Diabetes and Obesity

Harms of Lifestyle and Diet in the Arab World

Nawar M. Shara

ContentsIntroduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Scope . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Obesity-Associated Complications in T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Other Risk Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Lack of Arab World Data Collection Causes Barriers to Uniform Policy . . . . . . . . . . . . . . . . . . . 6

State of Health and Disease in the Arab World . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Gulf Council Cooperation Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Non-GCC Arab Countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Policy Design and Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Obesity and Type 2 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Obesity on the Rise . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Women Versus Men . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Childhood Obesity and Type 2 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Childhood Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Type 2 Diabetes Mellitus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Diet and Lifestyle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Causes for Obesity and T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Solutions to Reduce Obesity and T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Public Awareness Using Public Relations for National Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Physical Activity and Accessible Nutrition . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Analyzing Supporting Data in Support of Modification of Diet and Life Style . . . . . . . . . . . . 18Consequences of Obesity and T2DM . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Simultaneous Economic Growth and Health Decline . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Public Health Initiative Possibilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

N. M. Shara (*)Department of Biostatistics and Biomedical Informatics, Georgetown University, BERD-CTSA(Georgetown-Howard), MedStar Health Research Institute, Hyattsville, MD, USAe-mail: Nawar.Shara@Medstar.net

© Springer Nature Switzerland AG 2020I. Laher (ed.), Handbook of Healthcare in the Arab World,https://doi.org/10.1007/978-3-319-74365-3_148-1

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AbstractType 2 diabetes mellitus (T2DM) is the fifth leading cause of death in the Arabworld. The International Diabetes Federation’s data suggests that the region hasthe second highest rate of T2DM in the world with a projected increase of 110%by 2045. Modifiable determinants of obesity, including harmful trends in diet andsedentary lifestyle behaviors, must be addressed to reduce its frequency. Comor-bid illnesses accompanying T2DM are swelling the economic burden on healthagencies and Arab world infrastructures. Rapid urbanization in the Arab countrieshas accommodated the introduction of diets saturated with fat and sugar over thelast two decades increasing the incidence of T2DM, while stronger economies ledto improved transportation and technology, exacerbating the ills of a sedentarylifestyle. Harmful effects of an inactive lifestyle and poor dietary intake lead tocardiovascular disease (CVD) as a common comorbidity of T2DM. These neg-ative behaviors may be adopted during formative years increasing the risks ofchildhood obesity that is associated with adult health complications. The GulfCooperation Council (GCC) countries have seen the highest increase in T2DM,because of their strong economies and over-indulgence, while other war-torn orpolitically unstable Arab countries struggle with undernutrition and lifestyle-related illnesses due to unhealthy diets and a lack of safe or temperate exerciselocations. The widespread epidemic of obesity and T2DM can be reversed bygovernment initiatives that include public education on active lifestyles and theidentification of formidable access points for nutritious food supplies based onindividual country requirements within the Arab world.

KeywordsDiabetes · Obesity · Diet · Lifestyle · Nutrition · Arab world · Middle East ·Metabolic syndrome · Sedentary lifestyle · Childhood obesity · Cardiovasculardisease

Introduction

Life expectancy is increasing in the Arab world but the quality of those increasedyears is peppered with chronic and debilitating disease processes burdeninghealthcare agencies and economies. There is a decline in deaths related to infectiousdiseases but an increase in deaths related to noninfectious and chronic diseaseprocesses. Common chronic diseases placing a heavy burden on health care deliveryagencies include (1) type 2 diabetes mellitus (T2DM), (2) obesity, (3) childhoodobesity, and (4) cardiovascular disease (CVD). Economic infrastructures are chargedwith developing approaches to increase services, data collection, and researchactivity as the base for a uniform public health policy across the region. The Centerfor Disease Control defines obesity as weight that is higher than what is consideredhealthy for a given height. A body mass index over 30 is considered obese. Theprevalence of obesity is high in the Arab world and has direct associations with

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metabolic syndrome (MetS) conditions including: (1) high blood pressure, (2) poorblood lipid profiles, and (3) elevated blood sugar, increasing the prevalence ofcardiovascular disease (CVD) and other prominent risk factors for adult mortalityin developed and developing countries (Gunnars 2018).

Obesity is one of the largest health problems in the world and a key public healthconcern in all 22 Arab countries, although its severity varies from one country toanother in that region, based on economic factors and political stability (Badran andLaher 2011). Disease manifestations may have slight variations based on eachcountry and the population, but all of the Arab countries are revealing upward trendsin poor health. Current changes in lifestyle have resulted in the large and expandingburden of chronic disease rooted in obesity, primarily type 2 diabetes mellitus,whereby the body does not produce or utilize insulin well. Secondary diseaseprocesses involve cardiovascular malfunction leading to persistent poor healtheven though mortality, due to acute coronary syndrome conditions such as a heartattack, has declined.

Scope

This chapter summarizes the current national health decline in Arab countries andthe impact of rising obesity on the worldwide healthcare delivery platform. Obesityis one cause for an increase of T2DMwith comorbid diseases and is a modifiable riskfactor in the Arab population. The T2DM epidemic in the Arab world with itscomorbid CVD complications can be addressed by utilizing similar initiatives tothose already in play in other parts of the world that measure direct impacts tomortality rates. Measuring successful treatment modalities of comorbid illnesses ofobesity including T2DM and introducing modifiable determinants that decreaserelated chronic illnesses must be the goal of a formal Arab health organization.Rapid urbanization in prosperous countries has fueled poor eating habits and sed-entary lifestyles, and reversing this trend requires reeducation and increasing accessand availability of nutritious food supplies and safe places to engage in regularexercise.

