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Table 4 Data Extraction

From: The ticking time bomb in lifestyle-related diseases among women in the Gulf Cooperation Council countries; review of systematic reviews

# Author/ Year of publication Search engine/yrs. CVD Risks Included in the Study Definition Results* CVD risk factors among women in GCC Countries Limitation & comments Gender/Age prevalence & Summary
1 (Aljefree & Ahmed, 2015) [25] ProQuest Public Health, MEDLINE, PubMed, Google Scholar, and World Health Organization (WHO) website, from 1990 and 2014 • Obesity
• DM
All used WHO in defining the obesity.
WHO (BMI >30 kg/m2)
All but one study used the WHO definition to describe DM. In UAE define DM fasting blood sugar > = 7 mmol/l or on medication
All but one study uses WHO definition to report HTN
Bahrain HTN > =160/95 or on HTN medications
KSA, UAE current smoking definition (1 cigarette per day)
all but one study used from national / regional studies on GP, one on SP Obesity
Qatar (1) study = 33.6%
Kuwait (2) studies = 43% & 53%
Oman (2) studies =23.8% & 26.1%
KSA (4) studies = (26.6%,34%,44%,) 51.8%
UAE (3) studies .2 studies = (38.3%, 35%), 1 study among SP = (6.7%)
Bahrain (2) studies = (33.2%–48.7%)
DM
Qatar (1) study = 18.1%
Kuwait (2) studies = (14.8%, 6%)
Oman (3) studies = (11.3%, 11.9%, 12.1%)
KSA (3) Studies = (21.5%, 20% & 44%)
UAE (2) studies = (17.9% & 19.2%)
Bahrain (2) Studies. 1st study report according to age group
Age 50–59 = (36%)
Age 60–69 = (37%)
2nd study = (5%)
Hypertension
Qatar (2) studies = (31.7%- 33.6%)
Oman (3) studies = (22.7%, 13.8%, 31%)
KSA (2) Studies = (23.9%–29%)
UAE (2) studies = (20.9%–53%)
Bahrain(1) Study reported according to the age group:
In 50–59 age = (33%)
In 60–69 age = (43%)
Smoking
Qatar (1) study = (3.2%)
Kuwait (2) Studies. 1st Study reported both type of smoking among SP.
Cigarette = (7.9%)
Water-pipe = (5.5%).
2nd study overall smoking = (1.9%)
Oman (2) studies = (0.5%–0%)
KSA (2) studies = (1–9%)
UAE (1) study = (0.8%)
Bahrain (1) study. Cigarette smoking = (3.2%),
Water-pipe = (17.5%) total = (20.7%)
Physical Inactivity
Kuwait (1) study = (80.8%)
Oman (1) study = (69.3%)
KSA (1) Study = (98.1%)
UAE (1) study = (56.7%) not walking daily 20 min.
Bahrain (1) study.t report Walk 1–3 km = (6%)
Walk less than 1 km = (93%)
Lack of recent nationally representative reports in the GCC countries, and thus it is difficult to compare the data between GCC countries.
There was significant heterogeneity between studies with respect to definitions of the risk factors, design and population characteristic.
Few studies focusing on HTN, dyslipidaemia and physical activity.
Studies relating to the prevalence of risk factors in Qatar and Bahrain were also relatively low.
Most studies cited were publish before 2000.
Gender/Age & obesity
• The prevalence of obesity in males ranged from 10.5% to 39.2% and in females ranged from18.2% to 53%. Higher in female than male.
• The prevalence of obesity increased with age with the highest level in the middle age groups (30–39 and 40–49 years).
Gender/Age & DM
• Three studies showed higher DM rates among females, while three studies indicated the opposite. Four studies showed almost no difference in the prevalence of diabetes between genders
• The prevalence of diabetes rose proportionally with age and reached the highest rates in both sexes among those aged 55–64 years and over.
Gender/Age & HTN
• Rate of HTN in GCC states ranged from 26% to 50.7% in males and from 20.9% to 31.7% in females.
