Ras al Khaimah (RAK) Friedman School Blog

Obesity is not only a problem for developed countries like the United States. In fact, the Middle East has the second highest mean body mass index next to North America. More than 50% of total deaths in the Middle East can be attributed to chronic, noncommunicable diseases such as cardiovascular disease, diabetes, and high blood pressure - all diseases which are associated with obesity. Over the past 20 years, developing countries have seen their obesity rates triple as their citizens have adopted lifestyles of physical inactivity and overconsumption of energy-dense foods. Arab countries especially have seen a great increase in overweight, obesity, and noncommunicable chronic diseases. In these countries, 40-60% of adult males are classified as overweight or obese, while 50-70% of adult females are overweight or obese. For school-aged children ages 6-10 and adolescents ages 11-18, 12-25% and 20-45%, respectively, are overweight or obese. Individuals in the Middle East are now eating less fruits, vegetables, whole grains, and legumes, and more fat, sugar, and salt. They are consuming more fast food and sugary drinks, while skipping breakfast and eating more snacks between meals. As the Arab diet becomes more Western, its citizens are also adopting more Western patterns of physical activity, or lack there of. Individuals in the Middle East are spending more time in front of the screen (television, computer, video games), and less time being active. Researchers at universities across the Middle East recognize overweight and obesity as major health and economic burdens to their countries. As a result, they are taking charge by developing strategies for preventing and controlling obesity in their nations. The “Strategy to combat obesity and promote physical activity in Arab countries” was created by The Arab Taskforce for Obesity and Physical Activity. The strategy was presented to representations from 14 Arab countries last year at the Third Arab Conference on Obesity and Physical Activity. The strategy is a 5 year plan with the following summarized goals: 1. to control and reduce the incidence of overweight and obesity in Arab societies through promotion of healthy dietary habits and physical activity, 2. to reduce the risk factors for chronic noncommunicable diseases, 3. to raise awareness in the community about the importance of physical activity, nutrition, and weight maintenance, 4. to develop partnerships between government institutions, the private sector, and the civil society, 5. to establish ways of monitoring and assessing obesity and activity in these Arab societies, 6. to conduct research on the health, nutrition, social, and economic factors leading to obesity in these countries, and 7. to provide effective treatment services to obese individuals. The Taskforce emphasizes that the programs and activities implemented must be evidence based, practical, and sustainable, while being applicable to all ages and social and economical backgrounds. The strategy will target childcare centers, schools, primary healthcare centers, secondary healthcare centers (hospitals and treatment centers), food companies (manufacturers and producers), food preparation and service institutions (restaurants, cafeterias, fast food establishments), the media (commercial promoters and marketers of food), public benefit organizations (associations, institutions, non-governmental organizations), and the workplace (private sector). For each target area, the Taskforce outlines specific expected outcomes, objectives, indicators to assess achievement of objectives, and actions needed to meet these objectives. Briefly, some of the main objectives of the taskforce are to: increase healthy breakfast consumption by 25% among school-aged children, increase physical activity by 25%, increase health and nutrition knowledge among healthcare staff by 50%, increase by 25% the number of people who consume 4 servings of fruit and vegetables daily, reduce the percentage of students who eat fast food more than three times/week by 30%, increase by 50% the number of programs related to early detection of obesity risk factors, increase the proportion of low-calorie foods and beverages available in food markets by 25%, increase the number of healthy meals served in large restaurants by 25%, increase by 30% the proportion of food advertisements that contain accurate information and positive messages in the media, and to