Reducing non-communicable diseases among Palestinian populations in Gaza: A participatory comparative and cost-effectiveness modeling assessment.

We sought to assess the effectiveness and cost-effectiveness of potential new public health and healthcare NCD risk reduction efforts among Palestinians in Gaza. We created a microsimulation model using: (i) a cross-sectional household survey of NCD risk factors among 4,576 Palestinian adults aged ≥40 years old in Gaza; (ii) a modified Delphi process among local public health experts to identify potentially feasible new interventions; and (iii) reviews of intervention cost and effectiveness, modified to the Gazan and refugee contexts. The survey revealed 28.6% tobacco smoking, a 40.4% prevalence of hypertension diagnosis (with a 95.6% medication treatment rate), a 25.6% prevalence of diabetes diagnosis (with 95.3% on treatment), a 21.9% prevalence of dyslipidemia (with 79.6% on a statin), and a 9.8% prevalence of asthma or chronic obstructive pulmonary disease (without known treatment). A calibrated model estimated a loss of 9,516 DALYs per 10,000 population over the 10-year policy horizon. The interventions having an incremental cost-effectiveness ratio (ICER) less than three times the GDP per capita of Palestine per DALY averted (<$10,992 per DALY averted)(<$10,992 per DALY averted) included bans on tobacco smoking in indoor and public places [$34 per incremental DALY averted (95% CI: $17, $50)], treatment of asthma using low dose inhaled beclometasone and short-acting beta-agonists [$140 per DALY averted (95% CI: $77, $207)], treatment of breast cancer stages I and II [$730 per DALY averted (95% CI: $372, $1,100)], implementing a mass media campaign for healthier nutrition [$737 per DALY averted (95% CI: $403, $1,100)], treatment of colorectal cancer stages I and II [$7,657 per DALY averted (95% CI: $3,721, $11,639)], and (screening with mammography [$17,054 per DALY averted (95% CI: $8,693, $25,359)]). Despite high levels of NCD risk factors among Palestinians in Gaza, we estimated that several interventions would be expected to reduce the loss of DALYs within common cost-effectiveness thresholds.

Urban school neighbourhoods dominated by unhealthy food retailers and advertisements in Greater Tunis: a geospatial study in the midst of the nutrition transition.

OBJECTIVE: Food environments are a major determinant of children's nutritional status. Scarce evidence on food environments exists in low- and middle-income countries (LMIC). This study aims to fill this gap by documenting the obesogenicity of food environments around schools in Greater Tunis, Tunisia - an LMIC of the Middle East and North Africa region with an ongoing nutrition transition and increasing rates of childhood obesity. DESIGN: In this cross-sectional study, we assessed built food environments around fifty primary schools. Ground-truthing was performed to collect geographic coordinates and pictures of food retailers and food advertisement sets within an 800-m road network buffer of each school. Retailers and advertisement sets were categorised as healthy or unhealthy according to a NOVA-based classification. Associations between school characteristics and retailers or advertisement sets were explored using multinomial regression models. SETTING: Greater Tunis, Tunisia. PARTICIPANTS: Random sample of fifty (thirty-five public and fifteen private) primary schools. RESULTS: Overall, 3621 food retailers and 2098 advertisement sets were mapped. About two-thirds of retailers and advertisement sets were labelled as unhealthy. Most retailers were traditional corner stores (22 %) and only 6 % were fruit and vegetable markets. The prevailing food group promoted was carbonated and sugar-sweetened beverages (22 %). The proportion of unhealthy retailers was significantly higher in the richest v. poorest areas. CONCLUSIONS: School neighbourhood food environments included predominantly unhealthy retailers and advertisements. Mapping of LMIC food environments is crucial to document the impact of the nutrition transition on children's nutritional status. This will inform policies and interventions to curb the emergent childhood obesity epidemic.

Inequalities in Wellbeing in Lebanese Children and Different Refugee Subpopulations: A Multidimensional Child Deprivation Analysis.

