Nutritional value of the Middle Eastern diet: analysis of total sugar, salt, and iron in Lebanese traditional dishes

Background: The expanding burden of diet-related non-communicable diseases in the Eastern Mediterranean Countries requires urgent public health vigilance and actions. This study aimed at establishing a database analysis of total sugar, salt and iron content in Lebanese foods, focusing on traditional dishes. Methods: The collection of food samples was done using stratified sampling techniques. These samples were classified into five strata, taking into account variation by geographical area (Mount Lebanon, Bekaa, Beirut, Tripoli, and Saida). The number of samples per governorate was estimated to be 30 according to the variability in the dishes' composition. Food samples were chemically analyzed for total sugar, salt, and iron. Results: Among all the governorates, all the tested traditional Lebanese dishes contained little total sugar. More than 60% of the samples tested were rich in sodium. The sodium content ranges were 120-720 mg/100 g in Mount Lebanon, 240-960 mg/100 g in Bekaa, 80-520 mg/100g in Beirut, 252-1952 mg/100g in Tripoli and 40-680 mg/100 g in Saida. The highest mean amount of sodium was observed in the dishes Fatayer Sabanikh and Malfouf Mehche (≥ 600 mg/100 g). Furthermore, more than 80% of the samples had poor amounts of iron in all governorates. Conclusion: This study emphasizes the need for multi-cultural education and awareness on food sources of salt and iron, and the health effects regarding high intake of salt and low intake of iron. This study is a stepping stone for further research exploring total sugar, salt and iron content of traditional dishes, as well as potential intake by individuals in the Lebanese population.


Introduction
In light of global spread of non-communicable diseases (NCDs), accounting for 70% of the 41 million deaths each year, the probability of premature death, in 2018, caused by NCDs is 91% of all deaths in Lebanon 1 . The global rise in the prevalence of NCDs is a consequence of shifting dietary patterns specified by a high intake of meals rich in fat, sugar, salt, and low in fiber and micronutrients 2 . Home cooking and at-home eating have become scarce, while processed foods and prepared meals are increasing and have become a major part of the population's lives 2 . Furthermore, it is widely believed that urbanization has played a role in producing side effects for NCDs-related health outcomes 3 . Cardiovascular diseases (CVDs) constitute the primary cause of death in the Middle Eastern Region 4 . According to the World Health Organization (WHO), based on 2017 data, 17.9 million people die each year from CVDs, representing 31% of all deaths worldwide 5 . Furthermore, around 23.6 million people are expected to die from many forms of CVDs by 2030 6 .
High blood pressure is a dominant factor for CVDs 7 . A higher intake of dietary salt (equivalent to 5 g salt/day) is associated with high levels of blood pressure, cardiovascular diseases and strokes 5 . In May 2013, the WHO Member States decided to target a reduction in the global intake of salt by 30% by 2025 8 . A systematic review, published in 2020, on 133 randomized control trials showed a reduction of 1.10 mmHg in systolic blood pressure and 0.33 mmHg reductions in diastolic blood pressure with every 50 mmol reduction in 24-hour sodium excretion. This can lead to a protection against vascular complications and decrease CVD risk 9 . In addition, there is considerable evidence of the advantages of Mediterranean diet on health 10 . An umbrella review and meta-analyses of observational and randomized controlled trials showed a strong relation between the adherence to Mediterranean diet and the 50% reduction in mortality from NCDs 10 .
Today, the major target of nutrition interventions is the energy dense "added sugars". The WHO definition for added sugars is "all monosaccharides and disaccharides added to foods and beverages by the manufacturer, cook, or consumer, and sugars naturally present in honey, fruit juices, and fruit concentrates" 11 . In this definition the "total sugar" term that is "naturally occurring or intrinsic sugars, which are stored within the cells of intact fruits, vegetables, or involve lactose in milk or unsweetened dairy products" was not included 11 . In 2015, the WHO recommended the reduction of the daily intake of added sugars to less than 10% of the total energy intake 12 . Additional suggestion of reducing the daily intake of added sugars to less than 5% of total energy intake may promote additional health benefits 12 . Until today, total sugar has no recommendation for the daily intake 13 . However, for the aim of achieving the goals set by the Global Action Plan for NCDs 2013-2020, a guideline on total sugar was developed to help in the reduction of the prevalence of diabetes and obesity, and decrease the incidence of premature deaths caused by NCDs by 25% by 2025 14 .
Furthermore, deficiencies in iron lead to the development of anemia, which is one of the most common nutrition problems. As per the WHO, more than 2 billion people are anemic and iron deficiency is one of the main causes 15 . In addition, there is a high prevalence of 42% of children less than 5 years of age and more than 40% of pregnant women who are anemic 15 . In 2012, specific dietary guidelines for Arab countries were developed by the WHO and the Arab Center for Nutrition. Only seven countries that represent 29% of the Eastern Mediterranean Region population (namely Afghanistan, KSA, Oman, Lebanon, Qatar and Iran) designated their national food based dietary guidelines 16,17 .
The main purpose of this study is to initiate a database analysis of total sugar, salt and iron content in Lebanese foods, focusing on traditional dishes.

