241 ass 1

doi:10.1017/S1368980016003141
Public Health Nutrition: 20(6), 1075–1081
Diet in Saudi Arabia: findings from a nationally representative
survey
Maziar Moradi-Lakeh1, Charbel El Bcheraoui1, Ashkan Afshin1, Farah Daoud1,
Mohammad A AlMazroa2, Mohammad Al Saeedi2, Mohammed Basulaiman2,
Ziad A Memish2, Abdullah A Al Rabeeah2 and Ali H Mokdad1,*
1
Institute for Health Metrics and Evaluation, University of Washington, 2301 5th Avenue, Suite 600, Seattle,
WA 98121, USA: 2Ministry of Health of the Kingdom of Saudi Arabia, Riyadh, Saudi Arabia
Submitted 30 March 2016: Final revision received 8 September 2016: Accepted 10 October 2016: First published online 15 December 2016
Abstract
Objective: No recent original studies on the pattern of diet are available for Saudi
Arabia at the national level. The present study was performed to describe the
consumption of foods and beverages by Saudi adults.
Design: The Saudi Health Interview Survey (SHIS) was conducted in 2013. Data
were collected through interviews and anthropometric measurements were done.
A diet history questionnaire was used to determine the amount of consumption for
eighteen food or beverage items in a typical week.
Setting: The study was a household survey in all thirteen administrative regions of
Saudi Arabia.
Subjects: Participants were 10 735 individuals aged 15 years or older.
Results: Mean daily consumption was 70·9 (SE 1·3) g for fruits, 111·1 (SE 2·0) g for
vegetables, 11·6 (SE 0·3) g for dark fish, 13·8 (SE 0·3) g for other fish, 44·2 (SE 0·7) g
for red meat, 4·8 (SE 0·2) g for processed meat, 10·9 (SE 0·3) g for nuts, 219·4 (SE 5·1) ml
for milk and 115·5 (SE 2·6) ml for sugar-sweetened beverages. Dietary guideline
recommendations were met by only 5·2 % of individuals for fruits, 7·5 % for
vegetables, 31·4 % for nuts and 44·7 % for fish. The consumption of processed
foods and sugar-sweetened beverages was high in young adults.
Conclusions: Only a small percentage of the Saudi population met the dietary
recommendations. Programmes to improve dietary behaviours are urgently
needed to reduce the current and future burden of disease. The promotion of
healthy diets should target both the general population and specific high-risk
groups. Regular assessments of dietary status are needed to monitor trends and
inform interventions.
Dietary risks are among the most important risk factors
globally and in the Kingdom of Saudi Arabia (KSA) in
particular(1,2). Like many other regions of the world, the
nutrition transition in the Middle East has contributed to the
rising burden of non-communicable diseases(1,3). In KSA in
2013, poor diet accounted for 10·4 % (95 % CI 8·9, 12·2 %) of
disability-adjusted life years and 22·1 % (95 % CI 18·7,
24·5 %) of deaths(3,4). FAO data show an overall increase in
food supply (1961–2007) in KSA, with an increase in the
supply of sugar, meat, animal fat, offal (organ meats), eggs
and milk, and a levelling trend in the vegetable and fruit
supply(5). A similar trend was reported earlier in 2000(6).
Khan and Al Kanhal reported a rapidly increasing surplus of
energy and protein availability in KSA after 1975, compared
with the recommended daily allowances(7).
Keyword
Diet
Foods
Beverages
Nutrition epidemiology
Saudi Arabia
Previous reports have shown the dietary patterns or
energy/nutrient intakes in specific population subgroups
or regions of KSA(8). However, nationally representative
diet data from KSA are limited to food availability. Food
availability data (such as FAO data) do not represent
intake, as they do not account for wastage and other uses.
Moreover, they do not provide information on diet by age,
sex and socio-economic status.
In 2012, the KSA Ministry of Health published dietary
guidelines on the amount and composition of recommended foods to promote a healthy diet among the
population(9). However, there are not enough data on the
success of the guidelines’ implementation, the population’s current dietary status and the potential impacts of
the guidelines. Therefore, the aims of the present study
*Corresponding author: Email [email protected]
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© The Authors 2016
1076
were to describe the amount of consumption of different
types of foods and beverages in KSA; to describe dietary
consumption by age, sex, socio-economic status and subnational administrative regions; and to assess the degree to
which Saudis’ diets met the dietary guidelines.