This chapter also introduces the need for uniform health policies and healthcaresupport options in each of the 22 countries of the Arab world. Due to difficulties inuniform health information data collection, and the insufficient and inaccurate grouphealth data to be analyzed for the 22 countries of the Arab world, coupled with theinstability of some government infrastructures, public health policies will be difficultto draft and adopt until the importance of reversing the obesity epidemic and itsnegative impact of T2DM on the overall health of the Arab world populationbecomes a priority for those in power. The wealth and political stability of theGulf Council Cooperation (GCC) countries, including Bahrain, Kuwait, Oman,Qatar, Saudi, Arabia, and the United Arab Emirates, affords them great influenceon stabilization policy for other individual Arab country’s infrastructures, throughthe development and implementation of initiatives that will improve the health of allcitizens. The GCC governments have advanced their healthcare systems with the use

Diabetes and Obesity 3

of electronic medical records for patient data and actively conduct clinical studiescreating a fertile ground for multigroup patient data collection to complete a baselinemeta-analysis of common disease processes related to T2DM in the region. Theirleadership in a national health services campaign should: (1) identify a data collec-tion method to compare and contrast variations in disease processes related toT2DM, (2) develop healthy initiative proposals specific to the variations identified,and (3) deliver country-specific healthy lifestyle educational programs including theidentification of access points to quality nutritional food sources that will improveoverall health outcomes in the Arab world.

One of the most significant problems in creating a unified Arab world healthfacility might present itself in the disparities of record keeping in non-GCC coun-tries. Examples of these disparities are seen in Yemen through reductions in acces-sible health care facilities due to corruption and economic downturn, and in Syriabecause of the civil wars that have caused citizens to flee the unstable governmentinfrastructure negatively impacting health care systems and valid data storage.

Utilizing the existing health systems platform in the GCC Countries of the Arabworld and relying on their economic stability and increased technological advance-ment could help to create a basic comprehensive policy. Once drafted, that generalpolicy could be used as a template to add country-specific language regardinggeographical, political, and resource access against actionable policies and proce-dures that target successful outcomes in each country. Implementation of thosepolicies must occur in a timely manner to address the increasing prevalence ofobesity and chronic diseases, specifically diabetes (Mattke et al. 2015).

The design and implementation of an Arab health policy constructs an Arabworld platform to measure and treat chronic illnesses driven by the negative effectsof obesity and T2DM. Viable formal health data collection systems have beendelayed due to underreported or absent regional data that can be addressed throughsampling methods and data analysis standards used in Arab American studies thatidentify common disease processes based on ethnicity, internal and external envi-ronments, genetics and consanguinity prevalent in Arab countries, endogamy, familyhistory, poor diet, lifestyle, and risky behaviors.

Obesity-Associated Complications in T2DM

The Arab world has seen dramatic increases of T2DM with current projectionsclimbing to 110% by 2045 (International Diabetes Federation 2017), largely becauseof poor dietary choices and decreased physical activity, actions that negativelyimpact insulin resistance causing deficiencies that allow disease processes to takeover. Obesity has increased to dangerous levels worldwide, affecting both developedand advanced countries, with the rates doubling between 1980 and 2014 (Alqarni2016). Obesity is a major contributor to CVD and is a leading risk factor fordeveloping the metabolic syndrome (MetS) condition that has the following hall-marks: (1) high blood pressure, (2) poor blood lipid profiles, and (3) elevated bloodsugar (Hebert et al. 2013). MetS represents a bundle of cardiovascular risk factors

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where patients carry three or more dysmetabolic abnormal health problems, includ-ing increased weight around the middle (central adiposity) evident from waistcircumference measurements, high fasting blood sugar, elevated triglycerides, andhigh blood pressure that often result in serious complications of CVD and T2DM. Itis a concern for public health officials who want to impose the value of healthylifestyles supporting a reduction in obesity and drops in comorbid disease processes.According to a 2008 World Health Organization study, CVD was estimated to havecaused about 49% of the deaths in Oman and 46% of the deaths in Kuwait. The rateof deaths caused by CVD was high in the UAE, Bahrain, Qatar, and Saudi Arabia(Ahmed et al. 2017). The Gulf RACE and INTERHEART study has found thatpatients in the Middle East have heart attacks earlier in life than Westerners. Geneticsmay be partially to blame, but changes in lifestyle and the lack of uniform publichealth care policies addressing poor diet and inactive lifestyle have contributed toincreased risk factors of cardiac events in this region.

Other Risk Factors

Obesity is not the only risk factor for T2DM. Other risk factors for T2DM in Arabcountries include: (1) genetic predisposition, (2) environmental factors, (3) familyhistory, (4) old age, (5) physical inactivity, and (6) ethnicity (Ng et al. 2011).

Genetic predisposition. Genetic diseases are most commonly inherited fromparents through a mutation of the DNA sequence, or a germ cell mutation. When agene code is mutated, it cannot perform its normal function and a predisposition to adisease may be the consequence. The high rate of consanguinity in the Arabcountries predisposes children to disease processes held by one or both parentsbecause they share blood lines. Several studies on the association of consanguinityto noncommunicable disorders such as diabetes, hypertension, and psychiatricdisorders among Arabs are presently nonconclusive (Tadmouri et al. 2009). Childrenborn from consanguineous marriages in Saudi Arabia and Qatar revealed anincreased risk of T2DM. Rare diseases reveal themselves through Mendelian disor-ders in which a single gene is mutated, but many genetic diseases have multiplefactors such as mutations in more than one gene exacerbated by lifestyle andenvironmental factors as modifiers that increase susceptibility toward a diseasesuch as CVD or T2DM. Arab populations exhibit many rare, Mendelian, andfamilial genetic disorders (Blair et al. 2013). To address the national crisis on theharmful effects of fast-food consumption and sedentary lifestyles, scientists studiedmetabolic traits through a review of published reports on T2DM genetics in the Arabpopulation originating in Kuwait, Lebanon, Saudi Arabia, Qatar, the UAE, Oman,and Tunisia and determined established risk in some studies but not all (Hebbar et al.2019). Findings in one Qatar study revealed the development of T2DM complica-tions in patients with either paternal or maternal history of diabetes mellitus weremore common than those without. Hypertension was the only significant differencein patients with or without a family history of diabetes mellitus (Bener et al. 2013).

