Food systems are increasingly recognized as critical for advancing nutrition, and the food environment is viewed as the nexus between those systems and dietary consumption. Developing a measurement framework of the market food environment is a research priority, particularly for low- and middle-income countries (LMICs), which face rapid shifts in markets, dietary patterns, and nutrition outcomes.In this study, we sought to assess current conceptions and measures of the market food environment that could be adapted for use in LMICs.We conducted a narrative review of the literature to identify measures of the market food environment in recent use. First, we identified and reviewed frameworks of the food environment for LMICs with a specific focus on the market food environment. Second, we compiled 141 unique measures of the market food environment from 20 articles into a list that was pile-sorted by 5 nutrition experts into domains. We then categorized the measures based on percentage agreement across all sorts. Finally, we compared measured and conceptual domains of the market food environment to identify measurement gaps and needed adaptations.Conceptual frameworks provide differing definitions of the market food environment but conform in their definitions of food availability, price, marketing, and product characteristics. Greater clarity is needed in defining relevant vendor and product characteristics. Eight measured domains of the market food environment emerged from the literature review, with significant overlap among conceptual domains. Measurement gaps exist for food quality, safety, packaging, desirability, and convenience. Personal characteristics also emerged as measured domains, although these are not part of the food environment per se.These results are a step toward elucidating how, why, and where we measure the market food environment in LMICs. Future research should focus on prioritizing the most meaningful methods and metrics and on developing new measures where gaps exist. The food environment is the nexus between food systems and dietary consumption. This study elucidates how, why, and where we measure the market food environment in low- and middle-income countries. Lancet series for maternal and child health underlined the need for nutrition-sensitive approaches that align the priorities of food production and supply systems with nutrition  conceptual frameworks of the food environment in LMICs and 2) existing measures of the market food environment that have been used globally and may be adapted for use in LMICs. The conceptual frameworks we reviewed were similar in intended scope, and all aimed to define the broader food environment in the context of food and nutrition programming for LMICs. We reviewed broad frameworks of the food environment with the objectives of identifying and focusing on the market. Our review of measures was not intended to be exhaustive but instead aimed to capture the main methodological tools and constructs that have been used to describe food environments. Our search of measures was not limited to LMICs to ensure that we could capture a breadth of methodological approaches and given that few studies of the food environment have been conducted overall. We focus our discussion on how measures may be used or adapted for LMIC contexts, specifically. For an exhaustive list of measures of the food environment see Lytle and Sokol, 2017  terms “food environment” AND “nutrition” AND “diet.” A total of 428 studies were returned and 158 were retained after title screening. Animal studies and articles that did not refer to the food environment or any aspect of it  were excluded. In a second screening, studies were excluded if they did not present a measure of the food environment; were focused solely on school, work, or home food environments; or assessed food environment policy measures , 18. A tSecond, we identified additional articles using a snowball approach, which entailed reviewing the bibliographies of the initial set of articles to identify relevant peer-reviewed articles and agency-developed tools. Finally, given the variable language used to describe and measure the food environment or aspects of it , a series of additional searches were conducted on PubMed by using a combination of the following (non-MeSH) terms: “consumer OR community OR nutrition OR store OR food OR food venue AND environment OR nutrition environment”. An additional 35 articles were identified in this manner.Measures of the food environment were extracted from 20 articles. Only unique measures were extracted to present the breadth of measures available. Where studies used the same or very similar measurements, the measure was only recorded once. For each study, we compiled a list of all individual measures used to assess the food environment. Where indexes were described, only the individual questions or observations constituting the index were listed. In total, 141 measures were compiled. The list was shared with 5 nutrition experts, purposively approached because of their documented expertise in the areas of food environment, ethnographic methods, drivers of food choice, dietary assessment, and value chains research. The experts represented a breadth of epistemological positioning within the field of nutrition, which ensured that the sorting of measures considered different perspectives across the field of nutrition. The list of items was shared with the experts in random order on an online platform: Proven By Users. The experts were asked to group items into an unspecified number of piles so that similar items were in the same pile. A follow-up discussion was conducted with each expert to understand the reasoning behind his or her sorts. Two experts (AH and GHP) who participated in the pile-sort are coauthors of this article. The methods deployed in this study primarily involved a narrative review of the literature, coupled with an analysis of data extracted from published articles. As such, they did not meet the definition of research with human subjects and consequently, were not submitted for ethical review.n = 11 items) to a given pile were reviewed individually and categorized into an existing pile. Within piles, subcategories were identified where items reached 100% agreement. Once all domains and subdomains were identified and considering errors made during sorting that experts mentioned in the pile-sorting exit interviews, individual items that did not logically belong to a domain were reclassified (n = 3 items).Two of the authors (DT and MNNM) reviewed the piles and identified emergent domains based on the percentage agreement between the assignment by experts. Reviewers were blind to the individual sorting decisions of the 5 experts and analyzed the aggregate percentage agreements among items. All piles with ≥80% item agreement were reviewed and discussed by the authors to determine the emergent construct of the food environment captured by the measures. Any individual items with <80% agreement  framework defines the food environment as the physical, economic, political, and sociocultural context in which consumers engage with the food system to acquire, prepare, and consume food. This framework emphasizes physical proximity, affordability, food promotion and advertising, quality, and safety as domains of the food environment that dictate food choice. The domain of proximity accounts for both an individual's mobility to access food and the physical position of food resources relative to his or her home.Turner et al.  build onSupplemental Table 1).Individual consumer characteristics  that influence people's individual interactions with the food environment are discussed in the presentation of all frameworks, pointing to their importance in considering how food environments affect food choice and diet. However, these characteristics are largely distinct from the environment itself in the frameworks by the Global Panel  and HerfOnly Downs et al.  specify The following section reviews the available metrics of the market food environment. We did not review metrics of wild or cultivated food environments, which are discussed in Downs et al., and which are relatively scarce.Few studies have attempted to characterize market food environments in LMICs as a whole in an effort to facilitate understanding of consumers’ food purchases and choice . Studiesn = 35 items), access to food retail (n = 13 items), perceived availability of food near home (n = 11 items), perceived availability of food at a retail location (n = 15 items), perceived food promotion (n = 5 items), objective availability of food at a retail location (n = 24 items), price (n = 7 items), affordability (n = 12 items), perceptions of food insufficiency (n = 5 items), and factors affecting food choice (n = 14 items). The domains separated into 2 overarching categories: 1 related to the position of food retail in space and a second related to the characteristics of foods encountered inside a market or retail location.Ten domains, based on piles of items with 80% agreement, emerged from the pile-sort exercise  included subcategories addressing the selection and quality of available food. Quality measures referred to produce freshness, and selection to the availability of different food groups or specific items. The domain addressing perceived food promotion included 4 measures, which assessed the extent to which consumers notice nutrition labeling and promotion when purchasing foods .n = 5 items) included measures of shelf space allocated to a specific food or the proportion of a food display dedicated to an item. Food quality referred to the observed freshness of produce and to aspects of safety and hygiene (n = 1 item). Freshness measures were based on visual assessments of the quality of fruits and vegetables as bruised, rotten, or acceptable (n = 424 items) included the absence or presence of promotional materials for food items or food groups.The domain addressing objective availability of food at retail included subcategories pertaining to food placement; quality and safety; the physical presence of food items or food basket items; variety; and advertisement. Food placement  and perceptions of cost as a barrier to consumption of foods within a specific group (n = 5 items). Items related to food security, meal size and frequency, and total food expenditure figured in the domain addressing perceptions of food insufficiency. Factors affecting food choice included measures of encouragement for specific food intake as well as barriers to and facilitators of healthy food intake .Items in the domain of affordability measured on a Likert scale consumer perceptions of food cost , food price (perceived and objective), and food promotion. These measured domains of the food environment include both objective  and subjective subdomains and measures .Food environment research often includes measures of consumer characteristics that are relevant to but outside of the food environment, notably individual access to food stores, factors affecting food choice, and perceptions of food insufficiency.There is significant agreement in the domains represented in frameworks of the food environment and the domains measured in food environment research. However, gaps remain in the completeness of the available measures of product characteristics , retail or vendor types, food marketing, desirability, and convenience. Furthermore, adaptations of existing measures are needed to determine their relevance to LMIC markets. Below, we