Lifestyle Interventions for Prevention and Management of Diet-Linked Non-Communicable Diseases among Adults in Arab Countries

The increased incidences of diet-related non-communicable diseases (NCDs) such as diabetes, obesity, and cardiovascular diseases among adults are becoming the chief public health concern in most Arab countries. Economic expansion has contributed to a nutrition shift from a traditional seasonal diet to Westernized eating habits coupled with a sedentary lifestyle. Despite the rising concern for NCD mortality, public health policies are inadequately addressed. This narrative review aims to discuss the effectiveness of nutritional interventions focusing on diet and physical activity in the management of NCDs among Arab adults. A comprehensive literature search was performed using different database platforms such as Cochrane reviews, Scopus, and PubMed for articles published between 1 December 2012 and 31 December 2021. Fifteen recent research articles addressing NCDs, mainly diabetes and obesity, from different Arab countries were included in this review. Structured lifestyle interventions involving behavioral therapy approaches and personalized goals for diet and physical activity were found to improve specific health outcomes in most studies. Significant improvements in health outcomes were reported for longer-duration interventions with follow-ups. A combination of both online and face-to-face sessions was found to be effective. It is important to identify barriers to physical activity for a culturally acceptable lifestyle intervention and conduct further studies to evaluate interventions for the long-term maintenance of health outcomes.


Introduction
Globally, non-communicable diseases (NCDs), such as cardiovascular diseases (CVD) and diabetes, are responsible for around 41 million deaths annually [1]. In 2016, unhealthy diets were categorized as the second risk factor contributing to the global burden of diseases, accounting for nearly 11 million casualties in 2017 [2,3]. Physical inactivity was also rated as one of the chief factors causing global mortality, amounting for over 1.3 million global deaths [4].
Regionally, increased incidences of type-2 diabetes, obesity, cancer, CVD, and other diet-related NCDs among adults are becoming the main public health concern in most Arab countries [5,6]. The intake of energy-dense foods is negatively influencing public health care and social and economic practices [5,6]. In 2008, 1.2 million deaths were recorded due to NCDs in Arab countries, amounting for 60% of all mortalities [7,8]. Furthermore, the mortality percentages from NCDs in fourteen Arab countries ranged from 73% to 89%, with Kuwait [25]. A comprehensive literature search was performed using the Google Scholar, ResearchGate, SpringerLink, Cochrane reviews, Scopus, and PubMed database platforms for relevant articles. Articles that were published in the past 10 years from 1 December 2012 to 31 December 2021 were considered in the review. The search terms used in combination included 'NCD prevention interventions' OR 'nutrition programs' OR 'nutrition interventions' OR 'lifestyle interventions' OR 'diabetes prevention programs' OR 'obesity prevention programs' OR 'heart disease programs' OR 'hypertension programs' AND 'Middle East' OR 'Arab countries' OR 'Arab Adults'. In addition, the names of some Arab countries (such as 'Egypt' OR 'Jordan' OR 'Oman' OR 'United Arab Emirates' OR 'Bahrain' OR 'Qatar' OR 'Saudi Arabia OR 'Tunisia') were included in the search to identify possible missed articles. The articles obtained from the search were assessed for topic relevance and hand-reviewed to further find related publications. Only articles that involved interventions for adults (18 and above) to combat diet-related NCDs, such as type 2 diabetes, obesity, or heart diseases, were included in this study. Studies evaluating different parameters as health-related outcomes were included, such as physical activity and dietary habits (or energy intake). Randomized and non-randomized studies involving intervention groups (with diet and/or physical activity) and control groups (without intervention or with placebo) were also included. In total, 1198 articles were identified in the initial search. After the removal of 144 duplicates, 1054 titles or abstracts were screened, where 952 of them were not deemed to be relevant and were excluded. The remaining 102 fulltext articles were further reviewed for eligibility, leading to the elimination of 87 full-text articles due to the inclusion criteria, as outlined in Figure 1. Therefore, 15 research articles were included in this narrative review.

