Think Forward.

El Angioedema : "Desde los ataques de hinchazón localizados hasta la asfixia potencialmente mortal" 506

El Angioedema se caracteriza por una acumulación de líquido en las mucosas y en la piel, lo que produce unhinchazón e inflamación de la cara, de las extremidades o de los genitales. UN ANGIODEMA DE ORIGEN ALERGICO Puede poner en peligro la vida del paciente, cuando afecta a la vía aérea. En la gran mayoría de los casos, es un angioedema de origen alérgico. Afecta a aproximadamente el 20% de la población en algún momento de su vida, y esta a menudo asociado a la presencia de una urticaria. Puede ser causado por un alimento, una picadura de insecto o un medicamento. El angioedema histamínicose trata concorticosteroides y antihistamínicos. En los casos más graves (edema de Quincke), la adrenalina constituye el tratamiento de elección para evitar el shock anafiláctico. OTRA CAUSA : EL ANGIOEDEMA BRADIQUINO HEREDITARIO Otra causa del angioedema, a menudo desconocida en Marruecos es : el angioedema bradiquínico hereditario. Se trata de una forma rara que ocurre con mayor frecuencia durante la infancia o la adolescencia. Los pacientes presentan edemas recurrentes que duran de 2 a 5 días y que desaparecen sin secuelas. Los episodios o ataques de la enfermedad se producen de forma impredecible y varían de un paciente a otro. Se conocen una serie de factores que pueden desencadenar los ataques como los procedimientos dentales, las infecciones de la esfera ORL, el estrés, el embarazo ... El hinchazón puede incluso afectar al abdomen, provocando dolores intensos, náuseas y vómitos, así como diarrea. El edema laríngeo es potencialmente mortal, con un riesgo de muerte del 25% en ausencia de un tratamiento adecuado. Una forma aún más rara es el angioedema bradiquínico adquirido no hereditario, cual ocurre generalmente en adultos mayores de 50 años, y es consecuencia de otra enfermedad (autoinmune o cancerosa) o de ciertos medicamentos como los antihipertensivos de la familia de losinhibidores de la enzima convertidora de angiotensina (IECA) o los antidiabéticos. El tratamiento de los ataques de angioedema bradiquínico consiste en el uso de medicamentos que aún no están disponibles en Marruecos (inyecciones subcutáneas de icatibant o administración intravenosa de concentrados de INH-C1). El ácido tranexámico o el danazol constituyen tratamientos de fondode la enfermedad. LA ASOCIACION AMMAO La Asociación Marroquí de Pacientes con Angioedema (AMMAO) presidida por el Sr. Imad Elaouni, fue creada en febrero de 2018 por personas de la sociedad civil y miembros del cuerpo médico y paramédico con el objetivo de informar y sensibilizar la población a estaspatologías, asícomo el de unificar los esfuerzos para atendera las personas que las padecen. El presidente honorario es la profesora Laurence Bouillet, profesora de Medicina Interna y coordinadora del centronacional de referencia sobre el angioedema en Francia. AMMAO es también miembro de la Red Global de los angioedemas - HAEI. 9 de enero de 2024 Dr Moussayer Khadija, Especialista en medicina interna y geriatría, presidente de la alianza de enfermedades raras de Marruecos, vicepresidente de AMMAO RESUME L’angioedème : « De crises de gonflement localisé à l’asphyxie potentiellement fatale» Les angioedèmes se caractérisent par une accumulation des liquides au niveau des muqueuses et de la peau se traduisant par des crises de gonflement du visage, des membres ou des organes génitaux. Ils peuvent comporter un risque d’asphyxie quand la gorge est