• Across all studies, the prevalence of HTN considerably increased with age with the highest rates in the 45–65 age groups.
Gender/Age & smoking
• The rates of cigarette smoking in the GCC ranged from 13.4% to 37.4% in males and from 0.5% to 20.7% in females.
• In females, the highest rates of smoking were in the older age group (40–49 years)
Gender/Age & physical inactivity
• Across all age groups physical inactivity was higher in females than males. The rates of inactivity ranged from 24.3% to 93.9% in males and from 50% to 98.1% in females in the GCC.
Summary:
Effective preventative strategies and education programs are crucial in the Gulf region to reduce the risk of CVD mortality and morbidity in the coming years.
2 (Alharbi et al., 2014) [20] Medline and Embase. From 1st January 1979 to 31st December 2011 • DM
• Obesity
Obesity and DM have been reported according to WHO criteria. DM
Kuwait (3) studies. Only one study reporting both type 1, type 2 DM on GP = 11.7%. 2 Studies type 2 DM only. First in PC = 8%. and the second on GP = 14.8%
UAE (3) studies. (2) studies on GP = 6%,11.1%
(1) Study not gender specific.
Oman (3) studies. 2 Studies on GP = 10.1%–11.3% for type 2 DM only. 1 study in both type 1 + 2 = 11.3%
Bahrain (1) study GP in both type 1, 2 DM =13.4%.
Qatar (1) study GP in both types 1, 2 diabetic =18.1%.
KSA (10) studies.
7 Studies reporting both type 1, and 2 DM from which 6 studies on GP = (13.8%, 13.8%, 17.1%, 17%, 18.3%, 21.5%). & 1 study on PC = 29.2%.
3 Studies reporting type 2 DM only from which 2 Studies on GP = (11.9% 12.2%) & 1 Study in PC = 30.9%.
Obesity
Kuwait (3) studies. 2 Studies in PC = (32.2%–40.6%), 1 study on GP = 34.9%.
UAE (2) studies on GP = (27.5%-16%)
Bahrain (2) studies on GP = (31.4% -53.2%)
KSA (6) studies.
2 Studies in PC = (43.9%, 40.5%)
1 study among SP = 20.8%
(3) Studies on GP = (24%, 55.2%, 49.2%).
Oman (1) Study on GP =4 9.5%
The majority of the studies reviewed did not distinguish between type 1 and type 2 DM, and the studies reviewed displayed heterogeneity of methods, sample size, and age range.
Insufficient data on the prevalence of obesity in adults to observe a clear trend occurring over time.
Most studies cited published before 2000
Gender & DM
Despite the rise in the prevalence of diabetes among Saudi women and men between 1980 and 2012 however, the trend more with men than women. They also address the need of urgent intervention such as the implementation of prevention, health promotion, and improved DM management systems.
Summary: Diabetes and obesity have a higher prevalence in GCC. Among the Saudi population, the prevalence of diabetes increased from 10.6% in 1989 to 32.1% in 2009.
3 (Alhyas et al., 2012) [23] Medline and Embase from 1982 and 2009. • DM KSA (total 11 study only 6 reported the gender) national All studies have been conducted on GP sample size ≥1000
DM
KSA (6) Studies = (5.9%, 3.6%, 11.8%, 9.8%, 4.53%, 21.5%)
UAE (4) studies. 3 studies =2.58%,22.1% 22.3%,
1 study by age
Age 20–29 = (1.7%)
Age 30–39 = (5.3%)
Age 40–49 = (26.2%)
Age 50–59 = ((27.1%)
> 60 yr. = (43.3%)
Bahrain(1) study
Age 50–59 = (35.4%)
Age 60–69 = (37.6%)
Oman (3) Studies = (10%, 11.3% 11.3%)
Qatar (1) Study = (18.1%)
The major limitation of this studies was heterogeneity of the reviewed studies, and variable availability of sub group data.
Most studies cited published before 2000.
