What are the Typical Dietary Patterns in Aleppo, Syria?

A Collaboration

Proper nutrition plays a very important role in achieving and maintaining optimal health. The field of nutritional epidemiology, which focuses on elucidation of the relationships between nutrition, health, and disease in populations, has been highly influential in improving diet and reducing the incidence of some chronic diseases in the United States and other developed nations. In contrast, the burden of many chronic diseases such as cardiovascular disease, diabetes and hypertension is increasing in many developing nations, especially as urbanization and westernization increases.¹ Unfortunately, little research exists on how diet affects health in developing countries.

The aims of my proposed research are: first, to review the current nutritional epidemiological picture in Syria, specifically, to address what is known about diet and disease and what has already been studied; the second aim is to review the established methods used for collecting nutrition data in the United States and to discuss what nutrition tool may be most appropriate for use in nutrition research in Syria; the third aim is to describe an innovative international team approach for this research project; the fourth and final aim is to discuss areas for future nutrition study in Syria.

Developing nations in the Eastern Mediterranean region appear to be at risk for several diet-related diseases. Syria has a total population of 16,609,000. Life expectancy at birth for Syria is substantially lower than in more developed countries (68.7 and 74.3 for males in Syria and the US, respectively; and 72 and 79.5 for females in Syria and the US, respectively). Child mortality in Syria is 27 male deaths and 23 female deaths per 1000, which ranks 10th out of 17 Eastern Mediterranean countries.² The leading cause of death in Syria is cardiovascular disease. Although mortality data are limited in this region, reliable data from several Eastern Mediterranean countries revealed that 18% to 40% of total deaths are caused by cardiovascular disease.¹ Other diet-related diseases common to Syria include growth retardation among young children and iron deficiency anemia.(3) Chronic diseases related to diet such as obesity, diabetes, hypertension and some types of cancer also have become emerging health problems in Syria.⁴

Patterns of food consumption play an important part in the incidence of many of these diseases. Demographic, socio-economic and health conditions have changed in Syria over the past four decades,¹ and these changes have altered dietary habits and lifestyles. The traditional Eastern Mediterranean diet, characterized by foods high in fiber and low in fat, cholesterol and sodium is changing to a more westernized diet, especially among those with middle and high incomes.⁵ These dietary changes, along with inadequate physical activity and increases in obesity, diabetes, hypertension and tobacco use, are all partially responsible for the increasing incidence of cardiovascular disease and are contributing factors to the emerging chronic diseases.⁴

Incidence of diet-related chronic diseases in Syria also is increasing as life expectancy increases.⁶ Although life expectancy in Syria is lower than in many developed countries, it has increased by approximately 15 years since 1970,² likely due in part to improvement in health services and standards of living. Given the chronic nature of many dietary influences on health, increased life expectancy will provide more opportunity for the incidence of lifestyle diseases, such as diabetes, obesity and hypertension to increase.

There is extensive documentation on the association between certain dietary components and many of the chronic diseases occurring in Syria. Excessive dietary fat has been linked to increased risk of obesity, coronary heart disease and certain cancers. Increased intake of fiber has been shown to reduce blood cholesterol levels and the risk of certain cancers.⁷ Excess energy intake is directly related to obesity, diabetes, high cholesterol, high blood pressure and coronary heart disease.

Looking at the nuances of the Syrian diet is the first step in establishing appropriate national dietary guidelines and beginning nutrition therapy at the individual level. Data on Syrian food intake patterns are scarce and limited to information on per capita consumption. Currently, the only available dietary data for Syria comes from food balance sheets collected by the Food and Agriculture Organization (FAO). These reports take the food available for consumption and divide it by the total population in order to determine trends in daily per capita dietary energy and fat supplies over set periods of time. Although the accuracy of the food balance sheets depends on reliable reports on agriculture, trade and population, they provide an approximate picture of the overall food trends in a country. These reports show that there was an increase of 43% and 50.1% in per capita energy and fat supplies, respectively, in Syria during the period from 1971 to 1997.⁸

Understanding these food patterns is an important factor in implementing established dietary guidelines for the prevention and reduction of diet-related chronic diseases. While population-level consumption data are useful, it is important to collect individual-level dietary data. Information on food consumption patterns collected from the people who are purchasing and eating the food are essential because it provides a more fine-grained analysis of specific macro- and micro-nutrient intake patterns, and elucidates important sub-group differences in these patterns (e.g., children versus adolescents, males versus females, urban versus rural residents, Muslims versus non-Muslims). These sources of basic nutrition data are not currently available for Syria, however.