atteinte. UN ANGIOEDEME REPANDU D’ORIGINE ALLERGIQUE Dans la très grande majorité des cas, il s’agit d’un angioedème d’origine allergique, environ 20 % de la population en sont touchées à un moment de leur vie. UN ANGIOEDEME PLUS RARE D’ORIGINE HEREDITAIRE Les angioedèmes peuvent être avoir une autre cause : c’est l’angioedème héréditaire bradykinique. Cette forme plus rare se déclare le plus souvent durant l’enfance. Le gonflement peut toucher l’abdomen, donnant de fortes douleurs, des nausées et vomissements ainsi que des diarrhées. L’œdème laryngé met en jeu le pronostic vital avec un risque de décès de 25 % en l’absence de traitement approprié. L’AMMAO POUR MIEUX SENSIBILISER A CETTE PATHOLOGIE L'Association Marocaine des Malades d'Angioedèmes (AMMAO), présidée par M. Imad Elaouni, a été créée en 2018 avec pour objectif l’information et la sensibilisation de la population à ces pathologies. Le Pr Laurence Bouillet, coordinatrice du centre de référence national sur les angioedèmes en France, en est la présidente d’honneur. L’AMMAO est par ailleurs membre du réseau mondial des angioedèmes – HAEI. C'est une organisation “ombrelle” de défense globale des patients représentant la communauté des malades partout dans le monde. Maria Ferron en est la représentante régionale pour tous les pays Méditerranéens et elle est une des interlocutrices privilégiées de l’Association AMMAO SUMMARY Angioedema: "From localized swelling attacks to potentially fatal asphyxia" Angioedemas are characterized by an accumulation of fluid in the mucous membranes and skin resulting in swelling of the face, limbs or genitals.They may carry a risk of asphyxiation when the throat is affected. ANGIOEDEMA OF ALLERGIC ORIGIN In the vast majority of cases, it is an angioedema of allergic origin, about 20% of the population are affected at some point in their life. Often associated with an urticaria, it can be caused by food, insect bite or drug. THE HEREDITARY ANGIOEDEMA Angioedema may have another cause, often unknown : it is the hereditary bradykinic angioedema. This rarer form occurs most often during childhood or adolescence. Laryngeal edema is life-threatening with a 25% risk of death in the absence of appropriate treatment. AN ASSOCIATION FOR ANGIOEDEMA The Moroccan Association of Angioedema Patients (AMMAO), chaired by Mr. Imad Elaouni, was created in 2018 with the aim providing information and awareness to the population about these pathologies. Professor Laurence Bouillet, coordinator of the national reference center on angioedema in France, is the honorary president. AMMAO is also a member of the global network of angioedema -HAEI. BIBLIOGRAFÍA - Isabelle Boccon-Gibod , Laurence Bouillet, MD , Clement Olivier, Clinical Characteristics of Hereditary Angioedema (HAE) Type III Patients Compared with Those with HAE Type I/II , JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY 26/01/13, Doi : 10.1016/j.jaci.2012.12.791 - Laurence Bouillet, Diagnostic des angioedèmes héréditaires, La Presse Médicale, Volume 44, Issue 1, 2015, Pages 52-56, ISSN 0755-4982, https://doi.org/10.1016/j.lpm.2014.06.027. - Khadija Moussayer, Les angioedèmes en débat à Casablanca le 19 janvier 2019, Mescursus 29 Décembre 2018. https://medcursus.com/442/les-angioedemes-en-debat-casablanca-le-19-janvier-2019 - Khadija Moussayer, On estime que 2.000 personnes sont touchées par les angioedèmes bradykiniques au Maroc, Le Matin ma, 4 janvier 2024 https://lematin.ma/express/2022/maroc-compte-2000-cas-angioedeme-bradykinique/384170.html
Dr Moussayer khadija