compare the conceptual domains of the food environment with the available measures and identify gaps.Measures of food availability dominated the list of food environment measures in the literature. These included both objective and subjective measures of food at retail and the availability of food retail locations. The use of measures such as checklists and shelf space to determine the presence and quantity of food items at retail has applications in LMICs, as do measures of food retail density and location. However, studies adapting these measures are needed. Adaptations of measures of food availability in LMICs using audit or market basket checklists will need to consider the dietary patterns of the specific population and the contribution of different foods to local diets.The availability of digital information on food store location and consumer home or other activity space has allowed for the wide breadth of studies investigating food store density and its relation to diet in high-income countries , 49, 31.We found multiple measures of food prices in markets, which is consistent with the prominence of this domain among conceptual frameworks in the literature on the food environment. These included both objective and subjective measures of food cost.Price indexes that have been calculated for LMICs tend to rely on secondary data, often generated from government sentinel market monitoring . These data can be useful for understanding food prices at national level, and depending on the country may be high-resolution enough to characterize regional and district levels . HoweverDespite differences in definitions, all frameworks highlighted the importance of certain product characteristics and, to a lesser extent, vendor characteristics. Product characteristics included aspects of food quality, safety, processing, and packaging.Measures to describe vendor characteristics identified in the literature included assessments of store type and opening hours . MeasureThe measures of product characteristics identified in the literature pertained to food quality and food safety. Although all frameworks included food quality, safety, and packaging as part of the food environment, measures for these constructs were sparse. We identified 1 observation-based measure of hygiene and related infrastructure. This included assessments of the presence of trash, animals, dust, and stagnant water and the condition of the floor, walls, doors, and windows in markets . MeasureNine measures relating to marketing and advertisement were identified. These included objective measures of product arrangement and of the presence of certain types of labeling and signs. Research has also measured consumers’ perceptions of promotional materials and their influence on purchase, accounting for an additional 5 measures. The extent to which consumers notice nutrition labeling or purchase foods that are at eye level or are prominently displayed has also been measured . Data inAdaptations for LMICs will vary by context and the predominant dietary issues that a population faces. As noted above, in urban areas and where high-energy, low-nutrient foods are increasingly displacing nutritious foods or leading to overconsumption, understanding the marketing forces that affect consumer food choice serves public health interests. Similarly, in urbanizing areas where diets are transitioning, monitoring these types of changes is important. Market observation tools that assess the predominance of shelf space and consumer-oriented questions that assess the influence of marketing on food choice can be easily adapted in survey modules.Our review identified individual characteristics that are not part of the food environment per se, but are important in understanding how consumers interact with the food environment. These include perceptions of food insufficiency, and access to food retail, which includes personal mobility and availability of time to access food stores.We identified measures of an individual's physical and temporal access to food—easily adaptable survey questions that can be administered in LMICs. Affordability was largely measured via perception-based questions on the cost of food and cost as a barrier to obtaining food , 40, 52.In this article, we reviewed frameworks and measures of the market food environment and highlighted the utility of the concept to understand and monitor how food systems “deliver nutrition” through markets. Through our review, we identified areas of consensus among the frameworks in terms of the key domains of the market food environment: availability, price and affordability, promotion, and product characteristics. We presented and organized previously uncollated measures of the market food environment that can be adapted for future use in LMICs. Finally, we compared the conceptual and measured domains of the food environment to reveal gaps in the available measures of each domain and in adaptations of existing measures needed for use in LMICs. This work is an initial step toward the development of a measurement framework and tools that can be used to characterize market food environments in LMICs.It is important to acknowledge that the food environment is inherently intangible and therefore difficult to define. The food environment is a concept defined relative to the ways that people interact with the food system and reflects cultural norms and preferences, economic conditions, and geography, all of which change over time. Although “food environment” is inconsistently defined in the literature, the concept of a food environment is valuable as an organizing framework that facilitates research on critical features and determinants of food intake and nutrition. Furthermore, it guides exploration of the cognitive frameworks  that dictate food choice and that can be modified to promote more positive dietary outcomes.Building on the aforementioned concepts, we defined the market component of the food environment as the context in which consumers interact with and purchase food created by a consortium of complex social, economic, and physical factors. This definition is in line with the socioecological model of the food environment that places environments between individual factors and larger systems . From a Adaptations to the measures presented in this review, largely from high-income countries, are required to determine the relevance of those measures to LMICs. Where gaps were identified, new measures must be developed. We noted the need for greater specificity of relevant product characteristics and for better measures of these characteristics. In particular, measures of food quality, safety, and packaging are lacking, as are measures of vendor typologies. Furthermore, the cost of collecting primary data in the types of informal markets that are common in many LMICs must be considered.The market food environment affects consumer diet through interaction with individual characteristics—notably purchasing power and food preferences and tastes—as well as physical and temporal access to markets. Although these factors are not part of the market food environment per se, they are also fundamental determinants of how the food environment affects consumer food choice and diet. We also noted very few measures of desirability.We have identified 5 priority areas for future research:Develop audit or market-basket tools that capture a variety of foods or food groups needed for a healthy diet, as well as those detrimental to health given the current dietary trends in LMICs.Develop vendor typologies relevant to LMICs. Developing store or vendor typologies for LMICs is a low-cost adaptation of measures presented in this article that can help characterize the types of foods that consumers have access to in a geographical location. The measures identified here can be developed into a market observation survey module that captures information on vendor and food characteristics that offer a more complete characterization of informal markets, which dominate food retail in LMICs but for which data to date are lacking.Develop measures of food quality, safety, and packaging as well as measures of convenience and desirability relevant to LMICs. All of these factors play a role in shaping food choice. The nutrition transition, characterized by a shift from traditional diets to foods high in meat, sugar, and fats and rising rates of overweight and obesity, is underway in many LMICs. Aspects of packaging, convenience of food preparation, and desirability have been successfully leveraged by the private sector to increase the consumption of low-nutrient-density, high-calorie, obesogenic foods as studies of the nutrition transition in other contexts have shown. Understanding aspects of convenience, packaging, and desirability is key to prevent the overconsumption of these foods and to promote the consumption of nourishing foods. Further, food-borne illness is a significant source of disease and disability. Transitions toward food retail in LMICs are outpacing food safety infrastructure and regulation, and better knowledge of food safety characteristics and valuations are needed.Research the association between perception-based measures and objective measures of the market food environment. This will help to elucidate where the highest-impact interventions might be, either in knowledge, attitudes, and practices; or in objectively improving the food environment; or both.Conduct assessments of informal markets that collect information on all domains of the market food environment, especially in contexts of urban and rural poverty in LMICs. The vast majority of studies reviewed were from high-income countries and there is very little complete information on the market food environments of LMICs. Most studies reviewed here investigated individual domains of the food environment and as such cannot speak to the relative effects or importance of other domains on consumer food choice. Future studies should seek to characterize the environment as a whole and explore the utility of a composite food environment index in addition to individual domain measures. Above all, better assessments of informal market environments are needed to guide efforts to improve the acquisition and consumption of nutritious foods.Little is known about the impact of interventions targeting transport, processing, and retail on market food environments, even without considering their effects on consumption. The private-sector actors involved in the production, processing, transport, and retail of foods represent potentially important points of intervention to improve food access and nutrition. Operationalizing the framework of the market food environment is a first step in building the evidence base to determine the private sector's current impact on diet and the potential for private-sector interventions to improve diets and nutrition.In conclusion, the concept of the food environment provides an organizational framework to examine the impact markets have on consumer food choice and diet. There is conceptual consensus among frameworks that availability, price, food characteristics, and promotion are key domains of the market food environment. There are gaps in available measures of food and vendor characteristics, notably food quality, safety, packaging, convenience, and desirability. Further research is needed to adapt promising measures to LMICs and to develop new measures where they do not exist.nzab023_Supplemental_FileClick here for additional data file.