Results
Fifteen lifestyle-intervention-based articles representing eight Arab countries, namely Bahrain [32], Egypt [33], Oman [34], the occupied Palestinian territories [35], Qatar [36], Saudi Arabia [24,28,[37][38][39][40], Tunisia [41], and the United Arab Emirates (UAE) [21,26,42], were incorporated in this review paper. The summarized data from the incorporated studies, including the region where the study was performed, the study design, the target group, the sample size, and the intervention characteristics (the name, duration, and measured components or health outcomes) are shown in Table 1.  IG: one-on-one intensive lifestyle modification sessions on weight decrease (5% from baseline), PA (4 h/week), dietary counseling on decreasing fat intake (30% and 10% of total energy for total and saturated fat) and increasing fiber intake (15 g/1000 kcal). CG: standard guidance.

Assessment of Diet and Physical Activity Levels
Nutrition knowledge and behaviors were mainly evaluated through standardized questionnaires corresponding to each program [21,24,26,33,[35][36][37]41]. The questionnaires were translated into Arabic to suit programs' needs [24,26,36,37]. A study by Al-Hamdan and his colleagues [24] assessed dietary intake using the Food Frequency Questionnaire (FFQ) [24]. The accuracy of the questionnaire was tested using approaches such as criterion-related validity, test-retest reliability, and internal validity [24]. On the other hand, Alfawaz et al. used 24 h dietary recall to assess overall calorie, micronutrient, and macronutrient consumption by applying a validated computerized food database, i.e., "ESHAthe Food Processor Nutrition Analysis program" [39]. A study in the UAE by Sadiya et al. involved both dietary recall and FFQ [21]. Another study by Bhiri and colleagues in Tunisia assessed dietary behavior using the default daily intake of five servings of vegetables and fruits [41].
Physical activity was also mainly evaluated through standardized questionnaires [24,26,33,34,39,41]. One such study in Oman conducted by Alghafri et al. involved the use of the Global Physical Activity Questionnaire (GPAQ) to evaluate self-perceived PA changes [34]. Moreover, this study used pedometers and accelerometers to objectively assess PA after one year of intervention [34].
The interventions in the studies conducted in Palestine and Saudi Arabia by Rashed et al. and Sani et al. were associated with significant improvements in diabetes knowledge among participants (p ≤ 0.001) [35,37]. Similarly, studies in Qatar, Tunisia, and the UAE by

Assessment of Diet and Physical Activity Levels
Nutrition knowledge and behaviors were mainly evaluated through standardized questionnaires corresponding to each program [21,24,26,33,[35][36][37]41]. The questionnaires were translated into Arabic to suit programs' needs [24,26,36,37]. A study by Al-Hamdan and his colleagues [24] assessed dietary intake using the Food Frequency Questionnaire (FFQ) [24]. The accuracy of the questionnaire was tested using approaches such as criterionrelated validity, test-retest reliability, and internal validity [24]. On the other hand, Alfawaz et al. used 24 h dietary recall to assess overall calorie, micronutrient, and macronutrient consumption by applying a validated computerized food database, i.e., "ESHA-the Food Processor Nutrition Analysis program" [39]. A study in the UAE by Sadiya et al. involved both dietary recall and FFQ [21]. Another study by Bhiri and colleagues in Tunisia assessed dietary behavior using the default daily intake of five servings of vegetables and fruits [41].
Physical activity was also mainly evaluated through standardized questionnaires [24,26,33,34,39,41]. One such study in Oman conducted by Alghafri et al. involved the use of the Global Physical Activity Questionnaire (GPAQ) to evaluate self-perceived PA changes [34]. Moreover, this study used pedometers and accelerometers to objectively assess PA after one year of intervention [34].
The interventions in the studies conducted in Palestine and Saudi Arabia by Rashed et al. and Sani et al. were associated with significant improvements in diabetes knowledge among participants (p ≤ 0.001) [35,37]. Similarly, studies in Qatar, Tunisia, and the UAE by  [21,26,36,41]. A study by Metwally et al. showed significant improvements in the mean scores of the studied behaviors compared to their pre-education levels, including dietary habits and physical activity [33]. Similarly, there were reductions in barriers related to diet, physical activity, medication adherence, and blood glucose monitoring in Egypt (p < 0.001) [33].
