Abstract

Background

Cardiovascular diseases (CVD) are the major cause of disability and premature death. This is due to the ascending trend of consuming an unhealthy diet and obesity which increases the risk of hypertension and type 2 diabetes mellitus. The main aim of this review was to fill the knowledge gap by providing an up-to-date overview of the prevalence of CVD risk factors among women and to estimate the pooled prevalence among adolescent and pregnant women in Morocco.

Methods

The review included original cross-sectional studies reporting the prevalence of CVD risk factors in Moroccan women aged鈥夆墺鈥�15 years, published between January 2008 and December 2022. The databases searched included MEDLINE, Scopus, Web of Science, Google Scholar and national government publications (PROSPERO ID: CRD42023426809).

Results

Initially, 1471 articles were identified, and 76 studies were included. The most commonly reported CVD risk factor was obesity (reported in 56 studies), the prevalence of obesity varies according to the age groups of women with the rate being particularly high in urban women aged鈥夆墺鈥�35 years (ranging of 14鈥�44.9%). Followed by diabetes (ranging from 7.2 to 12.6%) with a high rate in menopausal women. Hypertension prevalence ranged from 29.8 to 39.29%. Among adolescents, the overall prevalence of obesity was 3.15% (95% CI: 2.6%, 3.7%) and the prevalence of physical inactivity was 56.5% (95% CI: 36.9 鈭掆��76%). Among pregnant women, the overall prevalence of obesity was 26.8% (95% CI: 15.5 鈭掆��38.2%). Gestational diabetes and hypertension were 15.2% (95% CI: 6.3 鈭掆��24.1%) and 7.07% (95% CI: 2.5 鈭掆��11.6%), respectively.

Conclusion

This review highlights the significant burden of CVD risk factors among Moroccan women, with a high prevalences of diabetes, obesity, hypertension. The prevalences of these risk factors varies with age, being notably higher in older age groups. These findings underscore the need for targeted public health interventions to address these risk factors. Future research should focus on longitudinal studies and standardized assessment tools to enhance the robustness of prevalence estimates and inform effective prevention strategies.

Background

Cardiovascular diseases (CVD) constitute a serious global health issue, particularly for women. Research indicates that in 2019, there were approximately 8.94 million deaths due to CVD among women worldwide, marking a concerning increase from the 6.10 million deaths recorded in 1990 [1]. Although age-standardized mortality from cardiovascular disease has declined globally among women over the past 30 years, most of this decline has occurred in countries with a high Socio-Demographic Index. In contrast, the Global Burden of Disease study reported that this mortality has remained stagnant in most other parts of the world, with minimal or no change. Indeed, in countries with a low socio-demographic index, the highest rates of mortality from CVD shift from men to women [2]. In conclusion, the stagnation in reducing the prevalence of cardiovascular disease is an important observation and a call to action.

The majority of CVD is caused by risk factors that can be controlled, treated, or modified. To prevent, recognize and treat CVD in women, it is essential to collect increasingly precise and comprehensive data [3]. Numerous systematic reviews have assessed the prevalence of CVD risk factors in various populations, providing a broad understanding of these determinants globally and regionally. For instance, a systematic review by Motlagh et al. [4] highlights the Prevalence of cardiovascular risk factors in the Middle East鈥嬧��. Similarly, Koller et al. [5] emphasize prevalence of CVD Risk Factors in the Gambia [5]. In Morocco, a systematic review conducted in 2021 [6] provide an overview on CVD and their risk factors in the Moroccan population. In this study, the prevalence rates of CVD risk factors were reported for both women and men. However, the study did not focus on age-specific prevalence among women, particularly missing detailed analysis for adolescents and pregnant women. Additionally, previous studies have explored individual risk factors among Moroccan women, yet there has been a lack of comprehensive reviews that consolidate these findings to provide a holistic understanding of CVD risks in this demographic. Therefore, the main aim of this review was to fill the knowledge gap by providing an up-to-date overview on prevalence of CVD risk factors among women and to estimate the pooled prevalence among adolescent and pregnant women of in Morocco.

Methods

The PRISMA guidelines was used to guide the reporting of the systematic review [7]. A systematic review protocol was registered by PROSPERO 2023 with ID: CRD42023426809.

Eligibility criteria

Original articles of cross-sectional analyses reporting the prevalence of at least one cardiovascular risk factor in women aged鈥夆墺鈥�15 years, in Morocco, and any data source indicating the total sample size and reporting the percentage or number of diagnosed cardiovascular risk factors.

Studies were excluded if they focused on women with a history of CVD or under medical treatment for CVD.

Information sources and search strategy

A search was performed in the MEDLINE (PubMed), Scopus, Web of Science, and Google Scholar, as well as national government publications, without language restrictions for reports published from January 2008 to December 2022.