In Brazil, the sheep market, including lamb meat consumption, is regionalized, and the consumption of lamb meat is higher in production areas; yet, consumption of lamb still remains below that of other meat livestock. The aim of this study was to identify the profile of Brazilian lamb meat consumers in order to understand their behavior in relation to food in general and on the consumption of this species. Therefore, a survey on consumer habits and preferences regarding food buying and consumption habits, their preferences in relation to the quality attributes of lamb meat, and sociodemographic characterization was performed. Data collected were analyzed by nonlinear canonic relationship analysis and categorical principal component analysis, followed by multiple factor analysis. Three consumer profiles were identified: traditional, interested, and disinterested, and a fourth group was considered independent but could not be described. Among lamb meat consumers, men with higher income seemed to be more frequent consumers than the others, and the intrinsic characteristics of meat quality, especially color and freshness, were the most important at the time of purchase. Thus, the results could be important to the industry in order to guide marketing strategies to certain niche markets. Lamb meat is nutritionally very rich, as it contains proteins, fatty acids, vitamins, and minerals of great importance for the maintenance of vital human functions . Its conDespite challenges for the growth of the sheep-farming production chain, the latest agricultural censuses in Brazil indicate production growth, with the Brazilian herd representing 1.5% of the world herd, the largest in South America, concentrated in the northeastern and southern regions of the country . These rThese dissimilarities in the interest of consumers among meats of different species and regions can be attributed to numerous factors, such as traditional foods in locations where they are produced, availability, cost, family habits, product perception, sociodemographic characteristics, and lifestyle in relation to food . ConsumeConsumer segmentation was widely studied and applied to several issues related to consumption habits and food perception: food benefits , healthyQ1.Whether the purchase or consumption habits of food in general or lamb meat depend on whether the consumer lives in a rural or urban area.Q2.Whether the purchase or consumption habits of food in general or the perception of lamb meat quality depend on the region of the country where the consumer lives.Q3.Whether sociodemographic variables  affect the purchase or consumption habits in general or of lamb meat.Q4.Whether the consumption habits or perception of lamb meat quality are related to the frequency of lamb meat consumption.Q5.Whether the groups of consumers that will consume lamb meat can be predicted and consumer profiles identified.Therefore, with the objective of identifying the profiles of Brazilian lamb meat consumers, this work sought to better understand food buying and consumption habits and preferences of lamb meat consumers in relation to meat quality attributes, seeking information for the industry to have data to outline marketing strategies based on what is more important for consumers. Therefore, the research was based on six research questions:An online survey was conducted with the Google Forms tool from Google, Inc.  and applied between the months of May and June 2019. The territory that was desired to be reached with the research was restricted to Brazil, with the participation of the largest number of Brazilian meat consumers. The research was exempted from the obligation to present a signed free and informed consent form when it was evaluated by the Human Research Ethics Committee of the Faculty of Animal Sciences and Food Engineering of the University of São Paulo.The methodological framework of the lifestyle related to food (FRL)  was usedThe questionnaire  was elabIn the questionnaire, there is an unusual measurement unit for other countries, the minimum wage, which is a frequent way of measuring income in Brazil. The minimum wage is a value established by the Brazilian federal government that is annually updated. It is the minimum amount that must be monthly paid to people who work 44 h a week. The minimum wage is usually the monthly income of people without specialization. Specialized professionals usually earn higher salaries stipulated by unions. At the time of the research, the minimum wage in Brazil was R$ 998.00, and the questionnaire asked the family’s monthly income considering this criterion.The online questionnaire was applied by sharing the access link via email, the WhatsApp application, and the social network Facebook, with disclosure to all contacts of researchers involved and at least one Facebook group dedicated to students from public universities of each of the 26 Brazilian states. After 40 days online, 1477 responses were collected, and 1457 were considered complete. Respondents who did not consume meat were excluded and valid responses were 1401. Respondents were mostly people with higher education and higher social classes, who live in urban areas. In addition, the percentage of responses from women in the sample was greater than the percentage of women in the Brazilian population. The last official demographic census carried out in Brazil that took into account the distribution of the population in different regions occurred in 2010, so it does not exactly indicate the current distribution of the population. The Brazilian population has grown since then, so there are approximate values that indicate the northern and northeastern regions were underrepresented, while the southeastern region was overrepresented.Statistical analysis was performed using XLStat 17.03 , with Kruskal–Wallis tests for research questions Q1 to Q4, study of frequencies by chi-square tests, and analysis of multiple correspondences. As the sample size is large, small variations between observed frequencies and those expected in the Pearson’s chi-square test can generate high chi-square values. A chi-square test was used, and the corrected standardised residual between the observed and expected cases within each cell greater than |1.96| was considered.The study of how socioeconomic variables affect consumer behavior was performed through the nonlinear canonical relationship analysis and by the categorical principal component analysis (CATPCA). The first one consists of procedures that aim to understand in the best possible way the variance in relationships between two sets of numerical variables in a space of few dimensions. CATPCA allows reducing an original set of variables to find a smaller set of uncorrelated components that represent most of the information found in original variables. These analyses were performed for the group of 1401 valid responses using variables that showed a significant relationship with each other.Research question Q5 was studied using the decision tree method and multiple factor analysis (MFA)  of XLStaThe Kruskal–Wallis test, which is a non-parametric method for one-way ANOVA, reported that food buying and consumption habits are not different for residents of urban or rural areas. The frequency at which the population living in urban areas have meals outside their homes is slightly higher than in rural areas (CC = 0.064), and individuals living in rural areas eat more organic foods than those living in urban areas (CC = 0.091). Among respondents who consume lamb meat at least once a week, a greater proportion of people are from rural areas (CC = 0.086).The small differences found between rural and urban populations, were considered irrelevant due to the contingency coefficient being very close to zero. It may have occurred due to availability, as there is greater ease for residents of urban areas to find restaurants, while for those living in rural areas, there is greater availability of organic food and even lamb meat directly from the producer. This is very common in Brazil, where most of the herd is spread over small properties that are often family-based, and informal marketing is frequent .Furthermore, respondents from rural areas were underrepresented. The fact that the questionnaire was online was a limitation for providing answers from rural areas that sometimes do not have internet access. This underrepresentation may have been reflected in results. Respondents from urban areas were expected to be more interested in foreign and gourmet options, but this has not been verified. Thus, the research question Q1 is rejected, and for the study of the following questions, the variable addressed here is no longer considered, and these two groups are now treated as a single population since separation is of no practical use.With the grouping of Brazilian states into each of the five regions of the country , a few habits and preferences were dependent on the region where the respondent lives, like enjoying cooking, foreign food, celebrating with friends and family, whether everyone at home cooks, time spent cooking, having meals only in restaurants, reading labels, using the shopping list when shopping for food, being interested in trendy and gourmet foods, as well as always choosing organic options. However, at the individual state-level within specific regions, variation was minimal. Furthermore, states did not prove important in defining food purchasing and consumption behaviors, as results across states were not significantly different from one another.In addition, the region of origin did not affect the distribution of responses regarding most food purchase and consumption habits covered in the survey . Thus, iConsidering the specific case of the buying and consumption habits of lamb meat, region and state do influence the proportion of people who consume lamb meat. The northeastern and southern regions presented higher consumption of this species than the other regions. As these are traditionally sheep producers and traders, consumption in these regions is also higher, but the northeastern region is the region with the highest growth in the consumption of this species .In the southeastern region, which is formed by four states, São Paulo and Minas Gerais are meat producers. In Minas Gerais, there is a large number of small producers with an extensive production system. In São Paulo, the production system is predominantly intensive, focusing on commercial breeding of animals with higher added value and sheep for special cuts. It was observed that in the state of São Paulo, the most populous, more people consume lamb meat and also do so more frequently than in the other states in the region. This may be due to the greater purchasing power of residents of this state in relation to others since São Paulo is the richest state. On the other hand, these results may have been influenced by the sample, as the population of this region was overrepresented. In the midwestern region, the state of Mato Grosso do Sul is the greatest lamb meat consumer, and in the southern region, the largest consumption was observed for the state of Santa Catarina. Although Rio Grande do Sul is the largest sheep meat producer in the southern region, Santa Catarina has the largest number of establishments regularly operating for slaughter processes, with organized structure for meat production. The greater consumption in this state may be the result of this consolidated structure for product marketing.Despite all variations described according to the different Brazilian regions, the analysis of multiple correspondences found that the origin of consumers did not lead to differences in the degree of importance that they attribute to intrinsic and extrinsic criteria of lamb meat at the time of purchase, according to the four-point scale of questionnaire section (D). These responses were then divided into only two groups : little At the time of purchase, survey respondents placed great importance on freshness (93.3% of responses) and meat color (87.2%), far beyond the importance attributed to other quality criteria covered by this study, as also found in other studies ,31. On tAs for the importance that consumers give to these criteria, these individuals need practical experience and knowledge to assess the quality of a product ; therefoThe analysis of multiple correspondences also indicated that there is no relationship between intrinsic and extrinsic characteristics under study. Thus, research question Q2 can be rejected.Considering that living in urban or rural areas or in a certain region of the country did not influence habits and perception of lamb meat quality, the sample was treated as a unique population to analyze whether or not there is influence of sociodemographic characteristics.Age, schooling, and income affected 80% of the food buying and consumption habits under