This nationally representative STEPS survey is the largest survey conducted in Oman which focused on collecting comprehensive information on both modifiable behavioural risk factors (smoking, alcohol consumption, physical inactivity, and unhealthy diet) and biological risk factors (overweight and obesity, raised blood pressure, raised blood glucose, and raised total cholesterol) for NCDs. The 2008 World Health Survey (WHS) was the last survey done in Oman to assess the national prevalence of some of the risk factors of NCDs (10). The current survey demonstrated that the Sultanate of Oman has a high prevalence of overweight and obesity, raised blood pressure, raised total cholesterol, insufficient fruit or vegetable intake, salt intake, and insufficient physical activity.
Table 5
Comparison of risk factors from recent STEPS surveys in various EMRO countries
| Risk Factor Topic | Oman* (2017) | Egypt (2017) | Qatar (2012) | Iraq (2015) | Lebanon (2017) | Kuwait (2014) |
Behavioural Risk Factors | Current tobacco smoking (%) | 8.0 | 22.7 | 16.4 | 20.7 | 38 | 20.5 |
Current daily tobacco smoking (%) | 6.7 | 18.4 | 14.7 | 19.6 | 75.6 | 18 |
Alcohol use (in past 30 days) (%) | 1.6 | 0.8 | NA | 0.6 | 23.4 | 0.3 |
Insufficient fruit/vegetable consumption (%) | 61 | 90.3 | 91.1 | 79.2 | 73.4 | 83.8 |
Salt intake (g) | 8.6 | 9 | NA | NA | NA | NA |
Insufficient physical activity (%) | 39 | 24.9 | 45.9 | 47 | 61 | 62.6 |
Biological Risk Factors | Overweight & Obesity (%) | 66 | 63 | 70.1 | 65.4 | 62.8 | 77.2 |
Obesity (%) | 36 | 35.7 | 41.4 | 33.5 | 28.6 | 40.2 |
Raised Blood Pressure (%) | 33.3 | 29.5 | 32.9 | 35.6 | 32.8 | 25.1 |
Raised Blood Glucose (%) | 15.7 | 15.5 | 16.7 | 13.9 | 9.4 | 14.6 |
Raised Total Cholesterol (%) | 36 | 19.2 | 21.9 | 39.6 | 48.8 | 55.9 |
* Inclusive of non-Omani residents |
Behavioural Risk Factors
In this survey, smoking was found to be mainly prevalent among males and the non-Omani resident population. The overall prevalence of current smoking (9%) is consistent with the 2008 WHS (9%). The prevalence of current smoking among men (16%) increased slightly from 2008 (15%). This increased trend in tobacco smoking can be attributed to urbanization and underlying cultural factors. The government has taken into account the issue of smoking and has implemented several measures to control the usage among the common public. According to the Royal Decree 43/2018, the advertisement of tobacco products is banned in Oman (11). There has also been a ban on smoking in public places since 2010 (12). As a result, Oman also has the lowest prevalence rate in the EMRO region, in contrast with other countries in the region some of which have the highest prevalence rates worldwide (13). Jawad et al. (13) suggests that Oman needs to adopt policies recommended by WHO’s MPOWER package in order to maintain the current low prevalence of smoking.
Alcohol use was among the least frequent risk factors in the Sultanate of Oman, with the prevalence at just around 2% of the total population. There was significant difference found between the alcohol use prevalence among Omani nationals and non-national residents. The prevalence among Omani was very low owing to cultural factors and strict compliance to religious values. Non-Omani residents were the largest proportion consuming alcohol in Oman at 8%. Table 5 demonstrated that Oman is higher than most other EMRO countries - however when only nationals are taken into account, prevalence rates are in line with other EMRO countries. It is important to note that alcohol availability has also been regulated by the stringent laws and monitored by the government sector in Oman (14) (15). Also, given that alcohol consumption is somehow stigmatized in society, low reported prevalence may also be in part an underestimation, so results should be interpreted with some caution.
Insufficient intake of fruit and vegetables intake per day was found to be fairly high at 61% overall, even though the average consumption of fruits and/or vegetables per day of 4.4 servings seen in the survey is close to the recommendation. Furthermore, Oman is the lowest in terms of insufficient intake of fruits and/or vegetables in recent STEPS surveys conducted in the EMRO region while Qatar and Egypt reported prevalence rates of above 90% (Table 5) (16). Also on a positive note, the trend of insufficient fruit and vegetables intake decreased from 68–61%, and among the Omani population from 70–58% in 2008 WHS as compared to this survey, respectively. There was also a significant difference found among unhealthy diet variables between Omani nationals and non-Omani residents. A serious concern was the mean salt intake per day (9 g) which was found to be almost double the recommended amount (5 g). This could be attributed to persons adding salt or salty sauce to their food always or often before or while eating which was found to be 24% in this survey. The STEPS survey conducted in Egypt which also performed urine analysis reported the same high level of salt intake (16). The current survey revealed that women had the highest prevalence of adding salt to the food. Women can have a contributory role in this risk factor as are an important part of the family especially in food preparation. It is also vital that knowledge of healthy eating habits starts young as the prevalence of adequate intake of fruit and vegetables in the eleven EMR countries among adolescents was found to be low (17). Strategies and/or other alternatives to reduce salt intake, a matter that may require health promotion and education to improve knowledge about sources of salt, should be thought of in order to reduce/modify the risk. The health sector has an important role in determining salt content of processed foods and initiate discussions with the food industry on means to address their reformulation.