The search equation was constructed using a combination of MeSH terms and text words, combined with the Boolean operators 鈥淎ND鈥� and 鈥淥R,鈥� parentheses, and truncations. The search strategy will use the following keywords: 鈥渞isk factors,鈥� 鈥渃ardiovascular diseases,鈥� 鈥渨oman,鈥� " adolescent鈥�, " pregnant women鈥�, 鈥淢orocco鈥� and each individual CVD risk factor 鈥� hypertension, diabetes, elevated blood lipids, overweight and obesity, tobacco smoking, and inadequate physical activity. The citations from the pertinent articles or reviews were meticulously examined to identify further research.

All stages of the search were performed by 2 independent researchers (E.F) and (L.L). Any disagreements were resolved by a third researcher (O.M).

Selection process

We used Rayyan (), a free web and mobile app, that helps expedite the initial screening of abstracts and titles using a process of semi-automation. First, all duplicates will be removed by one author (F.E). Second, titles and abstracts will be independently reviewed by two authors (E.F) and (L.L) to exclude irrelevant publications. Third, full-text articles will be inspected to ensure that studies meet eligibility criteria.

Finally, all articles were integrated into Zotero, a reference management tool. Next, the full text was read to identify eligible studies. Identified studies will be compared by both selection authors (E.F) and (L.L). In case of disagreement, a third reviewer (O.M) was asked to make a clean agreement. Finally, the articles included in this review were downloaded and additional manual searching of reference lists of included articles will be conducted during the data extraction phase.

Study risk of bias assessment

The quality assessment of eligible studies was reviewed by two independent reviewers (E.F) and (L.L). This process was conducted using the JBI Critical Appraisal Checklist for Studies Reporting Prevalence Data [8]. This checklist is made up of a grid of nine items which assesses the risks of bias in prevalence studies; for each of the nine items, assessing risk of bias is done so by marking either by yes, no, unclear or inappropriate. This checklist is divided into nine items. Each item is scored with one point. A study was considered low quality if it had 0鈥�3 points, moderate quality if it had 4鈥�6 points, and high quality if it had 7鈥�9 points.

A third reviewer (O.M) was consulted in cases of a discrepancy. When information was absent from the studies, we attempted to reach the authors via email. All studies were included, regardless of their quality score.

Data extraction

Data covering author, city, year of publication, sample size, age of participants, and prevalence of risk factors of cardiovascular disease were extracted. Any disagreements were resolved by consensus with a third reviewer (O.M).

Since the magnitude of the risk for prevalence can be different by population subgroups, articles were grouped as adolescents, women of general population, and pregnant women.

Statistical analysis

To calculate the pooled prevalence of CVD risk factors among adolescents and pregnant women, we used a random-effects model due to significant heterogeneity observed between studies. The effect sizes and confidence intervals (CI) were calculated using standard methods for meta-analysis. Initially, a fixed-effect model was used to calculate the combined prevalence using the inverse variance method; however, due to significant heterogeneity, this model was deemed inappropriate. The random-effects model was then employed, adjusting for between-study variability, with the Tau虏 (between-study variance) estimated using the restricted maximum likelihood (REML) method. Heterogeneity among the studies was evaluated using Cochran鈥檚 Q statistic and the I虏 statistic, which quantifies the percentage of variation across studies due to heterogeneity rather than chance. The calculations were performed using Jamovi software and also used to conduct tests for publication bias and the generation of forest plots.

Results

Literature search

The flow of studies through the systematic review process is presented in Fig. 1. The systematic literature search yielded a total of 1471 relevant records. Of these, 1043 abstracts were assessed for eligibility, after excluding duplicates (n鈥�=鈥�428). A total of 849 articles were rejected at title and abstract level. Then we examined the full text of the remaining 194 articles for eligibility. Of these, 118 articles were rejected for different reasons, mainly because prevalence estimates on women was not reported or could not be determined. Other reasons for exclusions were (1) the studies did not fulfil the inclusion/exclusion criteria and (2) articles reporting results that were already published in other articles. therefore 76 studies were eligible.

Fig. 1

Systematic review flowchart

Characteristics of included studies

The studies were published between 2008 and 2022. Regarding the region where the studies were conducted, the majority (57,4%) of the studies were from three regions, Rabat-Sal茅-K茅nitra 26%, casablanca-Settat 18%, Marrakech-Safi 13.4% and 11.57% were a national study. Some of the 76 included studies provided data on one risk factor and some on multiple risk factors.

Risk of bias in studies

The average methodological quality score was 6,69, Overall, 52 studies were determined as having a low risk of bias, 18 as having moderate risk of bias and 6 as having a high risk of bias.