Dr Moussayer khadija

Dr MOUSSAYER KHADIJA الدكتورة خديجة موسيار Spécialiste en médecine interne et en Gériatrie en libéral à Casablanca. Présidente de l’Alliance Maladies Rares Maroc (AMRM) et de l’association marocaine des maladies auto-immunes et systémiques (AMMAIS), Vice-présidente du Groupe de l’Auto-Immunité Marocain (GEAIM)


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Genesis... 719

I greatly enjoy looking out windows, any windows. Windows have always offered me a picture of life. A picture that constantly changes, a picture that I alone see before it disappears forever. Maybe that is where my taste for the ephemeral comes from. It is my only certainty. What I am also sure of is that it comes from the fact that as a baby and young child, my mother would place me by the window where I would hold onto a grille. An opportunity to be both inside and outside at the same time and to let her go about her many responsibilities as a housewife. It was a traditional Moroccan grille, typical of ours. Today, I have reused that same grille design on the windows and balconies of my house. I have in fact remained my mother’s eternal child, no doubt like we all remain so, but probably differently, otherwise, uniquely. The window is an escape from the cramped space of the house. In fact, all houses are cramped. The house, paradoxically despite its smallness, is a space of freedom, intimacy, and security. It is also a space that distances the horizon and makes it sublime. The window allowed me to raise my head and look far. As far as this window allowed me to see. The house cultivates the dream; the window waters it. On the evening my mother passed away, I stood by the window. It seemed to me I heard her voice again speaking from afar to reassure me. My mother loved me very much. She did not say it, but made me feel it through the tone of her voice, her gaze, and a slight smile at the corner of her lips. A smile she had a special secret to. My mother’s smile was genetic. I clearly saw she inherited it from my grandmother—Cherifa Lalla Zhour had the same smile. My mother was not expansive. She extended her love to my children later, and I felt it. I was her eldest, her first female experience, her first pains, her first childbirth, the first baby cry to her ears. I owe my mother much: the sensation of a pencil in hand, the touch of the softness of paper before writing on it, the taste for reading and the pleasure of manual work. My mother was among the first classes of the modern school in Fès. My maternal grandfather, Si Ahmed Ben Ali, had the wisdom to send her to school against the opinion of people at the time—family, neighbors, and onlookers. She traveled a long distance from Saqaet El Abbassyine to her school. It was in Fès j’did, a neighborhood of great nationalists, intellectuals, artists, and state clerks: Bahnini, Benbouchta, Moulay Ahmed El Alaoui, Ahmed Chajai, and many others. It is the stronghold of Wydad of Fès. I have many wonderful memories of Saqaet El Abbassyine. From time to time, I go for a walk there to recharge myself. The dilapidation of Bab Riafa, the sad passage by Lalla Ghriba to reach Saqaet El Abbassyine, the continuation by Sidi Hmama to arrive at Qobt Assouk, saddens me every time. So, to soothe my pain and sorrow, I go and sit at Bab Boujloud to enjoy a good glass of tea prepared in a traditional samovar, under the famous mulberry tree. The magic of Fès is unmatched. My father, on the other hand, was affection in the absolute. The exemplary man. The man who forged my pride and committed my life to serving the country. Moroccan at heart, attached to the land of his ancestors. Proud to have been an active nationalist against the protectorate. He spoke of his people’s struggle against French soldiers. He kept fresh memories of the fights of Bou Gafer and the brave battle of his people. He was happy to have served his country but also disappointed with the evolution of some things. He said that we were losing our soul with the decline of our attachment to ancestral values; remembered by all the families of old Rabat who still recall him for having treated their children and eased their pains. He passed away certain that Morocco could have done better. He remained attached to his parents and adored them, attached to his native land that he visited every year, attached to his people to whom he offered land to expand the Sidi Daoud cemetery, his forever village, today swallowed by a soulless Ouarzazate. I am not surprised. My father is a direct descendant of Sidi Daoud, a Sufi Sheikh and great scholar who left many works including the famous *Oumahat Al Wataeq, Al Mountafaa Bih Fi Anawazil*. My father loved Rabat and its beach. It was there he saw the sea for the first time in his life, coming from the other side of the Great Atlas, which climate change is now altering. It was at the Rabat beach that he learned to swim. Today, his grave overlooks that beautiful beach and ocean. His resting place is bathed in the sea air that blows continuously over the hilltop, the final abode of thousands of souls at rest, of lives both rich and less rich, and of memories forever lost. The cemetery tells a lot about the place we give to our dead, and it does not speak well of us. So, like my brothers and sisters—Jalil, Moughni, Rajae, Atika, Abdelmoutaleb, Elhoussein, Soumaya, I am a kind of accident of nature. A father from Ouarzazate marrying a girl from Fès; that was rare. It was 1950. The maternity hospital where my lungs filled for the first time with air and where I cried out announcing my coming to life is still there. It was Tuesday, 11:37 am, May 15, 1951. Each time I pass by, something brings me back to memories I have created from my mother's stories. I see again her pride and my father's joy at my birth. By chance, on the way to bury my mother, and years later my father, we passed along the Almohad wall. The historic maternity hospital of Rabat is just behind. The circle was thus completed. My mother's name was Lalla Amina Makhloufi and my father’s Ahmed Belhoucine El Ouarzazi. The civil registry attendant gave him the surname Daouda, probably because he was born in Sidi Daoud or simply because that person had been influenced by a stay in sub-Saharan Africa...

