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

Cardiovascular diseases (CVD’s) remain the leading cause of death worldwide [1], resulting in more than 17.9 million mortalities in 2015. More than 3 million of such deaths occurred in people under the age of 60, which could have been largely prevented [1, 2]. The World Health Organization (WHO) and other organizations such as the American Heart Association (AHA) have recognized many risk factors, some of which are modifiable. These include hypertension (HTN), diabetes, obesity and metabolic syndrome (MetS) [3, 4]. In addition, many unhealthy lifestyles like smoking, physical inactivity, high consumption of carbohydrates and fatty foods have been identified as factors that increase the risk of CVD [5]. Rapid economic growth as well as urbanization have been also associated with higher consumption of unhealthy foods and lower physical activity, which may increase the risk of CVD [6].

The Gulf Cooperation Council (GCC) is a political and economic alliance of six Middle Eastern countries that includes the Kingdom Saudi Arabia (KSA), Bahrain, Oman, Qatar, the United Arab Emirates, (UAE) and Kuwait. The GCC was established in 1981 to ensure mutual investment and free trade between its member countries. This agreement also contributed to improvements in several fields including: education, culture, tourism, social opportunities, and health among member states [7]. Life in the GCC has changed dramatically after the discovery of oil, which became the main revenue for financing healthcare services. However, the recent fluctuation in the price of oil has affected the healthcare budget. Although GCC countries are examining different options to finance the healthcare service, up to this point, there is no clear alternative or implemented approach to achieve this goal [8, 9]. In 2013, Chahine et al., calculated the direct and indirect costs of five selected non-communicable diseases (NCD) in the GCC was $36.2 billion, where specifically, the cost of CVD and diabetes reached over $11 billion. This cost is estimated to increase to $67.9 billion by 2022, which is equivalent to one and a half times the healthcare budget of the six governments (see Table 1: The direct and indirect factors of the five selected NCDs in the GCC) [10]. However, with these healthcare expenses, the current healthcare systems adopted by some of the GCC countries is below what is available in middle-income countries [9].

The prevalence of CVD risk factors, especially physical inactivity and obesity, is particularly high among women in the region [11]. This is highlighted by a report published by the Gulf Registry of Acute Coronary Events, which found that among 7900 patients with acute coronary syndrome, women had significantly higher prevalence of HTN, diabetes, and hyperlipidemia compared to men. Women were also diagnosed with unstable angina and non-ST-segment elevation myocardial infarction more frequently than men [12, 13]. Beside, women at higher risk especially in third world countries due to less access to health service, and use of medications [14]. In addition, growing evidence shows that gender inequality in income, education, health care, nutrition and political voice are strongly associated with poor health and well-being [15], making these issues extremely relevant to Arab countries in general and GCC in particular, where gender inequality is substantial [11, 16]. Such inequalities are reflected in the literature; studies focusing on women in GCC countries are limited, despite the magnitude of the problem. This review aims to provide a comprehensive overview of the modifiable CVD risk factors among women in GCC in order to inform clinicians and decision-makers in the region.

Electronic literature searches for all systematic reviews published from January 2000 to February 2016 were conducted to identify all systematic reviews of CVD risk among women in the GCC region. The search was carried out in the following electronic databases: Medline, Google Scholar, and Cochrane Database (see Table 2 for search terms). No language restrictions were applied. Throughout this review, special attention was given to the modifiable risks such as HTN, diabetes, obesity, MetS, physical inactivity and smoking. Unhealthy diet, although a known CVD risk factor, was not explored in this study. The effect of diet on health is complex and different studies have focused on either overall diet patterns or individual components that include salt, sugar, fat content, fruit and vegetables, also, Also the problem with an acceptable definition of healthy diet. Hence, a comprehensive assessment of unhealthy diet would warrant a separate review. We included all systematic reviews that reported the prevalence of CVD risk factors among women in the GCC region countries. We excluded studies that reported combined data for both genders without separate prevalence for women. However, all included studies that reported the differences between genders were documented to compare gender differences in the prevalence of CVD risk factors. Any other systematic reviews from the Middle East and North Africa that included any individual GCC countries were also included. Abstracts of reviews were inspected by two authors (MA, HA) and those appearing to meet the inclusion criteria were retrieved and read in full by both authors (see Fig. 1). The quality of those studies was assessed by two authors using the Assessment of Multiple Systematic Review Tool (AMSTAR), a tool which has been validated as a means to assess the methodological quality of systematic reviews [17]. It uses an 11 point scale, where the maximum score is 11. Scores 0–4 indicate low quality, 5–8 moderate quality, and 9–11 high quality [18]. The data has been extracted independently by two researchers (MA, HA). Any disagreements were resolved by discussion between them (See Table 3: Quality assessment for reviewing the systematic reviews (AMSTAR®).

