Nutrition and body composition as risk factors of non-communicable diseases in Saudi Arabia

Background: Saudi Arabia is an affluent nation faced with steep population increase (~75% in just over 10 years) and a young population (63% aged under 30) in the context of globalized dietary habits and food supply leading to increase the trend of consumption junk food use. However, there are no national dietary surveys to give more accurate details. With existing high prevalence of obesity, it is foreseeable that Saudi Arabia (SA) will face a significant increase in the burden of non-communicable diseases (NCDs) in a short space of time. Reducing the behavioural and environmental risk factors associated with NCDs (physical activity, alcohol overuse, exposure to tobacco smoke, and low nutritionally balanced diet including high salt and energy intake and low intake of fruit and vegetables) requires cross-community sectors, including health, education, agriculture, and planning. Early detection and intervention also require reliable and cost effective tools. The relationship between chronic high salt intake and CVDs has already been established. This thesis examines the relationship between body composition and nutrition, and NCDs using techniques from the full breadth of Human Nutrition Research. Methods: The first cross-sectional study focused on developing and validating a culture-specific FFQ for salt intake against 24-h urinary outputs and repeated 24-h dietary recall, to identify relationships between salt intake, socio-economic factors and blood pressure (BP); and explore dietary sources of salt intake. In the second study, a secondary analysis of integrated data from five Saudi National Surveys assessed the performance of different anthropometric measures (body mass index (BMI), waist circumference (WC), waist to hip ratio (WHR) and waist to height ratio (WHtR)) and body composition indices (estimated skeletal muscle mass (SMM), the percentage of skeletal muscle mass to body weight (%SMM) and Skeletal Muscle Mass Index (SMI)) in predicting metabolic diseases. Saudi nationals only were included in the study. ROC analysis was used to explore the best predictor of metabolic diseases and develop new thresholds. To assess the agreement and misclassification of overweight and obesity using BMI and WC measurements, BMI in combination with WC measurements were used to classify participants as [High-Risk Adiposity by BMI and WC], [High-Risk Adiposity by BMI only], and [High Risk Adiposity by WC only] based on the action levels. Each anthropometric and muscle mass indices were categorised to deciles. Additionally calculated were age-adjusted odds ratios by applying logistic regression models of the different metabolic risk factors in case of an increase of one decile of the respective anthropometric and estimated SMM parameter. In the third study, a cross-sectional survey was developed using the Theory of Planned Behaviour to provide a holistic understanding of factors that may influence food choices and behaviours, and in particular, intentions of adopting a nutritionally-balanced diet. External variables including age, gender, socio-economic status, and being aware of health and nutrition policies and others were included into the model as they were potentially related to TPB constructs. Attitude toward behaviour, subjective norms, perceived behavioural control and knowledge as actual barriers to behaviour were assessed. Results: In the first study, the newly developed Saudi FFQ was found to be of moderate validity in ranking people based on their estimated salt intake, and performed as well as other salt FFQ developed for other nations. The Riyadh population used in this survey consumed 8.7 g salt per day (estimate), higher than the recommended level of salt (>5 g/d for salt). A minority (18%) met the recommended level. The main sources of salt were, surprisingly, vegetables and un-processed foods, and a positive relationship between income and salt intake was observed. Meanwhile, salt intake, defined by FFQ, was associated with systolic BP only (R=0.089, p=0.036), an association which disappeared when adjusted for age, WC and gender. The second study highlighted that a majority of Saudi adults could be categorized as overweight or obese (72%). Worryingly, short of half of those with a normal BMI (18.5–25) aged over 45 also had a large waist. Combining WC and BMI did not improve their value as predictors of metabolic diseases and WC was the best overall predictor of metabolic diseases while BMI was the poorest. This study suggests new cut-off points for WC in SA, in a context of metabolic diseases, ranging between 90 to 92 cm (women) and 94 to 99 cm (men). The newly developed WC cut-offs are higher than the cut-offs for Asian men and women (90 and 80 cm, respectively). The new WC cut-off for women is higher than the cut-off for Caucasian women (88 cm); and the WC cut-off for men is lower than the cut-offs for Caucasian men (102 cm). The obesity prevalence based on BMI and WC also increased proportionately with both SMM (kg) and SMI (kg/m2) increase while the obesity decreased proportionately with %SMM increase. SMI was a poor predictor of metabolic diseases while %SMM was the best, having the highest AUC levels. New (defined) cut-off points for %SMM for metabolic diseases were defined, ranging from 29 to 32% for men and 26 to 28% for women. The third study highlighted that very few SA adults have been exposed to national nutrition and health guidelines (18%). Awareness of these was the strongest predictor of attitude toward behaviour, social norms and knowledge of nutritionally-balanced diet whilst perceived social pressure to engage in behaviour toward a more nutritionally balanced diet (SN) was the strongest predictor of subjects’ intention. Conclusion: Study 1 added a new and unexpected source of salt intake including vegetables and unprocessed foods. These findings raise a concern regarding the encouragement to increase intake of vegetables without including advice regarding cooking advice, in light of the risk of higher salt intake in SA. It would be worthwhile to consider education strategies towards the use of alternative ingredients or dressings in salad and cooked vegetables. Study 2 added an evidence about the weakness of BMI and SMI in predicting metabolic diseases and misclassifying the population. The study suggests using WC and %SMM as alternative measures and adopting the newly developed cut-offs. Study 3 sheds the light on possible avenues for policies, health promotions and nutrition interventions to focus on Saudi adults, in order motivate the population to adopt nutritionally balanced diet by increasing population knowledge and awareness