In terms of physical activity, WHO recommends exercising at least 150 minutes of moderate or vigorous physical activity weekly. However, it was found in this survey that the median time spent even on total physical activity was only 69 minutes. Omani nationals and women spent only one hour on average for total physical activity per day. This led to 39% of the population having insufficient physical activity, which was consistent with 2008 OWHS (42%) (7). There was highly significant difference found among Omani nationals and non-Omani residents on the median time spent on physical activity per day. The prevalence of insufficient physical activity in Oman was higher than Egypt (25%) and lower than Qatar (46%), Iraq (47%) Lebanon (61%) and Kuwait (63%) (18). Modernisation coupled with the hot, humid climate lead to people resorting to using private cars for even fairly short distances thus attributing to the lack of regular outdoor physical activity (19). However, health promotion, education, transport modality planning, and policy should be brought together to address this multifactorial issue.
Biological Risk Factors
A serious cause for concern is the prevalence of overweight and obesity (BMI ≥ 25) which stands at 66% in Oman. There has been a dramatic increase in the prevalence of overweight and obesity among the Omani population from 54% in 2008 WHS to 67% in 2017 (7). Also alarming is the prevalence of obesity among the Omani population which is at 35% overall (up from 24% in 2008 WHS) and strikingly among women at 41% (up from 24% in 2008 WHS). The survey findings are Gulf Cooperation Council (GCC) in line with the prevalence of overweight and obesity in the as well as WHO EMRO countries (20, 21). This remarkable change is due to the changes of lifestyle and increase in socioeconomic status. With urbanisation, the availability of junk and fast food has increased, and hence increased public awareness of balanced healthy eating habits are imperative to mitigate this availability.
The prevalence of raised blood pressure from this survey was reported as 33%, which means that one in three people in the population had high blood pressure, a prevalence level that calls for attention from policy makers, health professionals, and civil society to address this multifactorial problem. Also, the prevalence of raised blood pressure among men is more than 10% higher than women, so specific targeted interventions to this group are vital to halt the rise and reduce the prevalence of raised blood pressure overall. Interestingly, the same phenomenon was reported by WHO among the EMRO region as well. (22) In terms of the Omani population, the trend of raised blood pressure seems to be reduced from 40% in 2008 to 32% in this survey. Several researchers consistently report an increasing trend in raised blood pressure in the region. (23, 24). In 2015, the Oman Heart Association (OHA) released the internationally recommended guidelines in management of hypertension to be followed. (25). In addition, the national screening program for 40 years and above may have also had an influence to help to reduce the prevalence of increased Blood pressure.
The observed prevalence of raised blood glucose in Oman is currently at 16% showing a steady increase. The prevalence trend in raised blood glucose among the Omani population is also on the rise from 12% in 2008 to 15% in 2017. The prevalence of raised blood glucose was similar to Egypt (16%), lower than Qatar (17%), but higher than Kuwait (15%), and Iraq (14%) (18). Similarly, the prevalence of impaired fasting glycaemia stands at 12%, a three-fold increase from 2008 WHS (4%). This pre-diabetic group is a significant group, which should be targeted in order to treat them early, hence providing an opportunity to reduce health impacts and costs of diabetes treatment later on in the progression of the disease. Our study found a highly significant difference between Omani nationals and non-national residents in terms of prevalence of raised and impaired fasting blood glucose.
The national prevalence rate of raised total cholesterol was reported as 36% in the survey, which was in line with the global prevalence of raised total cholesterol (26). Our results are lower than a majority of Gulf countries where the prevalence was 50% or higher (27). The prevalence among women was higher than men, which also seemed to be the trend globally (26). The prevalence among the Omani population was observed at 37%, which was higher than the prevalence reported in 2008 (34%) (7). There was also a significant difference found between Omani nationals and non-national residents. The reported overall total cholesterol level is lower than Kuwait (56%) and Iraq (40%) but higher than Egypt (19%), Qatar (22%) (18). It is important for the public to recognise that keeping cholesterol levels in check is vital for their overall cardiovascular health.
Number of behavioural or biological risk factors
Only 5% of the study population were found to be free of all the five NCD risk factors. Furthermore, the overall proportion of adults in Oman with three or more risk factors was 33%, with the proportion substantially increasing to almost 45% among the 45 years and above age group. There were no significant differences found between Omani nationals and non-Omani residents. This analysis of combined risk factors is an alarming figure which informs us that the burden of NCDs is likely to increase in the future if no prompt action is taken by the stakeholders involved.