Dish selection
The definition of 'composite dishes' is "dishes consumed at main meals (i.e. lunch or dinner), whose preparation involves culinary skills and contains ingredients from at least three of five main food groups: meat/poultry/fish and eggs; dairy products; fruits and vegetables; starchy foods including legumes; added sweets and fats" 18 . The list of Lebanese composite dishes frequently consumed by Lebanese citizens was retrieved from a study done in 2005 on a representative sample of 799 Lebanese adults 18 , and in line with a study conducted in 2009 where the objective was to compare the consumption of traditional dishes between Lebanon and France 19 . The Lebanese diet includes a range of foods with often complex recipes, and it is rarely possible to analyze all the types of dishes. In such cases, a laboratory analysis of the traditional dishes and a calculation of some nutrients should be achieved. The names of the dishes most eaten by Lebanese citizens and chosen for this study are shown in Table 1.

Data collection
Samples of cooked composite dishes were collected (see below). The food samples were bought from five different governorates (Mount Lebanon, Bekaa, Beirut, Tripoli and Saida), taking into account geographical and cultural variations.
A total of 500 g of each dish was collected and used for analysis. According to Greenfield and Southgate, this size is a convenient sample to avoid errors during analysis 20 .
Our research group collected 500 g of 30 types of traditional dishes from five different central kitchens in the following governorates: Mount Lebanon, Beirut, Bekaa, Tripoli, and Saida to show wide representation. Thus, 150 samples were collected. A list of kitchens that served tradition meals, found on internet, was prepared for each of the governorates. The central kitchens were randomly chosen from the results of the internet search, based on the following criteria: 1) their specialty in cooking home-made dishes; 2) their popularity; and 3) their involvement in supporting women as part of the

Chemical analysis
After the receipt of food samples, 500 g of each composite dish was mashed, and then analyzed in the laboratory. The remaining samples were kept frozen at -18°C in tight containers for further analysis.
Total sugar. An amount ranging between 2 and 10g (depending on expected value of sugar content) of the sample was put in a 250 ml volumetric flask. 125 ml of 50% alcohol solution was placed in steam bath overnight. The volume was made up to 125 ml with 95 % ethanol followed by filtration with filter paper. 100 ml of the filtrate was pipetted into a beaker and evaporated to reduce the volume to 20 -30 ml. After that, the solution was placed in 100 ml volumetric flask and rinsed thoroughly with water and then added to the flask. Then the solution was made up to volume of 100 ml and mixed thoroughly. Later on, 50 ml of the obtained solution was placed in 100 ml volumetric flask,then a piece of Lithmus paper was added and the total was neutralized with hydrochloric acid (HCL). An addition of 5 ml of HCl was added and the inversion of sucrose was done at room temperature. When the inversion of sucrose was complete, the solution was transferred to a beaker and neutralized with Na 2 CO 3 until a pink color appeared. Later, the solution was returned to 100 ml flask, diluted to volume of 100 ml with water.

