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Copyright of Eastern Mediterranean Health Journal is the property of World Health Organization and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

Aflatoxins (AFs) are hepatotoxic, mutagenic, genotoxic, and immunosuppressive toxins. Several food commodities consumed in the Kingdom of Saudi Arabia (KSA) are susceptible to AF contamination because of improper storage practices and the warm and humid climate of the country. Therefore, the occurrence of AFs in 2388 food samples was measured and the estimated daily intake (EDI) of AFs in Saudi adults was assessed. The risks of AFB1 exposure were characterized using the margin of exposure (MoE) approach and by estimating the number of possible hepatocellular carcinoma (HCC) cases in the KSA. The results revealed that 12.1% of the analyzed samples were contaminated with AFs and the highest concentration of total AFs was observed in the nut and seed group. The mean EDI of AFB1 was estimated to be 0.21 and 0.55 ng/kg body weight (bw)/day for the lower bound (LB) and upper bound (UB) scenarios, respectively. The MoEs were estimated to be 1902.4 and 722.1, while the estimated liver cancer risk ranged from 0.002 to 0.008 cancer cases/year/100,000 persons. Based on the study's findings, contamination with AFs in the KSA is low; however, AFs are considered potent genotoxic contaminants, and therefore, exposure through food should be kept as low as possible. [ABSTRACT FROM AUTHOR]

Early childhood exposure to heavy metals like arsenic (As), cadmium (Cd), and lead (Pb) through baby foods unfolds many concerns about their toxic effects on growth and health. In this study, occurrence and dietary intake of As, Cd, and Pb in stage 1 infant formula (0–6 months), stage 2 infant formula (7–12 months), cereal‐based meals, and biscuits were estimated. First, the levels of As, Cd, and Pb were determined with ICP‐MS, followed by the calculation of estimated daily intake (EDI), target hazard quotient (THQ), and hazard index (HI) for As and Cd, and margin of exposure (MoE) for Pb. Mean levels of As, Cd, and Pb were the highest in cereal‐based meals and biscuits as 15.5–11.1, 5.18–8.76, and 35.2–53.8 μg/kg, respectively. Newborns to 6 months old infants were estimated to be the highest exposed population to Cd and Pb (0.08 and 0.36 μg/kg bw/day), while infants aged 7–12 months old were exposed the highest to As. Based on the THQ, HI, and MoE findings, the current exposure levels from the selected baby foods to As, Cd, and Pb pose low potential chronic risks to both infant age groups. This research provides a roadmap for future investigations in chemical contaminants often detected in baby foods consumed regularly by Saudi infants. [ABSTRACT FROM AUTHOR]

No study has investigated the effect of the COVID-19 pandemic on the public's interest in using energy labelling on restaurant menus. This study explores the effects of the COVID-19 pandemic on the public interest in using energy labelling on restaurant menus and meal delivery applications and the impact of energy-labelling availability on food choices during the COVID-19 pandemic in Saudi Arabia. An online questionnaire was completed by 1657 participants aged ≥ 18 years. Before the COVID-19 pandemic, 32% of customers visited a restaurant 2–4 times/week. However, during the pandemic, 35% of customers visited a restaurant only once per week. There was no difference in interest in reading energy labelling or using meal delivery applications before and during the pandemic. During the COVID-19 pandemic, about 55% of restaurant customers reported that they had noticed energy labelling, with 42% of them being influenced by the energy-labelling information. Regarding energy information on food delivery applications, 40% of customers noticed energy labelling when using the applications, with 33% of them being affected by the energy labelling. Customer interest in reading about energy on restaurant menus during the pandemic did not change significantly from the level of interest before the pandemic. The interest expressed by the public in using the energy labelling was low both before and during the COVID-19 pandemic. [ABSTRACT FROM AUTHOR]