increase by 50% the proportion of enterprises that foster a healthy environment for employees that encourages activity and nutrition. The Arab Taskforce for Obesity and Physical Activity will conduct research, establish guidelines, and provide outreach to all of their countries to ensure implementation and on-going participation in the new developed strategies. Written By: Katy Hartman, Dietetic Intern, Frances Stern Nutrition Center, Tufts Medical Center; MS Nutrition Candidate, Friedman School of Nutrition Science and Policy, Tufts University Strategy to combat obesity and to promote physical activity in Arab countries Abdulrahman O Musaiger, Hazzaa M Al Hazzaa, Aayed Al-Qahtani, et al. March 2011;4:89 - 97

Have you ever counted how many times per day you snack? How about tracking what types of snacks you consume on a daily basis? Well, researchers from Ajman University in the UAE did exactly that with preschool children in Ajman. Previous research suggested that the dietary patterns of children and adults in the UAE have shifted to include increased amounts of “westernized” foods and drinks rich in fat, cholesterol, salt and sugar. These foods are becoming more readily available in the UAE and sugar-containing foods, in particular, represent a major source of sugar intake by children. Given the cariogenic nature of sugar-containing foods and drinks and the fact that UAE children have a high rate of caries by international standards, Ajman University researchers chose to investigate the potential association between food and drink consumption and the prevalence and severity of dental caries in young Emirati children. While prior studies did find connections between sugar consumption and caries, they did not tease out the contribution of particular meal and snack patterns. Researchers used one-stage cluster sampling to gather a sample of 1,036 children, ages 5 to 6 years old, from 11 primary schools in Ajman. Parents completed questionnaires collecting data on maternal educational level, parental income and the child’s dietary habits. Specifically, parents were asked about the child’s frequency of eating and drinking per day, the frequency of snacks per day, and the frequency of consumption of snack foods/drinks commonly consumed in the UAE (i.e. chocolate, candies, jelly beans, ice cream, ice munch, sweet biscuits/pastries, dates, soft drinks, juices and tea with sugar). In addition, all children received a clinical dental examination to record the incidence of dental caries; in this study, caries were defined as decayed, missing or filled surface teeth (dmft) and a total dmft score was calculated for each child. The overall mean dmft score for the group was 4.5, and there was a trend for children from the lowest income and/or least educated households to have higher dmft scores. In terms of dietary patterns, the researchers found that children who ate 3-4 times per day had lower mean dmft scores than those who ate 5+ times per day. In particular, children who snacked 3+ times per day had dmft scores almost one-third higher than those who only snacked once daily. Most of the snacks consumed by children were sugary foods, and children who snacked the most had dmft scores 49% higher than those who snacked the least. Consumption of soft drinks, fruit juices and tea with sugar was also significantly associated with mean dmft score. Children who drank tea with sugar 3+ times per day had mean dmft scores 25% higher than those who drank it <2 times per week. Overall, the researchers concluded that severity of dental caries is high in young Ajman children and their dietary habits, particularly of sugary snack foods and drinks, are a significant contributor. Childhood oral health is a strong predictor of adult oral health and thus the researchers note the importance of altering the determinants of poor oral health in young children. Potential interventions include creating an oral health promoting environment in schools, offering healthy snacks and drinks in schools and nurseries and providing overall nutrition and oral health education to young children. Original Research - Hashim R, et al. Diet and caries experience among preschool children in Ajman, United Arab Emirates. European Journal of Oral Health. 2009; 117: 734-740. Summary Written By: Alanna Eisenberg, Dietetic Intern, Frances Stern Nutrition Center, Tufts Medical Center; MS Nutrition Candidate, Friedman School of Nutrition Science and Policy, Tufts University.

