In common with many countries, the Eastern Mediterranean Region (EMR)^[i]  has a problem with obesity and its associated public health issues, including an increase in non-communicable diseases such as diabetes and cardiovascular disease. A policy goal of the World Health Organization (WHO) is to improve diet by reducing sugar, saturated fat and salt intake^[ii]. However, national food composition datasets representative of current diets, particularly traditional and regionally-produced foods and dishes, are lacking. Consequently, researchers have limited baseline data with which to estimate food and nutrient intakes accurately, or to monitor the impact of WHO policy implementation. By providing necessary training, experts from the Food Databanks National Capability (FDNC) group at the Quadram Institute have enabled national compilers in low and middle-income countries (LMIC) in the EMR to begin establishing this essential baseline data and move towards achieving WHO targets for reducing non-communicable diseases.

“60% of deaths in the EMR are attributed to non-communicable diseases and the region suffers from obesity, high salt, sugar and fat intake. Through sound and committed national, regional and international efforts in policy, actions, governance, monitoring and evaluation, the burden of non-communicable diseases in the Region could be controlled. For that to happen, food policy makers must have access to detailed and reliable food composition data which leads to the improvement of food consumption tables.” Dr Ayoub Al-Jawaldeh (Regional Advisor Nutrition) WHO Eastern Mediterranean Region.

This project was funded by the Medical Research Council (MRC) in 2019^[iii], and built on previous successful workshops involving Quadram scientists^[iv]. It provided both training across the region, via two workshops in Morocco and Jordan, where fifty scientists were trained in the use of standardized methodologies for evaluating food composition and food intake; participants came from Morocco, Tunisia, Egypt, Jordan, Sudan, Lebanon, Pakistan, Iran, Iraq, Kuwait, Mauritania and Sudan. There were also three training events held in; Belgrade, Serbia, hosted by Professor Maria Glibetic from Capacity Development Network in Nutrition in Central and Eastern Europe (CAPNUTRA); Tunis, Tunisia, hosted by Professor Jalila El Ati (National Institute of Nutrition and Food Technology (INNTA); and Lisbon, Portugal, organized and hosted by Dr Helena Soares Costa at the Instituto Nacional de Saúde Doutor Ricardo Jorge (INSA). At these events the participants learnt new methods for the analysis of sugar, dietary fibre, vitamins, fatty acids and amino acids in foods. The project also provided funding for collection and analysis of new food composition data in the Lebanon.

“This workshop was a valuable opportunity to gain new knowledge and the visit to INSA has benefited me through getting acquaintance with the infrastructure, equipment and procedures that will help in establishing a durable accredited laboratory in my country in the future.  I was also able to transfer the information to colleagues whose research includes food analysis.” Dr Mohammad Shahein, Amman, Jordan.

Attendees at the meeting in Jordan including Paul Finglas, head of FDNC, centre

“It benefits us a lot regarding the quality and metrology of the produced data. The knowledge we share is with high quality which can be transferred to others involved in same area, country”. Mohammed Saeed Dafaseed, National Chemical Laboratories, NPHLs, Federal Ministry of Health, Sudan.

Governments in the EMR have targeted reducing salt and sugar consumption as part of their strategy to prevent non-communicable diseases^[v], alongside subsidies for healthy alternatives, promotion of labelling, health education in schools, replacement of trans fats and saturated fats with unsaturated fats, and the implementation of marketing restrictions. Accurate and standardised evaluation of food composition is necessary to determine whether food products can be considered ‘healthy’; Quadram training has been key to pushing this work forward.

“During this project we have learnt the requirements needed to standardise and produce high quality data which can be acceptable at the regional level. In addition to that it has allowed us the opportunity to know a number of experts to contact and share their experiences” Dr Sawsan Balla, National Chemical Laboratories, Sudan

Datasets go online: For the first time, six national food composition databases from the EMR (Iraq, Iran, Morocco, Kuwait, Pakistan and Tunisia) are now standardised and included within an open access online platform https://www.eurofir.org/FoodEXplorer/datasets.php. Additionally, Jordan has published its food composition data in book form.

Furthermore, the scientists benefiting from training subsequently went on to transfer their new skills to other colleagues in their host universities/institutes through seminars and training. This will lead to reformulation of some products in the region, such as sugary drinks.

“This project has enabled us to generate food composition data based on EuroFIR standards in our countries. The outcome of this action will enable us to develop a regional food composition database.” Mina Esmaeili from National Nutrition & Food Technology Research Institute (NNFTRI), I.R.Iran.