An essential first step in addressing this problem is to develop techniques to reliably and validly assess diet in Syria. There are several methods for collecting nutrition data commonly used in the United States, the most popular of which are 24-hour dietary recalls, food frequency questionnaires (FFQs) and diet records (DRs). In 24-hour dietary recalls, the individual attempts to remember all of the foods and beverages consumed in the preceding day. This recall is administered by a trained interviewer in computer or paper-and-pencil format. The interviewer then probes for details. The advantages to this procedure are that it is quick to complete (about 20 minutes), utilizes a short recall period (24 hours) and it is interviewer-administered, which reduces the need of literacy by the respondent. Limitations to this technique are that memory may not be entirely accurate, the interview situation may reduce accuracy in reporting due to social desirability and the data collected only represent one day, which may not accurately reflect usual intake.⁹

The FFQ attempts to assess usual dietary intake, by collecting intake data over an extended time period, typically the past year. This method requires the individual to report what foods and beverages were consumed based on a comprehensive list of foods. One of the strengths to this method is that there is a long reporting period, which makes variability across daily intake easier to assess. This method is inexpensive and requires little work for the respondent. The primary drawback to this questionnaire is that reliance on memory is substantial and can be a burden for many populations. Either overestimation or underestimation of usual intake can occur as a result.⁹

Diet records require individuals to record everything they eat or drink in diary format over a period of days. The individual records how each food was prepared, the serving size, and the specific details such as the name brand of each item. In most cases, the individual is trained by a dietitian on recording intake with sufficient detail. At the end of the recording period, an interviewer reviews the records and asks for clarification if needed. This method is considered the "gold standard" for self-reported dietary assessment because the individual is recording actual consumption during the recording period and not relying on memory to recall past intake. This technique is burdensome, however, and may result in incomplete records. This method also requires extensive coding of foods that then must be entered into dietary assessment software.⁹

While the benefits of these three dietary methods are apparent, several factors such as expense, efficiency and validity are important to consider in determining what is the most feasible method to use. For these reasons the DR and 24-hour recalls may not be the most appropriate choice, especially when diet is only one of several types of information collected during a health assessment or research study. FFQs are the least expensive and most efficient of these three methods. The typical FFQ survey requires pen and paper and a brief amount of time to complete. Translation and coding time also will be minimal because the survey only requires the participant to report the frequency of consumption and portion sizes of foods.

Validation of FFQs is often done by comparing the FFQ data to more detailed methods of dietary assessment, most commonly DRs. Results of validity studies of FFQs have varied from zero¹⁰ to 0.94.¹¹ This is often due to the size and scope of the study. Many validity studies are small and the time frames being studied have varied considerably (one week to one year). Overall, however, FFQs have been shown to estimate total energy intake, as well as intake of several macro- and micro-nutrients, with good accuracy.¹²

Most dietary assessment methods have been designed for, and tested on, American, white adults. Because of this, some cultural assessment will be necessary in order to begin to develop an appropriate FFQ. Although Syria is somewhat westernized, illiteracy remains a problem¹³ and limits the usefulness of self-administered surveys. Alternative methods to self-administered surveys may be preferred, such as providing photos of foods rather than written descriptions, and using an interviewer rather than self-administered format may be beneficial. Such approaches to FFQ administration have been used effectively.¹⁴

While this method has great potential to understand diet/disease relationships in developing countries such as Syria, a good deal of formative work is needed to develop a culturally-appropriate FFQ for this setting. In addition to the cultural translation issues discussed above, it is essential to begin the development process by collecting data on usual foods consumed in the Syrian diet. Specifically, FFQs are developed based on knowledge of usual foods consumed in a given population. For example, widely used FFQs in the US such as the Block(15) and Willett FFQs¹⁶ were developed based on key informant interviews with dietitians- and population-based data on daily dietary patterns.