Gender/Age & DM
• Five studies included studies were in favor of a male. However, in nine further studies, higher prevalence, of undetermined significance (or close to significance was observed in females. A further three studies showed no significant gender difference.
• Most of the studies demonstrated a significant association between advancing age and prevalence of DM
Summary:
The prevalence of DM is an increasing problem for all GCC states. They may therefore benefit to a relatively high degree from co-ordinated implementation of broadly consistent management strategies.
4 Musaiger and Al-Hazzaa 2012 [22] PubMed and Google Scholar databases / between January 1, 1990 and September 15, 2011 was /102 • DM
• HTN
• High TC
• Smoking
• Physical inactivity
• Obesity/ Overweight/
• MetS
WHO definitions
HTN (BP ≥140/90 mmgHg
TC: 5.2 mmol/dl; %
Physical inactivity define as participating in PA ≤ 10 min.
All the studies has been conducted on GP
DM
Kuwait (1) study = 14.8%
KSA (1) study = 21.7%
Oman (1) study = 12.3%
Qatar (1) study = 11%
HTN
Kuwait (1) study =19.7%
KSA (1) study = 18.5%
High TC
Kuwait (1) study =37.2%
KSA (1) study =19.7%
Smoking
Kuwait (1) study = 3.0%
KSA (1) study = 1.2%
Physical inactivity
Kuwait (1) study = 71.7%
KSA (1) study = 74.3%
Overweight
KSA (1) study = 28.8%
Oman (1) study = 27.2%
Kuwait (1) study = 28.9%
Bahrain (1) study = 31.1%
Obesity
KSA (1) study = 50.4%
Oman (1) study = 22.3%
Kuwait (1) study = 53%
Bahrain (1) study = 40.3%
No limitation subhead was provided in this review.
Only national data used in this review.
No standardized tools in reporting the results which makes it difficult to establish accurate results.
Gender/Age & DM
• In general, the prevalence rates in men and women were very close
• Age-standardized adjusted estimates for raised blood glucose in the EMR countries showed the highest prevalence among Saudi men and women (20 years and older) at 22% and 21.7%, respectively.
Gender/Age & obesity
• Women in the GCC were more obese than men.
• Obesity was found high even among the children.
Gender/Age & MetS
• The prevalence MetS in the GCC was some 10%–15% higher than in most developing countries, with a higher prevalence among women. The proportion of metabolic syndrome in the GCC ranged from 20.7% to 37.2% (ATP III) definition, and from 29.6% to 36.2% using (IDF) definition.
Summary:
Several risk factors may be contributing to the high prevalence of N-NCDs in EMR, including nutrition transition, low intake of fruit and vegetables, demographic. Transition, urbanization, physical inactivity, hypertension, tobacco smoking, stunting of growth of preschool children, and lack of nutrition and health awareness.
Many EMR countries have been reporting the onset of DM in increasingly younger age groups.
Intervention programs to prevent and control N-NCDs are urgently needed, with special focus on promotion of healthy eating and physical activity.
5 Alhyas et al., 2011) [24] Medline and Embase from 1950 to July week 1 2010, and 1947 to July 2010 • Obesity/ Overweight
• DM
• HTN
• High TC
Overweight
(if not25 to < 30) Obesity (if not ≥30)
Obesity
Kuwait (3) Studies. 2 Studies in PC 40.6%, 29.9% & 1 study WP = 32.2%,
KSA (6) studies. 3 studies in PC = 49.15%, 47.0%, 40.5%
3 Studies on GP =23.6%, 26.6%, 23.97%
Bahrain (2) Studies from GP =31%–33.2%
UAE (4) Studies.
2 Studies GP = 16%,40%
1 Study SP 9.8%, &
1 study PC: 46.5%
Overweight
KSA (6) Studies. 3 Studies on GP = 28.4%, 29.4%, 29.09%
3 Studies in PC =31.55%, 26.8%, 31.5%
Kuwait (3) Studies. 2 Studies in PC (59.2%, 72.9%) and 1 study on WP: 32.8%.