Background and Objectives: This study constitutes the first attempt to describe the overlapping deprivations faced by Lebanese children (Lebanese) and that of the three sub-populations of refugees living in Lebanon: Palestinian refugees living in Lebanon, Palestinian refugees from Syria and Syrian refugees. Methods: Using data from the United Nations International Children's Emergency Fund (UNICEF) Household Survey 2016 (n = 10,555 Lebanese; 7,106 Palestinian refugees living in Lebanon; 2,768 Palestinian refugees from Syria and 5,891 Syrian refugee children aged 2 to 17 years old), we report on single and overlapping deprivations (at least two concurrent deprivations) using indicators related to survival (nutrition, health, water, sanitation and overcrowding), development (education) and protection (labor, exposure to violence and early marriage). Maternal education and geographical correlates of deprivation were explored using multivariable logistic regression models clustering for children in the same households. Main Results: In terms of co-occurrence of deprivations, Syrian refugees had the highest prevalence in all age groups (68.5%, 2-4y and 65.7%, 6-17y), followed by Palestinian refugees from Syria (46.2%, 2-4y and 45.5%, 6-17y), Palestinian refugees living in Lebanon (28.9%, 2-4y and 23.7%, 6-17y), with Lebanese children having the lowest prevalence (13.2%, 2-4y and 15.3, 6-17y). About half of Palestinian refugees from Syria and Syrian refugees (6-17y) were deprived in protection and housing. Education deprivation is of primary concern for Syrian children. Higher maternal education was consistently associated with lower odds of co-occurrence of deprivations among children aged 6-17y. Conclusion: This study highlights the importance of including refugee populations in reporting frameworks. This analysis additionally generates geographical and socio-economic profiles of the deprived children and identifies key deprivation areas of the affected sub-groups to inform effective policy design especially in light of the prevailing economic crisis. Supplementary Information: The online version contains supplementary material available at 10.1007/s12187-023-10040-2.

Effects of size at birth on health, growth and developmental outcomes in children up to age 18: an umbrella review.

BACKGROUND: Size at birth, an indicator of intrauterine growth, has been studied extensively in relation to subsequent health, growth and developmental outcomes. Our umbrella review synthesises evidence from systematic reviews and meta-analyses on the effects of size at birth on subsequent health, growth and development in children and adolescents up to age 18, and identifies gaps. METHODS: We searched five databases from inception to mid-July 2021 to identify eligible systematic reviews and meta-analyses. For each meta-analysis, we extracted data on the exposures and outcomes measured and the strength of the association. FINDINGS: We screened 16 641 articles and identified 302 systematic reviews. The literature operationalised size at birth (birth weight and/or gestation) in 12 ways. There were 1041 meta-analyses of associations between size at birth and 67 outcomes. Thirteen outcomes had no meta-analysis.Small size at birth was examined for 50 outcomes and was associated with over half of these (32 of 50); continuous/post-term/large size at birth was examined for 35 outcomes and was consistently associated with 11 of the 35 outcomes. Seventy-three meta-analyses (in 11 reviews) compared risks by size for gestational age (GA), stratified by preterm and term. Prematurity mechanisms were the key aetiologies linked to mortality and cognitive development, while intrauterine growth restriction (IUGR), manifesting as small for GA, was primarily linked to underweight and stunting. INTERPRETATION: Future reviews should use methodologically sound comparators to further understand aetiological mechanisms linking IUGR and prematurity to subsequent outcomes. Future research should focus on understudied exposures (large size at birth and size at birth stratified by gestation), gaps in outcomes (specifically those without reviews or meta-analysis and stratified by age group of children) and neglected populations. PROSPERO REGISTRATION NUMBER: CRD42021268843.

The hypertension cascade of care in the midst of conflict: the case of the Gaza Strip.

Although hypertension constitutes a substantial burden in conflict-affected areas, little is known about its prevalence, control, and management in Gaza. This study aims to estimate the prevalence and correlates of hypertension, its diagnosis and control among adults in Gaza. We conducted a representative, cross-sectional, anonymous, household survey of 4576 persons older than 40 years in Gaza in mid-2020. Data were collected through face-to-face interviews, anthropometric, and blood pressure measurements. Hypertension was defined in anyone with an average systolic blood pressure ≥140 mmHg or average diastolic blood pressure ≥90 mmHg from two consecutive readings or a hypertension diagnosis. The mean age of participants was 56.9 ± 10.5 years, 54.0% were female and 68.5% were Palestinian refugees. The prevalence of hypertension was 56.5%, of whom 71.5% had been diagnosed. Hypertension was significantly higher among older participants, refugees, ex-smokers, those who were overweight or obese, and had other co-morbidities including mental illnesses. Two-thirds (68.3%) of those with hypertension were on treatment with one in three (35.6%) having their hypertension controlled. Having controlled hypertension was significantly higher in females, those receiving all medications for high blood pressure and those who never or rarely added salt to food. Investing in comprehensive but cost-effective initiatives that strengthen the prevention, early detection and timely treatment of hypertension in conflict settings is critical. It is essential to better understand the underlying barriers behind the lack of control and develop multi-sectoral programs to address these barriers.

School and community drivers of child diets in two Arab cities: The SCALE protocol and innovative tools to assess children's food environments.