COVID-19's intimidating spread has challenged the resilience of the global health systems, causing shifts in the practices of healthcare workers, including dietitians. The current study aimed to assess the change in dietitians' practices and duties in hospitals/clinics after the commencement of COVID-19 pandemic. This cross-sectional study was conducted in five Arab countries between November 2020 and January 2021. A convenient sample of 903 dietitians filled an online self-administered questionnaire to meet the study aims. Nearly 40.0% of the dietitians experienced a change in their workload and caseload during the pandemic. Besides, 18.7% of the dietitians had been assigned additional tasks in their facilities. Nearly half the dietitians (46.9%) had started giving remote nutrition consultations, associated with a 21% drop in the number of dietitians offering in-person consultations (p = 0.001). Approximately 58.9% of the dietitians provided nutrition care to COVID-19 patients, with 48.4% having access to personal protective equipment. Moreover, 17.0% of dietitians supported COVID-19 patients with enteral and parenteral nutrition. In addition, 45.0% of dietitians reported that managing COVID-19 was challenging given that it was a newly discovered condition. [ABSTRACT FROM AUTHOR]

Objective: Mandatory menu energy-labelling policy in restaurants has received increasing attention worldwide as a useful tool for promoting balanced energy intake and encouraging healthier food selection to reduce obesity prevalence. Therefore, we aimed to evaluate the knowledge, views and observations of the public and restaurant owners towards the mandatory menu energy-labelling policy (introduced in August 2018) in restaurants in Saudi Arabia.Design: In February 2019, we conducted a cross-sectional study using an electronic questionnaire.Setting: Saudi Arabia.Participants: Saudi individuals (n 1228) aged 18-80 years and forty-one restaurant owners.Results: Most participants identified the correct daily energetic requirements for moderately active men (51 %) and women (69 %), but not for inactive adults (36 %). Although 40 % reported adequate knowledge to select low-energetic meals and 55 % perceived the policy as useful, 51 % reported they would be less likely to eat at restaurants displaying energy. Most participants (76 %) mentioned they would choose lower-energetic meals, and 79 % would feel guilty after consuming high-energetic meals. Moreover, 62 % of participants reported that the new labelling policy affected their food selections, prompting them to order different food items, eat less, change restaurants or eat at restaurants less frequently. Among restaurant owners, half were aware of the reason for the implementation of this policy and supported this measure. However, they did not consider modifying recipes to reduce energy. Sales of low- and high-energetic meals increased and decreased in 44 % and 39 % of restaurants, respectively.Conclusions: This policy may be an effective public health tool for promoting balanced energy intake and encouraging healthier food selection in Saudi Arabia. [ABSTRACT FROM AUTHOR]

This study aims at identifying national salt reduction initiatives in countries of the Eastern Mediterranean Region and describing their progress towards the global salt reduction target. A systematic review of published and grey literature was conducted. Key characteristics of strategies were extracted and classified according to a pre-defined framework: salt intake assessments; leadership and strategic approach; implementation strategies; monitoring and evaluation of program impact. Salt intake levels were estimated in 15 out of the 22 countries (68%), while national salt reduction initiatives were identified in 13 (59%). The majority of countries were found to implement multifaceted reduction interventions, characterized by a combination of two or more implementation strategies. The least common implementation strategy was taxation, while the most common was reformulation (100%), followed by consumer education (77%), initiatives in specific settings (54%), and front of pack labelling (46%). Monitoring activities were conducted by few countries (27%), while impact evaluations were lacking. Despite the ongoing salt reduction efforts in several countries of the region, more action is needed to initiate reduction programs in countries that are lagging behind, and to ensure rigorous implementation and evaluations of ongoing programs. Such efforts are vital for the achievement of the targeted 30% reduction in salt intake. [ABSTRACT FROM AUTHOR]