study and even whether people are lamb meat consumers or not and their frequency of consumption. The frequency of lamb meat consumption was also indicated by  as the fWith a focus on the quality criteria that lamb consumers consider at the time of purchase, it is clear that the criteria that are strongly influenced are ease of preparation and price.At the time of purchase, women were more concerned about the ease of preparation than men. As gender also influences the time spent cooking, and women cook more than men, it is possible that women give more importance to this aspect; while men also purchase lamb meat but in a much lower proportion, women will prepare it.Price, in turn, was influenced by age and family income. Price is considered less important for people aged 45 or older than for younger people, while for people with monthly income of two to three times the minimum wage, this factor is more important at the time of purchase than for families with income higher than 10 times the minimum wage. Obviously, individuals with lower incomes need to be more careful when choosing foods precisely because they have less money available, and price is considered an important factor in the decision-making process, as found in other studies ,25,26. PBy grouping the quality criteria into only two groups (low and high importance), it was found that other criteria were affected so that the perception of the importance of meat certification is affected by age and gender, and the importance given to meat color is influenced by gender. Consumers up to 30 years of age and women place more importance on certification, and women care more about color than men.The most relevant finding was that all sociodemographic variables influence whether people are lamb meat consumers and its frequency of consumption. Thus, it is possible that the fact of being a lamb meat consumer or not as well as the frequency of consumption are related to the consumer’s habits and preferences and to the meat quality criteria that they consider most important at the time of purchase. Therefore, research question Q3 was accepted.The Kruskal–Wallis test showed that lamb meat consumers have a positive relationship with preferences for foreign food, gourmet options, and specialized meat stores than non-lamb meat consumers and are less likely to use a shopping list when buying food. Analyzing lamb meat consumers separately, behaviors also vary according to the frequency of consumption of this food. Regarding the intrinsic and extrinsic criteria of lamb meat quality, the frequency of consumption revealed to be related to the importance given to cut and price, which are less important for the group that consumes lamb meat weekly than for the other groups.Nonlinear canonical relationship analysis  indicateThe finding that women are associated with lower lamb meat consumption is recurrent ,32,33, bThus, it was confirmed that research question Q4 was accepted.Decision tree analysis , using oWhen dividing the sample by gender, men are always more interested in consuming lamb meat. Among women, those who are more predisposed to consuming lamb meat are those who like foreign food and those who buy gourmet options, and in both cases, only 39.4% of women would consume lamb meat. On the other hand, men are more interested than women in any of the tree nodes. Among men, the higher the income, the greater the interest in consuming lamb meat (node 7), with the group of men with higher incomes being the group most likely (73.3%) to consume this meat.Regarding the difference in the probabilities of these groups of men and women of consuming lamb meat, there is need to understand the motivations of women for not consuming it. To investigate this result, questions in section (E) were studied by frequency, and 23.2% of women who do not consume lamb meat claim to dislike this meat, 26.7% affirm that they do not consume it because they have never tried it, 9.9% consider it difficult to find, and 6.4% do not know how or find it difficult to prepare.As for men who do not consume lamb meat, 25.1% do not like it, 13.6% have never tried it, 17.9% consider it difficult to find, and 5.1% do not know how or find it difficult to prepare. The other answers were related to factors such as lack of family habit, price, disgust, health issues, low availability of this type of product, and concern for animal welfare but in irrelevant proportions. For both genders, the main reason for not consuming lamb meat is not enjoying it, and this is a group of individuals that the industry cannot easily reach to increase consumption. The other most frequent reasons indicated by respondents do not coincide with what has been found in other studies, which address factors more related to the reduction of red meat consumption in general, mainly related to health issues ,34.However, these reasons informed by respondents can be circumvented by the industry, rural producers, and stores with the use of marketing tools to stimulate consumption by these individuals. Points in specialized meat stores, supermarkets, and butcher shops for customers to try the product near shelves where products are displayed for sale, promotions, and preparation suggestions on the packaging can be ways to attract this population. Manners of strengthening relationships and improving the market are ways to make it easier for the consumer to have information about the product  and be fIt is known that the segmentation of consumers based on their behavior in relation to food is significant for the formulation of marketing strategies for specific products because it informs the consumer’s particular choices ; therefoConsidering a juxtaposition of the three maps, the upper left quadrant includes people who considered meat quality criteria extremely important and who are mostly from the age group of 45 years, with minimum schooling (incomplete elementary school), who do not like foreign foods and who normally do not eat out on workdays. This consumer profile can be called traditional.The upper right quadrant includes people for whom quality criteria are of little importance, who do not like to cook and to have variations in their meals, and live in homes where not everyone cooks. This group has predominance of people with complete graduation and complete elementary education, but there is no predominant age group. These people have a consumption profile called disinterested.The lower left quadrant is composed of a combination of people who attribute intermediate importance to quality criteria . They have complete higher education, are in the age group of 31–44 years, and like to cook, to vary their meals, and live in homes where everyone cooks. They can be called interested.Finally, the lower right quadrant is composed of individuals who like foreign food, usually eat outside their homes, and who are younger (up to 30 years of age), with complete high school (possibly attending higher education). However, there are no data on the importance that this group attributes to the quality criteria of lamb meat at the time of purchase.As there is information to describe the consumption profiles of only part of the interviewees, the groups of individuals who were separated into clusters were identified; however, it was not possible to describe them completely or to know the number of individuals in each cluster, which was a study limitation. Nevertheless, the consumer profiles of traditional, disinterested, and interested provide rich information for building targeted marketing strategies since this information is accessible to the industry and allows making the product more accessible to consumers. Therefore, research question Q5 was accepted.In Brazil, age, schooling, and income affect food buying and consumption habits in general, but these behaviors are not influenced by the region of the country where the consumer lives. On the other hand, consumption habits and the perception of lamb meat quality depend on the frequency of consumption of this meat as well as on the sociodemographic characteristics of consumers. Parts of population with lower education and income were underrepresented, and these limitations should avoid in future studies using additional collecting methods, such as questionnaires with interviewers in person, in markets, and fairs, for example.It is possible to predict which groups of consumers will consume lamb meat based on the study variables; however, the segmentation of these individuals into clusters was not completely possible due to data complexity, with categorical variables of different natures and sizes. Even so, men with higher income seem to be more frequent consumers than the others, and knowing consumer profiles of traditional, disinterested, and interested allows the industry to focus different marketing strategies in determined niche markets. In addition, the results obtained on the reasons of non-lamb meat consumers were relevant to understand the low consumption of this species in Brazil. It generated valuable information that can be used by rural producers, industry, and points of sales in order to outline marketing strategies for the growth of the sheep meat market, with focus on intrinsic quality criteria and promotion of more direct contact between product and consumer.


This paper presents the development of a methodology to detect and evaluate faults in cable-stayed towers, which are part of the infrastructure of Brazil’s interconnected electrical system. The proposed method increases system reliability and minimizes the risk of service failure and tower collapse through the introduction of predictive maintenance methods based on artificial intelligence, which will ultimately benefit the end consumer. The proposed signal processing and interpretation methods are based on a machine learning approach, where the tower vibration is acquired from accelerometers that measure the dynamic response caused by the effects of the environment on the towers through wind and weather conditions. Data-based models were developed to obtain a representation of health degradation, which is primarily based on the finite element model of the tower, subjected to wind excitation. This representation is also based on measurements using a mockup tower with different types of provoked degradation that was subjected to ambient changes in the laboratory. The sensor signals are preprocessed and submitted to an autoencoder neural network to minimize the dimensionality of the resources involved, being analyzed by a classifier, based on a Softmax configuration. The results of the proposed configuration indicate the possibility of early failure detection and evolution evaluation, providing an effective failure detection and monitoring system. In recent years, the growing demand for electricity and the wealth of water resources in the Brazilian territory have led to an increased adoption of guyed towers for the distribution network due to their lower cost. Along with the growth in demand, a significant number of accidents with this type of structure has occurred. The collapse of guyed transmission towers is one of the causes of service failure in the national interconnected electricity system. The specific periodic inspections carried out in all towers of a concessionaire during the year are not sufficient to detect and predict faults in these towers until the next inspection, and involved complex and expensive operations. Therefore, in this study, we constructed an artificial-intelligence-based monitoring methodology to implement an effective predictive maintenance to avoid the occurrence of faults, and eventual tower collapse, benefiting the end consumer with stable service.The development of innovative continuous monitoring methods are a current engineering research important topic, based on the state identification of each monitored asset, through online measurements and signal processing, consequently assessing their health state in order to make reliable failure prognostics. The overall expected result is an improvement in maintenance costs, a significant reduction in field inspections and an increase in the reliability of the system and the quality of service.Given this problem, many studies have been aimed at assessing the structural condition of guyed towes. Initial targets were wind-induced vibration analysis towers coupled to transmission lines , and anaConsidering the complexity of mathematical modeling the faulty behavior of the towers, machine learning (ML) approaches were applied successfully to the identification of faults in electrical distribution systems . These aThis paper proposes a methodology to detect incipient failures and assess their severity in order to avoid the occurrence of a structural collapse. For this dual purpose, data-driven models of normal behavior were created and trained using two autoencoder and classifier