The present study reported the burden of LBP in the MENA region from 1990 to 2019 and found decreases in the age-standardised point prevalence (5.8%), annual incidence (4.4%) and YLD (6.0%) rates. There were no large variations between countries, each estimate was within the other’s UI, meaning that these are not statistically different. Therefore, a reasonable conclusion is that the point prevalence, incidence and YLD were all approximately homogeneous within the MENA countries. Moreover, the age-standardised rate of LBP increased slightly with advancing age and reached a peak around the eighth and ninth decades of life, while no substantial association was found with SDI. Interestingly, the YLD rate among adult males was higher than at the global level, whereas the burden was lower for females in almost all age groups in both 1990 and 2019.
Using GBD 2019 data, a recent article on the global burden of LBP reported that the global age-standardised point prevalence, incidence and YLD rates of LBP in 2019 were 6972.5, 2748.59 and 780.2, respectively . The corresponding figures for the MENA region were 7668.2, 3215.9 and 862.0 per 100,000 population (age-standardised prevalence, incidence and YLD rates, respectively), demonstrating a higher burden than the global average. Furthermore, the percentage changes in the age-standardised rates in the prevalence (− 5.8% vs. -0.16%), incidence (− 4.4 vs. -0.13%) and YLD (− 6.0% vs. -0.16%) were also higher than the global average . The greater burden of LBP in the MENA region could be explained by a higher prevalence of risk factors, such as occupational exposures, smoking, high body mass index (BMI), and lower physical activity, than the global average [13, 14]. In 2016, it was reported that the ergonomic risk factors for LBP were responsible for 21.5% of the occupational attributable DALYs in the MENA region, which was 1.2% greater than the global value for the same year . Interestingly, during the period of study (i.e., 1990–2019), the global reduction in the prevalence of smoking was much higher than in MENA (− 27.5% vs. -11.2% for males and − 37.7% vs. -2.9% for females) . Furthermore, the MENA region had one of the highest increases in smoking among children aged 5–19 years between 1975 and 2016 . Furthermore, in 2014 the prevalence of excess body weight (BMI > 25) was found to be higher in MENA, for both males and females, than the global average . In addition, the countries located in Central Asia and MENA had the highest non-communicable disease burden that was attributable to physical inactivity, accounting for 32.8% of all attributable risks in these countries .
At the national level, Iran and Turkey had the highest age-standardised prevalence, incidence and YLD rates. A cohort study conducted on 163,770 Iranians from the general population found that the lifetime prevalence of LBP was 25.2% and that being overweight [odds ratio (OR): 1.13 (95% confidence interval (CI): 1.07–1.19)] or obese [OR: 1.21 (1.16–1.27)], a former smoker [OR: 1.25 (1.16–1.36)] or a current smoker [OR: 1.28 (1.17–1.39)] and having low physical activity [OR: 1.07 (1.01–1.14)] were all significantly associated with the occurrence of LBP . Iran had a higher prevalence of low physical activity than the Eastern Mediterranean Region (EMR) average (55% vs. 31%) . Moreover, Iran was one of the countries that had an increase in the age-standardised prevalence of smoking among females (8.3%) and males (2.3%), despite a decrease in the age-standardised prevalence rate in the MENA region . In addition, regarding occupational LBP, a systematic review reported that neglecting basic ergonomic principles in workplaces and a lack of effective interventions were major risk factors among Iranian workers . Therefore, the higher burden of LBP in Iran could be due to the higher prevalence of risk factors in this country. Furthermore, a cross-sectional study, conducted on 7897 participants in the Trabzon province in Turkey, showed that smoking, low educational attainment and underlying chronic diseases were risk factors for LBP . In light of the above, interventions in these countries should focus on reducing smoking and ergonomic stressors, as well as increasing physical activity in order to control and reduce the burden of LBP. Moreover, educational programs, such as holding ergonomic training courses and advising individuals to remain active, as well as non-pharmacological therapies, like cognitive behavioral therapy, spinal manipulation, massage, acupuncture, yoga and interdisciplinary rehabilitation could be effective in the prevention and management of LBP . Furthermore, while Turkey and Iran were the MENA countries with the highest age-standardised YLD rates of LBP in 2019, they also experienced the largest decrease from 1990 to 2019. These decreases may be as a result of the implementation of programs to prevent LBP or to manage LBP properly. Therefore, it is suggested that these programs are continues, in addition to the abovementioned measures.
Previous research has reported the global burden of LBP to be higher among women than men in almost all age groups, although the differences in the prevalence, incidence and YLDs were not significant . Although we also found that the burden of LBP did not differ discernibly by sex, the prevalence, incidence and YLDs were higher in males across all age groups. In accordance with our findings, the GBD 2013 study also reported that males had higher DALYs for LBP in the EMR (911.5 vs. 827.3 per 100,000 population) . However, in 2017 the age-standardised point prevalence of LBP in MENA was higher in females than among males (10.8% vs. 9.1%) . One reason for the higher number of cases of LBP in MENA, than worldwide, could be the higher number of individuals of working age in the MENA region, since LBP is 2.5 times more prevalent in those working than in the general population . Nevertheless, the number of prevalent cases in MENA was higher in males, which highlights the need for future studies to explore the reasons (e.g. occupational exposures) for this finding. Consistent with the findings at the global level, the age-standardised prevalence rate of LBP in MENA peaked in the 80–84 age group, for both sexes, and then started to decrease . In 2019, after the age of 40, the sex differences in the prevalent counts started to decrease in MENA and after 75 years of age, females had more prevalent cases than males. This difference could be due to the fact that disc space narrowing and the presence of osteophytes are significantly associated with chronic LBP . Since disc degeneration is accelerated in postmenopausal women, they are at higher risk for the development of LBP, than premenopausal women .
Our report showed no overall association between SDI and the age-standardised YLD rate, over the period 1990–2019, although the age-standardised YLD was higher in countries with an SDI between 0.4 and 0.75. There was a similar association between the burden of LBP and SDI in most other GBD regions between 1990 and 2019. In contrast, at the global level there was an overall positive association between SDI and the burden of LBP .
The present study is the first to report the burden of LBP in the MENA region by age, sex, and SDI, using the most recent iteration of the GBD project. Nevertheless, our study has several limitations that should be taken into account when interpreting our findings. Firstly, the GBD uses modelled estimates instead of primary data. Furthermore, differences in the definition of LBP and the lack of an appropriate survey for gathering data on the burden and prevalence of LBP in many countries is another major limitation of the GBD study. For instance, an article by Maher et al. on LBP reported that only about 16% of countries had at least one report that used an appropriate measurement tool, so the prevalence data across countries and years remains sparse . Furthermore, there are some unclear points in the results. For instance, Turkey had a very sudden and suspicious drop in the last 2 years of observation. This dramatic change may not be valid since there is no explanation for a change of over 10% in just 2 years when the region has only changed by 6% in 30 years. Secondly, the DWs that represent the severity of the disease, and were used to compute the YLD, were derived from the six LBP health states, which were based on the United States Health Service data . Therefore, the LBP burden in MENA should be interpreted with some caution. Thirdly, we only assessed the patterns of LBP by sex and socioeconomic status, but there are other factors that are associated with LBP, which were not included in the present study, such as occupation, religion, education, social capital, race/ethnicity, culture and language . Therefore, reporting the burden of LBP by religion, culture and race/ethnicity should be considered in future GBD iterations. Fourthly, the burden of LBP reported for each country might not be generalisable to all provinces of that country, as the subnational burden was not reported for any of the MENA countries.