Salt.
To measure the salt content, 2-3 g of the food sample was weighteded into a pre-weighed furnace-proof crucible. It was baked until ash in a 600° C furnace overnight.
When the sampled had cooled, the ash was dissolved in water and was transferred quantitatively in a 50 ml volumetric flask. After making up to volume of 50 ml, the solution obtained was transferred into an Erlenmeyer flask. Later on, 1 ml of potassium chromate indicator solution was added and the solutions was titrated drop wise with the addition of 0.1 N silver nitrate solutions until the color of the solution changed to a reddish brown. A blank test was carried out in parallel using 50 ml of distilled water instead of the sample solution. The blank value did not exceed 0.2 ml of silver nitrate (AOAC 937.09 & ISO 9297) 21 .
The chloride content in the sample was calculated using the formula. Iron. An amount of 15 g of the edible portions was dried in an air oven at 105°C for more than 2 hours then charred until smoke disappearance. A muffle furnace was used to bake the charred sample at 550°C until a grey-colored ash yielded. 25-30 ml of 3.7% HCl was used to treat the ash, and then the mixture was conveyed to a container and done up to a volume of 50 ml with HCl. For each tested food, two solutions of ash were made ready to be analyzed twice. Each fraction of the ash sample was used for iron measurement using a Varian Atomic Absorption Spectrophotometer model 175 with an air-acetylene flame. Ferric nitrate solution was used as a standard. For each ash solution, at least three readings were obtained, and the average was calculated based on AOAC 975.03, 985.35 &965.09 21 .
All the above chemical analyses were conducted at the Industrial Research Institute (Beirut, Lebanon), which is an accredited laboratory for chemical analyses. After food samples were analyzed, stamped laboratory results were received and data was entered on Excel 2019. The data validation process was conducted, and cross checked by two research assistants.

Recipes
The recipes of the dishes in this study were selected from those mostly consumed in Lebanon. The dishes were bought and analyzed as they are consumed by customers. The description (ingredients) of the selected recipes is presented in Table 1.

Results and discussion
The composition of 100 g of the Lebanese traditional dishes in the five Lebanese governorates is shown in Table 2.
Total sugar Among all the governorates, all the tested traditional Lebanese dishes contained little total sugar. The highest total sugar (≥3 g/100 g) was observed in the dishes Hindbe b bzet and Falafel from Mount Lebanon, in Yakhnet Bemieh and Lahm bi ajeen from Bekaa, in Lahm bi ajeen and Foul Moudamas from Beirut, Lahm bi ajeen and Fattoush from Tripoli, and in Table 2. Analysis of total sugar, salt and iron in 100 g of traditional dishes from five governorates in Lebanon. Units: Total sugar (Tot S.) in gram, salt (NaCl) in gram, sodium (Na) in milligram, and iron in milligram.
One of the main factors of the richness of these Lebanese dishes in salt is mainly the high amount of salt added to the ingredients. Additional factors could be the use of spices rich in Na, like coriander leaf, cumin, cloves and cinnamon, during cooking, which are commonly used in the Lebanese cuisine 22 . The Bahraini plates Shawarma Lahme and Shawarma Djeij contained 100 mg of Na 23 , less than the Lebanese plates (Table 3). Unfortunately, we could not compare the Lebanese traditional dishes to the traditional dishes in other Arab and Middle Eastern countries because few dishes are common between them.