Vitamin D is a hot a topic in the United States, with awareness of vitamin D deficiency and interventions aimed at addressing deficiencies growing. Recent research suggests that vitamin D may warrant equal attention in the UAE as in the US. Severe vitamin D deficiency in mothers and breastfed infants has been established as a serious problem in the Middle East and parts of Asia. Women who follow a conservative style of dress when outdoors receive only a limited amount of sunlight exposures, and traditional diets are low in vitamin D. Additionally, vitamin D fortification is uncommon and not mandatory in the UAE. Supplements are also not routinely prescribed. Infants in the UAE are at high risk for vitamin D deficiency related complications such as rickets. In the UAE, 60-75% of infants are routinely breastfed. While breastfeeding is the preferred form of infant nutrition, vitamin D content of breastmilk reflects maternal status. Researchers have found that exclusively breastfeeding non-supplemented women in the UAE have roughly half the baseline vitamin D status of exclusively breastfeeding non-supplemented women in the US. The researchers reported in a previous study that supplementation of vitamin D deficient breastfeeding women in the UAE with 2000IU daily or 60,000 IU monthly was moderately effective at improving vitamin D status. In this study, they investigate the effect of combined maternal and infant vitamin D supplementation. The study included 90 healthy breastfeeding mothers in the UAE and their 92 infants (including 2 sets of twins) who were recruited between September 2005 and February 2006. All women received education and support from a lactation consultant and agreed to exclusively breastfeed for the next three months. Women were randomized to receive either oral 2000IU daily supplements of vitamin D or monthly 60000IU supplements. Infants in both groups received 400IU of vitamin D daily. Vitamin D2 was used rather than the more potent D3 because of availability of supplements in the UAE. At baseline, mothers in both groups were likely to be vitamin D deficient; 86% of mothers in the daily regimen group and 91% of mothers in the monthly regimen group were deficient. Prevalence of vitamin D deficiency in infants was similar, with 96% and 92% of infants deficient in both groups respectively. After three months of supplementation, significant improvements were noted in the serum vitamin D levels of both groups of mothers and infants. Following supplementation, vitamin D deficiency was reduced to 36% of the daily regimen group and 50% of the monthly regimen group. Deficiency in infants was reduced to 23% and 38% in both groups respectively. No symptoms of hypovitaminosis D or serum levels indicating hypovitaminosis were reported. The antirachitic activity of breastmilk samples was also improved from undetectable as baseline to a median of 50.9IU per liter after 3 months. In this study, researchers demonstrate that supplementation of vitamin D deficient mothers and infants in the UAE can reduce the prevalence of vitamin D deficiency, and may ultimately reduce the risk of long-term complications associated with vitamin D deficiency. However, the authors do note that it is difficult to separate the effects of maternal supplementation and infant supplementation on the infant. Further studies that include groups with only infant supplementation would be required. The authors also report that compliance with vitamin D daily supplementation was less than ideal, underscoring the need for further education among women on the benefits and importance of adherence to vitamin supplementation regimens. Written by Victoria Ho, Dietetic Intern, Frances Stern Nutrition Center Tufts Medical Center, MS Candidate, Nutrition, Tufts University AB, Biochemical Sciences, Harvard University

Alarming Rates of Metabolic Syndrome in the Middle East—Says Nationwide Study By: Corinne Dobbas, BS Nutritional Sciences, Dietetic Intern at Tufts Medical Center A nationwide study in the Middle East found that metabolic syndrome is setting alarming prevalence rates. Out of 3,024 Iranians aged 25 to 64 years living in urban and rural areas of all 30 provinces in Iran, metabolic syndrome was discovered to affect a large portion of the population: 34% based on the National Cholesterol Education Program (NCEP) Adult Treatment Panel III (ATP III) criteria for metabolic syndrome; 37% based on the International Diabetes Federation (IDF) definition of the syndrome, and 42% based on the NCEP/ATP III (ATP III/American Heart Association [AHA]/National Heart, Lung, and Blood Institute [NHLBI]) metabolic syndrome criteria. Although this data originated from the Middle East’s third population-based nationwide health survey, the National Survey of Risk Factors of Non-Communicable Diseases (SURFNCD 2007), this was the first time a nationally representative study was conducted showcasing the burden of metabolic syndrome in this region. And the findings were troubling. Metabolic syndrome was estimated to affect greater than 11 million Iranians, specifically women. By all definitions, women