Bahrain (2) Studies on GP = (29.4%–32.7%)
UAE (2) studies on GP = (27%, 35%)
Heterogeneity of the reviewed studies.
Make only crude observation, and could not provide measures of confidence in the outcomes.
The quality of reporting of results is also variable.
Most studies cited were publish before 2000.
They include School student population in their study in the same table with adult population.
This study concentrated mainly on obesity and DM. The rest of CVD risk factors such as HTN and Hyperlipidaemia and their result have not been included as they reported the prevalence in both genders.
Gender/Age & obesity/overweight
• prevalence of obesity and overweight was higher in women in most of the studies, and 1 study where overweight was higher in men, indeed, the combined prevalence of overweight/ obesity remained
higher in women
• Age as a potential predictor of prevalence of over- weight/obesity was considered in eight studies (of adult populations) specially from age,36 and a significantly higher mean BMI in a 45–54-year age group versus a 55–64-year age group
Summary:
There is high prevalence of risk factors for diabetes and diabetic complications in the GCC region, indicative that their current management is suboptimal. Enhanced management will be critical if escalation of diabetes-related problems is to be averted as industrialization, urbanization and changing population demographics continue.
6 (S. W. Ng et al., 2011) [28] Medline database, PubMed Central, Academic OneFile, LexisNexis ® Academic, Google Scholar,
WHO InfoBase and manual cross references from retrieved articles. English language between 1st January 1990 and 31st June 2009
• Obesity/overweight
• HTN
• DM
WHO definition was used: overweight
(25 BMI < 30) obese (BMI 30)
All studies have been conducted on GP sample size ≥1000
Overweight/ obesity Oman
(1) Study = (23.8%)/ (27.3%)
Bahrain
(1) Study = (28.3%)/ (34.1%)
UAE
Only obesity was reported (1) Study = (39.9%)
KSA
(1) Study = (27.6%/ 43.8%)
Qatar
(1) Study = (33%/45.3%)
Kuwait
(1) Study = (29.5%/47.9%)
HTN
* self-report.
** Measured HTN
UAE (2) Studies = (7.8%, 11.2%)*
Measured HTN = (32.4%)**
Saudi Arabia (1) Study. Age 30–70 yrs. = (33.5%)**
Bahrain (1) study
Age 40–59 yr. s = (37.4%)**
Qatar (1) Study
Age 25–65 = (31.7%)**
Oman (3) Studies = (6.1%)*, (26.3%)**, (31.1%)**
DM
* self-report.
** Measured DM
UAE (3) Studies = (5.2%)*, (12.1%)* (53.1%)*
KSA (2) Studies = (20%) **, (17.2%)*
Bahrain (1) Study = (36.4%)**
Oman (3) Studies = (9.7%) **, (11.8%) **, (3.3%)*
The only limitation that reported was the comparison of the prevalence trend for children and adolescents which is difficult due to differing standards used. Gender/Age & Obesity/Overweight
• Gender differential in the prevalence of overweight and obesity, with women having notably higher rates than men, particularly starting from their mid-20s.
• Obesity is common among women; while men have an equal or higher overweight prevalence.
• Among adults, overweight plus obesity rates are especially high in Kuwait, Qatar and Saudi Arabia, and especially among 30–60 year olds
Gender/Age & HTN
• The prevalence of HTN rose with age for all cohorts across all the countries with nationally representative data broken down by age groups.
Gender/Age & MetS
• Certain populations, such as Saudis, older Qataris and women in general appear have particularly high rates of MetS.
Summary:
• The UAE and Saudi Arabia have some of the highest prevalence and growth of hypertension.
• In the UAE, prevalence of self-reported DM more than doubled between 1995 and 2000. Similarly, seen in Saudi Arabia and Oman but wasn’t sharp increase.
• There is a need for continued surveillance of overweight, obesity (by various grades, not just BMI >30) and N-NCDs, particularly from nationally representative samples using clinical measures over self-report. N-NCDs are largely preventable.
