevalence in adults to 2010 levels. Thus, NCD-RisC has projected the prevalence of these two metabolic risk factors and has estimated the probability that this target will be reached for each country within this timeframe (table 2, 3). The highest projected prevalence for obesity in the Middle East and north Africa was attributed to Kuwait, Qatar, and Saudi Arabia, with a prevalence of about 40% for men and 50% for women. For diabetes, it was attributed to Iraq, Kuwait, the occupied Palestinian territory, and Qatar for men, with a prevalence of about 25%, and to Egypt for women 10

with a prevalence of 29%. The probability of reaching the target for obesity is null in almost all countries. Bahrain has the highest probability of reaching the diabetes target (35% for men and 43% for women), but most other countries of the region have a probability below 15% (table 2, 3).

Prevention programmes Although about 70% of countries in the Middle East and north Africa have national targets for the prevention and control of non-communicable diseases, only 38% of them have a fully achieved national strategy plan, according to the 2017 WHO progress report on non-communicable diseases (table 4).84 In the area of policies for prevention and reduction of risk factors, about 70% of countries have fully achieved their policies on physical activity, showing that many countries have understood the problem with

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Review

obesity and have established appropriate policies. In the area of surveillance, monitoring, and evaluation, approximately 70% of countries have partially achieved their programme targets. Regarding primary health care, fewer than 50% of countries have national guidelines and programmes for prevention and control of noncommunicable diseases. Iran and Saudi Arabia have better organised policies than other countries in the region (table 4). To the best of our knowledge, evidence for national programmes for primary, secondary, and tertiary prevention of type 2 diabetes has been documented only in Kuwait, Turkey,85 and Iran.86–88 Nevertheless, data regarding the outcomes of the implementation and efficacy of these programmes are scarce.50,89 In the primary health-care centres of Kuwait, between 2010 to 2012, the proportion of people with type 2 diabetes whose LDL was lower than 100 mg/dL increased from 22% to 28%, and those whose blood pressure was below 140/90 mm Hg increased from 45% to 50%.89 The prevalence of people with type 2 diabetes who had HbA1c concentrations higher than 9% decreased from 80% to 55%.89 In Iran, after more than a decade of implementation of the National Program for Prevention and Control of Diabetes,88 the proportion of patients with undiagnosed diabetes declined by 50% and the affordability of diabetes medications increased.50 However, metabolic control in patients remained suboptimal.50 To target nonadherence to treatment, the Iranian rural primary healthcare system could be an effective template for the Middle East and north Africa. In this system, community health workers (called Behvarz) identify adults aged above 30 years who are at high risk of type 2 diabetes and refer them to a physician for evaluation and, if diagnosed with it, patients are then followed up monthly by the Behvarz. An evaluation of this system indicated that the efficacy of treatment of patients with type 2 diabetes in rural areas was higher than in urban areas, which did not use the Behvarz system.90

before 2000 and had regular follow-up for repeated measurements of metabolic risk factors and related outcomes every 2–3 years. These kinds of studies will generate appropriate data to address the determinants of non-communicable diseases and the trajectory of risk factors in the region, which will improve future predictions. Developing prospective, multicentre, epidem­ iological studies such as the Prospective Epidemi­ological Research Studies in Iran94 (or PERSIAN) and the Prospective Urban Rural Epidemiology study95 (or PURE) in some countries in the region, and consortiums such as the Iran Cohort Consortium96 will broaden the possibilities to identify and address cardiometabolic disorders with improved collaboration in the region. Given the scarcity of comprehensive preventive programmes in the Middle East and north Africa, robust multisectoral systems that support primordial preventions to avoid the appearance of risk factors for metabolic diseases, and primary preventions to modify the risk factors, are required (eg, the TLGS and the Isfahan Healthy Heart Program from Iran97,98 and a guideline imple­ mentation study from Turkey99 are community-based trials evaluating such interventions.) The United Nations Relief and Works Agency for Palestine Refugees in the Near East100 could serve as a model for many underdeveloped countries in the Middle East and north Africa. Additionally, comprehensive surveillance and monitoring of metabolic diseases for accurate docu­mentation of the performance of health systems and improvement of health indicators must be implemented, as recommended by the WHO STEPwise approach. Furthermore, robust multisectoral systems supporting primordial and primary preventions and continuous education of health-care providers for optimal evidence-based medical care are recommended to improve the metabolic health status of people in the region. WHO’s Package of Essential Non-communicable diseases101 is a prioritised set of such interventions for primary health-care in low-resource settings.

