The Emirates Heart Health Project: A Stepped-wedge Cluster Randomized-controlled Trial of a Family-based Health Coach Guided Dietary and Exercise Intervention for Reducing Weight and Cardiovascular Risk in Overweight and Obese Adult Nationals of the United Arab Emirates.

Introduction In the past century, non-communicable diseases (NCDs) replaced infectious diseases as the leading cause of death worldwide. Despite concerted efforts by nations and health systems, NCDs continue to contribute to the deaths of millions each year. A growing body of literature suggests that these diseases may be associated with modern lifestyles which include reduced physical activity and an increased intake of calorie-dense nonnutritive foods leading to obesity (1,2) and overweight (3). Elevated body-mass-index (BMI) is associated with increased risk of cardiovascular disease (4, 5) as well as cancer (6). These trends have been documented in the United Arab Emirates (UAE), as well as in the specific region of this study, the emirate of Abu Dhabi (7, 8).

Existing knowledge Data from Abu Dhabi's Department of Health document that the leading cause of death among the population of the emirate of Abu Dhabi is cardiovascular disease (CVD) (7, 8). Even with significant investment of time and resources, this has not improved over time. CVD was the cause of death in over 39% of deaths occurring in patients above 45 years of age. In those older than 60 years of age, CVD causes more deaths than cancer, respiratory diseases, and infectious disease combined. (7) Eating an unhealthy diet is the leading risk factor for CVD-related deaths and one study estimated that the current diet accounted for 72% of CVD-related deaths in the United Arab Emirates (UAE). Interestingly, the limited intake of whole grains was associated with 22% of CVD-related deaths in the UAE. Other risk factors include consumption of processed meat, red meat, and sugar sweetened beverages (5).

Despite recognition among the population of the UAE regarding what constitutes healthy diet and exercise practices, barriers exist to lifestyle change. In one study of patients in the UAE with type 2 diabetes, only 3% of the 390 individuals surveyed met numerous guidelines' weekly recommendations for 150 minutes of moderate intensity aerobic activity or 90 minutes of vigorous aerobic activity. The most common reasons given in that study for not exercising included cultural reasons (29.2%), "exercise is boring" (20.3%), and lack of family support (4.1%).

Widespread availability and access to outpatient dieticians has not lowered rates of obesity, overweight, and cardiovascular disease risk factors.

Despite access to appointments on an individual basis, rates of obesity, overweight, and CVD risk factors have not improved.