In conversation with Heba Fouad, regional advisor for NCD surveillance, monitoring and evaluation, WHO Regional Office for the Eastern Mediterranean.

Atrial fibrillation (AF) is a significant public health problem and a major contributor to premature mortality. Prevention of AF is paramount, given its rising incidence, associated disease burden and cost. Heba Fouad, regional advisor for NCD surveillance, monitoring and evaluation at the WHO Regional Office for the Eastern Mediterranean, outlines the challenges faced and progress made in curbing the tide of noncommunicable diseases (NCDs) in the Middle East and North Africa (MENA) region, and the importance of addressing modifiable risk factors for AF and other NCDs.

Addressing risk factors for AF is essential to achieving SDG and WHO goals

Turning the tide of cardiovascular disease (CVD) and mitigating their modifiable risk factors are essential steps toward achieving the 2030 UN Sustainable Development Goals (SDGs) and World Health Organisation (WHO) NCD targets.

• SDG Goal 3 aims to “ensure healthy lives and promote well-being for all ages”. A strategic target (3.4.1) identified by the UN is the reduction of premature mortality (between the ages of 30 and 70) from NCDs by one-third by 2030.¹
• The WHO Global NCD Action Plan, which targets a 25% reduction in premature mortality from NCDs by 2025, has been extended to 2030, to align with the SDG target for NCDs. The WHO framework targets five diseases (CVD, cancer, diabetes, chronic respiratory disease and mental ill-health) and five modifiable risk factors (unhealthy diet, physical inactivity, tobacco use, alcohol consumption and air pollution).²

Premature death from NCDs is already a major challenge across the WHO Eastern Mediterranean Region. “Approximately one in four people are dying early [below the age of 70] from NCDs in the EMRO region,” says Dr Fouad. “We have among the highest rates of premature mortality. Premature mortality, morbidity and disability associated with NCDs are more than a health issue—they negatively affect socioeconomic development and long-term fiscal sustainability.”

The four main NCDs—cancer, CVD, diabetes and chronic respiratory disease—account for 55% of deaths in the UAE and 35% in Saudi Arabia. Many of these deaths are premature and result in significant economic losses, ranging from US$11bn in the UAE to almost US$25bn in Saudi Arabia annually in healthcare costs and lost productivity.^3,4

AF is a major trigger of CVD-related mortality, as well as a consequence of CVD risk factors

CVD is the largest contributor to global mortality, accounting for almost 18m, or half, of annual deaths from NCDs.⁵ Achieving global NCD targets requires aggressive action on CVD and its risk factors—of which AF is one. “Atrial fibrillation cannot be prevented or treated in isolation,” says Dr Fouad. “It has to be integrated with broader NCD and CVD prevention, management and control.”

The silent nature of AF (approximately 30% of individuals with AF are asymptomatic) and the presence of other conditions make AF particularly challenging to prevent and manage.⁶ Individuals with AF have an average of five co-existing conditions, often including hypertension and obesity.⁷ “While AF is a disease, it is also a trigger of stroke, heart failure and other lethal consequences, and a result of other NCDs, such as diabetes and hypertension,” explains Dr Fouad.

Addressing modifiable risk factors for AF and other NCDs

At least 80% of premature heart disease and stroke can be prevented by eliminating risk factors.⁸ The risk of AF and other NCDs can be addressed through the modifiable risk factors identified in the WHO NCD Global Action Plan. The Global Action Plan sets the following targets linked to modifiable risk factors: ²

• Unhealthy diet: 30% reduction in mean population intake of salt/sodium
• Physical inactivity: 10% reduction in prevalence of insufficient physical activity
• Tobacco use: 30% reduction in prevalence of current tobacco use

Available data indicate that countries in the WHO Eastern Mediterranean region remain far from reaching these targets. People in many countries in the region consume double the WHO recommended salt intake of 5g per day.⁹ The region is also among the world's most physically inactive, with levels of inactivity ranging from 30-70%. And although tobacco use has been declining in the region, over 30% of men and 4% of women smoke regularly.¹⁰ “With population growth, the uptake of smoking among adolescents, and new and emerging tobacco products, substantial efforts are needed to meet the 2030 reduction target of 30%,” says Dr Fouad. Just two countries in the region, Pakistan and the UAE, are currently on track.¹¹

Dr Fouad urges countries to start with implementing evidence-based, cost-effective public health interventions, known as “best buy” interventions. These interventions aim to reduce NCDs at the population level by targeting shared risk factors, such as tobacco use, physical activity and diet.