Iron
In general, meat-based dishes contained the highest levels of iron compared with other dishes. This was observed in Mount Lebanon particularly in Chichbarak and Batata w kafta (≥2.5 mg/100 g) ( Table 2). However, in all other governorates, the highest level of iron was shown in Fatayer Sabanikh (≥4.5 mg/100g) ( Table 2). As for the highest mean level of iron, Table 3 shows that Fatayer Sabanikh and Kafta w Batata ranked first. The Bahraini plates, Shawarma Lahme and Shawarma Djeij, contained the triple amount of iron (>3 mg) compared to the Lebanese plates (around 1 mg of iron) 23 .
Given the available evidence about the influence of culture on health and health behaviors, reducing total sugar or salt and improving iron intake cannot be separated from cultural factors influencing nutrition-related-attitudes towards the health benefits of iron intake or the use of salt when cooking foods. Cultural influences play a critical role in framing how people perceive food preparation patterns, dietary habits, and coping with variability in agricultural conditions 24 .

Contributions to daily values
The nutrient goal represents the average intake that is compatible with maintaining of good health in individuals 25 . According to the US Food and Drug Administration (FDA) definition, the daily value (DV) is "reference values for reporting nutrients on the nutrition labels". The percentage (%) DV assists the consumer in recognizing how the serving of food and its content in nutrients, fit into their daily diet 25 . As per FDA regulations, the expression "high," "rich in," or "excellent source of" nutrients are used if the food has≥20% of the daily value per reference amount. The terms "good source," "contains," or "provides" are used if the food yields 10-19% of the Recommended Dietary Intake (RDI) per reference amount of the nutrient. Foods that carry <10% of the RDI from the nutrient per reference amount are considered as having low amounts 25-27 .
Lahm bi ajeen and Falafel from Saida ( Table 2). As per Table 3, Lahm bi ajeen and Falafel ranked first in the highest mean total sugar.
In our study, the contribution of each dish to the overall amount of iron, salt and total sugar needed per day was calculated. The calculations are presented in Table 4 and Table 5. The term "total carbohydrate" (CHO) includes dietary fiber, total sugar, added sugars and sugar alcohols. As per the updated FDA regulations, the DV of total CHO is 275 g/day (55% of energy intake in a 2000 kcal-diet) and the DV of added sugar is 50 g/day (10% of energy intake in a 2000 kcal-diet) 26,27 . As Table 4. The percentage contribution to a 2000 Kcal diet of 100 g of traditional dishes for the amount of total sugar (Tot.S), salt (NaCl) and iron based on daily recommend amounts. The daily recommended amount of total sugar is 147 g; NaCl is <5 g;iron is18 mg. per Rapaille et al, and because of the low digestibility of polyols or sugar alcohols, the intake level is restricted to 40-50 g per day in adults 28 . We hypothesized that based on the above recommendations; the daily total sugar consumption should not exceed 147 g per day. This number was obtained by subtracting 50g (recommendation of total sugar) and 50 g (recommendation of polyols) and 28 g (recommendation of fiber) from 275 g (recommendation of total carbohydrate). As per WHO, the iron intake should be limited to 18 mg/day 15 and the salt intake should not exceed 5g/day (1 tsp) 29 .