Prevalence of cardiovascular disease risk factors

Findings and characteristics of the 76 studies featured in this review are presented in Tables 1, 2 and 3. This review included several different populations of women, encompassing women of various age groups.

Table 1 The prevalence of CVD risk factors among Moroccan women

Table 2 The prevalence of CVD risk factors among Moroccan female adolescent

Table 3 The prevalence of CVD risk factors among Moroccan pregnant women

The most commonly reported CVD risk factors was overweight and obesity (n鈥�=鈥�56), diabetes (n鈥�=鈥�25), followed by Hypertension (n鈥�=鈥�19), Tobacco smoking (n鈥�=鈥�17), metabolic syndrome (MS) (n鈥�=鈥�12), inadequate physical activity (n鈥�=鈥�10), and eating habit (n鈥�=鈥�8).

Overweight and obesity

Measurements of the BMI were objectively measured according to the WHO Guidelines and all the studies used the same measures of overweight as Body Mass Index (BMI) of 25鈥�29.9 kg/m² and Obesity as BMI of 30 kg/m² and above.

Out of 18 studies (Table 1) that reported data on overweight and obesity among general population of women, 5 did so by residence status (rural/urban).

Research indicates a significant prevalence of overweight and obesity across various Moroccan women, and all found overweight and obesity to be more prevalent in urban women than rural women. Overweight proportions ranged from 28.3 to 39.2% among urban women versus 25鈥�37.9% among rural women [9,10,11,12,13,14,15,16,17,18]. Similar patterns were observed for obesity with ranges of 15.4鈥�47% among urban women versus 8.9鈥�43.04% among rural women (Table 1) [9,10,11,12,13,14,15,16,17,18,19,20]. Additionally, there were notable geographical differences, with some regions exhibiting higher rates of overweight and obesity than others.

The proportions of overweight ranged from 25,4 to 38.7% among general population of women, while obesity ranged from 14 to 47% (Table 1).

The proportions of overweight ranged from 31.6 to 38.9% among woman in menopause, while obesity ranged from 32.7 to 48.5%.

Significantly, the most common factor found to be associated with overweight and obesity was increasing age [9, 12, 14, 19, 21,22,23,24]. Indeed, an increase in women鈥檚 age by one year increased the risk of overweight by 11鈥�18% (Crude OR鈥�=鈥�1.15; 95% CI [1.11鈥�1.18]) [12]. The prevalence of obesity, varied across different age groups. Among individuals aged 26 to 40 years, the prevalence was 18.3%. This percentage increased in the subsequent age group of 41 to 55 years, with a prevalence of 28.2%. Interestingly, for individuals aged 56 to 70 years, the prevalence slightly decreased to 25.9% [21].

Other risk factors commonly found by four studies [9, 12, 17, 24] to be associated with being overweight were education level. According to study鈥檚 findings from 2022, education level was inversely proportional to obesity, with women who had received university education showing significantly lower mean BMI (P鈥�=鈥�0.001) and WC (p鈥�=鈥�0.004) compared to women with no formal education or those with only primary education [9, 12, 17].

Marital status also emerged as a significant influence on obesity measures in tow studies [9, 17], as married women exhibited a higher BMI and waist circumference compared to never-married women (p鈥�<鈥�0.001) [17].

Additionally, parity is strongly associated with overweight and obesity. indeed, obesity increases significantly with the number of children in care (OR鈥�=鈥�5.27; 95% CI, 1.7鈥�16.3; P鈥�=鈥�0.006) [12, 13, 18].

Ethnicity was associated with overweight and obesity, with Sahrawi Arab ethnicity correlating with higher excess weight (OR鈥�=鈥�1.82; CI95% [1.13鈥�3.93]) and Amazigh ethnicity being protective (OR鈥�=鈥�0.65; CI95% [0.44鈥�0.98]) [12].

Diabetes

The proportions of diabetes among women ranged from 7.2 to 12.6% in the general population and from 10.7 to 34% in menopausal women (Table 1). Diabetes is strongly associated with hypertension, with diabetic women having significantly higher odds of hypertension (OR鈥�=鈥�7.1, 95% CI [4.59鈥�11.12]) [20], and hyperglycemia increases with BMI, affecting 25% of obese women [18].

High blood pressure

The proportions of hypertension ranged from 29.8 to 39.29% (Table 1). According to Mziwira et al.鈥榮 findings, age emerged as significant factors, with the prevalence of hypertension increasing from 8.3% among women under 25 to 47.4% among women over 35, indicating a positive correlation between age and hypertension prevalence [15].