Thirteen out of 88 systematic reviews were deemed to meet inclusion criteria; however, two of them were excluded as they report results for both genders combined [19, 20]. As a result, only 11 of them were considered in this paper (See Figure 1). The majority of these studies are conducted in Saudi Arabia (Table 4). The quality of most of them was moderate according to the AMSTAR criteria [18]. Three studies were identified as low quality [21‐23] and one as high [24]. (See Table 3 for more information).

Our review showed that the prevalence of major lifestylerelated risk factors for CVD is very high among women in GCC countries and seem to be increasing over the past decades.

Obesity among Arab women is highly prevalent, with the greatest increase reported in the literature among Middle Eastern countries in the six GCC countries [34]. The prevalence of obesity among women in GCC countries is higher than in countries such as Iraq, Libya, Algeria as well as European countries [35]. With regards to the marital status, married women within the GCC are more susceptible to obesity than unmarried one [35]; one of the possible reasons is that married couples are less active and tend to eat together, which may reinforce increased food intake [36]. The WHO has announced that Gulf countries have the highest prevalence of obesity, mainly among Kuwaiti, KSA, and Bahraini women [37]. The Middle East is recording the fastest increase in obesity prevalence over time, with more women than men being obese [34]. This may be attributed to multiple factors; for example the majority of households in this region, especially in Kuwait and Saudi Arabia, commonly hire housemaids which could lead to low activity and sedentary lifestyle [38]. In addition, high consumption of fast foods (high in fat and carbohydrates) combined with a sedentary lifestyle which are norms in today’s GCC have played an important role in increasing levels of obesity in recent years [39, 40]. Multiple pregnancies can also contribute to weight gain, as women may retain an average of 4.5kg after each birth [41].

Physical inactivity is a global public health problem. Around 31% of adults aged 15 and over were insufficiently active in 2008, with women being less active than men (34% vs 28%) [42]. Physical inactivity is very common in the Muslim world especially among Arabs. Based on data from 163,556 participants in 38 Muslim countries, Arab women were more likely to be physically inactive than non-Arab women (Odds Ratio=2.15, 95% CI: 2.09–2.21) [43]. Also, in a study conducted by Daryani et al, Arab immigrants in Sweden reported a higher prevalence of abdominal obesity than Swedish-born women, and a high degree of physical inactivity during leisure time, highlighting potential cultural factors [44]. Sedentary lifestyle is very common, especially among women in the Middle Eastern countries. This could be due to various reasons. In countries such as Saudi Arabia, physical education was not included in the public girl’s school curriculum until early 2013 and women are still forbidden from driving, which limits their access to fitness centers [45]. Other barriers may include the desert climate, high temperatures and frequent sand storms, which makes it difficult to exercise outdoors, the lack of social support, and the common use of cheap migrant labor for household work [46].

Diabetes is a complex disease that is linked between multiple genetic and environmental factors including diet, lifestyle, and obesity [47]. Several studies show that Arabs have a greater genetic predisposition to diabetes than Caucasians [48, 49]. In Saudi Arabia, like other GCC countries, the prevalence of consanguinity is as high as 60%, which is considered the highest rate of consanguineous marriages in the world [50, 51] and has contributed to the high prevalence of diabetes within the GCC countries [52, 53]. Additionally, the fast urbanization and increased per capita income have had negative influences on GGC lifestyle resulting in increased sedentary lifestyle, leading to obesity [54]. Obesity is a major risk factor for developing diabetes, where in many cases, more than half of the diabetic patients were found to be obese [55, 56]. From a cost perspective, Saudi Arabia spends 21% of their total health expenditure on diabetes, with other GCC countries spending between 16 and 19% [57].

The prevalence of HTN was also high among women in GCC countries. Data from the Second Gulf Registry of Acute Coronary Events (Gulf RACE-2) showed that 47.2% of the registered individuals were hypertensive, and women were more likely to have HTN than men [13, 58]. In 2014 El Bcheraoui et al., reported the prevalence of HTN from a large national health survey of more than 10,000 households throughout KSA. The overall prevalence was 15.2% of those with hypertension were found to be undiagnosed [59]. Underreporting should not be ruled out, as many of the studies included collected self-reported data [28]. Likewise, a study published in Saudi Arabia also showed that almost 40% of people affected by HTN were unaware of their disease at the time of the survey [60].

Low prevalence of smoking among women in the GCC countries could be an indication of under reporting, as smoking cigarettes traditionally is not accepted among Arab Muslim women, especially in the GCC countries [61]. In contrast, the acceptance and popularity of water pipe smoking is very common among Arabs in general, especially women [62‐66]. There is also a false perception that water pipe smoking is less harmful than cigarettes [67]. Up to this point, the data shows a growing trend of women smoking water pipes in the GCC countries, but it is still less than other neighboring Arab countries [32].

The high prevalence of lifestyle-related diseases among women population in GCC is a ticking time bomb and is reaching alarming levels, and require a fundamental social, cutural and political changes. These findings highlight the need for comprehensive work among the GCC to strengthen the regulatory framework to reduce and control the prevalence of these factors.