Methods
Performed between April and June 2013, the Saudi Health
Interview Survey (SHIS) was a national multistage survey
of individuals aged 15 years or older. For this survey, KSA
was divided into thirteen regions. Each region was divided
into sub-regions and blocks. All regions were included in
the survey. A probability-proportional-to-size method was
used to randomly select sub-regions and blocks. Households were then randomly selected from each block.
A roster of household members was conducted and an
adult aged 15 years or older was randomly selected to be
surveyed from each selected household. If the randomly
selected adult was not present, our surveyors made an
appointment to return. A total of three visits were
attempted before the household was considered as a nonresponse. More details about the study are available in
previous publications(10–13).
The Saudi Ministry of Health and its institutional review
board (IRB) approved the study protocol. The University
of Washington IRB deemed the study IRB-exempt, since
the Institute for Health Metrics and Evaluation received deidentified data for the present analysis. All respondents
had the opportunity to consent and agree to participate in
the study.
The survey included forty-two questions on diet (a diet
history questionnaire), as well as questions on socioeconomic status (educational and household monthly
income levels) and other aspects of health. Respondents
were asked to report the number of days that they
consumed eighteen food or beverage items in a typical
week over the last year. The food and beverage items
included in the survey were: fruits; pure (100 %) fruit
juices; vegetables; dark meat fish; other fish; shrimp; red
meat; poultry meat; processed meat (meats preserved by
smoking, curing or salting, or by the addition of
preservatives, such as in the case of pastrami, salami,
bologna, other packaged lunch meats or deli meats,
sausages, bratwursts, frankfurters and hot dogs); other
processed foods (such as fast foods, canned foods, packaged entrées or packaged soup); eggs; nuts; milk; yoghurt;
laban (a beverage of yoghurt mixed with salt, which is
also known as ayran or doogh); labneh (strained yoghurt);
cheese; and sugar-sweetened beverages (SSB). For each
type of food/beverage that the respondents reported at
least one day of consumption per typical week, the
respondents were asked: ‘How many servings of [this
food/beverage] do you usually consume/eat/drink on one
of those days?’ The interviewers used specific pictures that
M Moradi-Lakeh et al.
represented the serving size of each type of food/beverage. Moreover, respondents were asked about the type
of oil or fat most often used for meal preparation, and the
usual type of dairy products (full-fat, low-fat, non-fat) and
bread in the household.
There were insufficient data to calculate total energy
consumption directly. Supplemental File 1 (see online
supplementary material) shows the method for indirect
estimation of energy intake and the energy-adjusted daily
food/beverage consumption estimates. Although not an
ideal method for energy adjustment, it can provide more
comparability with other studies for interested readers. An
energy adjustment is also necessary to compare the status
with the dietary guideline recommendations.
Average numbers of daily servings – and their equivalent weight (grams) for foods, or volume (millilitres) for
beverages – were calculated. In cases where the weight of
a serving size had not been clarified in the survey manuals
(fruits, vegetables, processed meat, processed foods
and eggs), we matched our visual manual as closely as
possible to phrases in the guidelines of the US Department
of Agriculture to assign an average weight(14). For fruits
and vegetables, we used the weighted average weight of
one serving of the most common types of fruits and
vegetables based on the most recent food supply data of
FAO in KSA(15). The 99th percentiles of consumption were
used as cut-off points to identify and exclude implausibly
high levels of intake.
The statistical software package Stata 13.1 for Windows
was used for the analyses and to account for the complex
sampling design.
Results
A total of 12 000 households were contacted and 10 735
participants (5253 men and 5482 women) completed the
SHIS, for a response rate of 89·4 %.
Table 1 demonstrates the average daily consumption
of different food and beverage items. Table 2 shows the
food and beverage consumption of men and women.
Non-adjusted consumption of fruit, red meat, other
processed foods, eggs and SSB was statistically higher in
men than women, while yoghurt and cheese consumption
was higher in women than men. Daily consumption of
fruits and vegetables was reported by 10·8 (SE 0·4) % and
25·9 (SE 0·6) %, respectively, and 27·0 (SE 0·7) % reported
daily drinking of SSB.