neural network configurations, based on simulated and experimental datasets. These models were then used to detect anomalies through comparative analysis of a testing subset of signals from the datasets. These resulting residual signals were used to characterize different cable-stayed tower models. The simulated dataset was from a finite element model, developed for the original tower design, and the experimental data were acquired from a laboratory mockup tower. The ML models were trained considering different wind excitations for normal and faulty states of the cables that stabilize the towers.The remainder of this article is organized as follows: In In the field of artificial intelligence, several different artificial neural networks are commonly used. Among them, multilayer perceptron (MLP) was the first network to attain real success in applications, and it is now widely adopted. The simplest MLP configuration is based on three layers: a data input layer, a hidden neuron nonlinear activated layer, and an output layer. The neuron layers are based on the basic perceptron configuration of an artificial neuron, as shown in n is the number of inputs, x is the set of inputs, w is the input weights, b is the neuron bias, and y is the output of the neuron that is activated by a nonlinear function f, for example, the sigmoid function defined by Equation y(x)=Equation :(2)fz=11x and an output vector y. The architecture of a multilayer perceptron with more than three layers is referred to, in general, as a deep MLP.Multilayer perceptron classifiers have the ability to learn through training in a supervised manner. MLP training generally uses the backpropagation technique, performed by retroactively calculating the mean squared error of the output sample against the training dataset labels, according to Equation ,(3)Jx^=f∑Then, the mean square error (MSE) of the reconstructed data Equation ,(7)Lx,xA deep autoencoder is a multilayer neural network with more than three layers in the encoder and decoder. The deep autoencoder may be trained successively, called a stacked autoencoder, which we adopted in this work. As shown in The 1D convolutional autoencoder is a variant of the deep autoencoder, using convolutional layers followed in general by subsampling in the encoder, and transposed convolutional layers and oversampling in the decoder. Convolutional layers are kernel-based, which means that their neurons are not fully connected. They are used to learn hierarchical representations from the input data, which results in particularly effective feature extraction from signals. The Softmax classifier is a fully connected perceptron network used for multiple classes, where the last layer has a logistic regression activation function, with one probability output for each class . Figure Considering Equation  correspoThis section describes the data preprocessing and configurations of two different classifying networks, for the finite element (FE) model and the experimental mockup tower, adopted for the case studies. For each case, the behavior of the towers, under normal and faulty conditions, were obtained in response to wind excitations, represented by the measurements of cable-positioned sensors.We modeled the tower using the FE method based on the drawings of a real tower;Using the FE model, we performed simulated acceleration measurements under normal and faulty operating conditions;We conducted experiments and acceleration measurements in the laboratory using the mockup tower under normal and provoked faulty operating conditions;The simulated and experimental datasets were divided into two subsets, for training and testing, with a validation subset separated from the training one;Acceleration data were preprocessed using short-time Fourier transform (STFT) or power spectral density (PSD);Two configurations of unsupervised autoencoder algorithms were implemented and trained for the faulty states;We trained a Softmax classifier using the autoencoder latent models as inputs under supervision, with each operating condition as class labels;Finally, the test datasets were used to estimate the condition of the tower.The FE-based model was developed according to the original tower drawings of the cable-stayed towers, provided by TAESA™, with the aim of analyzing the tower’s behavior for different wind speeds and directions, considering the degradation of cable foundations. The basic tower FE model including cable positions is shown in Simulated time-domain triaxial acceleration signals were obtained in response to wind excitations with a 200 N magnitude. Signals were sampled with a 100 Hz frequency and 120 s of total acquisition time, resulting in 12,000 sample points for each measured node direction. Experiments were performed for five wind directions, considering one normal and two faulty conditions for each separate cable connector foundation.The mockup tower installed in UNICAMP’s LabEDin laboratory is illustrated in As already mentioned, two different signal processing methods, STFT and PSD, were adopted to generate spectrograms based on simulated and experimental data, enabling time-frequency data analysis.For the STFT algorithm, the original signals were divided into several parts of equal length using a sliding Hann window, before applying discrete time Fourier transform (DTFT), producing a spectrogram of the signal . The STFThis subsection details the first proposed configuration for classifying the tower faults for both datasets. The procedure is illustrated through the represented network architecture in The deep autoencoder architecture has 12,000 neurons in the first layer, the second layer has 700 neurons, the third layer has 450 neurons, the fourth layer has 250 neurons, and the last layer has 160 neurons, which significantly reduce the dimension of the input data.This subsection details the second method used for classifying tower failures, which is similar to the first one, but adopts a convolutional autoencoder based on 1D kernels instead of a deep multilayer autoencoder. The procedure is illustrated based on the network shown in The 1D convolutional autoencoder architecture has a size of 12,000 in the first convolutional layer, a second convolutional layer of 7608, a third convolutional layer of 5532, a fourth convolutional layer with a size of 3612, and a final convolutional layer with a size of 1788. Each convolutional layer has a max pooling and a dropout layer in the encoder.This section details the results of the proposed methodologies for locating and classifying tower faults.2 and a cut-off frequency of 256 Hz, located on the truss near the base, as shown in To assess the proposed methodology, we used systematic relaxation of the cable tensioners as a procedure to simulate failures in the tower. The deep autoencoder was trained with 60% of the dataset, 20% was used for training validation, and the other 20% was used for testing. The STFT was normalized by its maximum amplitude value. The confusion matrix, as shown in The test data in The second proposed architecture was used to analyze the experimental dataset, obtained according to the experiments in Here, we proposed a noninvasive approach for anomaly detection and severity estimation for monitoring cable-stayed power transmission towers. The performance of two proposed neural network configurations was analyzed for two datasets, where the first was based on a finite element method of a real tower and the second was based an experimental one with data acquired from a mockup laboratory tower. Vibration excitation was created for sensor measurements under normal and faulty conditions for the two datasets, and machine learning algorithms were developed to assess the tower behavior, aiming anomaly detection and health state estimation.For both datasets, an architecture based on spectrogram analysis, resulting from processing signals from an accelerometer installed on a cable, was used to train an unsupervised autoencoder, followed by a fully connected multilayer neural network classifier with a Softmax output. For the simulated dataset, an STFT spectrogram with a deep autoencoder configuration was used and, for the experimental dataset, a PSD spectrogram and a 1D convolutional autoencoder both followed by the supervised Softmax classifier.The proposed methods allows the generation of machine-learning models that identify anomalous conditions of a tower and classify the failure severity, identifying the faulty cable with an overall accuracy of 94% and 95% for the simulated and measured datasets, respectively.We used the spectrograms obtained with the preprocessing of the tower vibration data to generate a training dataset for the machine learning deep autoencoder algorithm, which achieved an adequate representation of the characteristics of the tower’s behavior under different cable failure conditions. The test results showed the detection of the anomalous vibration behavior of the tower in 100% of the cases, also locating the damaged cable in all cases and estimating the corresponding severity for 94% of the simulated conditions tested and 95% of the experimental tests.The next steps in this line of work are to extend the application of the architectures and models to real towers in the field. This will be pursued through domain adaptation techniques or a generative adversarial network that allows the generation of new simulated datasets, which are indistinguishable from the experimental signals, and thus can be used to train models that may easily generalize to real towers datasets.


As the importance of the gut microbiota in health and disease is a subject of growing interest, fecal microbiota transplantation (FMT) was suggested as an attractive therapeutic strategy to restore homeostasis of the gut microbiota, thereby treating diseases that were associated with alteration of the gut microbiota. FMT involves the administration of fresh, frozen, or dried fecal microorganisms from the gut of a healthy donor into the intestinal tract of a patient. This rediscovery of the potential benefits of an ancient practice was accompanied by a rapid progression of our understanding of the roles and mechanisms of gut microbes in the pathogenesis of disease. With a growing number of diseases being associated with dysbiosis or the alteration of gut microbiota, FMT was suggested as an attractive therapeutic strategy to “reset the gut” and initiate clinical resolutions or remissions. The number of FMT clinical trials is increasing worldwide, but no trials are registered in the Gulf region; this suggested the need for raising awareness of the latest studies on FMT. This review presented the emergent preclinical and clinical data to give an overview of the potential clinical applications, the benefits, and inconveniences that were worth considering for eventual future testing of fecal transplants in Qatar and the Middle East. This study highlighted the diversity of methods tested and commented on the variables that can affect the assessment of the effectiveness of FMT in specific diseases. The risks associated with FMT and the threat of antimicrobial resistance for this therapeutic approach were reviewed. From gastrointestinal diseases to neurodevelopmental disorders, understanding the roles of the gut microbiota in health and disease should be at the heart of developing novel, standardized, yet personalized, methods for this ancient therapeutic approach. This therapy is currently the focus of heated discussions between scientists, clinicians, and the general public8  infections (fulminant pseudomembranous colitis) in four critically ill patients.16Interspecies allocopraphagy has been practiced in human societies for thousands of years. The earliest evidence comes from India 3000 years ago in the form of ancient Ayurveda texts advocating the intake of cattle dung for gastric disorders.C.difficile infections started to become evident and the use of FMT spread widely,17 the US Food and Drug Administration classified FMT as an investigational drug in July 2013; this resulted in significant limitations of its use by subjecting it too expensive and stringent criteria.18 This step has been met with much criticism from both doctors and patients.19 Meta-analyses have shown that FMT is indeed an effective treatment for recurrent and refractory C. difficile infections.20Because the efficacy of FMT in treating difficile infections, such as inflammatory bowel diseases, diabetes, obesity, metabolic syndrome, cardiovascular diseases, various types of cancers, and neurodevelopmental disorders such as autism.22 Preclinical studies using animal models have shown how diabetes and obesity can be transferred from humans to germ-free mice via a fecal transplant,23 and how diseases such as diabetes, obesity, or even behavioral disorders can be reversed in mice using FMT.28 These preclinical studies