Stray dogs and cats: a growing challenge for public health and urban peace in Morocco... 3380

The proliferation of stray dogs and cats in the streets raises major challenges for urban quality of life and even more so for public health. As their numbers increase exponentially, the consequences are multiple: noise nuisances, risk of accidents, spread of diseases, and a sense of insecurity for many citizens. A notable aspect of this issue is the significant difference between the social perception of cats and stray dogs. Cats, often perceived as less aggressive, are generally not considered harmful. They are abundantly fed in public spaces by individuals, sometimes due to so-called religious beliefs. According to some, Muslims should show compassion towards cats, which would explain a certain social tolerance towards them. They thus benefit from some benevolence and are extremely numerous, living and multiplying in public spaces without being disturbed; on the contrary, shelters are often provided to help female cats give birth peacefully. In contrast, stray dogs do not receive the same treatment. Many people suffer from cynophobia (fear of dogs), a quasi-cultural phenomenon. More often perceived as a threat, especially because of their ability to attack, they are generally criticized. This negative image has been reinforced following several serious incidents in recent years: violent attacks resulting in serious, even fatal injuries have marked public opinion and increased concerns. The massive presence of these stray animals has direct repercussions on public health. The absence of veterinary control and regular sanitary interventions promotes the spread of diseases transmissible to humans. Stray dogs and cats can carry highly contagious and serious diseases. This issue is even more worrying in dense urban areas where contact between animals and humans is frequent. Children, in particular, are especially vulnerable to bites or scratches, as well as to the infections that may result. The health risk is therefore extremely concerning, especially since many diseases can be transmitted to humans. 1. Rabies: a deadly viral disease mainly transmitted by the bite or scratch of an infected dog. It remains a major public health problem in several regions despite vaccination campaigns. Nearly 400 cases and 20 deaths are recorded each year. Four recent death cases have been widely reported. 2. Toxoplasmosis: an infection caused by the parasite Toxoplasma gondii, transmitted by contact with contaminated cat feces, notably via litter. Generally mild, it poses a serious risk for pregnant women, potentially causing fetal malformations. 3. Leptospirosis: a bacterial disease transmitted by the urine of infected dogs, which can cause serious infections in humans. Between 2005 and 2017, 372 cases were declared with a mortality rate of 17.7%. 52.2% of cases occurred in urban areas. 4. Leishmaniasis: a serious parasitic disease transmitted by stray dogs, which are reservoirs of this parasite. Nearly 2,000 cases per year. 5. External and internal parasites: fleas, ticks, intestinal worms, which can also infect other animals. 6. Cat scratch disease: caused by the bacterium Bartonella henselae. It causes fever, swollen lymph nodes, and fatigue, especially in children and immunocompromised people. 7. Ringworm: a contagious fungal infection through contact with the fur or environment of infected cats, causing distressing skin lesions. 8. Pasteurellosis: a bacterial infection transmitted by bite or scratch, caused by Pasteurella multocida, which can cause local pain and inflammation. 9. Echinococcosis: a parasitic disease related to intestinal worms developed in cats, which can severely affect the human liver and lungs. 10. Mange and other parasitic infections: transmitted by direct contact with affected stray cats. Strict sanitary management is therefore necessary, including vaccination, sterilization, and responsible handling of this animal population in urban areas. Beyond health risks, stray animals cause nuisances in streets and residential neighborhoods. Nocturnal barking disturbs residents' sleep, while droppings in public spaces degrade cleanliness and the image of cities. Facing this complex situation, several approaches can be considered. It is crucial to develop awareness campaigns to encourage citizens to adopt responsible behaviors, especially regarding food given to stray animals. Special emphasis should be placed on sterilization to control reproduction. Moreover, implementing integrated public policies combining capture, veterinary care, and relocation of stray animals appears essential. These measures must respect the cultural and religious sensitivities of the country, notably involving religious authorities in creating harmonious responses. A fundamental effort towards creating dedicated spaces—shelters and controlled feeding points—could channel animal presence and reduce conflicts with the population. Moroccan NGOs published an open letter addressed as a last resort to His Majesty the King on August 3rd, reacting to extermination campaigns led by some local authorities:* "We have exhausted all institutional channels without finding attentive ears among the authorities concerned," *they say, describing the methods used as "cruel,*" contradicting " *the values of compassion promoted by religion and the monarchy." The problem is exacerbated, according to some, by an ineffective public policy and a lack of resources dedicated to capture, sterilization, and care. The cycle of proliferation would continue, reinforcing a difficult-to-reverse spiral. The government denies these accusations and states that it applies the method **"Trap, Neuter, Vaccinate" **(catch, sterilize, vaccinate, and release animals identified by an ear tag in their original territory). It would have allocated 230 million dirhams to this. However, few tagged animals are seen in the streets. Clearly, this is not just an animal issue but a major public health and urban coexistence challenge that requires a pragmatic and balanced approach, respectful of traditions and sanitary and security needs.

