Mohamad M. Almedawar

Lifetime cumulative exposure to waterpipe smoking is associated with coronary artery disease

OBJECTIVE Globally, waterpipe (WP) smoking is becoming a more prevalent form of tobacco consumption. Whilst research so far has demonstrated a significant link between WP use and a number of health outcomes, little is known of its association with heart disease. We examine in this study the association of WP smoking with angiographically confirmed coronary artery disease (CAD). METHODS A total of 1210 patients, aged 40 years and over and free from smoking-associated illnesses or history of cardiovascular procedures, admitted for coronary angiography at four major hospitals in Lebanon, were included. The extent of CAD was summarized in two ways, firstly as diseased (≥ 50% and ≥ 70% occlusion in at least one main coronary artery) versus non-diseased (entirely normal coronaries), and secondly, as CAD cumulative score based on Duke CAD Prognostic Index. A score of WP-years, capturing intensity and lifetime duration of exposure, was estimated for each individual. RESULTS Lifetime exposure exceeding 40 WP-years was associated with a threefold significant increase in the odds of having severe stenosis (≥ 70%) compared to non-smokers (OR = 2.94, 95% CI 1.04-8.33) as well as with the CAD Index (β = 7.835, p-value = 0.027), net of the effect of socio-demographic characteristics, health behaviors and co-morbidity. A dose-response relationship between WP-years and percent stenosis was also established. WP smoking status (never, past and current) did not associate with CAD. CONCLUSIONS Cumulative exposure to WP smoking is significantly associated with severe CAD. There is a need to monitor WP use among cardiac patients and include this information in their medical charts in the same manner cigarettes smoking is documented. This is likely to increase awareness of the hazards of WP smoking and prompt physicians to target WP tobacco control by providing advice to their patients on WP smoking cessation.

Consumer Knowledge, Attitudes and Salt-Related Behavior in the Middle-East: The Case of Lebanon

Sodium intake is high in Lebanon, a country of the Middle East region where rates of cardiovascular diseases are amongst the highest in the world. This study examines salt-related knowledge, attitude and self-reported behaviors amongst adult Lebanese consumers and investigates the association of socio-demographic factors, knowledge and attitudes with salt-related behaviors. Using a multicomponent questionnaire, a cross-sectional study was conducted in nine supermarkets in Beirut, based on systematic random sampling (n = 442). Factors associated with salt-related behaviors were examined by multivariate regression analysis. Specific knowledge and attitude gaps were documented with only 22.6% of participants identifying processed foods as the main source of salt, 55.6% discerning the relationship between salt and sodium, 32.4% recognizing the daily limit of salt intake and 44.7% reporting being concerned about the amount of salt in their diet. The majority of participants reported behavioral practices that increase salt intake with only 38.3% checking for salt label content, 43.7% reporting that their food purchases are influenced by salt content and 38.6% trying to buy low-salt foods. Knowledge, attitudes and older age were found to significantly predict salt-related behaviors. Findings offer valuable insight on salt-related knowledge, attitude and behaviors in a sample of Lebanese consumers and provide key information that could spur the development of evidence-based salt-reduction interventions specific to the Middle East.

Sodium intake reduction efforts in Lebanon

Sodium intake reduction efforts in Lebanon are quite recent and have just started to take effect on the national level. Starting out from an academic institution, the Lebanese Action on Sodium and Health (LASH) campaign was established to counter the increasing prevalence of hypertension and associated adverse health effects. The campaigns strategy was based on four pillars: research, health communication, advocacy, and monitoring. The LASH group set out with determining: baseline sodium intake of the population, main sources of sodium intake, and the knowledge, attitudes, and behaviors (KAB) of the population as a situation analysis that prompts for action. This gave LASH tangible evidence of the magnitude of the problem and the need for the government, the food industry, and the consumers, to be mobilized to take part in devising a solution. Currently, Lebanon is at a stage of technically working to reduce the sodium content in the major sources of sodium, namely local bread and bread-like products. The next steps will include implementation of a plan for monitoring industry compliance, while studying other food targets, including dairy products and processed meat. Meanwhile, the health communication plan is ongoing and the Salt Awareness Week is celebrated every year with media appearances of LASH researchers to raise the issue to the public eye.

Worsening of the Cardiovascular Profile in a Developing Country: The Greater Beirut Area Cardiovascular Cohort

BACKGROUND Lebanon has no established governmental noncommunicable diseases surveillance and monitoring system to permit reporting on noncommunicable diseases rates. The last World Health Organization-supported surveillance report showed worrying trends in cardiovascular disease (CVD) risk factors. OBJECTIVES A cardiovascular cohort was established to permit CVD outcomes studies in an urban sample in the Lebanese capital and the study in hand presents the baseline CVD risk factors of this cohort. METHODS A cross-sectional study was carried out including 501 Lebanese adults (64.3% women) from the Greater Beirut area using random multistage probability sampling. Interviews, physical exams, and blood withdrawal were conducted to collect information on demographic and lifestyle factors, body mass index, blood pressure, fasting blood glucose, blood lipids, as well as history of coronary artery diseases, hypertension, diabetes mellitus type 2, dyslipidemia, and stroke. Means with SD for continuous variables and frequencies and percentages for categorical variables are reported. RESULTS The prevalence CVD risk factors including obesity, smoking, diabetes mellitus type 2, hypertension, and dyslipidemia prevalence in the Greater Beirut area was higher than that reported for the general population. Important sex and age differences were also observed, whereby older participants and women had higher rates of obesity, diabetes mellitus type 2, and dyslipidemia and younger participants and men were engaged more in cigarette smoking and alcohol consumption. Interestingly, water pipe smoking was similarly prevalent among genders. CONCLUSIONS The overall prevalence of CVD risk factors in this urban population is higher than reported in the 2010 World Health Organization Stepwise Approach to Surveillance report on the Lebanese population, indicating that the urban population in the capital carries a higher burden of CVD risk. In addition, sex and age difference rates of CVD risk factors highlight the need for tailored public health measures to tackle the sex- and age-based CVD risk factors.