Diabetes and Obesity 5

Environmental factors. It is thought that obesity gene variants interact withmultiple environmental factors and increase susceptibility to metabolic diseases(Castillo et al. 2017). Environmental factors include air, water quality, sanitary livingconditions and stress, and the impact of personal choices including smoking ciga-rettes, drinking alcohol, making unhealthy food choices, engaging in low levels ofphysical activity, and participating in other risky behaviors.

Family history and old age. Family history is based on past mental health ormedical occurrences in family members and behaviors to which a person may beprone. Old age is the time that a person nears or surpasses life expectancy. Familyhistory considerations related to T2DM and CVD can include: lifestyle; anthropo-metric facets comprised of body fat composition, height, weight, and hip, waist, andchest circumference measurements; and genetic risk factors, but they are only part ofthe risks for T2DM. Being aware of relational tendencies allows an individual toembrace a healthy diet and exercise regimen (InterAct Consortium et al. 2012).Metabolic rates slow during aging, and insulin levels become unstable when aperson is sedentary, causing weight gain and ineffective use of insulin.

Physical inactivity. The World Health Organization (WHO) confirms that peopleare less active worldwide, and that there are increased risk factors for non-communicable diseases (NCDs), including T2DM, CV, cancer, and respiratoryillnesses (WHO 2015).

Ethnicity. The Arab world encompasses a large social group with origins in 22nations, where the ancestry is diverse and the people have differences in physicalfeatures, lifestyles, languages and are cast in a wide geographical net due to a sharedhistory, language, and culture. Because the governing bodies, politics, health facil-ities, physical features, diets, and activities in each of the 22 nations are unique,systemic grouping for health care sampling based on ethnic impact contributing toT2DM and comorbid illnesses can be challenging. One example where culture hasplayed a part in the negative effects of obesity as reflected by the World HealthOrganization’s estimate that a quarter of the 1.5 million women in Mauritania areobese without the effects of fast food but because of practices of forced feeding andbeing looked down upon by relatives if they are of a healthy weight.

Lack of Arab World Data Collection Causes Barriers to Uniform Policy

Rapid growth and political crises have gripped the Arab world, leading to drastictransformations in diet and lifestyle behaviors that are causing poor health. Thisdynamic has increased demands on governments and health agencies for organizedsupport and deliverables in all 22 countries in the Arab world. While some countriesin the Arab world have ongoing political turmoil (such as Libya, Syria, and Yemen),other regions, such as Egypt and Saudi Arabia, have experienced economic trans-formation impacting socioeconomic and political growth, and technologicaladvancement through rapid urbanization. Causal effects of both situations have ledto a transformation in dietary habits, resulting in illnesses from undernutrition, infant

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catch-up growth causing metabolic disturbances later in life, and overnutritionresulting in obesity (Musaiger et al. 2011).

Minimal data is available to indicate the level of obesity in the poor countries ofthe Arab world, but the incidence of T2DM reported over a period of 13 years invarious studies was recorded as follows: 2007 for Lebanon was 18.9%; 2010 forLibya was 18.8%; 2008 for Jordan was 17.4%; 2012 for Egypt was 17%; 2010 forSyria was 15.6%; 2014 for Tunisia was 15.1%; 2007 for Algeria was 20.14%; 2001for Palestine was 12.0%; 2008 for Yemen was 10.4%; 2001 for Sudan was 10.4%;2012 for Comoros was 8.4%; 2009 for Morocco was 8%; 2008 for Iraq was 7.43%;2012 for Djibouti was 7.43%; 2013 for Mauritania was 4.7%; and 2012 for Somaliawas 3.9%. The mean prevalence of T2DM in GCC countries was 25.45% and themean prevalence of T2DM in non-GCC Arab countries was 12.69% equaling acombined mean prevalence of T2DM in all the Arab world countries at 16.17%(Meo et al. 2017).

Chronic disease patterns are associated with comorbid health issues associatedwith obesity. Strategic steps utilizing global data on similar disease markers can bethe base of actionable policies and procedures that can benefit the Arab world’spublic health education, including promotion of healthy diets and increased physicalactivity in the region. Standard treatment policy may benefit wealthy individualswith a higher standard of living. The wealth of the individual cohorts impacts theseverity of CVD and other comorbid disease factors (Shara et al. 2010). Thecomorbid disease processes experienced in relation to CVD support an increasedneed for health services that are disease specific in the Arab population (Radwan etal. 2018). Each country in the Arab world should identify and address the changes indiet, exercise, and health care delivery to reverse obesity trends in adults andchildren.