Appetizer/Dish
We determined the percent contribution of 100 g of each traditional dish to the mean daily need of total sugar, salt, and iron in a 2000 Kcal-diet. The percentage of contribution of nutrients and minerals in a 2000 kcal-diet tested in 100 g of the dishes is shown in Table 4. Our data showed that all the traditional dishes in the five governorates contain low amount of total sugar (<10% of the DV). As for the salt, the majority (67%) of the dishes contains a high amount of salt; however this differed between governorates. A total of 43% of the dishes from Mount Lebanon and Bekaa, 13% of dishes from Beirut, 86% of the dishes from Tripoli, and 40% of dishes from Saida contained a high amount of salt (>20% of the DV). High sodium intake is associated with hypertension, a modifiable risk factor for CVDs 5 . In 2013, Powles et al. estimated that 3.13 g per person per day was the daily sodium intake in the Lebanese population 30 . In addition, a representative survey on 2,543 Lebanese adults showed that the average sodium intake was 2.9 g/day, with high intake in men (3.4 g/day) compared to women (2.4 g/day) 31 . Around 60% of the adults in Lebanon are considered as exceeding the WHO limit level of Na intake of 2 g/day 31 . Parallel to these alarming results, another study was conducted to investigate the knowledge, attitudes, and salt-related behaviors in Lebanese consumers. It showed that the majority of Lebanese participants developed discernible behaviors that increase the intake of salt and had limited knowledge of the food sources of salt 22 . Thus, the adoption of long-term strategies by healthcare providers is required to control adding salt to reduce its negative effects, in Lebanon and elsewhere.
As for the iron content in the Lebanese traditional dishes, more than 60% of the recipes are deficient in iron (<10% of the DV of iron). Only 6% of the dishes from Mount Lebanon and Bekaa, and 3% of the dishes from Beirut, Tripoli, and Saida contain a high amount of iron in 100 g from each dish. Furthermore, in Table 5, the range of the percentage of DC of iron fluctuates between 4% and 27% indicating low content of iron in these dishes. Pellet and Shadarevian tested some of the same traditional dishes in 1970; their data also showed that all the dishes were also deficient in iron 32 . More than one third of the region's population suffers from anemia especially preschool children, pregnant women and women of childbearing age 15 . Iron deficiency and iron-deficiency anemia have numerous adverse health consequences that affect the health of high-risk groups (women and children) 15, 33 . Iron deficiency and iron deficiency anemia can be caused by numerous factors such as low iron intake, decreased iron absorption, chronic blood loss, and chronic inflammation 15,33 . There is a high worldwide prevalence range of iron deficiency anemia among pregnant women (14-75%) 33 . This type of anemia can lead to maternal complications and increased the risk of obstetric hemorrhage in pregnant women 34 . Furthermore, more than 50% of Lebanese hospitalized children aged between 1 month and 12 years, were anemic moderately or severely 35 . Taking into consideration that anemia is prevalent in children and women, preventive measures related to good nutritional patterns and supplementation of iron-rich food are recommended. Strategies to tackle iron deficiency involve nutrition education and food fortification as well as targeted interventions for high risk groups, when needed. Wheat and maize flour fortification is a simple, inexpensive and effective strategy for supplying vitamins and minerals 36 .
There have been widespread priority actions that were implemented by the WHO Regional Office for the Eastern Mediterranean Region in response to unhealthy eating patterns among this population and the high prevalence of obesity.
In 2016, taking into account the recommendations made by the WHO's Commission on Ending Childhood Obesity, the WHO Regional Office for the Eastern Mediterranean Region prioritized the importance of dietary patterns modification at a regional level to halt the rise of NCDs in all age categories 37 . These priority targets and interventions have sufficiently strong evidence based expert analysis 38 . Furthermore, the WHO Regional Committee for the Eastern Mediterranean Region translated the United Nations political declarations and recommendations into a regional framework for action targeting the endorsement of population and individual measures by WHO Member States 39 .

Conclusions
At the national government level, all the related-health sectors should develop a comprehensive range of policy actions that provide support of healthy diet adherence to ensure that agriculture and food policies meet health recommendations. They should also assess the effects of the agri-food systems on NCDs. At the research level, academia should be engaged proactively in building evidence based, and communicating this data to policymakers, handling and supporting the development of data systems with research donors to enable countries to monitor the implementation of effective policies in conjunction with international health agencies.
The main limitation of this study is the analysis of nutrients and minerals in limited numbers of Lebanese traditional dishes. Furthermore, since the food samples were purchased from central kitchens, the proportions of ingredients were not described. The ingredients were retrieved from the literature ( Table 1). In addition, variations in ingredients and preparation methods among traditional dishes from various governorates in Lebanon were inevitable.
In conclusion, this study is a stepping stone for studies exploring the total sugar, salt and iron content of traditional dishes, as well as potential intake in the Lebanese population. It emphasizes the need for multi-cultural education and awareness on salt and iron and their impact on health because nutrition education has the power to productively modify behaviors, attitudes and consumption. Healthy choices result from empowering and motivating people by increasing their knowledge. In general, food composition data are essential for taking action to educate and inform the public about nutrition. There remains a need to expand implementation of rules on nutrition labeling and to scale up introduction of simplified front-of-pack nutrition labeling. Widespread adoption of nutrition policies and/or strategies, along with implementation of multisectoral coordination mechanisms, is indicative of strengthened political commitment to improve nutrition in the countries of the Eastern Mediterranean Region.