Qualitative data collection techniques, including participant observation, informant interviews and focus groups, are useful tools¹⁷ in epidemiological research to guide instrument development. These methods are particularly useful for formative data collection on health issues in developing countries where lack of adequate scientific infrastructure often contributes to a poor foundation in understanding the relationships between health behaviors and outcomes. In terms of dietary assessment in developing countries, qualitative methodologies can provide rich data by allowing researchers to interact extensively with people in their natural settings, fostering understanding of the contextual factors, which determine nutritional status.

An important step in developing a culturally appropriate FFQ for Syria is to collect data on common foods, preparation methods and eating patterns, in order to create a comprehensive food list. We will adopt a multi-model approach to accomplish this task, using established qualitative data collection techniques. We will begin with key informant interviews to gain an overview of common foods, usual consumption patterns and relevant sub-groups with potentially different dietary patterns (e.g., urban versus rural, Muslim versus Christian, professional versus working class, men versus women). Approximately 20 key informants will be interviewed who are knowledgeable about Syrian dietary patterns, including primary care physicians, grocery store owners, restaurant owners and other people in the food industry.

Next, we plan to conduct a series of focus groups with Syrian men and women, 18 to 59 years of age, to obtain more detailed information on dietary patterns. Focus groups are a useful data collection tool because they take advantage of group dynamics and use an informal setting to obtain information about norms, behaviors and attitudes.^18,19 We anticipate that focus groups will be conducted separately for specific subgroups with potentially different dietary patterns. Data obtained from key informant interviews will be used to develop focus group questions and probes. The conduct of the groups, as well as data analysis, will be performed using established methods that have been used extensively by our research team.^18,19

The above qualitative data will be used to create a comprehensive food list. From this list, a FFQ will be developed that is culturally appropriate and provides a comprehensive and accurate assessment of the usual Syrian diet. This will include a place to write in additional foods not covered by the list. The FFQ will be administered to 20 (10 men and 10 women) adults, age 18 to 59, and assessed for appropriateness of administration format, time taken to administer and any missing foods.

Further research will depend on time constraints. I have the opportunity to travel to Syria and conduct research for one month during the 2003 to year. The research trip is part of an NIH-funded grant to conduct tobacco control research in Syria. My project would provide a unique opportunity to gather nutritional data apart from the funded project with the possibility of enhancing the smoking study.

Two University of Memphis faculty members, Dr. Linda Clemens, Director, Clinical Nutrition Internship and Dr. Kenneth Ward, Assistant Professor and Principle Investigator on the NIH-funded international grant to conduct tobacco control research in Syria both have offered to provide consultation on this project. Dr. Ward will be in Aleppo, Syria along with me and, therefore, will able to provide first hand support.

This research will be conducted at the Syrian Center for Tobacco Studies, where three of my Syrian colleagues, Wasim Maziak MD, PhD, Taghrid Asfar MD and Fadi Hammal MD, will be conducting research and have offered to assist me in translating the survey to Arabic and helping with recruiting participants, and gathering and translating data. They have all three visited our department at the University of Memphis and are currently working on the NIH-funded international grant to conduct tobacco control research in Syria.

Looking ahead, there are many areas in which this project may lead. Validation of the FFQ will be an important next step. This will be done by comparing FFQ results with those obtained by diet record. If further funding becomes available this may involve gathering 24-hour recalls that are interview administered, test-retest of the FFQ and comparing the interviewer-administered FFQ to a picture-sort FFQ.

Further applications for the FFQ involve using it in epidemiological studies in Syria. Determining the individual macro-nutrients such as fat, fiber, protein and carbohydrates is a critical part of examining hypotheses about diet and disease at the nutrient level. Nutrient data available from the US Department of Agriculture is used to analyze FFQs in the US.¹⁶ This type of nutrient data is only available for Syria in limited form from a food composition database assembled by the FAO of the UN. Efforts are slowly being made to update and add to the completeness of this database.²⁰ Data collected in this study could be very useful to assist in such efforts. The Syrian Ministry of Health in Syria is a partner in the parent NIH grant that will sponsor my project. This partnership will facilitate working with appropriate national health officials to develop a comprehensive national nutrient database and furthering understanding of diet/health relationships in this country. Data collected in my project also are directly relevant to the parent project, which is seeking to develop culturally appropriate smoking cessation interventions in Syria. Dietary changes and weight gain commonly occur after smoking cessation in developed nations and are associated with relapse.²¹ Elucidating these relationships in Syrian smokers may prove very helpful in developing effective cessation interventions.

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