State of Health and Disease in the Arab World

The total population of the Arab world is approximately 345 million with originsfrom 22 nations including the 10 Arab countries in Africa: Algeria, Comoros,Djibouti, Egypt, Libya, Mauritania, Morocco, Somalia, Sudan, and Tunisia; andthe 12 countries in Asia: Bahrain, Iraq, Jordan, Kuwait, Lebanon, Oman, Palestine,Qatar, Saudi Arabia, Syria, the United Arab Emirates, and Yemen. The term Arab isa classification based mainly on common language (Arabic) and a shared sense ofgeographic, historical, and cultural identity. It is not a racial classification andincludes persons with wide-ranging physical features. The Arab world is experienc-ing an interesting demographic phenomenon characterized by natural growth andmigration based on fertility, mortality, and migration. These advances beg foruniform public health policies and initiatives with concerted efforts toward improv-ing living conditions that support healthy life expectancy (Abdul Salam et al. 2015).

In 2010, the Global Burden of Disease study showed that the Arab world isexperiencing an alarming high prevalence of several chronic diseases includingdiabetes and cardiovascular disease resulting from risk factors such as tobacco use,

Diabetes and Obesity 7

inactivity, and unhealthy diets in adults and children. Despite the health crisis and theidentified cost-effective treatment interventions, governments in the Arab countrieshave not prioritized policies to address these risk factors to contain and reverse thisnew epidemic (Rahim et al. 2014). The Middle Eastern and North African regionsreveal a potential for a 110% projected increase in diabetes by 2045 reflecting thesecond highest rate in the world (International Diabetes Federation 2017). Economicburden will be experienced through carrying the costs of treatments, managingdisease complications, loss of productivity, and costs of disability for individualsin these regions (Al-Maskari et al. 2010).

While countries in the region share social, cultural, and economic characteristics,many differ in their historical and geopolitical stances, creating a highly diversifiedprofile for health outcomes and disease burdens in each of those 22 countries. Thisdiversity has complicated evidence-based health outcome comparisons generatedfrom studies undertaken in the Arab world and globally. Arab country governmentalpriorities must include tailored regional public policy addressing positive changesnecessary to decrease the obesity epidemic by showcasing the importance of healthydiets and increased physical activity; including healthy food access and safe exercisespaces.

Gulf Council Cooperation Countries

The Gulf Council Cooperation (GCC) countries, including Bahrain, Kuwait, Oman,Qatar, Saudi, Arabia, and the United Arab Emirates, are experiencing the largestimpact from economic prosperity, coupled with the increased availability of tech-nology and transportation, promoting a sedentary lifestyle and Western-influencedfast food dietary changes saturated with fat and sugar. Kuwait has been rated numberone in the world among countries who are experiencing the obesity crisis, and SaudiArabia falls in second place. Egypt falls at number four on the list, representing thehighest diabetes rates in the world, while Jordan is number five with two times asmany obese women, compared to men. The United Arab Emirates is number six withmore obese women than men, suggesting that being fat is a sign of wealth, and Qatarfalls at number eight on the list as they are suffering a childhood diabetes crisis(Carlson 2018).

While these regions are experiencing superior wealth, the overall health conditionof Arab countries is spiraling downward due to obesity and its comorbidities. Therapid economic growth reflected in some parts of the Arab world such as in the GCChas led to dramatic transformations translated into sedentary lifestyles with poornutrition and a decline in health (Mattke et al. 2015). The lifestyle of the Arabpopulations can be described as sedentary, reliant on high caloric food intake withpoor nutritional value and rapid economic growth with migration from rural to urbanareas (Mattke et al. 2015). Moving from a rural area to an urban area decreasesactivity levels at the outset because walking and traveling distances will becomeshorter and variations in food sources and amounts will be readily available in urbanareas, gradually changing an individual’s overall eating habits.

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Non-GCC Arab Countries

Much of the Arab world continues to benefit from strong economic growth, whileother countries in the region such as Libya, Syria, and Yemen are plagued by war andpolitical instability shifting the focus of government resources and priorities tosecure basic needs in those areas as the population seeks refuge in other countries.Measuring the incidence of disease and addressing diet and lifestyle changes in theseregions is not as high a priority as stabilizing government and insuring basic needsfor people who live there. Deaths related to T2DM from 2017 revealed 10,859 or6.25% of all deaths in Algeria; 123 or 2.40% of all deaths in Comoros; 243 or 3.78%of all deaths in Djibouti; 21,045 or 4.10% of all deaths in Egypt; 1,221 or 4.12% ofall deaths in Libya; 888 or 3.15% of all deaths in Mauritania; 20,285 or 11.54% of alldeaths in Morocco; 1,109 or 0.81% of all deaths in Somalia; 5,179 or 1.93% of alldeaths in Sudan; 7,965 or 12.04% of all deaths in Tunisia; 6,382 or 3.62% of alldeaths in Iraq; 1,874 or 7.08% of all deaths in Jordon; 1,972 or 5.83% of all deaths inLebanon; 1,289 or 0.94% of all deaths in Syria; and 3,359 or 2.31% of all deaths inYemen. These totals are significant as they show the impact diabetes has on middle-to lower-income countries of the Arab world.

Policy Design and Development

Arab countries lack cumulative crossover vital statistics data, complicated by weakhealth information systems that cannot be trusted or used to support reasonableprojections of disease burdens and risk factors specific to each Arab country,partially due to government instability in certain countries where there are limitedresources to track disease processes based on nutritional deficits and lack of physicalactivity and doing so is not a government priority. The GCC countries have theability to compare data trends via use of patient data stored electronically as well asclinical studies being conducted in the organized healthcare facilities available inthose countries.

Obesity and Type 2 Diabetes Mellitus

The following tables reflect upward trends in adult obesity and increased diabetes inthe GCC Countries of the Arab world, with global target probability projections for2025. The data suggests a higher rate of obesity for women but reveals a higher rateof diabetes for men in the case of all but the United Arab Emirates where the percentof men to women is the same. The projected trends in obesity and diabetes in thefollowing charts were estimated for adults 20 years and older for obesity and18 years and older for diabetes.