During the COVID-19 pandemic, most healthcare professionals switched from face-to-face clinical encounters to telehealth. This study sought to investigate the dietitians' perceptions and practices toward the use of social/mass media platforms amid the transition from face-to-face to telenutrition in the time of COVID-19. This cross-sectional study involving a convenient sample of 2,542 dietitians (mean age = 31.7 ± 9.5; females: 88.2%) was launched in 10 Arab countries between November 2020 and January 2021. Data were collected using an online self-administrated questionnaire. Study findings showed that dietitians' reliance on telenutrition increased by 11% during the pandemic, p  = 0.001. Furthermore, 63.0% of them reported adopting telenutrition to cover consultation activities. Instagram was the platform that was most frequently used by 51.7% of dietitians. Dietitians shouldered new difficulties in dispelling nutrition myths during the pandemic (58.2% reported doing so vs. 51.4% pre-pandemic, p  < 0.001). Compared to the pre-pandemic period, more dietitians perceived the importance of adopting tele nutrition's clinical and non-clinical services (86.9% vs. 68.0%, p  = 0.001), with 76.6% being confident in this practice. In addition, 90.0% of the participants received no support from their work facilities for social media usage. Following the COVID-19 outbreak, the majority of dietitians (80.0%) observed a rise in public interest in nutrition-related topics, particularly those pertaining to healthy eating habits ( p  = 0.001), healthy recipes (p = 0.001), nutrition and immunity (p = 0.001), and medical nutrition therapies ( p  = 0.012). Time constraint was the most prevalent barrier to offering telenutrition for nutrition care (32.1%), whereas leveraging a quick and easy information exchange was the most rewarding benefit for 69.3% of the dietitians. In conclusion, to ensure a consistent provision of nutrition care delivery during the COVID-19 pandemic, dietitians working in Arab countries adopted alternative telenutrition approaches through social/mass media., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The author disclaim that the views expressed in this article do not necessarily represents the views, decisions or policies of Saudi FDA or other institutions with which the authors are affiliated., (Copyright © 2023 Bookari, Arrish, Alkhalaf, Alharbi, Zaher, Alotaibi, Tayyem, Al-Awwad, Qasrawi, Allehdan, Al Sabbah, AlMajed, Al Hinai, Kamel, Ati, Harb, The Arabic Dietitians practices (ADP) survey Group and Hoteit.)

Introduction: Tobacco smokers are at high risk of developing severe COVID-19. Lockdown was a chosen strategy to deal with the spread of infectious diseases; nonetheless, it influenced people's eating and smoking behaviors. The main objective of this study is to determine the impact of the COVID-19 lockdown on smoking (waterpipe and cigarette) behavior and its associations with sociodemographic characteristics and body mass index., Methods: The data were derived from a large-scale retrospective cross-sectional study using a validated online international survey from 38 countries (n=37207) conducted between 17 April and 25 June 2020. The Eastern Mediterranean Region (WHO-EMR countries) data related to 10 Arabic countries that participated in this survey have been selected for analysis in this study. A total of 12433 participants were included in the analysis of this study, reporting their smoking behavior and their BMI before and during the COVID-19 lockdown. Descriptive and regression analyses were conducted to examine the association between smoking practices and the participant's country of origin, sociodemographic characteristics, and BMI (kg/m 2 )., Results: Overall, the prevalence rate of smoking decreased significantly during the lockdown from 29.8% to 23.5% (p<0.05). The percentage of females who smoke was higher than males among the studied population. The highest smoking prevalence was found in Lebanon (33.2%), and the lowest was in Oman (7.9%). In Egypt, Kuwait, Lebanon, and Saudi Arabia, the data showed a significant difference in the education level of smokers before and during the lockdown (p<0.05). Smokers in Lebanon had lower education levels than those in other countries, where the majority of smokers had a Bachelor's degree. The findings show that the BMI rates in Jordan, Lebanon, Oman, and Saudi Arabia significantly increased during the lockdown (p<0.05). The highest percentages of obesity among smokers before the lockdown were in Oman (33.3%), followed by Bahrain (28.4%) and Qatar (26.4%), whereas, during the lockdown, the percentage of obese smokers was highest in Bahrain (32.1%) followed by Qatar (31.3%) and Oman (25%). According to the logistic regression model, the odds ratio of smoking increased during the pandemic, whereas the odds ratio of TV watching decreased. This finding was statistically significant by age, gender, education level, country of residence, and work status., Conclusions: Although the overall rates of smoking among the studied countries decreased during the lockdown period, we cannot attribute this change in smoking behavior to the lockdown. Smoking cessation services need to anticipate that unexpected disruptions, such as pandemic lockdowns, may be associated with changes in daily tobacco consumption. Public health authorities should promote the adoption of healthy lifestyles to reduce the long-term negative effects of the lockdown., (© 2022 Al Sabbah H. et al.)