Multidimensional Poverty: Decoding the Oxford Index and the Situation in Morocco 4223

When poverty is mentioned, it is often thought of as insufficient income. However, poverty encompasses much broader and more complex dimensions such as access to education, health, decent housing, and other basic resources depending on societies and their cultures. It is on this or a very similar basis that the Multidimensional Poverty Index (MPI) was designed and unveiled in 2010 by the Oxford Poverty and Human Development Initiative (OPHI) at the University of Oxford. The index was adopted during the 20th anniversary of the United Nations Development Programme (UNDP). But what exactly is multidimensional poverty or the Oxford Index? *Multidimensional poverty is the simultaneous and synchronous deprivation experienced by individuals across different essential aspects of life. The Oxford Index, or MPI, aims to measure this aspect of poverty based on 10 indicators grouped into three main dimensions: health, in terms of nutrition and child mortality; education, concerning school attendance, years of schooling, and living conditions; namely access to drinking water, electricity, sanitation facilities, quality housing, and essential assets.* A household is considered poor according to the MPI if its members are deprived in at least 33% of these indicators. The index is calculated using a simple formula: **MPI = H × A** where **H** is the proportion of people who are poor and **A** is the average intensity of deprivation among these people. This approach provides a more nuanced diagnosis than a simple monetary measure of poverty. It allows identifying the exact origin and nature of the deprivations and thus more effectively guides public action. The introduction of the MPI in Morocco has profoundly renewed the understanding of poverty in the country. Ten years ago, this index stood at 11.9%. Thanks to significant mobilization and targeted policies, this rate has decreased to 6.8% according to the 2024 national census, representing a halving. Translated into numbers of affected people, the rate dropped from 4.5% to 2.5% of Morocco’s current 36 million population. Despite these notable advances, poverty remains marked by strong regional and social disparities. Deprivations mainly concern education and living conditions such as access to drinking water, decent housing, and medical care. Multidimensional poverty is more concentrated in rural areas, accounting for 72% of the poor, with an alarming rate among rural children estimated at nearly 69%. In his 26th Throne Speech, His Majesty the King acknowledged the progress made while expressing dissatisfaction and the determination to rapidly correct the situation. Indeed, Morocco is still behind many other countries that display lower multidimensional poverty rates and have recorded faster declines in the index; some countries have therefore succeeded better. For example, Croatia already had a rate below 0.5% in 2022. China, with 12.5% in 2002, and Turkey, with an index of 8.5% in 2007, have recorded faster decreases and are now among the best-ranked countries. Several countries in Asia and Latin America have also seen significant declines thanks to innovative strategies, ambitious social policies, and sustained international support. Morocco remains better ranked compared to many Sub-Saharan African countries. Mali had an MPI of 77.7% in 2012 and Burundi 80.8% in 2010. However, Morocco still maintains a significant gap with global leaders and even some developing countries in the Mediterranean and Asia. To enable the Kingdom to maintain and accelerate its progress, drastic and effective measures requiring genuine political courage and boldness are needed. Several avenues should be considered simultaneously, such as: - Optimizing investment in education by reducing school dropout, promoting equal access for girls and boys in rural areas, and improving teaching quality and attractiveness through teacher qualification and adapted curricula. - Seriously addressing the issue of the language of instruction. Moroccans speak a language that is not reflected in schools. Darija is the Moroccan language and should be valorized to create a continuum between everyday life and learning. All education specialists and dedicated international bodies insist on the use of the mother tongue for more efficient learning, at least in the early school years, as seen in all countries successful in education. - Redefining what illiteracy means in Morocco. Is it still appropriate to consider illiteracy as the inability to master languages that are not used in daily life? The working language and trades that sustain Moroccans and in which all exchange, communicate, and act are not taken into account. This question must be reconsidered in light of scientific evidence, without outdated or unproductive dogma or ideology. - Accelerating medical coverage and social protection through a faster and less restrictive generalization. - Encouraging health and education professionals to settle in remote and targeted areas through significant financial incentives and housing. - Expanding and strengthening basic infrastructure with particular focus on drinking water, electricity, sanitation, and social housing even in rural areas. The issue posed by scattered housing should no longer be a taboo. Some recurring problems simply cannot be solved in certain regions due to the type and location of housing. - Targeting public efforts territorially through fine planning and priority allocation of appropriate resources to the most vulnerable regions, taking into account the real needs of the populations concerned. - Developing and refining social safety nets and resilience mechanisms to better protect populations affected by climate change. By adopting an integrated, territorially targeted approach based on precise MPI data, Morocco can consolidate the gains already made and catch up with the best performers in the region and the world in the near future, given its stability, significant growth rate, diversified and increasingly efficient economy, and, of course, the ingenuity of its people.