Diabetes and Obesity 9

Bahrain

Estimated prevalence in2010 Projection for 2025

Probability ofmeeting global target

Women Men Women Men Women Men

Obesity 35.6%(29.3–42.0)

23.0%(17.1–29.1)

42.3%(31.3–53.4)

32.9%(21.7–44.8)

4% 1%

Diabetes 10.4%(7.1–14.4)

11.6%(8.0–16.0)

12.0%(4.3–26.1)

14.1%(5.3–29.8)

43% 35%

Kuwait

Estimated prevalence in2010 Projection for 2025

Probability ofmeeting global target

Women Men Women Men Women Men

Obesity 44.6%(39.5–49.8)

30.4%(25.5–35.3)

51.0%(41.2–60.8)

41.2%(30.8–52.2)

4% 0%

Diabetes 18.3%(13.4–24.2)

18.4%(13.4–24.4)

24.9%(11.3–46.8)

25.4%(11.6–48.1)

15% 14%

Oman

Estimated prevalence in2010 Projection for 2025

Probability ofmeeting global target

Women Men Women Men Women Men

Obesity 31.0%(25.0–37.0)

19.3%(14.4–24.4)

41.6%(30.5–53.0)

32.5%(21.8–44.9)

0% 0%

Diabetes 11.6%(8.3–15.6)

13.1%(9.4–17.6)

15.7%(6.0–32.3)

20.1%(7.7–42.2)

21% 11%

Qatar

Estimated prevalence in2010 Projection for 2025

Probability ofmeeting global target

Women Men Women Men Women Men

Obesity 41.8%(35.3–48.2)

29.3%(23.1–35.8)

49.2%(38.3–60.0)

41.2%(29.8–53.2)

2% 0%

Diabetes 17.3%(12.9–22.8)

17.3%(12.6–22.9)

24.9%(11.0–48.7)

26.0%(11.2–50.0)

12% 10%

Saudi Arabia

Estimated prevalence in2010 Projection for 2025

Probability ofmeeting global target

Women Men Women Men Women Men

Obesity 40.5%(35.6–45.3)

27.2%(22.7–32.0)

49.1%(39.3–58.7)

40.0%(29.7–50.9)

1% 0%

Diabetes 15.7%(11.7–20.6)

16.1%(12.0–21.3)

22.1%(9.8–43.6)

23.5%(10.3–45.7)

14% 12%

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The United Arab Emirates

Estimated prevalence in2010 Projection for 2025

Probability ofmeeting global target

Women Men Women Men Women Men

Obesity 39.2%(32.9–45.6)

24.3%(18.4–30.6)

47.8%(37.1–58.9)

36.3%(25.0–48.5)

1% 0%

Diabetes 14.9%(11.1–19.7)

14.7%(10.7–19.6)

19.9%(8.0–40.4)

19.9%(8.0–41.1)

22% 21%

• Age-standardized estimates for adults 20 years and older for obesity and 18 yearsand older for diabetes were used.

• Global target for obesity and diabetes is to halt, by 2025, the rise in the age-standardized adult prevalence at their 2010 levels.

Obesity is a serious and dangerous medical disorder that is impacting the worldwith epidemic rates doubling between 1980 and 2014 and quickly unfolding as oneof the most serious public health problems of the twenty-first century. Type 2diabetes mellitus is a condition that does not allow the proper manufacture or useof insulin in a person’s body and can occur at any age. Economic stressors negativelyimpacting national infrastructures and health outcomes for persons around the worldhave increased in tandem with obesity rates due to health care costs associated withcomorbid disease processes associated with obesity.

Obesity on the Rise

According to the WHO, worldwide obesity has nearly tripled since 1975; 1.9 billionadults were overweight with 650 million considered obese in 2016, 41 millionchildren under the age of 5, and 340 million children/adolescents aged 5–19 wereconsidered overweight or obese during that same period (World Health Organization2018). Recent studies have shown that the etiology of obesity is more complex thanjust a simple imbalance in energy intake and output, with a predisposition to factorsincluding (1) endocrine, (2) metabolic, (3) genetic, (4) lifestyle, (5) diet, (6) race, and(7) gender (Alzaman and Ali 2016).

Women Versus Men

Arab women reveal a higher incidence of obesity compared to their male counter-parts; with causes varying in relation to their socioeconomic status, cultural differ-ences, and geography. Possible culprits to this increase have been the introduction ofthe Western diet; a lack of physical activity, blamed partly on restrictions of womenexercising in public; family commitments; and the idea that being plump is a sign ofbeauty and wealth (Sarant 2013). In a study conducted among Arab females, a strongassociation between breast cancer and obesity was detected revealing the proportion

Diabetes and Obesity 11

of overweight/obese females to be significantly higher among breast cancer patients(75.8%) than among healthy controls (61.3%). Obesity was just one of the contrib-uting factors identified but influenced other listed factors, such as early menarche,late age for giving birth to first child, and lack of physical activity (Elkum et al.2014).