had higher rates in urban areas and in the 55 to 64-year age-group compared with men in rural areas and in other age-groups, respectively. Interesting Study Findings: • Mean participant age was 41 years • Two-thirds of the population were urban residents • Mean systolic and diastolic blood pressure and fasting plasma glucose (FPG) were higher in urban residents than rural residents • 34% of the population was documented as overweight, with a higher prevalence in women • 25% of the population was obese, with a higher rate in women • In both sexes, overweight and obesity were more prevalent in urban areas than in rural areas Study Results Regarding Metabolic Syndrome: • Regardless of the definition used, the prevalence of metabolic syndrome was 30% to 100% higher in the urban population than the rural population • The most common component of the metabolic syndrome was low serum HDL cholesterol, found in 80% of the population • Half of the population had high waist circumferences • More than one-third of the population had high serum triglyceride and high blood pressure levels • A FPG greater than 100 was found in 16% of individuals Brief Study Discussion & Conclusion According to Delavari et al, the high prevalence rates of overweight and obesity and metabolic syndrome found in this study were in line with previous findings, regarding the Middle Eastern population. Moreover, other population-based studies, as in this one, have shown that low HDL cholesterol followed by abdominal obesity has been the most common component of the metabolic syndrome. The high incidence of low HDL cholesterol in many individuals without obesity and hypertriglyceridemia cause researchers to suspect that there is an ethnic predisposition to this type of dyslipidemia. This hypothesis supports IDF’s consensus that ethnic group-specific cut points should be used for Middle Eastern waist circumference values in order to properly assess abdominal obesity. It is thought that Middle Eastern populations have greater waist circumferences than Western populations due to body fat patterning, genetic tendency to abdominal obesity, high carbohydrate intake, and a sedentary lifestyle. Lastly, Delavari et al noted that since this is a cross-sectional study the findings cannot be confirmed. However, one can see that metabolic syndrome and obesity are alarmingly high in the Middle Eastern population, especially for those who are middle aged. In agreement with the researchers, national policies for prevention and control should be mandated, since Middle Eastern countries face the world’s greatest increment in the absolute burden of diabetes in the next two decades. Original Research - Cardiovascular and Metabolic Risk: Alireza Delavari, Mohammad Hossein Forouzanfar, Siamak Alikhani, Afsaneh Sharifian, and Roya Kelishadi First Nationwide Study of the Prevalence of the Metabolic Syndrome and Optimal Cutoff Points of Waist Circumference in the Middle East: The National Survey of Risk Factors for Noncommunicable Diseases of Iran Diabetes Care June 2009 32:1092-1097; published ahead of print March 11, 2009, doi:10.2337/dc08-1800 Summary prepared by Corinne Dobbas, Senior Dietetic Intern, Tufts Medical Center, M.S. Nutrition Candidate, Tufts Friedman School, Co-Coordinator, MDA, Socials for Success Vice President, MSDA

I just thought this was an interesting article about RAK and livlihoods in RAK. by Anna Zacharias March 10. 2010 2:31PM UAE / March 10. 2010 10:31AM GMT RAS AL KHAIMAH // For women, the first Habus tribe festival is about more than heritage. Women dominate the market, not just buying products but also selling them. They boil qimat dumplings, sell perfume and cook bread made with saffron and rosewater over glowing coals. >>>

According to the World Health Organization’s overweight and obesity classification standards, overweight is defined by a BMI between 25 and 29.9 and obesity is defined by a BMI ≥ 30. These criteria are based on values at which BMI is associated with increased risk for chronic disease and mortality. The current guidelines were established from European populations and have not yet been validated for all non-Caucasian populations. Asians have demonstrated an increased risk for disease at lower BMI values, which led to revised overweight and obese classifications as BMI > 23 and BMI > 25, respectively. The present study assessed the accuracy with which overweight and obese BMI classifications are associated with hypertension and diabetes within the Eastern Province of Saudi Arabia. Height and weight measures, BMI calculations and hypertension and diabetes screenings were conducted on 195,851 men and women participants. Sensitivity and specificity tests, false positive, false negative and total misclassification rates were calculated to determine optimal BMI values to predict for hypertension and diabetes. Regression analysis displayed increased risk for hypertension and diabetes with BMI scores as low as 21 to 23, with risk increasing progressively as BMI increased. These low BMI values resulted in a very low false negative rate, which means most individuals at