have encouraged the start of hundreds of clinical trials using FMT to treat most types of diseases and disorders, including cancers, neurological diseases, neuropsychiatric disorders, gastrointestinal diseases, liver and renal diseases, metabolic syndrome, and hypertension.29Nevertheless, there is growing evidence of the therapeutic potential of targeting the gut microbiome for treatment of other diseases beyond C. 30 (2014) has reported the prevalence of CDI in Qatar to be 7.9%, which is higher than Europe. The study also identified strains that are different from the ones found in America, Europe, and Asia. These findings highlight the importance of local surveillance to detect and control CDI. Although prevalence of inflammatory bowel disease (IBD) in Qatar has not been clearly established, some studies show that the frequency of IBD is relatively high and includes atypical cases.33This review provides a brief update on recently published and ongoing clinical trials worldwide as evidence supporting the use of FMT beyond the case of CDI is lacking. It also presents a discussion of the potential clinical applications and the benefits and risks that need to be considered for eventual future testing of fecal transplants in Qatar and the Middle East. A study by Al Thani and colleaguesdifficile and gastrointestinal diseases, this study reviewed those studies and their results. In order to raise awareness in Qatar on the extradigestive clinical applications of FMT, this study will reveal the results of FMT trials on diabetes, obesity, and autism spectrum disorders (ASDs), which have been shown to be of higher prevalence in Qatar than the worldwide averages.36As more than half of the trials are testing FMT on C. clinicaltrials.gov was accessed on April 23rd, 2020, using the expression “fecal transplant” under the condition or disease search window. The count of “active or completed trials” was obtained using the filter to exclude all trials that were labeled as withdrawn, of unknown status, terminated, or suspended. Descriptive statistics were performed on what we have labeled as “active or completed” trials using Microsoft Excel to generate the pie charts. Results of clinical studies for selected diseases were compiled and compared in tables. Selected diseases include C.difficile infections, IBD, diabetes, obesity, and ASDs.The database Another search was performed on PubMed database using the MeSH terms “fecal transplant” in all fields with a filter for the past five years (2015–2020). All types of studies were included in the search. Publications were scanned for relevant information facilitating discussion of applications, efficacy, and risks in preclinical and clinical studies.clinicaltrials.gov database that have met the criteria mentioned in the methods section   . Anotherinfectious disease and 23.6% of all fecal transplant clinical trials worldwide. This means that more than 70% of trials using FMT are being performed to investigate diseases other than CDI.This review focuses on the active or completed trials. Most of these trials are performed in the United States, China, Canada, and Europe . Fecal tFMT is being tested for various diseases including IBD with 25.9% of all trials, irritable bowel syndrome (IBS), other gastrointestinal disorders (GI), CDI, graft versus host disease (GVDH), cancer, liver disease, neurological diseases and neuropsychiatric disorders, antimicrobial resistance, endocrine diseases (endo), rheumatology, renal diseases, and other nonspecified diseases . StudiesC. difficile is a gram-positive, anaerobic, spore-forming, toxin-producing bacillus, which was renamed in 2016 as Clostridioides difficile. One of the first applications of the last century was in 1958 for the treatment of recurrent CDI.5 The infection causes the release of toxin in amounts large enough to damage the intestinal barrier resulting in poor ion absorption by the body and consequent severe inflammation of the colon. C. difficile is the leading cause of healthcare-associated infections worldwide.37 Given the widespread use of antibiotics, approximately 453,000 incidences of CDI cases were observed in the United States in 2011 alone, many of which were fatal.38 Dr. Ben Eiseman, an American surgeon, used fecal enemas to treat the symptoms of severe diarrhea in an attempt to restore healthy gut microbiota.39 This method was used as an alternative to other forms of treatment, such as antibiotics, which are known to alter the structure of the human gut creating further dysbiosis and thus yielding unsuccessful results. As results of the aforementioned study were promising, more than 100 case reports have since been published with up to 90 percent of the cases treated with FMT showing successful results.40The prevalence of CDI is of 7.9% in Qatar, with 5.9 cases per 1000 pediatric patients and 1.6 cases per 10,000 adult patients.clinicaltrial.gov and have published their results; these are compiled in Six clinical trials (using mixed methods and sample sizes) are listed on clinicaltrials.gov have published their results so far. Crohn's disease and ulcerative colitis are inflammatory bowel diseases for which prevalence is increasing. These IBDs are also found as comorbidity factors in other diseases and disorders such as ASDs. Seventy-five clinical trials on IBD and FMT are active and registered on the database , administration with and without prior use of antibiotics, or other premedication.Mixed results have been reported ranging from no clinical remission to full remission and maintenance of remission of the disease. The trials described in 42 FMT showed it could constitute an effective treatment with less adverse events when compared to biological agents that act against the immune system.43Recent meta-analyses concluded that FMT is relatively safe and significantly more successful than placebo in treating ulcerative colitis.44 A recent study showed promising results of the use of FMT in tbl2D in mice models. FMT was administered over a period of eight weeks to mice who had been fed a high-fat diet combined with streptozotocin for six weeks prior to the treatment.44 The results indicated a number of improvements in symptoms associated with diabetes. Insulin sensitivity increased and damage to the islets was significantly reversed after the treatment; this was accompanied by a reduction of the inflammatory response. This result suggests promise for reversing tbl2D in humans. Two human clinical trials are currently testing various protocols of FMT to treat tbl2D. However, none have published results at this time.Type 2 diabetes (T2D) is a common metabolic disorder characterized by decreased insulin sensitivity and impaired islet cell function; it can be caused by genetic and environmental factors. Dysbiosis may induce chronic inflammation of pancreatic islets. This may lead to damage of β-cells causing apoptosis, which is known to be associated with type 2 diabetes.45The role of dysbiosis in obesity may include changes in molecular signaling molecules released by bacteria and the translocation of intestinal bacteria and their products; as a result, paracrine and other endocrine signals are affected. Gut microbiota communicates with the host's adipose tissue, liver, and brain. One of the proposed mechanisms linking dysbiosis to obesity is that secretion of hormones by enteroendocrine cells could be modified by several species of gut bacteria, resulting in reduced satiety.23Many animal studies have been performed worldwide that use the germ-free mice model over the past few years; some of the results suggest that FMT may provide a potential treatment to reduce obesity. Germ-free mice inoculated with microbiota from obese or lean human twins took on the microbiota characteristics and the obese phenotype of their donor. Other studies showed that FMT reverses obesity in mice.Twelve studies were reported after excluding those that were suspended, terminated, or withdrawn. However, only one of them had published results specific to obesity. This randomized, triple-blinded, placebo-controlled trial used an induction dose of FMT via capsules, followed by monthly oral capsules or placebo capsule for maintenance. FMT capsules did not cause any adverse event and led to significant changes in the gut microbiome; bile acid profiles of participants shifted to become similar to those of the lean donor. However, FMT did not reduce body mass index (BMI) in obese, metabolically uncompromized patients. Although the preclinical studies seem very promising, further clinical studies, using different protocols, are still needed to support the use of FMT in the treatment of obesity.46 Some preclinical studies have shown very promising results for the reversal of autism-like symptoms in mice models using probiotics or fecal transplants; four clinical studies listed on the database are exploring the effectiveness of fecal transplants on ASD. One of them, perhaps the only one of its scale for neurodevelopmental disorders, was conducted at Arizona State University and has recently published its results. In this study, a modified FMT treatment plan was formed with multiple administrations of donor microbiota to 18 pediatric patients with ASD and GI problems. Patients underwent 14 days of oral vancomycin treatment followed by a bowel cleansing and a flourishing of the gut microbiota through FMT either orally or rectally. Patients were monitored for eight weeks and again two years after this treatment ended to determine if the effects of the treatment were long-lasting.47 The number of children with severe symptoms decreased by 50% after eight weeks and to approximately 80% after two years. Both the gastrointestinal and ASD symptoms were resolved. Abdominal pain, indigestion, diarrhea, and constipation showed substantial improvement. ASD symptoms related to speech, communication, and social skills also showed remarkable improvement. The gut microbiota of ASD individuals reflected the positive changes with an increase of certain beneficial bacteria that were previously reported as underrepresented in children with ASD. Up to a fourfold increase in the abundance of Bifidobacterium, Prevotella, and Desulfovibrio was noted, and the microbiome became comparable in abundance to that of neurotypical children. These changes persisted weeks after the treatment, which could be interpreted as an effective FMT protocol. This important, long-lasting feature of the treatment might, in reality, be related to the fact that all of the individuals in this study were children; this suggests that the nonmaturity of the gut microbiome at younger age might be a good prognostic factor for the long-term success of the intervention. Similarly, for other diseases data suggest that earlier interventions in relation to the diagnosis of the disease seem to have better rate of success , which are known to be neurotoxic. Therefore, dysbiosis may link the gut microbiota and the related metabolites to what is called the “gut–brain axis.” success .4148 It was initially thought that gut microbes only served to control the population of pathogenic bacteria in the body. However, now it is known that the microbiota plays a vital role in the production of essential metabolites and, more importantly, the regulation of the immune system.48 Changes in environment, diet, and even genetics have corresponded to abrupt and even chaotic changes in the gut.Fecal microbiota transplants aim to address a new and emerging theory in medical literature—the importance of the human gut microbiome and its central role in understanding how disease can be understood and treated. Many diseases have been associated specifically with dysbiosis or decreased bacterial diversity of gut microbiota—the bacteria, phages, archaea, fungi, viruses, and the billions of microorganisms present in the human body.49 Some of the mechanisms include the secondary bile acids produced by gut bacteria that inhibit the germination of C. difficile spores.51 When eubiosis is disrupted, C. difficile, which is a normal member of the microbiota, starts to dominate and colonize the large intestine. This colonization may lead to the disruption of epithelial barrier integrity resulting in the leaking of toxins and inflammation.52 The mortality rates related to C.difficile infections in United States increased between 1999 and 2004 from 5.7 per million population to 23.7 per million,37 before stabilizing at this level with the introduction of FMT for the recurrent CDI infections.The composition of the gut microbiota is a key factor in understanding the pathogenesis and prognosis of various diseases, including infectious diseases such as CDI. FMT has been shown to result in clinical resolution in 80%–90% of patients with CDI. A balanced microbiota was shown to be the main protective barrier against CDI as confirmed by meta-analysis.53 and two years in