Mean consumption of processed meat, other processed
foods and SSB was clearly higher in younger age groups
(Table 3), while laban consumption was higher in older
age groups. Consumption of fruit, shrimp, labneh and
cheese had an increasing pattern with higher education
(Table 4). As demonstrated in Table 5, consumption
of some of the food items (fruit, shrimp, red meat and
labneh) was higher in individuals with higher household
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Diet in Saudi Arabia
1077
Table 1 Average daily food and beverage consumption of Saudi adults, 2013
Food/beverage item
Fruits (g)
Vegetables (g)
Pure (100 %) fruit juices (ml)
Dark meat fish (g)
Other fish (g)
Shrimp (g)
Red meat (g)
Poultry meat (g)
Processed meat (g)
Other processed foods (g)
Eggs (g)
Nuts (g)
Yoghurt (g)
Milk (ml)
Laban (ml)
Labneh (g)
Cheese (g)
SSB (ml)
Weight/volume units
Serving size
Meet the recommendations
Serving size
N
Mean
SE
Mean
SE
%
SE
103 g*
105 g*
125 ml
75 g
75 g
75 g
75 g
75 g
69 g*
399 g*
92 g*
40 g
175 g
250 ml
175 g
175 g
50 g
125 ml
10 187
10 334
10 066
10 096
10 082
9801
10 223
10 336
9667
9664
10 219
9768
10 257
10 326
10 269
9866
10 113
9967
70·9
111·1
31·9
11·6
13·8
2·4
44·2
103·0
4·8
97·5
46·0
10·9
75·4
219·4
116·8
28·9
43·7
115·5
1·3
2·0
0·8
0·3
0·3
0·1
0·7
1·8
0·2
2·7
0·7
0·3
2·0
5·1
2·8
0·8
0·9
2·6
0·675
1·078
0·269
0·137
0·159
0·028
0·521
1·304
0·070
0·244
0·500
0·274
0·431
0·885
0·667
0·165
0·874
0·924
0·013
0·019
0·007
0·003
0·003
0·001
0·009
0·022
0·003
0·007
0·007
0·007
0·012
0·021
0·016
0·004
0·018
0·021
5·2†
7·5†
0·3
0·4
44·7‡
0·7
85·7§
0·5
80·2§
0·6
31·4†
26·2†
0·7
0·7
78·6‡
0·6
SSB, sugar-sweetened beverages.
*Estimated through matching of pictures in the survey manual with the descriptions of the US Department of Agriculture guideline(14).
Reference dietary guidelines: †Dietary Guidelines for Americans(25); ‡American Heart Association(24); §American Institute for Cancer Research(23).
Table 2 Daily food and beverage consumption of Saudi male and female adults, 2013
Male (N 5253)
Weight/volume units
Female (N 5482)
Serving size
Weight/volume units
Serving size
Food/beverage item
Mean
SE
Mean
SE
Mean
SE
Mean
SE
Fruits (g)
Vegetables (g)
Pure (100 %) fruit juices (ml)
Dark meat fish (g)
Other fish (g)
Shrimp (g)
Red meat (g)
Poultry meat (g)
Processed meat (g)
Other processed foods (g)
Eggs (g)
Nuts (g)
Yoghurt (g)
Milk (ml)
Laban (ml)
Labneh (g)
Cheese (g)
SSB (ml)
75·7
105·4
34·0
11·5
14·3
2·5
52·4
106·6
5·0
108·4
49·8
11·2
67·1
217·5
122·2
27·5
40·5
131·4
1·9
2·3
1·2
0·4
0·4
0·1
1·2
2·4
0·3
4·3
1·0
0·4
1·9
6·4
3·9
1·0
1·2
3·5
0·620
0·904
0·241
0·123
0·153
0·026
0·590
1·195
0·064
0·239
0·496
0·269
0·349
0·712
0·580
0·149
0·672
0·972
0·016
0·020
0·010
0·005
0·005
0·002
0·014
0·027
0·004
0·009
0·011
0·011
0·010
0·019
0·017
0·006
0·016
0·028
65·9
117·0
29·7
11·7
13·3
2·3
35·7
99·3
4·7
86·0
42·0
10·7
84·2
221·4
111·2
30·4
47·0
98·8
1·9
3·3
1·1
0·4
0·4
0·1
0·9
2·7
0·3
3·2
0·9
0·4
3·6
8·1
3·9
1·2
1·4
3·8
0·547
1·032
0·214
0·123
0·144
0·023
0·403
1·131
0·068
0·194
0·414
0·243
0·420
0·796
0·568
0·164
0·779
0·699
0·017
0·034
0·010
0·004
0·006
0·002
0·012
0·033
0·004
0·008
0·009
0·009
0·020
0·033
0·023
0·007
0·023
0·030
SSB, sugar-sweetened beverages.