The study also revealed that components of metabolic syndrome, notably hypercholesterolemia ( p鈥�=鈥�0.01), hypertriglyceridemia (p鈥�=鈥�0.025), high body mass index (BMI) (p鈥�=鈥�0.000), WHR ratio (p鈥�=鈥�0.000), large waist circumference (p鈥�=鈥�0.000) and diabetes (p鈥�=鈥�0.021) are significantly more common among hypertensive individuals [15].

Based on the study led by Mochhoury et al., according to the prepregnancy BMI, obese women are more vulnerable to hypertension (93.3%) (饾憙 <0.01). also blood pressure (P鈥�=鈥�0.001) increased as weight status increased among perimenopausal women [25]. Elayachi et al. reveals that higher BMI, waist circumference, and WH ratio are associated with unfavorable metabolic profiles, including elevated levels of BP [23].

Elevated blood lipids and the metabolic syndrome

Four studies provided data on prevalence of elevated blood lipids in the Moroccan women. The proportions of hypertriglyceridemia in general population of women based different definitions ranged from 5.7 to 32.0% and low HDL from 43.34 to 45.3%, and the metabolic syndrome ranged from 7% to 40,12% (Table 1).

Sellam et al. reported that hypercholesterolemia and triglycerides increases significantly with age (p鈥�=鈥�0.01, p鈥�=鈥�0.005 respectively). Distribution by BMI shows that high cholesterol increases significantly with obesity (OR鈥�=鈥�3,1 [1,092鈥夆垝鈥�9,18] (p鈥�=鈥�0.02)) and correlations with sociodemographic factors shows that high cholesterol is associated with the marital status of women (p鈥�=鈥�0.04) [18, 23].

Additionally, dyslipidemia tended to be more frequent in hypertensive women compared to normotensive women [15], and the plasma triglycerides (P鈥�=鈥�0.041) increased as weight status increased among perimenopausal women [25].

The prevalence of metabolic syndrome (MS) (P鈥�<鈥�0.001) increased as weight status increased among perimenopausal women [25]. Among menopausal women, a weak positive correlation between age and MS prevalence was observed (r鈥�=鈥�0.198, p鈥�=鈥�0.004) [26]. El Maghraoui et al. showed that postmenopausal women with MS were older (p鈥�=鈥�0.013) and had more pregnancies (p鈥�=鈥�0.008) [27].

Physical inactivity

Prevalence of physical inactivity was meaningfully assessed and reported in 10 studies, these studies examined physical inactivity by self-report. However, there were variations in the definition of physical inactivity across studies including achieving less than the WHO recommendations of at least 150 min of moderate-intensity physical activity (PA) or; 75 min of vigorous-intensity PA or an equivalent combination of moderate and vigorous intensity PA totaling at least 600 MET-minutes per week (n鈥�=鈥�2); the Physical Activity Index at 4 levels, which is derived from the General Practice Physical Activity Questionnaire (n鈥�=鈥�1); at least 3 times a week for 30 min each time (n鈥�=鈥�1); following regular moderate or intense physical activity of at least 1 h per week, being registered in sport clubs, or having active occupation gymnastics as min/week, or jogging/walking as min/day) (n鈥�=鈥�1); energy expenditure value鈥�<鈥�1680 MET-min/week (n鈥�=鈥�2); number of days physically active for at least 60 min per day, past 7 days (n鈥�=鈥�3); any subject with at least 14 MET per week(n鈥�=鈥�1). The differences in measurements of physical inactivity prevented meaningful comparisons of PA levels among studies and among populations.

According to the latest national survey conducted in 2017 (Table 1), the overall prevalence of insufficient PA among Moroccan women (according to WHO recommendations) was 26% [28]. However, as shown in Table 1, higher prevalence of physical inactivity has been reported in subnational studies, ranging from 21.7 to 72.0% among various adult female populations of the country.

Out of the studies that examined physical inactivity, only 03 reported on factors associated. These studies showed that PA levels significantly varied across age group, residence area, education, employment status, income, housing, marital status, and BMI. Indeed, 22,9% of women aged 18鈥�33 years had low PA, compared to 25,6% of those aged 34鈥�47 years; and 24,2% of those aged 48鈥�99 years [29].

The prevalence of moderate PA was significantly higher among women with college/university education, at 48.7%, compared to 28.8% among illiterate women [29]. Similarly, urban women tend to have higher rates of moderate PA than rural women, with 39.1% and 28.2%, respectively. On the other hand, 62,2% of adolescents girls in rural areas were active compared to 40,8% of urban girls [30].

There were also higher proportions of moderate PA among groups with a monthly income鈥夆墺鈥�5000: 50.0%, compared to 30.9% in the <鈥�2000 monthly income group [29]. Moreover, 77.94% of the girls are physically inactive and don鈥檛 meet the current global recommendation for PA a minimum of 60 min Moderate-intensity physical activities per day or 1680 MET [31].