BACKGROUND: In the context of the rapid nutrition transition experienced by middle-income countries of the Arab region, children and adolescent's food choices and dietary behaviors are early risk factors for the development of non-communicable diseases. Assessment of factors influencing food choices among this age group is challenging and is usually based on self-reported data, which are prone to information and recall bias. As the popularity of technologies and video gaming platforms increases, opportunities arise to use these tools to collect data on variables that affect food choice, dietary intake, and associated outcomes. This protocol paper describes the SCALE study (School and community drivers of child diets in Arab cities; identifying levers for intervention) which aims to explore the environments at the level of households, schools and communities in which children's food choices are made and consequently identify barriers and enablers to healthy food choices within these environments. METHODS: Field studies are being conducted in primary schools, among children aged 9-12 years, in Greater Beirut, Lebanon and Greater Tunis, Tunisia. A stratified random sample of 50 primary schools (public and private) are selected and 50 children are randomly selected from grades 4-5-6 in each school. The study includes surveys with children, parents/caregivers, school directors, teachers, and nutrition/health educators to assess individual diets and the contextual factors that influence children's food choices. Innovative locally adapted tools and methods such as game-based choice experiments, wearable cameras and neighborhood mapping are used to describe the environments in which children's food choices are made. DISCUSSION: The SCALE study will generate contextual knowledge on factors in school and neighborhood environments that influence child dietary behaviors and will inform multi-level interventions and policies to address childhood malnutrition (under-and over-nutrition). By integrating methods from various disciplines, including economics, data science, nutrition, and public health and by considering factors at various levels (home, school, and neighborhood), the study will identify levers for intervention with the potential to improve children's dietary behaviors. This will help fill existing gaps in research on food systems and consequently guide positive change in Lebanon and Tunisia, with the potential for replicability in other contexts.

Long Term Weight Loss Diets and Obesity Indices: Results of a Network Meta-Analysis.

Background: Scientists have been investigating efficient interventions to prevent and manage obesity. This network meta-analysis (NMA) compared the effect of different diets [moderate macronutrients (MMs), low fat/high carbohydrate (LFHC), high fat/low carbohydrate (HFLC), and usual diet (UD)] on weight, body mass index (BMI), and waist circumference (WC) changes at ≥12 months. Methods: We searched Medline, Embase, PubMed databases, and the Cochrane Library. We systematically assessed randomized controlled trials (RCTs) evaluating dietary interventions on adults (mean BMI ≥ 25 kg/m2) receiving active dietary counseling for ≥12 months. We pooled the data using a random-effect NMA. We assessed the quality of the included RCTs using the Cochrane risk of bias (ROB) tool. Results: We included 36 trials, 14 of which compared HFLC with MM diets. Compared with UD, all diets were associated with a significant weight loss (WL) at ≥12 months, HFLC [mean difference in kg (95% CI): -5.5 (-7.6; -3.4)], LFHC [-5.0 (-7.1; -2.9)] and MM [-4.7 (-6.8; -2.7)]. HFLC, compared with MM diet, was associated with a slightly higher WL (of -0.77 kg) and drop in BMI (of -0.36 kg/m2), while no significant difference was detected in other dietary comparisons. WC was lower with all diets compared to UD, with no significant difference across specific diets. There was no significant interaction of the results with the pre-specified sub-groups. The ROB was moderate to high, mostly related to unclear allocation concealment, high dropout rate and unclear or lack of blinding of participants, providers, and outcome assessors. Conclusion: Dietary interventions extending over ≥12 months are superior to UD in inducing weight, BMI and WC loss. HFLC might be associated with a slightly higher WL compared with MM diets. Systematic Trial Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=103116, PROSPERO (CRD42018103116).

Does a school snack make a difference? An evaluation of the World Food Programme emergency school feeding programme in Lebanon among Lebanese and Syrian refugee children.

OBJECTIVE: To investigate the effects of providing a daily healthy school snack on children's nutritional, social and educational outcomes and explore stakeholders' perceptions of an emergency school feeding programme (SFP). DESIGN: Convergence triangulation mixed-methods study design. Associations were examined between receiving the school feeding intervention and children's outcomes using multivariable regression models. Quantitative data were complemented with interviews and focus group discussions with parents and staff. SETTING: In vulnerable communities in Lebanon, the World Food Programme has implemented an emergency SFP targeting Lebanese (attending morning sessions) and Syrian refugee children (attending afternoon sessions) in public schools. PARTICIPANTS: Children from ten intervention schools (morning n 403; afternoon n 379) and ten matched control schools (morning n 399; afternoon n 401), as well as twenty-nine parents and twenty-two school staff members. RESULTS: Diet diversity was higher in intervention schools as compared with control with a significantly higher consumption of dairy products, nuts and fruit in both sessions. Child-reported food insecurity experience was lower in children attending the afternoon session of intervention v. control schools. The SFP intervention was associated with higher school engagement and sense of school community in the morning session only. While the SFP was significantly associated with higher attendance for children in afternoon sessions only, it was significantly associated with school retention of children in both sessions. CONCLUSIONS: A daily healthy snack potentially acts as an incentive to improve children's nutritional outcomes, school engagement, sense of belonging, equality between students and improvement in children's attendance and retention in public schools.