Discussion

Search strategy and selection criteria

Our Review describes the high burden of metabolic risk factors and diseases with multifactorial aetiology in the Middle East and north Africa. Many countries of this region have been affected by conflict and terrorism, which are two of the fastest growing causes of global mortality.3 Additionally, in most of these countries, there is no implementation of comprehensive preventive programmes with suitable policies, surveillance, monitoring, and evaluation for metabolic health in well organised primary-health settings. One of the major shortcomings in prevention and control of non-communicable diseases, including meta­ bolic diseases, in the Middle East and north Africa is the paucity of comprehensive longitudinal studies such as the Tehran Lipid and Glucose Study (TLGS)91,92 and the Turkish Adult Risk Factor Study.93 Both studies began

We searched PubMed for articles published from Jan 1, 1990, to Jan 1, 2019, using the search terms “obesity”, “overweight”, “body mass index”, “weight”, “diabetes”, “prediabetes”, “impaired glucose tolerance”, “impaired fasting glucose”, “blood pressure”, “hypertension”, “prehypertension”, “hypercholesterolemia”, “dyslipidemia”, “low-density lipoprotein”, “high-density lipoprotein”, “fatty liver”, “steatohepatitis”, “nutrition”, “diet”, “calorie intake”, “physical activity”, and “physical inactivity”, in combination with the terms “Middle East”, “North Africa”, “Eastern Mediterranean”, and names of all 21 countries of the Middle-East and north African region. Articles published in English were included. We focused mostly on articles from populationbased studies and used some related papers from local data if national and regional data were scarce.

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Our Review has a few limitations. First, considerable heterogeneity exists across health-care systems and data collection in the Middle East and north Africa. Second, we reviewed five main databases of global health that have their own limitations. For example, GBD provides data rated for overall quality with scores ranging from 0 stars (worst) to 5 stars (best) and relies on estimates for low levels of data completeness.102 We have summarised the strengths and limitations of the data sources in the appendix (pp 3–5) and suggest that the interpretation of data cited in our Review be taken with caution. In summary, the Middle East and north Africa is one of the global regions with highest burden of metabolic risk factors. Although some parameters have declined in the past two decades, the predicted increasing burden of non-communicable diseases due to rising prevalence of metabolic risk factors and population increases calls for immediate attention to the health sectors of Middle Eastern and north African countries. Funding of public health, social policy, and multisectoral actions with an all for health and health for all approach can have preventive and protective effects to maintain optimal metabolic health in the region. Contributors FA and DK contributed to the structure, literature search, data interpretation, and writing of the report. DK also contributed to the design of the figures and tables and retrieval and management of data. DP contributed to the literature search, retrieval and interpretation of data, designing the figures and tables, and writing of the report. FHa, FHo, HA, FT, GA, SAM, and ML contributed to the literature search, retrieval and interpretation of data, and writing of the report. AA and PM contributed to the literature search, data interpretation, and writing of the report. Declaration of interests All authors declare no competing interests. References 1 Kyu HH, Abate D, Abate KH, et al. Global, regional, and national disability-adjusted life-years (DALYs) for 359 diseases and injuries and healthy life expectancy (HALE) for 195 countries and territories, 1990–2017: a systematic analysis for the Global Burden of Disease Study 2017. Lancet 2018; 392: 1859–922. 2 Human Development Report 2015 Team. Human development report 2015: work for human development. New York, NY, USA: United Nations Development Programme, 2015. 3 Lancet. GBD 2017: a fragile world. Lancet 2018; 392: 1683. 4 Turk-Adawi K, Sarrafzadegan N, Fadhil I, et al. Cardiovascular disease in the Eastern Mediterranean region: epidemiology and risk factor burden. Nat Rev Cardiol 2018; 15: 106. 5 Yki-Järvinen H. Non-alcoholic fatty liver disease as a cause and a consequence of metabolic syndrome. Lancet Diabetes Endocrinol 2014; 2: 901–10. 6 Global Burden of Disease study 2017 results. 2017. http://ghdx. healthdata.org/gbd-results-tool (accessed March 20, 2019). 7 Mandil A, Chaaya M, Saab D. Health status, epidemiological profile and prospects: eastern Mediterranean region. Int J Epidemiol 2013; 42: 616–26. 8 Abarca-Gómez L, Abdeen ZA, Hamid ZA, et al. Worldwide trends in body-mass index, underweight, overweight, and obesity from 1975 to 2016: a pooled analysis of 2416 population-based measurement studies in 128·9 million children, adolescents, and adults. Lancet 2017; 390: 2627–42. 9 NCD Risk Factor Collaboration. Worldwide trends in diabetes since 1980: a pooled analysis of 751 population-based studies with 4·4 million participants. Lancet 2016; 387: 1513–30.

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