Tobacco use

The proportions of tobacco use among Moroccan women ranged from 0.4 to 3.3% (Table 1). Nejjari et al. reveal that women鈥檚 smoking rates were significantly associated with the level of education (p鈥�<鈥�0.001). Additionally, in terms of marital status, a significantly higher proportion of single women and divorced women smoked compared to married women (p鈥�<鈥�0.001) [32]. smoking rates were significantly higher in urban, as opposed to rural areas. Women in the highest income areas had significantly higher rates (9.0%) than in other income areas (p鈥�&濒迟;鈥�0.0001).

Dietary habits

To facilitate comparisons across studies, this review synthesizes the prevalence of dietary habits by focusing on fruit and vegetable intake as a common measure, along with adherence to the Mediterranean Diet (MD).

Among the eight studies that addressed dietary patterns, four [33,34,35,36] assessed adherence to the MD, while the remaining our studies [12, 28, 37, 38] provided data on various nutrients and foods consumed by Moroccan women, including fruits, vegetables (Table 1).

Studies that assessed adherence to MD utilized the Mediterranean Dietary Score, proposed by Trichopoulou et al. [39] (n鈥�=鈥�2) and a simplified score derived from an adaptation of the Mediterranean Dietary Score (n鈥�=鈥�2). Studies employing the Mediterranean Dietary Score, noted high adherence to the MD among 68% women in eastern region of morocco (2022) [33], while only 24.72% of women in El Jadida in west of the country exhibited high adherence (2015). Those who using the simplified Mediterranean Dietary Score reported 71.4% high adherence to the MD in national study (2012) and 57.2% in another study conducted in Casablanca (2020).

Regarding the fruit and vegetable intake, according to the latest national survey (2017) [28], 77.82% of the women consumed less than five fruits and vegetables per day. Meanwhile the rate was 29,5% in Southern Morocco [12]. Among female Moroccan adolescents according to the Global School-based Student Health Survey in Morocco, the consummation of vegetables three or more times per day was 27.4% and fruits twice or more per day 47.8% [37] (Table 2).

Only one study assessed factors associated with low MD adherence among Moroccan women. Age and family income did not influence the women adherence to the MD. To be married, to have children or to have a high educational level was associated with a low prevalence of low adherence to MD (p鈥�<鈥�0.05) [36].

Meta-analysis of the prevalence of CVD risk factors in Moroccan female adolescent

The results indicate that national trends of overweight and obesity have been increasing over time among adolescent girls, from 15.8% to 2.5% in 2010 to 17,9% and 3,2%in 2016, respectively [37, 40] (Table 2). The overall prevalence of overweight among adolescent was 11.52% (95% CI: 7.0%, 16%, I2: 97.01%), for obesity was 3.15% (95% CI: 2.6%, 3.7%, I2: 87.85%), as shown in the forest plot Fig. 2 (A, B).

Fig. 2

Forest plot of the prevalence of CVD risk factors among Moroccan female adolescent

Out of the studies that reported the prevalence of overweight and obesity among girls, only one provided a detailed gender-specific analysis beyond prevalence rates [38]. Indeed, Hamrani et al. [38] found that inactive adolescents females had over four times the risk (OR鈥�=鈥�4.23; 95% CI 1.04, 17.28) to be obese than active adolescents females. Additionally, adolescent females who did not consume breakfast at home on a daily basis were at increased risk of being overweight compared to those who had daily breakfast consumption, about fourfold (OR鈥�=鈥�3.70; 95% CI 1.28, 10.73).

The overall prevalence of physical inactivity as energy expenditure value鈥�<鈥�1680 MET-min/week was 56.5% (95% CI: 36.9%, 76%, I2: 98.34%). For physical inactivity defined as number of days physically active at least 60 min/day, past 7 days was 86.30 (95% CI: 83.8%, 88.9%, I2: 80.19%). The pooled prevalence of Smoking was 3.63% (95% CI: 1.18- 6.08%, I2: 96,32%), as shown in the forest plot, Fig. 2 (C, D, E).

Among adolescents, out of the four studies that reported the prevalence of tobacco use among girls, none provided a detailed gender-specific analysis beyond prevalence rates, suggesting a gap in understanding the unique factors influencing smoking among girls specifically.