7 (Musaiger, 2011) [21] Published in English between January 1990 and May 2011 using Medline database, PubMed Center, Google Scholar, and WHO Info Base was carried out. Health ministry and other official reports which included the prevalence of overweight and obesity among preschool children, school-aged children, adolescents, and adults were also covered. • Obesity/ Overweight They include national big sample size studies
All adult included studies used WHO definition of obesity
All the studies have been Studies conducted on GP.
Obesity
Bahrain (1) Study = (40.3%)
Kuwait (1) Study = (53.0%)
Oman (1) Study = (22.3%)
KSA (1) Study = (50.4%)
Overweight
Bahrain (1) Study = (31.1%)
Kuwait (1) Study = (28.9%)
Oman (1) Study = (27.2%)
KSA (1) Study = (28.8%)
No limitation subhead was provided in this review. Gender & Overweight/ Obesity
• Obesity is more prevalent among women in all countries of the EMR. The mean BMI for women is higher than that for men in all countries in the EMR.
Summary:
Among adults the prevalence of overweight and obesity ranged from 25% to 81.9%. Possible factors determining obesity in this region include: nutrition transition, inactivity, urbanization, marital status, a shorter duration of breastfeeding, frequent snacking, skipping breakfast, a high intake of sugary beverages, an increase in the incidence of eating outside the home, long periods of time spent viewing television, massive marketing promotion of high fat foods, stunting, perceived body image, cultural elements and food subsidize policy.
In all high and middle income countries in the EMR, overweight and obesity has become a major public health problem, with a prevalence higher than many of developed countries. This creates the need for urgent action to prevent and control obesity in EMR countries.
A national plan of action to overcome obesity is urgently needed to reduce the economic and health burden of obesity in this region.
8 (Akl et al., 2011) [58] Electronically searched the following databases in June 2008, MEDLINE (1950 onwards), EMBASE (1980 onwards), and ISI the Web of Science using no language restrictions. • Water pipe smoking They reported smoking & whoever tried to smoke a water pipe even if once. Water pipe Smoking
Kuwait (2) Studies = (3%, 1.9%)
Bahrain (1) Study = (3%)
KSA (1) Study WP = (11%)
UAE (1) Study = (3%)
Only four studies were conducted at national level
Variation in reporting the prevalence and type of smoking.
Only one study used validated tools to measure exposure to water pipe smoking.
All studies included were cross sectional in design and did not allow analyses for time trends.
Gender/Age & water pipe smoking
• Inconclusive evidence among genders.
• No age different was reported.
Summary:
While very few national surveys have been conducted, the prevalence of water pipe smoking appears to be alarmingly high among school students and university students in Middle Eastern countries and among groups of Middle Eastern descent in Western countries.
9 (Mabry et al., 2010b) [66] PubMed and CINAHL from 2003–2009 studies • MetS Definitions Third Adult Treatment Panel (ATPIII) of the National Cholesterol Education Program (NCEP-ATPII) and the international DM Federation (IDF) definitions are used
Sitting national GP and from PC
Only study reports from WHO
All the studies have been Studies conducted on GP.
MetS
KSA (1) Study on GP = ATPIII (42%).
Qatar (1) Study = ATPIII 32.1% & 37.7% (IDF)
Kuwait (1) = (36.1%) IDF
UAE (2) Studies = (24.2%, 42.7%) ATPIII, (45.9%) IDF
Oman(1) Study = (23%)ATPIII,(40%)(IDF)
This review focuses on Studies that are published in the English language. It is possible that additional studies are available within the grey literature (such as government reports of studies carried out by each country) as well in Arabic-language publications.
There was noticed variation in the methodological quality of the studies included, non-population base sample, use of un-validated measurement instruments, and varying physical activity definitions.
No standardized protocols provided.
Gender/Age & MetS
• Generally higher prevalence rates were reported in women.
• Studies in the GCC have reported a positive association between age and the prevalence of the MetS.