patients with C.difficile infection.54 An increased gut biodiversity has been shown after two years in a study conducted on ASD.55 For this reason, some believe in a microbiome “fingerprint” that could hold the key to increased understanding of the dynamics of health and disease. Xia et al. (2019) developed the “Stroke Dysbiosis Index” and reported a strong association between dysbiosis and stroke outcome in a mouse model.56 On May 28, 2020, the first FMT trial sponsored by the Chinese Academy of Medical Sciences, Fuwai Hospital was registered on clinicaltrial.gov database for the treatment of hypertension using oral capsules (NCT04406129).There has been a surge in clinical trials and studies of FMT to determine its effectiveness for a spectrum of diseases after its success. Recent studies have evaluated the long-term impacts of fecal transplants on the gut microbial composition. The microbial shift toward the donor's gut microbes has been shown to persist after one year in healthy individualsclinicaltrials.gov, many of which are still ongoing. This indicates that with more human clinical trials the understanding of FMT and its applications for other diseases beyond CDI might expand to include more trials for neurodegenerative , neuropsychiatric , neurodevelopmental  inflammatory bowel diseases , celiac disease, dermatitis, asthma, liver diseases, cancer, diabetes, obesity, and cardiovascular diseases.57 A recent randomized controlled trial run in Qatar and published by Taheri and colleagues (2020) reported that an intensive lifestyle change can reverse diabetes58; analysis of the gut microbiome and metabolome evolution during such lifestyle changes could lead to the consideration of FMT for acute treatment of dysbiosis.60Currently, more than 200 clinical trials on FMT are listed on the database The vast majority of information related to the effectiveness of FMT was derived from case studies; this limited the accuracy of assessments and comparisons to standard techniques and treatments. However, the understanding of efficacy of FMT is expected to improve with the growing number of controlled randomized and blind clinical trials.1. Donor's fecal sample characteristics: Fecal samples might need to be classified based on the microbiome and metabolome profiles in addition to screening for pathogens and antibiotic resistance to develop a more personalized FMT.612. Patient's characteristics: Severity of the disease might impact the efficacy of FMT, and personalized protocols might be needed. Lack of awareness of the potential of FMT renders the recruitment of participants to trials difficult. This also reduces the chances of creating trials that mainly test the efficacy of FMT on disease severity. A study by McLeod and colleagues (2019) analyzed the social representations of feces and gut microbes by investigating English language media coverage of the topic. This study results showed that the media progressively contributes to a change in public opinion toward feces and gut microbes.3. Patient's preparation: Some preparations were shown to trigger inflammation. For example, polyethylene glycol (PEG) is sometimes used for bowel cleansing to dislodge the endogenous intestinal microbiota prior to FMT. This type of preparation could eventually trigger new flares in patients with IBD and impair further assessment of the FMT. No trials have been made to date to compare the impact of patient's preparation on effectiveness of FMT via colonoscopy.C.difficile treatment. Interestingly, FMT performed with capsules were found to be of similar efficiency to FMT using colonoscopy.62 Nevertheless, further studies are needed to better define optimal methodology of the FMT delivery as confirmed by a meta-analysis.644. Method of delivery: The biggest challenge is to establish protocols for groups of conditions based on variables that can be assumed to influence the efficacy of the FMT. The variables collected in this study were related to (1) sample consistency: whole, fresh, frozen, filtered, and lyophilized; (2) the mode of delivery: enema, capsule, and nasogastric; (3) the number of FMT courses: single or multiple; (4) the addition of antibiotics or not; (5) the addition of other drugs or not. All these variables are adding a further challenge to the evaluation of effectiveness of FMT as a new therapeutic approach. A recent meta-analysis by Ramai and colleagues (2020) has investigated the different modes of delivery of FMT and concluded that colonoscopy was more efficient than the use of enema or nasogastric tube in the case of 27 However, this study does not necessarily indicate the inefficiency of FMT. It should not be expected that FMT can cure a noncommunicable disease when the root causes have not been addressed. If dysbiosis is caused by the lifestyle habits pursued by the patient, there is a high probability that a relapse will occur. However, if the causes of dysbiosis are addressed simultaneously, or if the gut microbiota maturation is still at its early stages, such as in children, FMT would be the best therapeutic approach that “resets” the gut to a normal state. The outcomes measured should include checking the alpha diversity and species richness of fecal samples of patients at follow-up as has been done in some studies.415. Measurement of outcomes: Most trials measure clinical resolution and long-term efficacy by following up with patients for eventual relapse. Despite being an important outcome measurement for infectious diseases such as the recurrent CID, it is necessary to highlight the fact that FMT has no effect on the factors that originally cause dysbiosis in the case of noncommunicable diseases (NCDs), most of which are related to lifestyle habits. Therefore, FMT is no more than an acute change of the gut microbiome that can only solve dysbiosis and its resulting health problems in the case of NCDs. The long-term effectiveness of FMT based on relapses in the cases beyond CDI or infectious diseases is not a scientifically sound approach. Sokol and colleagues (2020) reported that the patient's alpha diversity returned to the original diversity after 14 weeks of FMT.Several variables can influence the effectiveness of FMT and need to be controlled before drawing any conclusions regarding its effectiveness for treating specific diseases or disorders:65 Two patients died in 2019 because of multi-drug resistance acquired through FMT.66 The Federal Drug Administration responded with stricter guidelines67 to screen for antibiotic-resistant bacteria in fecal samples. This incident highlighted a deeper, rapidly growing issue that was directly and indirectly affecting humans and the environment. The growth of antibiotic resistance was posing a threat to several medical practices despite the medical advances gained with the discovery of antibiotics. This has the potential to compromise many medical treatments and is further exacerbated by the lack of treatment for pathogens that are resistant to antibiotics. The overuse and misuse of antibiotics for both humans and agricultural life have produced an increased number of antibiotic-resistant pathogens; bacterial pathogens containing resistant genes are constantly released into ecosystems, and the extent of their effects on humans and the environment is still unclear.68 From medicine to food to the environment, it could be argued that many individuals may have developed some form of antibiotic-resistant microbiota because of multiple prolonged exposures to antibiotics. In light of this FMT as a potential effective acute treatment of dysbiosis and its consequences could be hindered as antibiotic resistance is becoming a criterion of selection of donor stool samples. Antibiotic resistance could wipe out the new hope that FMT is raising to treat many diseases and disorders.While FMTs seem to hold promise for many diseases and their positive effects speak volumes based on the emerging data, recent events have triggered a greater need to reevaluate the donor stool screening measures and address the potential harms of growing antibiotic resistance. An important risk directly related to FMT has emerged in addition to the risks inherent in the methods of delivery itself .69; this raises the question of screening the samples for metabolites. Studies on the gut–heart axis have acknowledged the important role played by trimethylamine (produced by gut bacteria) in increasing the amount of trimethylamine oxide, a metabolite that was shown to be involved in cardiovascular diseases.57 Studies on FMT must consider the metabolomic and genomic studies that investigate the association between microbiome prints and diseases; an understanding of the mechanisms by which certain metabolites found in feces can act systemically, (including crossing the blood–brain barrier) is essential.Moreover, some deaths following FMT have been attributed to other causes such as heart attack70FMT could become a very successful approach in the treatment and management of diseases but only after some advances are made. Such advances include composition of the fecal samples, method of administration, and consideration of moving from simple screening to a real personalization of the fecal sample used. McGovern and colleagues (2020) in their study ran a gap analysis and proposed some recommendations to manage possible risks in the design of future trials that could involve FMT.clinicaltrial.gov database. While its primary application is the C.difficile infection, FMTs are being tested on a large panel of diseases and disorders including gastrointestinal diseases, cancers, neurological diseases, neurodevelopmental disorders, antimicrobial resistance, and many more.This review reports latest developments on FMT and its current clinical applications by giving an overview of the clinical trials registered in Results of trials for CDI and IBD constituted approximately 50% of the FMT trials registered on the database. Trials reported it was an optimal approach for CDI and promising one for IBD in using FMT as a treatment, and these are confirmed by several meta-analyses.C.difficile infections and forms of IBD, leading to clinical resolution, remission, or even cure of the infection. As prevalence of CDI in Qatar and atypical cases of IBD are calling to local surveillance, this review is a call to consider this rediscovered approach for research and treatment of these diseases in Qatar.Several meta-analyses have now concluded on the superiority of FMT compared to placebo in treating Bifidobacterium and Prevotella to, respectively, 5- and 82-folds after 2 years and a reduction from severe to mild or no autism in a significant proportion of the cohort. FMT is proposed as a novel approach to investigate on autism in Qatar.This study also reported extradigestive applications of FMT which are of a particular interest in Qatar because of their relatively high prevalence as compared to the world average and for being national health priorities. Results were scarce for diabetes and obesity and mixed in regard to improvements; further studies are needed to better define optimal methodology of the FMT delivery. Studies showed promising results, long-term benefits of the FMT with respect to ASD including microbial shifts toward the donor's microbiome with an increase of The study highlighted the potential risks of FMT and the necessity of monitoring transfer of antibiotic resistance, which is the main significant risk related to FMT. Variations of the FMT method and other factors such as sample origins have been shown to contribute to the heterogeneity of results published on the effectiveness of FMT, and this should be taken into consideration when designing future studies.The growing prevalence of NCDs creates a need for more treatment options. With the rapid advances of metabolomic and microbial prints of diseases, growing evidence is advocating for a role of the gut dysbiosis in the pathogenesis of chronic diseases and disorders. Fecal transplants could become an interesting approach to “reset” the gut to microbial homeostasis and minimum inflammatory status. This review is a call to perform preclinical studies on animal models to test the effectiveness of fecal transplants in managing chronic diseases in Qatar.In summary, this review features the potential benefits and risks of FMT and the necessity to invest in such preclinical and clinical trials in the Middle East.None of the authors have competing interests to declare.DA and AA contributed to data acquisition, data analysis and interpretation and revision of the manuscript. AS and DZ contributed to conception, writing and revisions. CM and AC contributed to design, writing and revisions and GB has conceived, designed, drafted and revised the manuscript. All authors read and approved the final manuscript.This work was supported by the Qatar National Research Fund. Grant Number: 5727002821.