Results of meta-analysis of the prevalence of CVD risk factors in Moroccan pregnant women

The overall prevalence of obesity and overweight pregnant women was 26.8% (95% CI: 15.5- 38.2%, I2: 97.66%) and 37% (95% CI: 26.3- 47.7%, I2: 94.84%), respectively, as shown in Fig. 3 (A, B). The proportions of overweight and obesity among pregnant women ranged from 24.71 to 56.7% and 6.17鈥�43.3%, respectively (Table 3). Obesity prevalence was significantly higher in pregnant women over 35 years old (53.6%) compared to those aged 25鈥�35 (45.4%) and under 25 (22.2%), and in multiparous women compared to first-time mothers (51% vs. 30%) [41]. Obese women had a significantly higher rate of cesarean Sect. (53.8% vs. 12.8%), multiple abortions (p鈥�=鈥�0.041), and post-term pregnancies (33.8% vs. 20.2%) [41].

Fig. 3

Forest plot of the prevalence of CVD risk factors among Moroccan pregnant women

The overall prevalence of gestational diabetes (GD) and hypertension was 15.2% (95% CI: 6.3-24.1%, I2: 98.57%), and 7.07% (95% CI: 2.5 鈭掆��11.6%, I2: 96.64%), respectively (Fig. 3: C, D).

The proportions of gestational diabetes reported ranged from 5.14 to 35.56% (Table 3). Studies on GD has employed various diagnostic methods. These methods included the use of capillary fasting blood glucose (FBG) tests and postprandial blood glucose (PPG) tests following a standard meal for screening purposes [42,43,44,45,46]. Diagnostic criteria involved a fasting blood glucose level of >鈥�=鈥�0.92 g/L for pregnant women before 12 weeks of gestation and >鈥�=鈥�0.92 g/L for FBG and/or >鈥�=鈥�1.20 g/L for PPG in women beyond the first trimester [42].

Research by Bouhsain et al. in 2008 and 2009 identified age, family history of diabetes, and history of macrosomia as significant factors associated with diabetes in women [42, 43]. The average age of diabetic women was 35 years versus 28 years in non-diabetic women, with a strong correlation to family history of diabetes with OR鈥�=鈥�12.54, 95% CI: [2.91鈥�54.01] [43] and OR鈥�=鈥�15.42, 95% CI: [3.33鈥�18.29] [42], and previous macrosomia with OR鈥�=鈥�2.24, 95% CI: [1.02鈥�18.92] [43] and OR鈥�=鈥�7.8, 95% CI: [5.4鈥�43.7] [42]. Additionally, another study found higher education levels, history of hypertension, and family history of diabetes significantly associated with GD, with multivariate analysis confirming the significance of higher education and heredity [44].

Discussion

This systematic review, supplemented by a meta-analysis, represents the first comprehensive assessment of cardiovascular risk factors among Moroccan women, to inform prevention strategies and direct future CVD factors in women research. The findings from the included studies provide valuable insights into the epidemiology of CVD risk factors in various women groups, including adolescents, pregnant women and women in menopause.

The review highlights that overweight and obesity are the most prevalent CVD risk factors among Moroccan women and suggests a trend of increasing obesity prevalence with advancing age, peaking in middle adulthood before showing a slight decline in older age groups. In Morocco, the national survey from 2000 [47] estimated the prevalence of obesity among women to be 21.7%, 24.5% in 2014 [48] and 29% in 2017 [28]. For instance, similar obesity rates were reported in Algeria and Tunisia. Still, the rates were lower than those observed in Egypt and Libya [49], reinforcing the need for targeted public health interventions across the region.

Consistent with our findings, Mendez et al. (2013) observed higher obesity rates in urban areas attributed to increased physical inactivity and dietary changes [50]. In fact, the results from a systematic analysis of population-based data across 199 countries from 1980 to 2008 suggests that urbanization may affect BMI independently of national income [51]. this could be due to the urban environments which often lead to reduced PA due to more sedentary jobs and greater reliance on transportation. Additionally, urbanization often leads to greater availability and consumption of calorie-dense foods, which are typically associated with a western diet. However, the study notes that the association of BMI with a western diet has weakened over time, indicating that the rise in BMI in developing countries may also be due to increased caloric intake from traditional food sources, not just a shift to western dietary habits [51].