incomes. Consumption of SSB was statistically higher
in individuals with lower household incomes (Table 5).
Fruit/beverage consumption in different administrative
regions can be found in Supplemental File 2 (see online
supplementary material).
Vegetable oils were the most common type of oil/fat
used for preparation of food (84·5 (SE 0·5) %). Olive oil and
butter/margarine were reported by 5·3 (SE 0·3) % and
4·8 (SE 0·3) %, respectively. Most of the respondents reported
use of full-fat dairy products (77·6 (SE 0·6) %), followed by
low-fat (15·0 (SE 0·5) %) and non-fat (1·3 (SE 0·1) %); others
had no preference. The most common type of bread was
white bread (79·1 (SE 0·5) %); brown bread and Saudispecific traditional breads were reported by 20·1 (SE 0·5) %
and 0·8 (SE 0·1) %, respectively, as the usual kind
of bread.
Discussion
The present study is the first to describe dietary patterns
in a nationally representative sample of adults in KSA. It
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5·5
13·5
2·9
0·9
1·1
0·5
5·3
6·1
0·3
4·0
2·4
1·1
19·6
27·7
14·5
3·1
3·0
3·6
SSB, sugar-sweetened beverages.
SE
Mean
60·1
112·5
24·3
5·9
7·7
1·0
36·8
78·0
0·9
29·8
26·8
5·4
108·0
247·1
129·0
21·3
28·7
21·6
4·4
5·0
2·2
1·0
1·3
0·3
3·1
4·5
0·7
4·7
2·1
0·8
5·0
11·2
7·7
2·5
1·5
3·5
SE
Mean
68·8
91·5
20·8
7·2
12·4
1·3
54·2
79·8
1·4
32·1
32·6
5·3
67·0
205·0
113·5
19·8
23·0
30·4
3·7
5·2
2·0
0·6
0·9
0·2
1·9
3·9
0·4
4·1
1·4
0·7
6·0
9·4
6·5
2·2
1·4
3·1
SE
Mean
65·5
109·2
25·3
8·7
12·5
1·5
37·9
83·1
2·7
54·1
37·0
8·8
80·5
187·4
112·6
29·4
33·1
42·5
3·5
3·5
2·1
0·6
0·7
0·2
1·8
2·9
0·3
5·1
1·7
0·6
3·2
7·4
4·2
2·1
1·3
4·3
SE
Mean
77·9
105·8
30·9
8·8
13·9
2·2
49·2
83·2
2·4
69·6
44·2
9·2
64·2
170·1
102·0
31·0
31·1
64·9
3·6
4·5
1·4
0·7
0·8
0·3
1·4
4·1
0·5
4·8
1·5
0·7
5·9
9·5
7·0
1·5
1·5
4·9
SE
Mean
65·1
104·8
26·5
12·8
14·6
2·7
34·8
87·2
5·7
84·4
44·1
10·3
72·7
191·3
99·4
27·6
40·5
84·3
2·4
7·4
2·4
0·7
0·9
0·3
1·8
5·5
0·6
6·5
1·4
0·6
6·4
18·0
7·2
2·6
2·5
8·0
46·2
104·8
24·8
10·4
11·7
1·9
31·2
96·4
5·8
93·5
35·8
10·4
64·9
201·3
87·0
30·2
42·9
127·3
SE
SE
2·9
3·8
2·3
0·8
0·8
0·2
2·4
3·9
0·7
7·8
1·8
0·8
3·4
9·1
5·8
2·0
1·7
6·6
SE
56·5
83·0
26·2
11·0
12·8
1·7
51·4
101·1
6·3
121·6
48·4
12·9
57·8
183·0
97·2
23·1
36·9
172·2
2·7
3·4
1·8
0·7
0·7
0·3
1·8
4·0
0·4
5·3
1·6
0·7
3·1
6·9
4·7
1·7
1·1
6·0
Mean
Mean
Mean
Food/beverage item
Fruits (g)
Vegetables (g)
Pure (100 %) fruit juices (ml)
Dark meat fish (g)
Other fish (g)
Shrimp (g)
Red meat (g)
Poultry meat (g)
Processed meat (g)
Other processed foods (g)
Eggs (g)
Nuts (g)
Yoghurt (g)
Milk (ml)
Laban (ml)
Labneh (g)
Cheese (g)
SSB (ml)
66·0
98·2
32·5
12·1
13·9
3·4
47·9
98·1
4·2
96·2
46·6
10·4
61·8
163·6
104·3
28·4
33·7
119·2
Male (N 1857)
Female (N 1193)
Female (N 2169)
Male (N 1495)
Female (N 1575)
Male (N 712)
Female (N 545)
M Moradi-Lakeh et al.