An Attempt to Halt the Ever-Increasing Prevalence of Morbidities Resulting from Excess Dietary Sodium Intake the Lebanese Experience

zation (WHO) on hypertension, one billion adults worldwide have been estimated to be affected, with an annual mortality of 9 million. Being the most common modifiable risk factor for cardiovascular disease and death, several worldwide initiatives are underway to prevent the fulfillment of the 2025 projections of 1.5 billion cases of hypertension [1,2]. A solid approach that has witnessed worldwide action and is still progressing with great momentum is the reduction of excess dietary sodium intake. Countless studies and trials have shown a positive relation between high sodium intake and risk of cardiovascular and renal disease [3-5]. Moreover, direct, independent relation to stroke [6], left ventricular hypertrophy [7], and proteinuria [5] have been documented, in addition to indirect relation to stomach cancer [8], obesity [9], increased risk of renal stones and osteoporosis [10], and severity of asthma [11]. To that effect, several health authorities have set guidelines for the optimal level of dietary sodium intake. The WHO have set the target intake at less than 5 g of salt or 2 g of sodium [12] while the Institute of Medicine (IOM) recommends an intake of 1.5 to 2.3 g [13] and 1.5 to 2.4 g of sodium per day as per the American Heart Association (AHA) [14]. On a global scale, implementation of the above guidelines has been ongoing for decades now by countries such as Finland and the United Kingdom through massmedia health campaigns, food reformulation by the food industry, and implementation of clear food labeling strategies [15]. The outcome of reducing 33% of sodium intake of the entire population of Finland was a staggering 80% drop in mortality due to stroke and coronary heart disease, concomitant with a fall of over 10-mm Hg in the population’s average blood pressure [16]. In the UK, similar measures and outcomes were observed and several governmental and non-governmental bodies such as the Consensus Action on Salt and Health (CASH), UK Food Standards Agency (FSA), and World Action on Salt and Health (WASH) were founded to implement and maintain the developed strategies [17]. In the last decade, dozens of countries have followed the trend, such as Canada, Australia, the United States, a dozen European countries, and many developing countries in Asia and Africa. In the Middle East, Kuwait is currently at the forefront of this endeavor as it has already reduced the amount of sodium added to bread during production by 20% in the last year. In Lebanon, the Lebanese Action on Sodium and Health (LASH) group was founded in 2012 as part of the Vascular Medicine Program (VMP) at the American University of Beirut (AUB). With the guidance of the WASH organization, LASH established its strategy to optimize sodium intake in the Lebanese population based on four pillars, namely, research, awareness raising, advocacy, and monitoring. The research was done in order to determine the current dietary sodium intake in the Lebanese population, estimated to be between 2.9 and 3.1 g, thus exceeding all set guidelines and upper limits [18]. On September 10-12, 2013, LASH participated in the workshop held by the World Health Organization Eastern Mediterranean Regional Office (WHO-EMRO) on salt and fat reduction and setting up protocols for measuring salt and fat intake and content in food, in Amman, Jordan. Research findings presented included the determination of the main contributors of salt in the Lebanese diet, which were found to be bread (26%), processed meat (12%). The average Lebanese intake of sodium was estimated to be between 2.9 and 3.1 g/day. Results of questionnaires about knowledge, attitudes, and behaviors (KAB) of Lebanese consumers regarding salt intake were also presented and reflected a poor knowledge of the effects of sodium on health and its sources in the diet and an unfavorable behavior of the consumers towards reducing their dietary intake. LASH also presented the obstacles Lebanon was facing at the time, primarily involving the government and the industry in planning a gradual reduction in salt levels in bread and other high-sodium processed foods that are widely consumed. This obstacle was starting to unfold when LASH held a press conference on March 11, 2014, on the occasion of World Salt Awareness Week, to announce the launch of the national campaign under the patronage of

Quantifying the impact of using Coronary Artery Calcium Score for risk categorization instead of Framingham Score or European Heart SCORE in lipid lowering algorithms in a Middle Eastern population

Background The use of the Coronary Artery Calcium Score (CACS) for risk categorization instead of the Framingham Risk Score (FRS) or European Heart SCORE (EHS) to improve classification of individuals is well documented. However, the impact of reclassifying individuals using CACS on initiating lipid lowering therapy is not well understood. We aimed to determine the percentage of individuals not requiring lipid lowering therapy as per the FRS and EHS models but are found to require it using CACS and vice versa; and to determine the level of agreement between CACS, FRS and EHS based models. Methods Data was collected for 500 consecutive patients who had already undergone CACS. However, only 242 patients met the inclusion criteria and were included in the analysis. Risk stratification comparisons were conducted according to CACS, FRS, and EHS, and the agreement (Kappa) between them was calculated. Results In accordance with the models, 79.7% to 81.5% of high-risk individuals were down-classified by CACS, while 6.8% to 7.6% of individuals at intermediate risk were up-classified to high risk by CACS, with slight to moderate agreement. Moreover, CACS recommended treatment to 5.7% and 5.8% of subjects untreated according to European and Canadian guidelines, respectively; whereas 75.2% to 81.2% of those treated in line with the guidelines would not be treated based on CACS. Conclusion In this simulation, using CACS for risk categorization warrants lipid lowering treatment for 5–6% and spares 70–80% from treatment in accordance with the guidelines. Current strong evidence from double randomized clinical trials is in support of guideline recommendations. Our results call for a prospective trial to explore the benefits/risks of a CACS-based approach before any recommendations can be made.