Several socio-demographic factors were found to be significantly associated with overweight and obesity. Older age groups exhibited higher prevalence rates of overweight and obesity, likely due to cumulative lifestyle factors and metabolic changes over time. Research indicates that body weight naturally increases with age in women, with an average gain of 1.94 pounds per year (about 0.88 kg). This trajectory of weight gain is influenced by pregnancy, but studies show that the aging process significantly contributes to long-term weight gain, independent of pregnancy-related changes [52]. The prevalence of obesity and overweight among women shows a progressive increase from adolescence to adulthood, stabilizes somewhat in middle age, and then rises significantly after menopause. Young adults face an early onset of obesity due to lifestyle changes, while middle-aged women experience a consistent prevalence influenced by increased responsibilities and hormonal changes. Senior women, particularly postmenopausal, show a marked rise in obesity, due to hormonal shifts and reduced PA. Besides all those factors this could also be due to cultural views on body size and attractiveness [12, 17, 53]. A study from 2022 revealed that women with a desire to gain weight and those with a positive attitude toward excessive weight were at an increased risk of weight gain (OR鈥�=鈥�25.60; CI95% [13.47鈥�48.64] and OR鈥�=鈥�1.60; CI95% [1.60鈥�1.03] respectively) [12]. Higher education levels were inversely related to obesity, highlighting the need for targeted health education programs. For comparison, studies conducted in Europe on Moroccan women highlighted that obesity prevalence was generally high (rating from 11.2 to 50.7%) [54, 55], similar to our findings in Morocco. This can be attributed to a different set of challenges and influences. The process of acculturation, during which immigrants adopt the dietary and lifestyle habits of the host country, may include increased consumption of fast food and lower levels of PA [56]. Additionally, socioeconomic factors such as income level, education, and access to healthcare services can significantly impact obesity rates among Moroccan immigrant women in Europe [57].

The findings of this systematic review underscore the substantial burden of diabetes among women in Morocco, encompassing both general diabetes prevalence and GD rates. The prevalence of diabetes among the general female population ranges from 7.2 to 12.6%, reflecting a significant public health concern. Comparable to our observations, studies undertaken in Europe on woman of Moroccan origin, show a high prevalence of diabetes (from 8 to 14.6%) [55, 58]. According to the Healthy Life in an Urban Setting (HELIUS) study multi-ethnic population-based cohort in Amsterdam, the Netherlands, a significant proportion of Moroccan immigrants are within the 鈥渟omewhat healthy鈥� group, which was associated with a high prevalence of family history of type 2 diabetes and insufficient PA [59].

Hypertension emerges as a prevalent risk factor among Moroccan women, with rate comparable to those observed in the Middle East and North Africa [60]. The strong correlation between hypertension and components of metabolic syndrome highlights the complex interplay between various physiological mechanisms contributing to cardiovascular risk, as demonstrated by Zahidi et al. [61]. Furthermore, the link between hypertension and obesity underscores the critical need for weight management interventions in the prevention and control of hypertension. Parallel to our results, woman of Moroccan origin in Europe had a significant rate of hypertension (from 10.4 to 24.5%) [55, 65, 67], and based on the HELIUS study there was a notable increase in systolic blood pressure levels over the study period and that age and BMI plays a crucial role in the observed BP trends [68]. Despite these known risk factors and the importance of managing them, challenges remain. For instance, the last national STEPS survey (2017) revealed that 20.5% of female participants continued to have high blood pressure even while undergoing treatment [28], indicating that current interventions may not be fully effective or adequately implemented.

Regarding gestational diabetes, the prevalence is also rising in Morocco ( pooled prevalence 15.2%, 95% CI: 6.3 鈭掆��24.1%), similar to other low- and middle-income countries [62]. Many cases remaining undiagnosed due to inadequate healthcare infrastructure and varying diagnostic criteria. Indeed, the debate continues regarding the optimal approach for screening and diagnosis, with some advocating for a more balanced risk-benefit ratio by requiring two distinct abnormalities for diagnosis to reduce the number of false positives. The lack of a clear threshold to define GD due to the linear relationship between maternal blood glucose and complications adds to the complexity of establishing universal diagnostic criteria [63]. In this review, several risk factors associated with GD were identified across the studies. Advanced maternal age emerged as a consistent risk factor, with older women being more predisposed to developing GD, our results align with those of Al-Rifai et al. [64] who found the prevalence of GD was high in pregnant women aged鈥夆墺鈥�30 years [64]. Additionally, a family history of diabetes was strongly linked to an increased risk of GD, highlighting the influence of genetic factors on disease susceptibility. Notably, a history of macrosomia in a previous pregnancy was also identified as a significant risk factor. These observations match those of Muche et al. (2019) [65]. Equally concerning is the prevalence of gestational hypertension among Moroccan women, which is notably high, similar to other low- and middle-income countries. in contrast, high-income countries generally report lower prevalence rates [66]. This high prevalence is attributed to various factors, including low household income, limited knowledge on gestational hypertension, primigravidity [67].

The prevalence of dyslipidemia and metabolic syndrome further exacerbates the cardiovascular risk profile among Moroccan women. High rates of hypertriglyceridemia and low HDL levels indicate the need for targeted interventions to improve lipid. The association between metabolic syndrome and age, parity, and menopausal status underscores the multifactorial nature of this condition and its implications for women鈥檚 health across the lifespan as also noted by Sun et al. (2022) in their systematic review and meta-analysis of 15 observational studies with 62,095 Women [68].