Male (N 1189)
25–39 years
15–24 years
Table 3 Daily food and beverage consumption of Saudi adults by sex and age group, 2013
40–59 years
60 years or more
1078
showed poor dietary practices in the Kingdom. Saudis’
dietary behaviours met dietary recommendations in only
a small percentage of the population, especially for fruit
and vegetable consumption, dairy products, nuts and
fish meat. Young adults (15–24 years old) had a concerning pattern of high consumption of SSB, processed
meat and other processed foods, as well as low intake of
fruits and vegetables. Other studies on schoolchildren
show that these unhealthy dietary behaviours start
even sooner(16). This evidence calls for a comprehensive
programme to improve the dietary situation of Saudis. The
programme should include all age ranges, considering the
different needs and different dietary challenges of each
age group.
A cluster of dietary risk factors is the leading risk factor
for non-optimal health, with 11·3 million attributed deaths
and 241·4 million attributed disability-adjusted life years
per annum around the world(1). The Global Burden of
Diseases, Injuries, and Risk Factors (GBD) study showed
that in Saudi Arabia, the average levels of consumption of
fruits, vegetables, nuts, whole grains, PUFA and seafood
n-3 fatty acids were far less than optimum, and the average
levels of consumption of processed meats, red meats, total
fatty acids, SSB and sodium were higher than optimal(3).
In the report of the WHO 2005 STEPwise survey, there
was limited dietary information on the consumption of
fruits, vegetables and oils. During the time between the
STEPwise survey and our current study (2005 to 2013), the
percentage of individuals consuming at least five daily
servings of fruits or vegetables increased slightly, from 5·5
to 7·3 %(11). However, based on food supply data, fruit and
vegetable availability in KSA (about 475 g/d in 2010)(17) is
more than twice the average consumption in our study
(less than 200 g/d). The difference might be related to
using fruits as pure juices (about 32 ml/d) or sweetened
juices, as well as the higher potential of decay in fruits/
vegetables compared with other food items. Further
details on consumption of fruits and vegetables by Saudi
adults have been reported elsewhere(11). Consumption of
olive oil has increased from 1·7 % in the Saudi STEPwise
survey to 5·3 %(18); since higher intake of olive oil is
associated with reduced risk of all-cause mortality, cardiovascular events and stroke, this can be considered a good
replacement(19).
Although there was higher consumption of meat and
SSB by men, and of vegetables by women, non-energyadjusted consumption is not directly comparable between
men and women. Considering the fact that average energy
consumption is usually higher in men, vegetable intake is
expected to remain higher in women after energy adjustment. Some of the different patterns of food and beverage
consumption between men and women may be explained
by theories about the association of meat consumption
with masculinity and vegetable consumption with femininity, but we do not have enough information for that
assessment(20–22).