A study conducted in the United Arab Emirates showed that many patients withobstructive sleep apnea and obesity hypoventilation syndrome were at risk forcardiovascular disease as well as pulmonary hypertension negatively impactingoverall health and increasing the country’s burden to develop preventive strategiesand uniform policies for healthy diet and physical activity (Mahboud et al. 2013).Obesity in Arab countries is widespread among urban-living, higher class womenand reveals a trend in Egypt, Jordan, Morocco, Oman, and Tunisia where urbanwomen experience higher rates of obesity than their rural counterparts in thoseregions (Musaiger et al. 2011). The International Association for the Study ofObesity has conducted surveys that reveal rates of obesity in women to be signifi-cantly higher than their male counterparts and is a health crisis threatening Arabwomen and family life due to a higher incidence of infertility and miscarriage inobese women (Sarant 2013). The common denominator for the increased weightgain in areas of Kuwait, Qatar, and Saudi Arabia, where between 40% and 50% ofwomen are obese, has been identified as higher intakes of animal fats and sugars, andthe cultural, socioeconomic, and geographical factors that impact lifestyle andphysical activity (Sarant 2013). Detrimental consequences of obesity in Arabwomen can include negative effects on reproduction through polycystic ovarysyndrome (PCOS) (Al-Jefout et al. 2017), which is the main cause of infertilitydue to anovulation, or pregnancy complications such as gestational diabetes due toabnormal fluctuations in insulin levels caused by obesity. The hormone adipokine isalso associated with obesity and T2DM causing reproductive issues. Children whosemother has had gestational diabetes are at risk for diabetes and obesity later in life,and child-rearing activities may be distorted toward unhealthy eating habits as a signof economic prosperity, setting children up for harmful lifestyles regarding dietaryintake and limited exercise as adults.

Strategic steps utilizing global data gleaned by similar disease markers can be thebase of actionable policies and procedures to increase healthy diets and physicalactivity to the region. A review of current literature speaks to increased negativeimpacts to women versus their male counterparts regarding costly health trends andfertility risks due to disease processes rooted in obesity. Peer partnerships to jumpstart physical activity can be community-based in order that women and children(who are most often in the care of the women) will adopt healthy living throughexercise, coupled with dietary support from government and health care agencies.

Figure 1 shows a significant upward trend in adult obesity from 1975 to 2015whereby females have a higher rate of obesity than their male counterparts. GCCincidents of obesity are the highest with the Arab world almost half way between theworld and the GCC. The GCC rates of obesity increased approximately 20% overthe 40-year span and are significantly higher than the world rates which increasedalmost 10%.

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Childhood Obesity and Type 2 Diabetes Mellitus

Childhood Obesity

Childhood obesity in the Arab world is due to an epidemiological transition, a phaseof development where infectious disease processes become replaced with chronicdisease processes, due to changes in population demography. Childhood obesitynegatively impacts disease processes in early development of children, persistinginto adulthood and manifesting in a series of health-related disorders includingCVD, T2DM, and premature death. Nutrition transfer seems to be at the root ofthe childhood epidemic of obesity in the Eastern Mediterranean countries, coupledwith a more sedentary lifestyle.

Nutrition transfer occurs in concert with an epidemiological transition such as theone that has occurred in the Arab world. The shift in childhood obesity is anepidemiological transition in the Arab world caused by urbanization, modern life-styles, decline in diet quality with the introduction of fast food, and increased use ofmodern transportation and technology creating a sedentary existence (World HealthOrganization 2018). Obesity in children is attributed to diet and physical inactivity

40%

30%

20%

Adu

lt O

besi

ty

10%

1975 1985 1995

Year2005 2015

Female

Male

Arab World

World

GCC

Fig. 1 Adult obesity in the Arab world, the GCC, and the world stratified by gender from1975–2015

Diabetes and Obesity 13

and has a direct correlation to obesity in women because children are more often intheir care, and women have a much higher rate of obesity than their male counter-parts in the Arab countries. Approximately 40–50% of women in some regions puttheir children at risk by offering poor food choices at home and allowing sedentarylifestyles that limit opportunities for physical movement to burn calories associatedwith high fat content and sugar intake. Cross-sectional data suggesting obesity trendsin the urban areas, such as Khartoum, revealed school children aged 6–12 to be14.8% overweight and 10.5% obese (Abdul Salam et al. 2015). Arab children,adolescents, and adults have replaced the once healthy traditional diet found inmost parts of the Arab world with high-caloric diets that are low in nutrients andfilled with fats and sugar.

Cardiovascular risks, dental decay, prediabetes, disturbances in eating behavior,hypertension, and metabolic syndrome are just a few of the negative health impli-cations related to childhood obesity. Active lifestyles exhibited by children in lesswealthy regions and genetics also play a significant part in the variations of child-hood obesity rates. One such example is showcased by a study conducted in theKingdom of Saudi Arabia (KSA) where children in the rural southwestern region ofKSA have a lower rate of obesity (4%) which may be attributed to an active lifestyle,such as fishing and farming (El Mouzan et al. 2012).

Results from genetic studies suggest significant genetic contributions and pre-dispositions to obesity with some markers showing maternal BMI having a strongerinfluence on childhood adiposity, which is a concern in all parts of the world,because it is much harder to reverse obesity once it has been established, leadingto other comorbid illnesses (Linabery et al. 2013). Preventive treatment measuresshould be undertaken before the ages of 5–7 years (Evensen et al. 2016). The field ofgenetics is underdeveloped in the Arab world and more studies are needed to teaseout genetic factors predisposing children to obesity and diabetes. Diet and lifestyleare measurable factors to obesity and they are also modifiable risk factors that can betargeted and managed through youth-focused initiatives regarding physical activitythrough sports and play and changes in dietary intake.

Type 2 Diabetes Mellitus

Children with severe obesity are at risk for T2DM, hypertension, sleep apnea, andliver diseases. Adequate sleep improves cardiometabolic health and may help with areduction in obesity among adolescents. Several studies have been conductedthroughout the Arab world investigating the outcomes of surgical interventions forweight loss. Addressing T2DM through weight loss has addressed the increasedobesity rates among children and adolescents in the Middle East and Saudi Arabia bysupporting a shift to young patients having bariatric surgery (Bell 2018). The mostfrequent procedure was a Roux-en-Y gastric bypass, and the outcomes showedimprovement in the triglyceride levels, like the heated hemoglobin levels, with

14 N. M. Shara

expected weight loss. Obese children and adolescents undergoing sleeve gastrec-tomy showed no recurrence up to 3 years after surgery and only some comorbidities.There was resolution, remission, or improvement in more than 90% of comorbiditiesincluding T2DM at 2 years with few complications, no mortality, and normal growth(Alzaman and Ali 2016).