Tobacco use in Moroccan women was less than in developed countries, likely due to cultural norms that discourage smoking among women [69]. Tobacco use and physical inactivity represent modifiable lifestyle factors contributing to the burden of cardiovascular disease among Moroccan women. The high prevalence of physical inactivity, especially among adolescents and perimenopausal women, underscores the urgent need for comprehensive PA promotion initiatives targeting different age groups and socio-demographic backgrounds. Similarly, addressing tobacco use requires targeted interventions focusing on education, behavioral counseling, and policy measures to reduce smoking prevalence, particularly among vulnerable populations.

The low adherence to the Mediterranean diet and inadequate fruit and vegetable intake among Moroccan women highlight the importance of promoting healthy dietary behaviors to mitigate cardiovascular risk. Socio-demographic factors such as education, and income influence nutritional patterns, emphasizing the need for tailored nutrition education programs and policy interventions to improve dietary quality and overall cardiovascular health.

The female gender, as a social determinant, plays a significant role in influencing health outcomes, particularly among women in Morocco. The interplay of gender with socioeconomic, cultural, and lifestyle factors is crucial in understanding these health issues within different Moroccan societal settings. Firstly, the socioeconomic status (SES) of women in Morocco significantly impacts health outcomes. The scoping review by Moujahid et al. highlights that structural determinants such as women鈥檚 employment, economic status, and education level, along with intermediary factors such as place of residence and maternal age, influence health service usage and outcomes [70]. These determinants are crucial in understanding the prevalence and management of CV risk factors as they affect access to healthcare and health literacy. The Moroccan healthcare system, despite making strides towards universal health coverage, still faces significant challenges in resource allocation, particularly in rural regions [71]. In these areas, the scarcity of medical facilities and formally accredited treatment providers further exacerbates the issue. women in these regions often rely on home-based care rooted in tradition and trust, as opposed to clinical interventions more common in urban areas [72].

Additionally, the broader cultural context in Morocco, characterized by language, religion, and social norms, further complicates healthcare access. These factors can either act as barriers or enablers, depending on how they interact with healthcare services [73]. They also contribute to stigma and discrimination which can deter women from seeking necessary medical care [73]. In the context of specific health conditions, such as the management of GD in Morocco is challenged by delays in detection and treatment, partly due to cultural and systemic barriers within the healthcare system. Efforts to improve management through primary healthcare interventions have shown some promise, but cultural factors still pose significant challenges to widespread implementation and effectiveness [46]. Moreover, ideas of faith, spirituality, and conceptions of death can deter women from accessing timely healthcare [74].

In addition, research indicates that cultural perceptions significantly influence body size preferences and attitudes towards obesity among Moroccan women. For instance, a study on Moroccan Sahraoui women revealed that the ideal body size was rated larger than the healthy body size, with a low desire to lose weight even among obese women. Many women engage in fattening practices, which involves overeating and reduced physical activity to gain weight. This preference is influenced by cultural factors such as the opinions of mothers, men, and traditional clothing, which collectively shape the perception of an ideal body size [75].

Moreover, the intersection of gender and SES is evident in the elderly population, where older women face numerous disadvantages, including lower education and employment levels, which can impede their ability to manage chronic health conditions effectively [76].

Limitations and future directions

While this systematic review provides valuable insights into the prevalence of cardiovascular disease risk factors among Moroccan women, several limitations should be acknowledged. Firstly, the heterogeneity in study methodologies and definitions of risk factors may have influenced the comparability of findings across studies. Secondly, the reliance on self-reported data and cross-sectional study designs may introduce recall and selection biases, limiting the accuracy of prevalence estimates. Future research should address these limitations by utilizing standardized assessment tools, longitudinal study designs, and representative population samples to enhance the robustness of findings.

Conclusion

This systematic review, supplemented by a meta-analysis, provides a comprehensive assessment of cardiovascular risk factors among Moroccan women. The findings reveal an alarming prevalence of obesity, diabetes, and hypertension, particularly among older women and those living in urban areas. Additionally, physical inactivity and poor dietary habits, including low adherence to the Mediterranean diet, are significant contributing factors that require urgent attention.

These results underscore the urgent need for targeted public health interventions to reduce the prevalence of these risk factors and prevent cardiovascular diseases among women in Morocco. Future research should focus on longitudinal studies and the use of standardized assessment tools to enhance the robustness of prevalence estimates and to inform more effective prevention strategies.

Furthermore, the complex interaction between socioeconomic, cultural, and health determinants highlights the necessity of a holistic and contextual approach in the development of public health policies. This study represents an important step towards a better understanding of cardiovascular risks among Moroccan women and should serve as a foundation for future research and public health interventions.