Other studies assessed the intake of specific food groups and nutrients [24,32,39,41,42]. A study in Saudi Arabia by Alfawaz and colleagues reported significant improvements in recommended dietary intake in the intervention group compared to the control group, especially in total carbohydrates (p = 0.003); dietary fiber (p = 0.002); and some micronutrients, such as vitamins B2 (p = 0.01), B3 (p < 0.001), B12 (p = 0.041), B6 (p < 0.001), vitamin E (p = 0.003), phosphorus (p < 0.001), copper (p = 0.03), potassium (p = 0.01), magnesium (p < 0.001), sodium (p = 0.01), and iron (p = 0.01) [39]. Worksite-intervention-based studies in Tunisia [32] and Bahrain [41] reported increments in fruit and vegetable intake among their respective participants after three years and six months of the programs [32,41]. A healthcare-setting-based intervention study in the UAE by Abdi et al. also reported increased fruit intake in the intervention but not in the control group after six months [42]. However, vegetable intake did not significantly improve in either group six months after the intervention started [42]. Healthcare-setting-based studies in the UAE and Saudi Arabia by Abdi et al. and Al-Hamdan et al. showed significant reductions in refined carbohydrate and total calorie intakes [24,42]. A study in Bahrain by Al Saweer et al. indicated a decreased intake of fat among employees, similar to the study in Saudi Arabia by Al-Hamdan et al., which also found significant reductions in fat intake in both the intervention and control groups after six months [24,32].
In the worksite-and healthcare-setting-based interventions conducted in Bahrain and Egypt by Al Saweer et al. [32] and Metwally et al. [33], significant increases in physical activity (p < 0.01) were reported among participants 6 and 12 months after the intervention [32,33]. A study by Bhiri et al. in Tunisia reported significant improvements in physical activity behaviors (p < 0.001) in both the intervention and control groups after the three-year worksite intervention [41]. Studies in Saudi Arabia and the UAE by Alfawaz et al. and Ali et al. showed that the intervention groups had significant improvements in moderate and vigorous physical activity levels and their frequency [26,39]. However, a study by Al-Hamdan et al. [24] in Saudi Arabia found no significant difference in physical activity levels in females when comparing within and between the groups [24]. Moreover, a UAE-based study by Abdi et al. [42] evaluated self-reported physical activity and found a non-significant increase in physical exercise levels (min/day) over the six month intervention period [42]. Further, as previously mentioned, a study by Alghafri et al. used pedometers and GPAQ to report changes after 12 months [34]. Although both groups showed constants increases in physical activity levels, the intervention group experienced a considerably greater mean increase from baseline than the control group at 12 months [34].

Discussion
This review evaluates the effectiveness of lifestyle interventions among adults in the Arab region based on the interventions' effects on modifiable health indicators. Overall, intensive lifestyle interventions involving behavioral therapy approaches and personalized goals related to diet and physical activity were found to improve specific health outcomes in most studies [21,24,28,32,33,35,36,38,39,41,42].
Hence, interventions are aimed to focus on diabetes and obesity management to reduce the burden of such diseases on the health and economic systems in Arab countries over the coming years [29,43,44,48,49].
Intervention studies in Tunisia, Bahrain, Saudi Arabia, Egypt, and the UAE that involved and assessed both dietary habits and physical activity behaviors showed improved health outcomes [26,32,33,39,41]. Although some studies assessed dietary behavior and various habits, physical activity was not assessed as a health indicator [21,35,36]. In contrast, a study in Oman by Alghafri et al. focused on and assessed physical activity, but not dietary habits, and did not find significant changes in body weight, BMI, or HbA1c between the two groups after 12 months, despite being a multicomponent intervention that used a behavioral therapy approach [34]. Likewise, previous studies in obese patients have shown that interventions focusing only on physical activity may have small to modest impacts on body weight compared to a combination of both dietary and exercise-based interventions [50][51][52][53][54][55]. The latter studies showed that participants achieved around 5-11% weight loss with improvements in controlling obesity-linked comorbidities such as asthma, osteoarthritis, or metabolic anomalies linked with metabolic syndrome [50][51][52][53][54][55]. A systematic review evaluating 66 programs found that a combination of nutrition and physical activity programs was successful at reducing the incidence of diabetes and enhancing cardiometabolic risk factors in people at elevated risk [56]. Combining diet and exercise is most favorable for improving metabolic regulation and lowering body weight compared to diet or exercise alone [57][58][59][60]. This pairing regulates energy intake and creates a negative energy balance by increasing the expenditure of energy [57][58][59][60]. Hence, this emphasizes the need for multicomponent behavioral interventions to improve health outcomes.