Acne vulgaris ranks among the most common dermatologic conditions encountered during adolescence up to adulthood. For moderate to severe cases of acne, isotretinoin is indicated as it is considered the most efficacious medication against acne. However, isotretinoin use is known to have its side effects and most importantly is the drug's teratogenic potential. As a response, programs such as the Retinoid Pregnancy Prevention Program (PPP), System to Manage Accutane-Related Teratogenicity (SMART), and iPLEDGE were put into action as attempts to promote awareness on isotretinoin's teratogenicity and reduce the incidence of exposed pregnancies. Such programs are lacking in Saudi Arabia. This study aimed, therefore, to evaluate the awareness of women of childbearing age in Makkah Province, Saudi Arabia, with regards to the side effects of the medication, specifically its teratogenicity. This study also intended to assess the compliance of both doctors and patients with the recommendations and precautions associated with isotretinoin. A cross-sectional study was conducted on 766 women participants using a previously validated questionnaire. Results showed that majority of the respondents (91%) are generally aware of the side effects of isotretinoin use, particularly its teratogenicity. However, lapses have been identified with regards to the compliance of both the treating physician and the patient. Three-fourths of sexually active women did not use any form of contraception while being on isotretinoin treatment. Two-thirds of the study participants responded that they were not issued approval forms indicating their understanding of the side effects of isotretinoin and the importance of compliance to the treating physician's instructions; 11.5% claimed that their doctors did not perform any blood tests; and 67.7% claimed that no pregnancy test was performed at any time during the treatment. These findings strongly suggest a need for improvement when it comes to compliance of both doctors and patients. It is recommended that doctor-patient communication be more comprehensive and more efforts should be made to follow international guidelines in that regard. Acne vulgaris is a common disease involving the pilosebaceous unit . AccordiIsotretinoin, a vitamin A derivative, is a first-generation synthetic retinoid drug most commonly known as Accutane or Roaccutane. It has been determined to be the drug of highest efficacy against moderate up to severe cases of acne as noted by the Food and Drug Administration (FDA) . DespiteInternational studies evaluating women's awareness on the teratogenicity of isotretinoin and the compliance with the concomitant precautions are extensive. However, in the Kingdom of Saudi Arabia, published studies mainly focused on the general knowledge surrounding the side effects of isotretinoin use, but only a handful went in-depth on the teratogenic aspect of the medication , 11–13. This study utilized a cross-sectional approach to determine the awareness on the teratogenic effects of isotretinoin, as well as the compliance to precautionary measures among women of childbearing age (12–52) in Makkah Province, Saudi Arabia, who were undergoing or have undergone treatment with isotretinoin. This research was conducted from February 2019 to May 2019, and nonresidents of Makkah province were excluded from the study. An 8-item online questionnaire that was developed by the authors and previously validated was deployed through social media platforms, e.g., Snapchat, Instagram, Twitter, WhatsApp, and Telegram, capitalizing on their accessibility and convenience . The quet-test was used for two group means while one-way ANOVA was used in comparing more than two groups. The post hoc test used was the least significant difference (LSD). These tests rest on the assumption of a normal distribution. In cases of a non-normal distribution, Welch's t-test for two group means was used. The criteria to reject the null hypothesis were set to be the conventional p value of p < 0.05.Statistical analyses of collected data were performed using IBM SPSS version 23 . The chi-square test was used to evaluate the relationship between categorical variables. In comparing group means, an independent Seven hundred sixty-six (766) women of childbearing age undergoing isotretinoin treatment agreed to participate in the study. The study participants were asked whether the treating physician asked them to sign an approval form indicating that the patient understood and received the information on the risks and precautions associated with isotretinoin. About 68% of the study participants claimed that they were not issued a consent form, and 28% responded that their treating physician issued a consent form, while 4% did not follow up with a doctor.n = 96), 22 reported that their doctor conducted a pregnancy test only prior to isotretinoin treatment; two responded that a pregnancy test was conducted before and during treatment; and another two participants said that a pregnancy test was performed before, during, and after treatment. 65 women claimed that a pregnancy test was never conducted in their case.In the proportion of women who were sexually active  study participants were identified to be sexually active during the treatment, and half of whom are unmarried. Two-thirds of these women did not inform their doctors about being sexually active during treatment, and three-fourths did not use any method of contraception. In the proportion of women who used contraceptives, only 28% responded that they are strictly committed and are always adherent to using them. Out of the 96 sexually active women, three participants reported pregnancy during treatment, and two of which underwent normal delivery while the other one had a miscarriage.Lastly, results showed that majority of women (approx. 93%) both from the sexually active and sexually inactive group were knowledgeable in the teratogenic effects of isotretinoin and pregnancy avoidance during and one month after treatment.This study aims to investigate the awareness of women of childbearing age in the province of Makkah, Saudi Arabia, regarding the teratogenicity of isotretinoin and patients' compliance with the precautionary measures associated with the medication. There have been similar studies conducted in different regions of Saudi Arabia including Western region, Al-Madinah, Riyadh, Qassim, and Al Ahsa, albeit focusing on the general understanding of isotretinoin usage and the concomitant compliance , 15–17. Results from the sociodemographic characteristics of the study participants revealed that the majority of the respondents are aged between 19 and 25 years old. In terms of acquisition of the medication, it can be noticed that a proportion of women were able to obtain isotretinoin from sources such as the Internet, friends/relatives, or pharmacies even without a prescription from a doctor. On a similar note, a small proportion of the respondents used isotretinoin for nonacne related reasons. Isotretinoin misuse can vary; it can manifest in improper dosage and duration of treatment , which are not in accordance to clinical guidelines , 19. ImpSixty-eight percent (68%) of the respondents claimed not being issued an approval form indicating their understanding of the risks and precautions associated with isotretinoin use. A significant number of women 11.5%) reported that their doctor did not perform any blood test at all throughout the duration of treatment. It is also important to note that most of the treating physicians for the sexually active group failed to comply with the recommendations in regards to conducting pregnancy tests before, during, or after treatment, as 67.7% of them did not perform any pregnancy test at any point in time. This supports the findings of a 2008 study in Riyadh, Saudi Arabia, wherein the level of compliance of attendees of a national conference on dermatology was assessed and showed that only 16% of dermatologists requested for monthly pregnancy tests [% reporteThe vast majority (91%) of study participants claimed understanding and awareness on the side effects associated with isotretinoin use, which is consistent with previous studies. Molla et al. (2020) reported that 62 of their respondents are generally aware of the side effects, while Al-Harbi (2010) noted that 77% of their study participants are knowledgeable about the medication and its uses , 16. AnoNinety-six (96) out of the 766 study participants were sexually active during the medication. Ten of these women did not follow up with a doctor at all, while 65 of them did not inform their doctor of their sexual activity. This is an indication of physicians failing to extract this relevant information, possibly due to sociocultural barriers, rendering the women hesitant to divulge such sensitive information. Another important statistic to point out is that 71 out of the 96 sexually active women did not even use any form of contraception during isotretinoin treatment. As a result, three women conceived: two of which culminated in a normal delivery, while the other one sadly resulted in a miscarriage.This study made use of a cross-sectional approach utilizing a previously validated online questionnaire to conduct a survey on the sample population . PossiblResults of this study showed that women of childbearing age from the Makkah province, Saudi Arabia, are generally aware of the side effects of isotretinoin, particularly its teratogenic potential. Unfortunately, there are lapses especially with regards to compliance of both patients and doctors. A significant proportion of treating physicians did not follow some of the recommendations, especially conducting pregnancy tests and blood tests throughout the treatment period. Some study participants were able to obtain isotretinoin without a doctor's prescription, and some of them also derive their information from unreliable sources . Women who were sexually active during treatment did not inform their doctors about their activity, possibly due to cultural barriers and other challenges in communication. Additionally, three-fourths of sexually active women did not even use any form of contraception at any point in time while on isotretinoin; this resulted to three cases of pregnancy: two of which culminated in a normal delivery while the other one sadly ended up as a miscarriage. These data suggest that drastic measures and improvements must be sought with regards to both doctor and patient compliance. It is also recommended that the communication between the patient and the doctor be comprehensive, as well as conducive and reassuring to women.