risk were correctly identified. However, these low BMI values also resulted in poor sensitivity and a high false positive rate, meaning many healthy individuals were improperly diagnosed as at risk. The unacceptably high misclassification rate underscores the limitations of BMI as a tool for assessing overweight and obesity and the associated metabolic risks. A couple of reasons have been proposed to explain the discrepancy in BMI efficacy among populations. Primarily, BMI is not a uniform measure of fat, which is stored and deposited differently across various ethnicities. Additionally, BMI less proficiently determines overweight and obesity for short stature individuals, thus reducing its efficacy within ethnicities of greater percentage short stature. The limitation of BMI in diagnosing overweight and obesity in this population suggests that additional measures for weight classification should be reviewed and considered as the WHO looks to develop culturally specific overweight and obesity standards. Almajwal, et al., 2009. http://www.saudiannals.net/temp/AnnSaudiMed296437-5231731_143157.pdf Prepared by Adrienne Elise Haschke MS Nutrition Candidate, Friedman School of Nutrition Science and Policy at Tufts; Dietetic Intern, Frances Stern Nutrition Center, Tufts Medical Center

In the Islamic world, Ramadan is observed during one of the holy months of the Islamic calendar. During this month, Muslims fast, abstaining from eating and drinking from sunrise to sunset. Some conditions, however, excuse people from the obligatory fasting, such as pregnancy. Although pregnant women are not required to fast, they can still choose to participate. There has been a lot of interest regarding the effects of fasting on pregnancy, with respect to the health of the mother, as well as the baby. Early reports have indicated that there are no significant effects on Apgar scores, birth weight, gestational age at delivery, or infant’s height. Speculation still remains, however, and some argue that these data do not ensure that fasting is totally safe for the mother and child. A study conducted by the Obstetrics and Gynecology Department at the Gaziantep University in Turkey examined whether fasting during Ramadan significantly affects the maternal cortisol and lipid profiles and fetal health. The study ran between September and October of 2006 and included two groups of women with uncomplicated pregnancies at >20 weeks of gestation; the first group consisted of 36 women who fasted during the study period, whereas the second group consisted of 29 women who did not fast. The study utilized ultrasonography to observe the following fetal measurements: increase of fetal biparietal diameter (BPD), increase of fetal femur length (FL), increase of estimated fetal body weight (EFBW), fetal biophysical profile (BPP), amniotic fluid index (AFI), and umbilical artery systole/diastole (S/D) ratio. Fetal body weight was also measured. Maternal blood samples were taken one week before Ramadan and on the 20th day of fasting, and the following was measured: maternal serum cortisol, triglyceride, total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), very low density lipoprotein (VLDL), and LDL/HDL ratio. In terms of fetal development, the results of the study indicated that there was no significant difference in the increase of BPD, FL, and EFBW. Additionally, the fetal BPP, AFI, and umbilical artery S/D ratios were all within normal ranges in both of the groups. The maternal blood tests revealed that the mothers in the control group had significantly higher blood cortisol levels on day 20 (when compared to the initial levels one week before Ramadan). The total cholesterol and triglyceride levels did not increase significantly, meanwhile the LDL and VLDL levels had a non-significant decrease at the end of Ramadan. HDL levels of the fasting group rose slightly, and the ratio of LDL to HDL was significantly decreased in the fasting group. The findings of this study are in agreement with earlier research, indicating that the fasting during Ramadan does not have negative effects on fetal development. There has been some research conducted regarding the effects of fasting on women’s cortisol levels and lipid profiles, however this is the first study to observe the effects on pregnant women. Past research on the effects of fasting on lipid profile is conflicting, and this study’s results align with but also differ from past studies. With regard to cortisol, studies in the past have shown that changes in eating and sleeping patterns can increase cortisol levels, so this could explain the increased levels in the fasting group. Overall, fasting during Ramadan does not appear to pose a significant risk to the mothers or their babies. Those women who do choose to fast during this holy month can have more peace of mind, as this practice will pose little, if any, harm.- Renee Reynolds, Frances Stern Nutrition Center Dietetic Intern and Tufts University Graduate Student For more information, you can view the original article at http://www.springerlink.com/content/h4w1840303242r0n/fulltext.pdf.