The foundation for the obesity problem in children is that it is not seen as anillness and dire consequences ensue with negative symptomology setting the chil-dren up for future illness in adulthood. As it is easy for a child to embrace unhealthyeating choices and lifestyles, it is just as easy to set them up for success with properhealth choices and structured activities. To reduce the trend toward epidemic obesitynumbers in the GCC population that were created with urbanization, disposableincome, and processed food consumption, negative factors must be addressed byparents, teachers, and health care officials.

Figure 2 reflects the upward trend in childhood obesity in the Arab world, theGCC, and the world with an apparent upshot for higher childhood obesity rates forboth males and females in the GCC as compared to the rest of the Arab countries andthe world. The upward trend from 1975 to 2015 shows GCC obesity rates areincreased approximately 10% over the 40-year span and are significantly higherthan the world rates.

Diet and Lifestyle

Causes for Obesity and T2DM

The World Health Organization (WHO) and the American Heart Association (AHA)recognize diabetes, obesity, hypertension, and MetS as major risk factors for CVDand lifestyle behaviors such as smoking, physical inactivity, unhealthy diet asmodifiable risk factors (Chomistek et al. 2015). Poor diet and sedentary lifestylesare both important facets of health that can be modified to reflect individual healthbenefits and lower costs to regional government economies and infrastructuresincluding health care delivery institutions. In 2007, a study showed that physicalinactivity from a large national health survey in the KSAwas as high as 96% in bothmen and women (Ng et al. 2013). A study conducted in 38 Muslim countries on163,556 participants revealed Arab women to be less physically active than non-Arab women (Benjamin and Donnelly 2013). There are major variations in theprevalence of physical inactivity in the Arab world and a combination of risk factorsrelated to emerging lifestyle changes and its health consequences are alarming (Auneet al. 2016; IHME 2015).

By comparison, non-modifiable barriers to an active lifestyle include globalchange in the Arab nations that causes increased higher temperatures for longe rperiods, increased polluted and dusty air quality, and political instability in many ofthe countries which can deter individuals from outdoor activities. Access to healthy

Diabetes and Obesity 15

food and medical care can also be harder to reach due to obstacles including weatherand political climates (Abuyassin and Laher 2016). Culturally, parents, peers, andteachers favor educational and spiritual activities over physical activity in the KSA,Egypt, and Jordan. Inactivity is very high, around 80% in all national surveys exceptTunisia. Women are found to be more physically inactive and are attributed to gendernorms and regional conservative attire (Sharara et al. 2018). Religious interpretationplays a role in discouraging physical activities in portions of the Muslim world(Kahan 2015).

The diet and nutritional status of Arab countries changed along with growth of thenation to the detriment of the health of its people because of socioeconomic changes.Disease processes include those related to inadequate nutrient intake sometimescausing growth retardation in children in less wealthy regions and alternate illnessesfrom poor nutrient, high-caloric intake causing CVD, T2DM, osteoporosis, cancer,and other diet-related noncommunicable diseases in wealthier regions. Variations innutritional problems stem from socioeconomic status and the overall wealth of thecountry. There are currently not enough programs to control or prevent nutrition-related diseases because of the lack of epidemiological studies, national interest, lownutrition information, cost-effective health care, and dietary intervention program-ming (Musaiger et al. 2011).

20%

15%

10%

Chi

ldho

od O

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5%

0%

1975 1985 1995

Year2005 2015

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Male

Arab World

WorldGCC

Fig. 2 Childhood obesity in the Arab world, the GCC, and the world stratified by gender1975–2015

16 N. M. Shara

Solutions to Reduce Obesity and T2DM

Addressing the obesity epidemic and its association with T2DM through transfor-mations in diet and lifestyle is the most cost effective, far reaching blanket toolavailable. The underpinning of physical activity as part of the lifestyle in the Arabworld is complex and differs between its 22-member countries due to socioeconomicfactors, religion, and tradition, considering individual cultural aspects pertaining toeach region. Similarities in the Arab world give way to a starting point to develophealthy living initiatives but individual distinctions within communities must beaddressed when considering physical activity patterns in each region. It is importantat the societal level to support individuals with evidence-based policies tailoredtoward regional populations. Policies must be actionable including availability ofhealthy food options and providing an atmosphere open to regular physical activity,with both facets being affordable and accessible. When policies and initiatives are inplace, responsibility falls to the individual to effectuate a healthy lifestyle outcomewith decreased illnesses and costs related to medical care, disability, disease, andearly death.

National policy should emergently act in the health interests of the Arab worldand incorporate modifiable strategies that will reduce obesity and T2DM, simulta-neously reducing and reversing poor health conditions overall. The fast-movingepidemic of obesity sweeping the Arab world can be reduced and removed once the22 governments within develop common health goals that will supersede geography,culture, religion, and wealth in the best interests of health care and interactive publiceducation that will decrease current and future economic burdens caused by poorhealth and comorbid diseases resulting from obesity, including T2DM and CVD.Alternate food parcels might be an effective means of introducing healthy diets backto the Arab region while lessening the consumption of a diet mostly comprised ofgrain, flour, and rice through the availability of more fruits and vegetables as a step tolessen the negative impacts of hypertension and T2DM (Basu et al. 2018).