Studies in the UAE and Saudi Arabia also reported significant weight loss (≥4-5%) among participants post-intervention, with program durations varying from 12 weeks to a year [21,28,38]. A one-year follow-up study by Sadiya et al. revealed sustained weight loss and improvement in other health outcomes, such as HbA1c, which was further reduced compared to the post-intervention results after three months [21]. Programs entailed strict diet plans (1200-1500 kcal/day), nutrition modification (total dietary fat < 30% of energy and fiber intake of 15 g/1000 kcal), physical activity (≥150 mins/week or ≥5000 steps/day), and behavioral therapy to achieve targeted weight loss of 5% more [21,28,38]. Moreover, these studies involved intensive lifestyle interventions that incorporated behavioral change by including individualized consultations as per participants' needs when making customized goals and sessions educating patients on the self-monitoring and self-management of their respective diet-related NCDs [21,28,38]. Furthermore, lifestyle intervention studies in Egypt, Qatar, Saudi Arabia, and Tunisia [28,33,34,36,41] conducted for a year or more revealed significant improvements in weight, BMI [28,33,36], and/or significantly improved health outcomes (lipid profile, blood pressure, HbA1c, diet, physical activity, and nutrition knowledge) [33,36,41]. A review involving eight studies revealed that significant longer-term weight loss was observed after a year of combined behavioral weight management interventions involving diet and physical activity [53]. Hence, intensive lifestyle interventions inducing behavioral change for a year or more, coupled with regular follow-ups, could improve health outcomes, such as weight or BMI, as shown in previous studies [50,53,[61][62][63][64][65][66].
Most programs were performed face-to-face [21,24,28,32,33,35,36,[38][39][40][41]. Some studies entailed both telephone/mobile-based and face-to-face interventions [34,37,42], whereas only one study was completely mobile-based [26]. Behavioral therapy (nutrition education, a cognitive behavior approach, goal setting, and monitoring) is an essential component that was carried out by qualified dieticians and healthcare professionals either in-person or via technology (individual or group sessions) [59,60,[67][68][69]. The use of technology (such as phone calls, phone apps, social media, online appointments, and online meeting sites) can be a useful alternative [59,60,[67][68][69]. Hence, interventions with both online and face-to-face delivery modes showed improved behavioral outcomes [34,37,42]. This was similar to previous studies in the United States (US), Canada, the Netherlands, and Australia that evaluated the modes of delivery of interventions and reported that a combination of both online and face-to-face sessions is effective and convenient, considering the current COVID situation, where remote work is a valid option [70][71][72][73]. This is supported by a recent study evaluating the effectiveness of different delivery strategies of weight loss programs, where more participants in the hybrid app and face-to-face program lost 5% or more weight in comparison to the app group alone, demonstrating beneficial outcomes in supporting health experts while decreasing their workloads [74].
Most of the studies reported herein used questionnaires to assess physical activity levels or dietary habits and behavior, which can result in subjective responses by the participants [21,24,26,33,[35][36][37]41]. Moreover, two randomized control trial based studies claimed to have assessed self-perceived or self-reported physical activity after the completion of the program [34,42]. Thus, bias related to self-reports is the main limitation of these studies. This highlights the need for standardized and validated measures for assessment to ensure consistent reporting and for comparison between studies [23,25]. Standardized interviews can be performed when managing the questionnaire to reduce under-or overestimating and guessing responses, which can occur when participants complete questions by themselves [75].