Data availability
All data underlying the results are available as part of the article and no additional source data are required.

Haleama Al Sabbah
Zayed University, Dubai, United Arab Emirates Thanks to the journal and authors for giving me this opportunity to review this excellent work.
The main objective of this study is to establish a database analysis of total sugar, salt and iron content in Lebanese foods, focusing on traditional dishes. To achieve this objective, the researchers collected the data by using a stratified sampling methodology. The number of samples per governorate was estimated to be 30 according to the variability in the dishes' composition. The presented results are mapped with the objective and assess the total sugar, sodium (Salt) and iron.
In order to improve the work of this paper I have the following comments for the authors:

General
There is a need for language editing and proof reading for the consistency in writing and phrasing some of the Arabic food names.
The list of References at the end of the paper needs to be checked, delete the repeated references and be consistent in the style of referencing. The majority the references are links to websites and when trying to open some of these links it says that the page is not found (e.g. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/industry-resourceschanges-nutrition-facts-label/ accessed on June 10, 2020).

Detailed comments:
Abstract: " ...food samples was done using stratified sampling techniques. These samples were classified into five strata, taking into account variation by geographical area (Mount Lebanon, Bekaa, Beirut, Tripoli, and Saida)".
The above statement needs rephrasing as by reading further in the methodology and sampling, it's clear that the sampling methodology is convenience sampling technique from five regions/ governorate and not a stratified method.
It is also not clear in the abstract if the analysis of the samples had been done theoretically or in the lab? You need to add the software used to analyse the data at the end of the methods section. Also, the study design and setting should be added to the methods of the abstract. The total sample size?
The following statement needs re-phrasing "... little total sugar" how you define little?" -What is the number/percentage?

Main Manuscript: Methods:
Need to be consistent with the methods presented under the abstract and in the main body of the manuscript (e.g. sampling methodology?) "Our research group collected 500 g of 30 types of traditional dishes from five different central kitchens in the following governorates" How many kitchen from each region they used? What are the selection criteria for the kitchen where you take the sample from? Do they know that you are analyzing their food contents for sugar, iron and salt? If they knew that do you think they did changes in the recipe/ ingredients for each dish of food?
It's not clear enough how did you do the analysis in the lab for each nutrient. "All the above chemical analyses were conducted at the Industrial Research Institute (Beirut, Lebanon), which is an accredited laboratory for chemical analyses. After food samples were analyzed, stamped laboratory results were received and data was entered on Excel 2019. The data validation process was conducted, and cross checked by two research assistants." The above paragraph should be revised and integrated with more information about the study design, settings and sampling methodology.
It's better to move Table 1 to the annex with more specific and quantifiable ingredients of the recipes for each kitchen you have selected and have samples from.

Total Sugar
"Among all the governorates, all the tested traditional Lebanese dishes contained little total sugar." What is the definition for 'little total sugar'? How did you judge that it is little and according to what? You need a reference to compare and say that it is little.

Salt
In the statements under salt "The sodium (Na) level was high in most dishes (Table 2)." and "One of the main factors of the richness of these Lebanese dishes in salt is mainly the high amount of salt added to the ingredients." How did you judge that the level is high and not low or medium? What is your reference for that and compared to what? You need to have a reference in order to compare and say that it's high otherwise it should be descriptive only without analytical statement that its high.
The titles of Table 4 & 5 are too long and some of the information can be inserted in the tables