Attenuation of the association between sugar-sweetened beverages and diabetes risk by adiposity adjustment: a secondary analysis of national health survey data

Purpose: While weight gain and obesity are the dominant factors, dietary sugar and specifically sugar-sweetened beverages (SSB) has been implicated in causing type 2 diabetes (T2DM). We assessed how much of the apparent effect of SSB is explained by adiposity, but not captured by adjustment for BMI, which is a poor index of body fat. Methods: We examined data from 5187 adults (mean age 50.8 years, SD = 16.4, 172 (3.3%) T2DM), from the Scottish Health Survey 2003 and 2008–2010 databases. Logistic regression was used to assess the association between SSB consumption and T2DM (non-insulin treated) and its attenuation (reduction in odds ratios, ORs), after entering published anthropometric indices of adiposity into the regression model, adjusted for age, sex, social class, education, smoking, alcohol consumption and physical activity. Results: Compared with low SSB categories (“less often/never”, once/week or 1–3 times/month), the OR without adiposity adjustment for having T2DM in high SSB consumers (2–3, 4–5, ≥ 6/day) was 2.56 (95% CI 1.12–5.83; p = 0.026). That OR was marginally changed by adjusting for BMI (+ 4.3%), WC (+ 5.5%) or total body fat (− 4.3%), but greatly attenuated by adjusting for estimated %body fat (− 23.4%). These indices had similar influences on the associations between SSB and T2DM combining known T2DM patients with unknown HbA1c > 6.5%, > 48 mmol/mol. Conclusions: Associations between SSB and T2DM are attenuated more markedly by adjustment with estimated %body fat than with BMI, indicating an adiposity effect not captured using BMI. Future research should employ best available estimates of adiposity

Perspectives and practices of dietitians with regards to social/mass media use during the transitions from face-to-face to telenutrition in the time of COVID-19: A cross-sectional survey in 10 Arab countries

During the COVID-19 pandemic, most healthcare professionals switched from face-to-face clinical encounters to telehealth. This study sought to investigate the dietitians’ perceptions and practices toward the use of social/mass media platforms amid the transition from face-to-face to telenutrition in the time of COVID-19. This cross-sectional study involving a convenient sample of 2,542 dietitians (mean age = 31.7 ± 9.5; females: 88.2%) was launched in 10 Arab countries between November 2020 and January 2021. Data were collected using an online self-administrated questionnaire. Study findings showed that dietitians’ reliance on telenutrition increased by 11% during the pandemic, p = 0.001. Furthermore, 63.0% of them reported adopting telenutrition to cover consultation activities. Instagram was the platform that was most frequently used by 51.7% of dietitians. Dietitians shouldered new difficulties in dispelling nutrition myths during the pandemic (58.2% reported doing so vs. 51.4% pre-pandemic, p < 0.001). Compared to the pre-pandemic period, more dietitians perceived the importance of adopting tele nutrition’s clinical and non-clinical services (86.9% vs. 68.0%, p = 0.001), with 76.6% being confident in this practice. In addition, 90.0% of the participants received no support from their work facilities for social media usage. Following the COVID-19 outbreak, the majority of dietitians (80.0%) observed a rise in public interest in nutrition-related topics, particularly those pertaining to healthy eating habits (p = 0.001), healthy recipes (p = 0.001), nutrition and immunity (p = 0.001), and medical nutrition therapies (p = 0.012). Time constraint was the most prevalent barrier to offering telenutrition for nutrition care (32.1%), whereas leveraging a quick and easy information exchange was the most rewarding benefit for 69.3% of the dietitians. In conclusion, to ensure a consistent provision of nutrition care delivery during the COVID-19 pandemic, dietitians working in Arab countries adopted alternative telenutrition approaches through social/mass media