Summary:
Significant socio-demographic associations with the MetS identified in the individual studies include: age, women, higher income, lower educational, urban residence in Saudi Arabia, and rural residence in the UAE.
10 (Mabry et al., 2010a) [38] PubMed and CINAHL databases.
The years of starting the search not reported.
• Physical activity They include national big sample size All the studies have been Studies conducted on GP.
Physical Inactivity
KSA (3) studies = (34.3%, 73.7%, 98.1%)
Kuwait (1) study = (71.6%)
Qatar (1) Study = (60.5%)
Bahrain (2) Study = (93%, 98.7%)
UAE (1) Study = (50.7%)
This review focuses on Studies that are published in the English language. It is possible that additional studies are available within the grey literature (such as government reports of studies carried out by each country) as well in Arabic-language publications.
Included only the national population in the sample. Given that the percentage of non-nationals living in the GCC states varies from 27% to 80%.
The prevalence of sufficient physical activity in the overall adult population (including both national and non-national residents) may differ from what has been reported.
variation in the methodological quality of the studies, including non-population-based sampling,
Use of un-validated measurement instruments, and varying physical activity definitions.
Lack of standardized study protocols, make it difficult for cross-country comparisons
Gender/Age & physical activity
• Men were significantly more active than were women
• The correlation of physical activity with age was less clear.
Summary:
Prevalence estimates for participation in physical activity in the GCC States are considerably lower than those for many developed countries. Given the increasing prevalence of overweight and obesity and associated chronic diseases in the GCC States, and with physical inactivity being an important and modifiable risk factor, health promotion strategies should aim to increase physical activity among both men and women as a priority public health issue.
11 (Motlagh et al., 2009)
[26]
MEDLINE/PubMed was conducted for articles published from January 1980 to April 2005 in the Middle East region • DM
• Obesity
• HTN
• Smoking
Obesity WHO (BMI >30 kg/m2)
DM used WHO definition
HTN (SBP ≥ 140 mmHg)
All studies have been conducted on GP sample size ≥1000
Obesity
Kuwait (3) Studies = 29.9%, 30%,40.6%
Oman (4) Studies ranged =17.7%–49.5%
Qatar (1) study = 45.3%.
KSA (6) Studies ranged = 20.3%–32.8%
DM
Kuwait (1) study = 21.8%
Oman (2) Studies = 9.8%,11.3%
KSA (5) Studies ranged = 3.6%–21.55%
HTN
Oman (1) Study = 18.7%
Qatar (1) study =31.7%
KSA (2) Studies ranged =3.2%,22.1%
Smoking
Bahrain (1) study
= 9.2%
Kuwait (2) Studies =1.4%,1.9%
Oman (2) Studies = 0.5%,1.6%,
Qatar (1) study = 11.6%
KSA (3) Studies ranged =0.9%–1.0%
Studies included in this review varied in study design, population include definition of risk factor.
Most studies cited were published before 2000.
No definition for the HTN has been given.
Lack of standardized definitions of dyslipidaemia limits ability to provide summary estimates for this risk factor.
No difference in diabetes between gender
2 studies association between HTN and obesity.
Low prevalence of Smoking was reported due to smoking being culturally unaccepted Underreporting may occur.
Gender & reported CVD risks
• Smoking was more common in men than women, whereas obesity and hypertension were more common in women.
Summary:
Middle East region (GCC specifically) was considerably higher among women compared with the men. Although the exact cause of such sex variations is not entirely clear, it has been reported that women are less active compared with men in certain areas. Physical and cultural barriers to physical activity have been reported among women in Saudi Arabia.
  1. *Self-reported
  2. **Measured
  3. Abbreviations: MetS Metabolic syndrome, DM Diabetes Mellitus, EMR Eastern Mediterranean region,NR Not Reported, GCC Gulf Cooperation Council, KSA Kingdom of Saudi Arabia, UAE United Arab Emirates, M/F Male/Female, SP Student Population, PC Primary clinic, GP General Population, WP Working Population, TC Total Cholesterol, N-NCDs Nutrition related non-communicable diseases