Proponents of uniform treatment directives that address obesity must develophealth-conscious policies and programs to control CVD and T2DM in Arab coun-tries and showcase the value of traditional diets in concert with the importance ofusing existing food supplies and engaging in daily physical activity. Collaborativeinternational efforts will be necessary to slow the disease process through compar-ative study analyses utilizing similar data sets, while the collection of Arab-focuseddata sets is fortified specific to each country’s region to develop evidence-basedhealth care protocols and programs to tailor toward obesity with a focus on T2DMand CVD reduction (Abuyassin and Laher 2016).

Public Awareness Using Public Relations for National Events

Recognition from Qatar’s winning bid to host the 2022 International Federation ofAssociation Football (FIFA) World Cup will spotlight the region and create anopportunity to highlight the value of sports, especially among children and young

Diabetes and Obesity 17

adults as they become engaged with the country’s activities leading up to the WorldCup. This excitement will hopefully fortify efforts to promote physical activities asthey gain momentum in the regions where societal constraints previously hinderedwomen from participating as needed. Educational campaigns that promote healthyliving and nutritional intake among the youth are imperative in this region, and themedia has opportunit to partner with government and health care agencies to play avital role in raising awareness about the importance of active living and a healthydiet, as they piggyback public service regarding health and wellness on the back ofpublic relations campaigns promoting World Cup activities.

Physical Activity and Accessible Nutrition

A multifaceted approach is necessary for the development of public health policyand procedure to address challenges regarding healthy eating through access andaffordability in Arab countries due to difficulty transporting healthy food supplies,and to promote physical activity in safe environmentally friendly venues supportingequal participation for men, women, and children. Peer partnerships to jump startphysical activity can be community-based in order that women and children (whoare most often in the care of the women) will adopt healthy living through exercise,coupled with dietary support from government and health care agencies.

Recent projects have been initiated in Saudi Arabia and Bahrain to promotephysical activity for women to address the concern that gender discrimination causesthem to be more sedentary because they carry the bulk of the family-related activitiesand have not had welcome venues to exercise in. The project mission is to open theschools at night where women might be able to exercise together. The idea ofbuilding muscle is not something women have a great interest in, because plumpnessis seen as physical beauty and an indication of wealth as noted by study results from2010 in the United Arab Emirates Philips Center for Health.

Analyzing Supporting Data in Support of Modification of Diet andLife Style

Adapting data collection methods similar to the “depression, metabolic syndrome(MetS) and locus of control (LOC)” study undertaken in the D.C. Metropolitan areato screen Arab persons through: (1) physical exam including weight and measure-ments, (2) blood work to benchmark comorbid disease possibilities, (3) question-naire completion related to depression and lifestyle, and (4) assessment of wealthwould be a mildly invasive broad-base screening tool to reach a larger cohort of at-risk individuals in the Arab regions. These methods would increase data yield tosupport development of regionally focused national policy to diagnose and supportobesity and its comorbid components (Shara et al. 2018).

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Consequences of Obesity and T2DM

If the Arab world does not address its current epidemic of obesity and T2DMbecause of poor diet and inactive lifestyles, it will continue to exacerbate increasesin comorbid disease processes that will debilitate individuals and hinder growth andexpansive public health services by government health care outlets as they will haveto absorb the high costs associated with comorbid diseases and disability of itscitizens.

Conclusions

Simultaneous Economic Growth and Health Decline

The Arab world is experiencing dynamic changes in growth of its economy andconcurrent decline of the health of its people. In 2016, the Arab world contributed3.31% to the world gross domestic product (GDP) and made up 5.5% of the world’spopulation (Population Reference Bureau 2016). In contrast, Arab countries con-tinue to lag in biomedical research even as there has been advancement in under-graduate and postgraduate education and an increase in the number of journalspublished. The publications have not been embraced by the scientific communityworldwide resulting in limited contributions to biomedical research literature(Bredan et al. 2011). The absence of verifiable research and statistics make it difficultto comprise blanket policy for all 22 Arab countries, but if a comparison to thedisease process itself is undertaken analyzing tangible outcomes for diet and activityinitiatives in other countries, it may be used as a starting place to develop policywhile embracing the national diversity and individual country parameters in the Arabworld.

Public Health Initiative Possibilities

Sports and exercise implications to health and wellness are new areas of interest inthe Arab world but lack evidence-based intimate subject research. Proponents whoare charged with building a case for physical activity initiative development willhave to defer to worldwide research on the topic and tailor specifics toward eachArab country. Lack of physical activity or physical inactivity has been identified asthe fourth leading risk factor for global mortality, leading to approximately 3.2million deaths globally.

The World Health Organization estimated that 87% of children and adolescentsand 33.2% of adults in the Arab world and the Middle East were insufficiently activein 2010 (World Health Organization 2018). Physical inactivity is associated with anincreased risk of cardiovascular diseases, diabetes, colon and breast cancer, hip orvertebral fractures, obesity, and depression (Fares et al. 2017). Public health chal-lenges marking physical inactivity and poor nutrition are recognized as the highest

Diabetes and Obesity 19

contributing factors to the obesity epidemic and the increase in CVD and T2DMamong Arab adults and children and must be addressed expediently. Obesity anddiabetes are sweeping the Arab world, with some of the highest rates identifiedglobally, while several Arab countries in the GCC, including Saudi Arabia, Oman,Kuwait, Bahrain, and the United Arab Emirates, reflect the highest obesity rates inthe world, with less prevalent occurrences in Mauritania and Somalia. Conversely,Arab countries who are not enjoying great wealth have diet and lifestyle harmsassociated with diabetes.

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