The United Arab Emirates produces 755,000 tons of dates per year. This makes up 12% of global date production, and ranks them as the 4th leading producer! It’s clear that dates are an important fruit crop in the UAE, and now researchers are interested in their potential health benefits. In the UAE the processing of dates into date syrup leaves a byproduct called date fiber. Recently researchers from the United Arab Emirates University examined date fiber’s potential use as an dietary fiber additive in yogurt. Yogurt; though a great source for protein, probiotics, and calcium; has no fiber. This is unfortunate, since dietary fiber may be associated with decreased gastrointestinal disorders, decreased coronary heart disease, and weight control. Although different types of fiber have been added to yogurt in the past, date fiber has not been examined. In this study, researchers added various amounts of date fiber to yogurt, and measured changes in yogurt quality. The Al Ain Dairy Company provided fresh milk to the United Arab Emirates University, who made fresh yogurt in their Food Preparation Laboratory. Date fiber was supplied by the Emirates Date Factory in Al Ain, and added to the yogurt. Researchers made five types of yogurt: control yogurt with no date fiber, yogurt with 1.5% wheat bran, and yogurts containing date fiber in 1.5%, 3%, and 4.5% quantities. To measure yogurt quality, researchers examined acidity, pH, color, texture, sensory properties, and consumer acceptance. Thirty-three students and staff from the university rated the appearance, color, smoothness, sweetness, sourness, flavor and overall acceptance of all the yogurts. In their results, researchers found that date fiber did not affect acidity or lactobacilli counts, yet increased pH. The date fiber darkened the yogurt, adding a brownish color. Additionally, the date fiber changed the yogurt texture by making it gummier, harder, and more adhesive. Consumers rated the date fiber yogurts as generally low in appearance, color, and flavor. When rating overall acceptance, the 3% date fiber yogurt came closest to control yogurt’s acceptance rate. Researchers concluded that yogurt with 3% added date fiber is an acceptable product to the consumer. Will date fiber increase the healthfulness of the yogurt? Can date fiber be used as a functional additive to other foods? First more research is needed on this sweet fruit. By Rachel Perez (Friedman Masters Candidate in Nutrition Communications and Dietetic Intern at Frances Stern Nutrition Center.) Source: Hashim, I.B., Khalil, A.H., Afifi, H.S. (2009). Quality characteristics and consumer acceptance of yogurt fortified with date fiber. Journal of Dairy Science, 92:5403-5407.

By Jeffrey R. Young Nicholas Presnell has two professors for linear algebra: one official and one virtual. The first is at Arizona State University, where Mr. Presnell is a part-time graduate student in electrical engineering. The other instructor is at the Massachusetts Institute of Technology, which has made lecture videos from a linear-algebra class free online as part of its long-running OpenCourseWare project. In a way, the MIT professor came first. Mr. Presnell stumbled upon the videos by Gilbert Strang, a professor of mathematics, while he was trying to solve a problem at his job as an electrical engineer at Honeywell Aerospace. The online lectures not only solved Mr. Presnell's technical glitch, they also inspired him to go back to graduate school—for credit, at an institution near him. Now he uses the MIT videos as a study aid when he needs help in the linear-systems course at Arizona State. "It's like auditing the course at MIT," he says.>>>

Sep 24th 2009 From The Economist print edition Poor countries have already benefited hugely from mobile phones. Now get ready for a second round, says Tom Standage (interviewed here) BOUNCING a great-grandchild on her knee in her house in Bukaweka, a village in eastern Uganda, Mary Wokhwale gestures at her surroundings. “My mobile phone has been my livelihood,” she says. In 2003 Ms Wokhwale was one of the first 15 women in Uganda to become “village phone” operators. Thanks to a microfinance loan, she was able to buy a basic handset and a roof-mounted antenna to ensure a reliable signal. She went into business selling phone calls to other villagers, making a small profit on each call. This enabled her to pay back her loan and buy a second phone. The income from selling phone calls subsequently enabled her to set up a business selling beer, open a music and video shop and help members of her family pay their children’s school fees. Business has dropped off somewhat in the past couple of years as mobile phones have fallen in price and many people in her village can afford their own. But Ms Wokhwale’s life has been transformed. >>