Notable interventions to address a rising burden of NCDs in the region include the introduction of taxes on high-sugar carbonated drinks in Oman, Saudi Arabia and the UAE.^12,13,14 The UAE Ministry of Health’s MA’KOM Initiative aims to promote active lifestyle among Emirati society.¹⁵ Health and education authorities in the country have increased physical activity requirements in schools to 150 minutes a week.¹⁶ Saudi Arabia has introduced initiatives to increase public participation in sports and athletic activities as part of the Quality of Life Programme.¹⁷ The country has also made significant progress to reduce tobacco use. The national tobacco strategy aims to reduce the prevalence of tobacco use to 5% by 2030. The country received the WHO Award for Excellence in Tobacco Control in 2019 owing to efforts including the establishment of over 1,000 specialised tobacco cessation clinics offering free services, including online and phone consultations and the implementation of advertising bans.¹⁸

Reinforcing commitment to reaching global NCD targets

Effective prevention and management of AF are intertwined with effective NCD policy. “We need a holistic approach,” says Dr Fouad, adding that targeting the five disease targets and five modifiable risk factors in the WHO Global NCD Action Plan would help to move the needle on the rising NCD burden in the MENA region.

According to Dr Fouad, progress towards the SDG 2030 and WHO NCD 2025 goals will require countries in the region to strengthen data and monitoring systems, supported by ongoing research to track the cost-effectiveness of interventions, effectively allocate resources and develop a strong investment case for NCD prevention and management.

Existing interventions also need to be supported by guidelines to improve health literacy and self-management to ensure that populations are aware of common NCDs, understand the risks and are empowered to make decisions that help them live healthy lives. “To make this paradigm shift towards a patient-centred approach and reinforce healthy behaviours, we need to involve healthcare providers, nurse practitioners and the wider community,” says Dr Fouad.

Read more about policy pathways to mitigate the rise of atrial fibrillation in Saudi Arabia here

References

^[1] United Nations. Sustainable Development Goals. Goal 3: Ensure healthy lives and promote well-being for all at all ages. https://www.un.org/sustainabledevelopment/health/
^[2] WHO. On the road to 2025: The global NCD deadline. https://www.who.int/teams/noncommunicable-diseases/on-the-road-to-2025
^[3] UAE Ministry of Health and Prevention. Gulf Health Council. UNDP. WHO. The Case for Investment in Prevention And Control of Non-Communicable Diseases in the United Arab Emirates. 2021. https://uniatf.who.int/docs/librariesprovider22/default-document-library/uae-ncd-report.pdf?sfvrsn=38501032_1
^[4] Saudi Arabia Ministry of Health. Gulf Health Council. UNDP. WHO. The Case for Investment in Prevention and Control of Non-Communicable Diseases in Saudi Arabia. 2023. https://www.undp.org/sites/g/files/zskgke326/files/2024-02/ksa_ncd_ic_report_eng.pdf
^[5] WHO. Cardiovascular diseases. https://www.who.int/health-topics/cardiovascular-diseases#tab=tab_1
^[6] Hindricks G, Potpara T, Dagres N, Arbelo E, Bax JJ, Blomström-Lundqvist C, et al. 2020 ESC Guidelines for the diagnosis and management of atrial fibrillation developed in collaboration with the European Association for Cardio-Thoracic Surgery (EACTS). European Heart Journal. 2021;42(5):373-498.
^[7] European Society of Cardiology. Patients with atrial fibrillation have an average of five additional medical conditions. 2023. https://www.escardio.org/The-ESC/Press-Office/Press-releases
^[8] WHO. Cardiovascular diseases: Avoiding heart attacks and strokes. 2015. https://www.who.int/news-room/questions-and-answers/item/cardiovascular-diseases-avoiding-heart-attacks-and-strokes
^[9] WHO EMRO. Eastern Mediterranean Health Journal. 2014. https://www.emro.who.int/emhj-vol-20-2014/volume-20-issue-12/emhjcmspass975.html
^[10] WHO EMRO. Health education and promotion. Physical activity. https://www.emro.who.int/health-education/physical-activity
^[11] WHO global report on trends in prevalence of tobacco use 2000–2030. Geneva: World Health Organization; 2024. Licence: CC BY-NC-SA 3.0 IGO.
^[12] UAE Government. Excise tax. https://u.ae/en/information-and-services/finance-and-investment/taxation/excise-tax
^[13] Deloitte. Excise tax in Oman. https://www2.deloitte.com/content/dam/Deloitte/xe/Documents/tax/me_oman-excise-tax.pdf
^[14] Alhareky M, Bedi S, AlMulhim A, El Tantawi M, Farooqi FA, AlHumaid J. Impact of Sugar Tax on Sugar-sweetened Beverage Consumption among Saudi Schoolchildren. Oral Health Prev Dent. 2021 Jan 7;19(1):189-194. doi: 10.3290/j.ohpd.b1075081. PMID: 33723978.
^[15] UAE Ministry of Health and Prevention. MA’KOM Initiative. https://mohap.gov.ae/en/about-us/projects-and-initiatives/makom-initiative
^[16] Emirates News Agency. DHA, KHDA agree to increase physical activity to 150 minutes a week. 2018.
^[17] Albujulaya N, Stevinson. Piggin J. Physical activity policy in Saudi Arabia: analysis of progress and challenges. 2023. International Journal of Sport Policy and Politics, DOI: 10.1080/19406940.2023.2228812.
^[18] WHO EMRO. Knowledge Action Portal on NCDs. Mitigating NCDs in Saudi Arabia: Lessons from the COVID-19 pandemic. 2023. https://www.knowledge-action-portal.com/en/news_and_events/country-stories/8088