Background: The COVID-19 pandemic along with its confinement period boosted lifestyle modifications and impacted women and men differently which exacerbated existing gender inequalities. The main objective of this paper is to assess the gender-based differentials in food consumption patterns, dietary diversity and the determinants favoring weight change before and amid the COVID-19 pandemic among Arab men and women from 10 Arab countries., Methods: A cross-sectional study was conducted based on a convenience sample of 12,447 households' family members (mean age: 33.2 ± 12.9; 50.1% females) and information from participants aged 18 years and above was collected about periods before and during the pandemic., Results: Findings showed that, during the COVID-19 period, the dietary diversity, declined by 1.9% among females compared to males (0.4%) ( p < 0.001) and by 1.5% among overweight participants ( p < 0.001) compared to their counterparts., Conclusions: To conclude, gender-sensitive strategies and policies to address weight gain and dietary diversity during emergent shocks and pandemics are urgently needed in the region., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Tayyem, Ibrahim, Mortada, AlKhalaf, Bookari, Al Sabbah, Qasrawi, Kamel, Dashti, Allehdan, Bawadi, Waly, Abuhijleh, Hammouh, Al-Awwad, Al-Bayyari, Cheikh Ismail, Abu Al-Halawa, Othman, The Regional CORONA COOKING Survey Group and Hoteit.)

Background The coronavirus pandemic has forced worldwide closures, especially of restaurants closed, which partly contributed to people all over the world changing the way they choose and prepare foods. Objective The objective of this study was to compare changes in behavioral food literacy (planning, selecting, and preparing food) and food consumption before and during the COVID-19 crisis in the Kingdom of Saudi Arabia (KSA). Design This was a cross-sectional study, with data from an online survey made in UAntwerpen Qualtrics Accounts and collected from April-June 2020. The study was part of the International Corona Cooking Survey. Results There were 2788 respondents (83%, n = 2323 females) who reported that the COVID-19 home lockdown had positively affected all their behavioral food literacy components (all p<0.05) except feeling confident about cooking a variety of healthy meals in which the difference was not significant (p>0.05); however, its impact on their food consumption was varied. There was a noticeable positive increase in fruit intake (Z= -3.330, p=0.001) and a noticeable positive decrease in processed meat (Z= -11.375, p<0.001) and sweetened drinks consumption (Z= -2.403, p<0.05). There were simultaneously noticeable adverse effects represented in the reduction in the consumption of the vegetable group (Z= -3.447, p=0.001) and an increase in sweets consumption (Z= -2.268, p<0.05). However, the overall impacts of these changes as measured by the Hedges' g measure indicated a small effect (Hedges' g = 0.04, 95% CI (-0.07, -0.16)). Discussion and conclusions Even though the pandemic may have created a sense of responsibility for one's health and increased people's nutritional awareness, the Saudi population may be still a long way from having healthy eating habits. Public health campaigns need to increase the population's level of nutritional awareness, educate them about the meaning of healthy eating, and how they can achieve that by advocating the national dietary guidelines and providing reliable and accurate information by authorized official bodies., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2022, Alkhalaf et al.)

Background : Maternal depression and anxiety are significant public health concerns that play an important role in the health and well-being of mothers and children. The COVID-19 pandemic, the consequential lockdowns and related safety restrictions worldwide negatively affected the mental health of pregnant and postpartum women. Methods: This regional study aimed to develop a machine learning (ML) model for the prediction of maternal depression and anxiety. The study used a dataset collected from five Arab countries during the COVID-19 pandemic between July to December 2020. The population sample included 3569 women (1939 pregnant and 1630 postpartum) from five countries (Jordan, Palestine, Lebanon, Saudi Arabia, and Bahrain). The performance of seven machine learning algorithms was assessed for the prediction of depression and anxiety symptoms. Results : The Gradient Boosting (GB) and Random Forest (RF) models outperformed other studied ML algorithms with accuracy values of 83.3% and 83.2% for depression, respectively, and values of 82.9% and 81.3% for anxiety, respectively. The Mathew's Correlation Coefficient was evaluated for the ML models; the Naïve Bayes (NB) and GB models presented the highest performance measures (0.63 and 0.59) for depression and (0.74 and 0.73) for anxiety, respectively. The features' importance ranking was evaluated, the results showed that stress during pregnancy, family support, financial issues, income, and social support were the most significant values in predicting anxiety and depression. Conclusion: Overall, the study evidenced the power of ML models in predicting maternal depression and anxiety and proved to be an efficient tool for identifying and predicting the associated risk factors that influence maternal mental health. The deployment of machine learning models for screening and early detection of depression and anxiety among pregnant and postpartum women might facilitate the development of health prevention and intervention programs that will enhance maternal and child health in low- and middle-income countries., Competing Interests: No competing interests were disclosed., (Copyright: © 2022 Qasrawi R et al.)