Studies in Palestine and Egypt reported sociodemographic differences between participants, where more women compared to men were found to be obese and showed limited participation in physical activity during program implementation due to sociocultural and environmental barriers [33,35]. Physical inactivity is becoming increasingly prevalent, particularly among Arab women, where sociocultural and economic barriers were reported [21][22][23][24][25]. In developing Arab countries, such as Egypt, being fat is thought to be a sign of affluence and beauty [33]. Hence, programs that promote awareness and education and emphasize the importance of diet and physical activity are incumbent in developing countries. Studies in the UAE and Saudi Arabia reported non-significant changes in physical activity after the program concluded, despite the improvement in dietary habits and behavior for 6-month durations in these studies [24,37,42], implying the need to identify barriers to physical activity and the necessity of implementing a structured, culturally sensitive physical activity program along with dietary education [21,26]. Cultural sensitivity is defined as the degree to which a target group's cultural or ethnic features, beliefs, experiences, behavioral patterns, values, norms, and related social, environmental, and historical features are merged into the design, evaluation, and delivery of targeted health promotion programs and materials [76]. This can be achieved through cultural adaptations such as matching materials to group characteristics or targeting the cultural values of the population [76]. Studies in the US also revealed the effectiveness and success of culturally based interventions in promoting a healthy diet and/or physical activity among various ethnicities of participants [77][78][79][80]. Few studies initiated culturally sensitive aspects in their programs, including the use of Arabic language in messages and questionnaires and culturally appropriate examples, such as health beliefs and food habits that represented their respective Arab communities [26,36,37]. Such interventions depicted significant improvements in primary and secondary health outcomes at the end of the program [26,36,37]. However, except one study [26], physical activity outcomes were either not assessed or improved in other studies [36,37]. Barriers to physical activity in Arab countries can occur due to individual factors (e.g., a lack of time or health status), cultural/policy/social factors (e.g., hiring housemaids, traditional roles for women, or not enough social support), and environmental factors (e.g., not enough facilities for exercise or hot weather) [21][22][23][24][25]81,82]. Factors that may promote physical activity are religion (Islamic teachings), the motivation to lose weight, having diseases, exercise benefits, and good social support systems [81,82]. Numerous physical-activity-based interventions aiming to combat the negative impacts of a sedentary lifestyle on health in Arab countries have been published [83,84], indicating the importance of addressing this issue in the region. Hence, there is a necessity to introduce dietary and physical-activity-based programs or policies, considering different genders as well as sociocultural and economic aspects for their success. This also suggests the important role of multidisciplinary teams of dietitians, physicians, lifestyle coaches, and other health professionals in implementing interventions to combat NCDs and promote lifestyle changes linked to physical activity and dietary behaviors to patients through group and individual sessions.
The limitation of this review is that comparisons between studies become challenging due to the differences in the study designs, modes of delivery (online versus face-toface), and program durations. The durations of the various interventions were less than a year [21,24,26,32,35,[37][38][39][40]42], where only two studies performed follow-ups at one year [21,42]. Moreover, only a few studies reported compliance among participants to their respective lifestyle modifications [33,42], while others admitted non-adherence [38,40]. Thus, further studies involving multicomponent interventions with longer durations are required to assess their impacts in managing NCDs and in the long-term maintenance of health outcomes.

Conclusions
This is the first review to assess diet and physical activity incorporated in their respective interventional programs and how such interventions impact an individual's lifestyle and work in combating diet-related non-communicable diseases among adults in Arab countries. Personalized, goal-oriented, and longer-duration lifestyle interventions combining diet and physical activity were found to be effective in improving health outcomes. Moreover, considering the mode of delivery for behavioral therapy, a combination of both online and face-to-face sessions was found to be effective and convenient.
Although most interventional studies showed improved health outcomes, some studies did not show any significant differences between the intervention and control groups in terms of physical activity. Hence, it becomes incumbent to identify barriers to physical activity for a culturally acceptable lifestyle intervention program resulting in long-term positive behavioral changes and improvements in health outcomes. The limitations of this review relate to variations in the research design, mode of delivery, and program length. Thus, more studies are needed to assess the effectiveness of multicomponent interventions with longer durations on NCD management.