Call for emergency action to restore dietary diversity and protect global food systems in times of COVID-19 and beyond: Results from a cross-sectional study in 38 countries

Background: The COVID-19 pandemic has revealed the fragility of the global food system, sending shockwaves across countries\u27 societies and economy. This has presented formidable challenges to sustaining a healthy and resilient lifestyle. The objective of this study is to examine the food consumption patterns and assess diet diversity indicators, primarily focusing on the food consumption score (FCS), among households in 38 countries both before and during the first wave of the COVID-19 pandemic. Methods: A cross-sectional study with 37 207 participants (mean age: 36.70 ± 14.79, with 77 % women) was conducted in 38 countries through an online survey administered between April and June 2020. The study utilized a pre-tested food frequency questionnaire to explore food consumption patterns both before and during the COVID-19 periods. Additionally, the study computed Food Consumption Score (FCS) as a proxy indicator for assessing the dietary diversity of households. Findings: This quantification of global, regional and national dietary diversity across 38 countries showed an increment in the consumption of all food groups but a drop in the intake of vegetables and in the dietary diversity. The household\u27s food consumption scores indicating dietary diversity varied across regions. It decreased in the Middle East and North Africa (MENA) countries, including Lebanon (p \u3c 0.001) and increased in the Gulf Cooperation Council countries including Bahrain (p = 0.003), Egypt (p \u3c 0.001) and United Arab Emirates (p = 0.013). A decline in the household\u27s dietary diversity was observed in Australia (p \u3c 0.001), in South Africa including Uganda (p \u3c 0.001), in Europe including Belgium (p \u3c 0.001), Denmark (p = 0.002), Finland (p \u3c 0.001) and Netherland (p = 0.027) and in South America including Ecuador (p \u3c 0.001), Brazil (p \u3c 0.001), Mexico (p \u3c 0.0001) and Peru (p \u3c 0.001). Middle and older ages [OR = 1.2; 95 % CI = [1.125–1.426] [OR = 2.5; 95 % CI = [1.951–3.064], being a woman [OR = 1.2; 95 % CI = [1.117–1.367], having a high education (p \u3c 0.001), and showing amelioration in food-related behaviors [OR = 1.4; 95 % CI = [1.292–1.709] were all linked to having a higher dietary diversity. Conclusion: The minor to moderate changes in food consumption patterns observed across the 38 countries within relatively short time frames could become lasting, leading to a significant and prolonged reduction in dietary diversity, as demonstrated by our findings

Impact of COVID-19 lockdown on smoking (waterpipe and cigarette) and participants' BMI across various sociodemographic groups in Arab countries in the Mediterranean Region