The COVID-19 pandemic has revealed the Eastern Mediterranean Region's food system's fragility posing severe challenges to maintaining healthy sustainable lifestyle. The aim of this cross-sectional study ( N = 13,527 household's family members, mean age: 30.3 ±11.6, 80% women) is to examine the impact of the COVID-19 pandemic on food consumption patterns and household's dietary diversity in 10 Eastern Mediterranean countries. A food frequency questionnaire was used to investigate the consumption patterns along with the calculation of the Food Consumption Score (FCS), a proxy indicator of dietary diversity. Data collected on cooking attitudes, shopping and food stock explore the community mitigation measures. In the overall population, before and during the pandemic, most food groups were consumed less or equal to 4 times per week. As evident from our findings and considering that the pandemic may be better, but it's not over, small to moderate changes in food consumption patterns in relatively short time periods can become permanent and lead to substantial poor dietary diversity over time. While it is a priority to mitigate the immediate impact, one area of great concern is the long-term effects of this pandemic on dietary patterns and dietary diversity in Eastern Mediterranean households. To conclude, the COVID-19 crisis revealed the region's unpreparedness to deal with a pandemic. While the aggressive containment strategy was essential for most countries to help prevent the spread, it came at a high nutritional cost, driving poor dietary diversity., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2022 Hoteit, Mortada, Al-Jawaldeh, Mansour, Yazbeck, AlKhalaf, Bookari, Tayyem, Al-Awwad, Al Sabbah, Cheikh Ismail, Qasrawi, Abu Seir, Kamel, Dashti, Allehdan, Al-Mannai, Bawadi, Waly and The Regional CORONA COOKING Survey Group.)

High intakes of trans fatty acids (TFA), particularly industrially-produced TFA, are implicated in the etiology of cardiovascular diseases, which represent the leading cause of mortality in the Eastern Mediterranean Region (EMR). This systematic review aims to document existing national TFA reduction strategies in the EMR, providing an overview of initiatives that are implemented by countries of the region, and tracking progress toward the elimination of industrially-produced TFA. A systematic review of published and gray literature was conducted using a predefined search strategy. A total of 136 peer-reviewed articles, gray literature documents, websites and references from country contacts were obtained, up until 2 August 2021. Randomized-control trials, case-control studies, and studies targeting unhealthy population groups were excluded. Only articles published after 1995, in English, Arabic or French, were included. Key characteristics of strategies were extracted and classified according to a pre-developed framework, which includes TFA intake assessment; determination of TFA levels in foods; strategic approach; implementation strategies (TFA bans/limits; consumer education, labeling, interventions in public institution settings, taxation), as well as monitoring and evaluation of program impact. Thirteen out of the 22 countries of the EMR (59%) have estimated TFA intake levels, 9 have determined TFA levels in foods (41%), and 14 (63.6%) have national TFA reduction initiatives. These initiatives were mainly led by governments, or by national multi-sectoral committees. The most common TFA reduction initiatives were based on TFA limits or bans (14/14 countries), with a mandatory approach being adopted by 8 countries (Bahrain, Iran, Jordan, KSA, Kuwait, Morocco, Oman and Palestine). Complementary approaches were implemented in several countries, including consumer education (10/14), food labeling (9/14) and interventions in specific settings (7/14). Monitoring activities were conducted by few countries (5/14), and impact evaluations were identified in only Iran and the UAE. The robustness of the studies, in terms of methodology and quality of assessment, as well as the lack of sufficient data in the EMR, remain a limitation that needs to be highlighted. Further action is needed to initiate TFA reduction programs in countries that are lagging behind, and to ensure rigorous implementation and evaluation of ongoing programs., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Al-Jawaldeh, Taktouk, Chatila, Naalbandian, Abdollahi, Ajlan, Al Hamad, Alkhalaf, Almamary, Alobaid, Alyafei, Azizi, Baqadir, Barham, Binsunaid, El Ammari, El Ati, Hoteit, Massad, Nejad and Nasreddine.)