A focus on food composition in the Lebanon: Historically, Lebanese dietitians have used food composition data from other countries. Unfortunately, the ingredients and preparation methods for traditional dishes widely consumed in Lebanon, can differ substantially from similar dishes from elsewhere. Funding from this project allowed new analysis of 30 traditional recipes and 35 Arabic sweets common in the Lebanese diet. This addressed an important need nationally while also serving as a model for how to introduce the importance of cultural traditions in cuisine to nutritionists and dietitians more widely in the Middle Eastern Region. Total sugar, salt and iron were quantified in traditional Lebanese dishes sampled from a variety of geographically distinct areas in the Lebanon (Mount Lebanon, Bekaa, Beirut, Tripoli, and Saida). Results showed that traditional Lebanese dishes contained little total sugar. However, 60% of the samples had high levels of sodium and 80% of the samples were low in iron^[vi]. This emphasizes the need for multi-cultural education to raise awareness of the variation in salt and iron amongst different foods, and the detrimental health effects of a high intake of salt and low intake of iron. The Lebanese scientists were also able to analyse sugar content of popular Arabic sweets^[vii]. Together, these data will also be of use to food and health researchers in Jordan, Syria and Palestine due to the similarity in their traditional dishes. Efforts like this provide a solid framework for the implementation of nutrition policies and practices across the region. These studies are stepping stones for further research exploring total sugar, salt and iron content of traditional dishes, as well as intake estimations in the Lebanese population.

The outputs from Lebanon and the online data sets illustrate that combining a plan for progression towards impact with appropriate funding has increased the impact reach and significance of the work and generated change at the national level. This progressional approach continues to strengthen links between participants and the Quadram Institute and supports the WHO’s roadmap for developing and updating new regional and national food composition tables and dietary intake data using a more standardised approachⁱⁱ,^[viii].

The high quality of the new data collected will support research to improve the understanding of dietary patterns and their relationship with health, and lead to production and consumption of healthier food products.

Through this project, production and use of food composition data in the region was improved, which supports WHO food and health policies to reduce salt, fat and sugar intake in low and middle-Income countries as part of the strategy to reduce the occurrence of non-communicable diseases.

“This year, Sudan federal ministry of Health was establishing technical committee, including universities, research institutes centres, National Nutrition Programme, National Chemical Laboratories, WHO, WFP and UNICEF to produce Sudan Food Composition Tables through; collecting the existing data, assessment the quality of the data and fill the gap of information (by laboratory testing).” Assistant Prof. Sawsan Osman Abdelrazig, Senior Consultant & Director, National Chemical Laboratories, Sudan.

This work was funded by Medical Research Council grant MC_PC_MR/R019576/1: Capacity building in dietary monitoring and public health nutrition in the Eastern Mediterranean Region (EMR).

References

[i] WHO’s Eastern Mediterranean Region comprises 21 Member States with a population of nearly 583 million people http://www.emro.who.int/countries.html

[ii] Plan of action for the prevention and control of noncommunicable diseases in the Eastern Mediterranean Region. Published by the World Health Organisation in 2011. WHO-EM/NCD/067/E. Microsoft Word – NCD plan of action FINAL 12 April (who.int).

[iii] Medical Research Council grant MC_PC_MR/R019576/1: Capacity building in dietary monitoring and public health nutrition in the Eastern Mediterranean Region (EMR).

[iv] GCRF case study. https://quadram.ac.uk/case_studies/prevention-of-non-communicable-diseases-in-africa/

[v] Egypt national Multisectoral Action Plan for prevention of NCD’s 2017-2021. https://www.iccp-portal.org/system/files/plans/EGY_B3_NCDMAPEgypt21March2017%20FINAL%20%20RS.pdf

[vi] Hoteit M, Zoghbi E, Al Iskandarani M, Rady A, Shankiti I and Matta J. A Nutritional value of the Middle Eastern diet: analysis of total sugar, salt, and iron in Lebanese traditional dishes [version 1; peer review: 2 approved]. F1000Research 2020, 9:1254 (https://doi.org/10.12688/f1000research.26278.1)

[vii] Hoteit M, Zoghbi E, Rady A and Shankiti I. Development of a Lebanese food exchange system based on frequently consumed Eastern Mediterranean traditional dishes and Arabic sweets [version 1; peer review: 2 approved]. F1000Research 2021, 10:12 (https://doi.org/10.12688/f1000research.27461.1)

[viii] Promoting a healthy diet for the WHO Eastern Mediterranean Region: User friendly guide. 2012 WHO published in Cairo. http://applications.emro.who.int/dsaf/emropub_2011_1274.pdf?ua