INTRODUCTION: Tobacco smokers are at high risk of developing severe COVID-19. Lockdown was a chosen strategy to deal with the spread of infectious diseases; nonetheless, it influenced people's eating and smoking behaviors. The main objective of this study is to determine the impact of the COVID-19 lockdown on smoking (waterpipe and cigarette) behavior and its associations with sociodemographic characteristics and body mass index. METHODS: The data were derived from a large-scale retrospective cross-sectional study using a validated online international survey from 38 countries (n=37207) conducted between 17 April and 25 June 2020. The Eastern Mediterranean Region (WHO-EMR countries) data related to 10 Arabic countries that participated in this survey have been selected for analysis in this study. A total of 12433 participants were included in the analysis of this study, reporting their smoking behavior and their BMI before and during the COVID-19 lockdown. Descriptive and regression analyses were conducted to examine the association between smoking practices and the participant's country of origin, sociodemographic characteristics, and BMI (kg/m2). RESULTS: Overall, the prevalence rate of smoking decreased significantly during the lockdown from 29.8% to 23.5% (p<0.05). The percentage of females who smoke was higher than males among the studied population. The highest smoking prevalence was found in Lebanon (33.2%), and the lowest was in Oman (7.9%). In Egypt, Kuwait, Lebanon, and Saudi Arabia, the data showed a significant difference in the education level of smokers before and during the lockdown (p<0.05). Smokers in Lebanon had lower education levels than those in other countries, where the majority of smokers had a Bachelor's degree. The findings show that the BMI rates in Jordan, Lebanon, Oman, and Saudi Arabia significantly increased during the lockdown (p<0.05). The highest percentages of obesity among smokers before the lockdown were in Oman (33.3%), followed by Bahrain (28.4%) and Qatar (26.4%), whereas, during the lockdown, the percentage of obese smokers was highest in Bahrain (32.1%) followed by Qatar (31.3%) and Oman (25%). According to the logistic regression model, the odds ratio of smoking increased during the pandemic, whereas the odds ratio of TV watching decreased. This finding was statistically significant by age, gender, education level, country of residence, and work status. CONCLUSIONS: Although the overall rates of smoking among the studied countries decreased during the lockdown period, we cannot attribute this change in smoking behavior to the lockdown. Smoking cessation services need to anticipate that unexpected disruptions, such as pandemic lockdowns, may be associated with changes in daily tobacco consumption. Public health authorities should promote the adoption of healthy lifestyles to reduce the long-term negative effects of the lockdown

An Evaluation of the COVID-19 Pandemic and Perceived Social Distancing Policies in Relation to Planning, Selecting, and Preparing Healthy Meals: An Observational Study in 38 Countries Worldwide

Objectives: To examine changes in planning, selecting, and preparing healthy foods in relation to personal factors (time, money, stress) and social distancing policies during the COVID-19 crisis. Methods: Using cross-sectional online surveys collected in 38 countries worldwide in April-June 2020 (N = 37,207, Mage 36.7 SD 14.8, 77% women), we compared changes in food literacy behaviors to changes in personal factors and social distancing policies, using hierarchical multiple regression analyses controlling for sociodemographic variables. Results: Increases in planning (4.7 SD 1.3, 4.9 SD 1.3), selecting (3.6 SD 1.7, 3.7 SD 1.7), and preparing (4.6 SD 1.2, 4.7 SD 1.3) healthy foods were found for women and men, and positively related to perceived time availability and stay-at-home policies. Psychological distress was a barrier for women, and an enabler for men. Financial stress was a barrier and enabler depending on various sociodemographic variables (all p < 0.01). Conclusion: Stay-at-home policies and feelings of having more time during COVID-19 seem to have improved food literacy. Stress and other social distancing policies relate to food literacy in more complex ways, highlighting the necessity of a health equity lens. Copyright 2021 De Backer, Teunissen, Cuykx, Decorte, Pabian, Gerritsen, Matthys, Al Sabbah, Van Royen and the Corona Cooking Survey Study Group.This research was funded by the Research Foundation Flanders (G047518N) and Flanders Innovation and Entrepreneurship (HBC.2018.0397). These funding sources had no role in the design of the study, the analysis and interpretation of the data or the writing of, nor the decision to publish the manuscript.Scopu

The Impact of the COVID-19 Pandemic on Public Interest in the Energy Labelling on Restaurant Menus