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Diet in Saudi Arabia
1079
Table 4 Daily food and beverage consumption of Saudi adults by educational level, 2013
Primary or less (N 3286)
Elementary/high school (N 4780)
College or higher (N 2649)
Food/beverage item
Mean
SE
Mean
SE
Mean
SE
Fruits (g)
Vegetables (g)
Pure (100 %) fruit juices (ml)
Dark meat fish (g)
Other fish (g)
Shrimp (g)
Red meat (g)
Poultry meat (g)
Processed meat (g)
Other processed foods (g)
Eggs (g)
Nuts (g)
Yoghurt (g)
Milk (ml)
Laban (ml)
Labneh (g)
Cheese (g)
SSB (ml)
64·2
99·6
22·0
10·3
12·9
0·9
43·9
99·2
4·8
66·3
36·4
11·7
74·9
219·6
104·5
20·3
33·0
86·5
2·3
4·3
1·4
0·5
0·7
0·1
1·6
3·5
0·5
4·2
1·2
0·8
5·0
9·5
4·3
1·4
1·3
5·1
55·6
96·9
25·6
9·9
12·3
2·1
42·1
93·8
4·2
95·3
43·8
9·6
62·1
177·2
97·6
27·9
37·3
120·9
1·7
3·0
1·2
0·4
0·5
0·1
1·2
2·5
0·3
4·0
1·0
0·3
2·4
6·9
3·8
1·3
1·1
3·9
74·8
108·0
35·8
11·9
13·3
3·6
41·5
82·5
5·1
92·8
44·8
9·7
69·7
168·6
99·8
35·5
38·9
88·5
3·0
3·9
1·6
0·6
0·6
0·3
1·4
3·5
0·4
4·7
1·3
0·4
4·0
8·5
5·1
1·7
1·4
4·3
SSB, sugar-sweetened beverages.
Table 5 Food and beverage consumption of Saudi adults by household monthly income level, 2013
Less than 5000 Riyals (N 3161)
5000–14 999 Riyals (N 4549)
15 000 Riyals or more (N 1131)
Food/beverage item
Mean
SE
Mean
SE
Mean
SE
Fruits (g)
Vegetables (g)
Pure (100 %) fruit juices (ml)
Dark meat fish (g)
Other fish (g)
Shrimp (g)
Red meat (g)
Poultry meat (g)
Processed meat (g)
Other processed foods (g)
Eggs (g)
Nuts (g)
Yoghurt (g)
Milk (ml)
Laban (ml)
Labneh (g)
Cheese (g)
SSB (ml)
51·5
94·1
20·9
9·8
13·3
1·7
37·2
89·3
3·4
91·0
38·9
8·1
66·4
188·5
104·7
22·7
37·5
113·6
2·0
3·7
1·5
0·5
0·7
0·2
1·5
3·3
0·4
5·3
1·2
0·5
3·4
8·7
4·9
1·5
1·8
5·4
65·2
96·2
28·3
10·8
13·8
2·3
42·4
88·6
4·4
86·8
45·2
10·1
64·6
166·5
99·5
31·9
36·2
95·9
1·7
2·2
1·4
0·5
0·5
0·2
1·2
2·1
0·3
3·7
1·0
0·4
2·3
4·9
3·2
1·4
0·9
3·2
79·3
118·3
40·5
10·6
14·0
3·9
50·3
93·3
5·2
82·7
42·2
11·2
61·9
189·4
98·7
36·4
35·9
91·0
4·7
6·6
2·4
0·8
0·9
0·4
2·4
4·3
0·7
6·6
1·8
0·8
4·0
11·1
5·8
2·7
1·8
5·6
SSB, sugar-sweetened beverages.
Compared with the recommendations of dietary
guidelines(9,23–25), consumption of fruits, vegetables, dairy
products and nuts is very low, and less than 45 % of the
KSA population consumes fish as recommended. On the
other hand, there is considerable unnecessary consumption of processed meat and SSB compared with the
recommendations(23,24). A 2006 study in Lebanon showed
that Lebanese adults consume the same amount of fish
and red meat as Saudis in our study, but less poultry meat
(36 v. 103 g/d) and eggs (12 v. 46 g/d), and more fruits and
vegetables (367 v. 182 g/d)(26).
The previously published GBD estimates for dietary risk
factors in KSA were close to our estimates for red meat,
processed meat and SSB. Our estimate for nuts was higher
than previous GBD estimates (about 11 v. 4 g/d)(3).