[Science #4] Precision Nutrition: Tailoring Your Diet Beyond Hunger and Excess 4416

Hunger and dietary excess may seem like opposite ends of the spectrum, yet both can undermine health. Too few calories disrupt essential physiological processes and energy metabolism, while chronic overeating—especially of nutrient-poor foods—can drive metabolic dysfunction, chronic inflammation, and raise the risk of long-term diseases. Ironically, consuming more nutrients than needed often fails to meet the body’s precise biochemical demands, accelerating cellular wear and potentially shortening lifespan. Emerging research suggests that certain calorie-dense foods, when consumed carelessly, may harm healthspan—the number of healthy years lived. Conversely, mindful nutrient intake—or even periods of moderate hunger—can sometimes benefit overall physiology more than habitual overeating. The key lies in recognizing that each individual’s nutritional needs are unique. This is the foundation of Precision Nutrition. **From "One-Size-Fits-All" to Tailored Nutrition** The term “precision” is often associated with medicine, where a treatment is matched to a patient’s genetic profile instead of relying on a standard prescription. That same philosophy is now transforming the way we think about food. Personalized nutrition moves beyond outdated dietary guidelines by using your genetic makeup, lifestyle, and preferences to determine which foods serve your body best. Your DNA might reveal, for example, that you absorb certain vitamins inefficiently, or that specific foods help stabilize your blood sugar more effectively. This approach empowers you to make dietary choices tailored to your biology—not to fleeting trends. **How Does It Work?** It starts with a DNA sample, analyzed for hundreds of tiny genetic variations known as polymorphisms. These influence traits like lactose intolerance, vitamin D absorption, caffeine metabolism, and sensitivity to salt or sugar. Using advanced algorithms, nutrition scientists translate this data into actionable diet strategies. For instance: - If your genes show low omega-3 absorption, your plan might emphasize fatty fish, flaxseed, or targeted supplements. - If you metabolize caffeine slowly, reducing coffee intake could help avoid sleep problems or anxiety. One striking example comes from the GC gene, which affects how well your body raises blood vitamin D levels after supplementation. People with certain GC variants may require more sunlight exposure or higher supplement doses to achieve optimal health. The power of personalized nutrition lies in decoding the relationship between your genes and every bite you take—turning food into a truly personal form of medicine. A comprehensive understanding of each individual’s unique nutritional needs—driven by genetic, metabolic, microbiome, and lifestyle factors—enables the development of personalized dietary interventions that have transformative potential far beyond individual health. Precision nutrition not only enhances quality of life and healthspan but also offers a pathway to optimize resource use and address global challenges such as hunger and malnutrition. Emerging perspectives highlight that precision nutrition, while often associated with high-income countries, is increasingly seen as a vital strategy to democratize health and tailor nutrition recommendations for entire populations, including those in low- and middle-income countries where malnutrition and food insecurity remain urgent issues. By leveraging advanced technologies and data-driven diagnostics, precision nutrition can target specific micronutrient deficiencies, metabolic conditions, and even genetic variations prevalent in different communities. This targeted approach moves beyond generic dietary guidelines, allowing for more effective, culturally relevant, and sustainable interventions that better meet the biochemical and physiological demands of diverse populations.