No study has investigated the effect of the COVID-19 pandemic on the public’s interest in using energy labelling on restaurant menus. This study explores the effects of the COVID-19 pandemic on the public interest in using energy labelling on restaurant menus and meal delivery applications and the impact of energy-labelling availability on food choices during the COVID-19 pandemic in Saudi Arabia. An online questionnaire was completed by 1657 participants aged ≥ 18 years. Before the COVID-19 pandemic, 32% of customers visited a restaurant 2–4 times/week. However, during the pandemic, 35% of customers visited a restaurant only once per week. There was no difference in interest in reading energy labelling or using meal delivery applications before and during the pandemic. During the COVID-19 pandemic, about 55% of restaurant customers reported that they had noticed energy labelling, with 42% of them being influenced by the energy-labelling information. Regarding energy information on food delivery applications, 40% of customers noticed energy labelling when using the applications, with 33% of them being affected by the energy labelling. Customer interest in reading about energy on restaurant menus during the pandemic did not change significantly from the level of interest before the pandemic. The interest expressed by the public in using the energy labelling was low both before and during the COVID-19 pandemic

Occurrence and dietary exposure assessment of heavy metals in baby foods in the Kingdom of Saudi Arabia

Abstract Early childhood exposure to heavy metals like arsenic (As), cadmium (Cd), and lead (Pb) through baby foods unfolds many concerns about their toxic effects on growth and health. In this study, occurrence and dietary intake of As, Cd, and Pb in stage 1 infant formula (0–6 months), stage 2 infant formula (7–12 months), cereal‐based meals, and biscuits were estimated. First, the levels of As, Cd, and Pb were determined with ICP‐MS, followed by the calculation of estimated daily intake (EDI), target hazard quotient (THQ), and hazard index (HI) for As and Cd, and margin of exposure (MoE) for Pb. Mean levels of As, Cd, and Pb were the highest in cereal‐based meals and biscuits as 15.5–11.1, 5.18–8.76, and 35.2–53.8 μg/kg, respectively. Newborns to 6 months old infants were estimated to be the highest exposed population to Cd and Pb (0.08 and 0.36 μg/kg bw/day), while infants aged 7–12 months old were exposed the highest to As. Based on the THQ, HI, and MoE findings, the current exposure levels from the selected baby foods to As, Cd, and Pb pose low potential chronic risks to both infant age groups. This research provides a roadmap for future investigations in chemical contaminants often detected in baby foods consumed regularly by Saudi infants

Call for emergency action to restore dietary diversity and protect global food systems in times of COVID-19 and beyond: results from a cross-sectional study in 38 countries

The COVID-19 pandemic has revealed the fragility of the global food system, sending shockwaves across countries' societies and economy. This has presented formidable challenges to sustaining a healthy and resilient lifestyle. The objective of this study is to examine the food consumption patterns and assess diet diversity indicators, primarily focusing on the food consumption score (FCS), among households in 38 countries both before and during the first wave of the COVID-19 pandemic. A cross-sectional study with 37 207 participants (mean age: 36.70 ± 14.79, with 77 % women) was conducted in 38 countries through an online survey administered between April and June 2020. The study utilized a pre-tested food frequency questionnaire to explore food consumption patterns both before and during the COVID-19 periods. Additionally, the study computed Food Consumption Score (FCS) as a proxy indicator for assessing the dietary diversity of households. This quantification of global, regional and national dietary diversity across 38 countries showed an increment in the consumption of all food groups but a drop in the intake of vegetables and in the dietary diversity. The household's food consumption scores indicating dietary diversity varied across regions. It decreased in the Middle East and North Africa (MENA) countries, including Lebanon (p < 0.001) and increased in the Gulf Cooperation Council countries including Bahrain (p = 0.003), Egypt (p < 0.001) and United Arab Emirates (p = 0.013). A decline in the household's dietary diversity was observed in Australia (p < 0.001), in South Africa including Uganda (p < 0.001), in Europe including Belgium (p < 0.001), Denmark (p = 0.002), Finland (p < 0.001) and Netherland (p = 0.027) and in South America including Ecuador (p < 0.001), Brazil (p < 0.001), Mexico (p < 0.0001) and Peru (p < 0.001). Middle and older ages [OR = 1.2; 95 % CI = [1.125–1.426] [OR = 2.5; 95 % CI = [1.951–3.064], being a woman [OR = 1.2; 95 % CI = [1.117–1.367], having a high education (p < 0.001), and showing amelioration in food-related behaviors [OR = 1.4; 95 % CI = [1.292–1.709] were all linked to having a higher dietary diversity. The minor to moderate changes in food consumption patterns observed across the 38 countries within relatively short time frames could become lasting, leading to a significant and prolonged reduction in dietary diversity, as demonstrated by our findings