Midhat et al. reported the consumption of different food
items as part of the routine meals in the Qassim region of
KSA. However, they did not report the amount (or serving
sizes) of consumption. That study showed an increasing
probability of routine intake of fish, vegetables, fresh fruits
and barbecued meats (called a ‘healthy diet’) with
increasing age(27). Our findings showed that Saudis of
older ages consume more fruit and vegetables, and fewer
processed foods. The healthier diet seen among older
individuals might be related to different factors, such as a
birth cohort effect (due to the nutrition transition in the
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1080
younger birth cohorts), the longer life of individuals with
healthy diets, more frequent contacts between health careproviders and older individuals (compared with younger
people), and better adherence among older individuals
to dietary guidelines because of their perceived risk of
disease and death.
The average consumption of fruit, vegetables and
shrimp in individuals with a college or higher education
was more than in other educational groups. The highest
intake of milk was reported by individuals with primary or
less education. Individuals with the lowest household
income had the highest consumption of SSB, while consumption of fruits, vegetables and pure juices was lower
than in individuals with higher income.
In our study, the highest intake of fish was in the Jizan,
Aasir, Al Bahah and Makkah regions (all located in the
south-western part of the country and close to the Red
Sea), as well as in Riyadh (capital); the lowest consumption of fish was reported by residents of Ha’il, Al Jawf and
Al Hudud ash Shamaliyah (all located in the north-western
part of the country).
Although the prevalence of obesity has decreased in
recent years in KSA, the current combination of high
overweight/obesity prevalence(28), sedentary lifestyle(10)
and inappropriate diet threatens the current and future
health of the population.
Our study has some limitations. First, we used a diet
history questionnaire that did not contain details for all
types of foods and beverages. Second, our food and
beverage consumption data are self-reported and subject
to recall and social desirability biases. Third, our study did
not include the amount of all foods and beverages (for
instance, complex carbohydrates), and we were not able
to directly calculate total energy expenditure. On the other
hand, our study is based on a large sample size and used a
standardized methodology for all its measures. It is
nationally representative and has the merit of providing
accurate data due to our near-real-time data quality
monitoring through the whole survey period.
The Saudi Ministry of Health has initiated programmes
and projects, such as the Crown Health Project(29,30) and
the Saudi dietary guidelines(9), to alleviate the burden of
risk factors of non-communicable diseases. The outcomes
of these programmes need to be evaluated, so that the
lessons learned from them can be used in the adjustment
of current programmes and the planning and installation
of new comprehensive programmes.
Conclusion
Our study showed that Saudis’ diets do not follow the
guidelines for healthy diets. Increased efforts to improve
eating habits in KSA are needed. These efforts should promote a balanced diet according to energy intake and composition of diet. Specifically, increasing the consumption of
M Moradi-Lakeh et al.
fruits, vegetables, dairy products, nuts and fish should be
targeted. Strategies are required to limit the consumption of
processed foods and SSB, especially in young adults. These
efforts should involve all stakeholders, including education
representatives, agriculture partners, food companies and
food importers. In addition, regular assessments of Saudis’
dietary status are needed to monitor trends and inform
interventions. Finally, political will is needed to enforce food
labelling and manufacturing regulations.
Acknowledgements
Acknowledgements: The authors would like to thank
Kevin O’Rourke at the Institute for Health Metrics and
Evaluation for editing the manuscript. Financial support:
This study was supported by a grant from the Ministry of
Health of the KSA. The Ministry of Health had no role in
the design, analysis or writing of this article. Conflict of
interest: The study and the authors have not received any
financial support from the food industries. Authorship:
A.H.M. conceived and designed the study. M.B., Z.A.M.,
M.A.S. and M.A.A. performed the survey. C.E.B. and F.D.
participated in questionnaire design and interviewers’
training. M.M.-L., A.A. and A.H.M. analysed the data.
M.M.-L., A.H.M., C.E.B., A.A., F.D., M.B., Z.A.M., M.A.S.,
M.A.A. and A.A.A.R. drafted or commented on the manuscript. A.A.A.R. supervised the study. All co-authors are
responsible for the content of this article and have read and
approved the final manuscript. Ethics of human subject
participation: The Saudi Ministry of Health and its IRB
approved the study protocol. The University of Washington
IRB deemed the study IRB-exempt, since the Institute for
Health Metrics and Evaluation received de-identified data
for the analysis. All respondents had the opportunity to
consent and agree to participate in the study.
Supplementary material
To view supplementary material for this article, please visit

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