Dietary Patterns in Saudi Arabian Adults Residing in Different Geographical Locations in Saudi ...

323 Pages·2014·7.11 MB·English

Dietary Patterns in Saudi Arabian Adults Residing in
Different Geographical Locations in Saudi Arabia
and in the UK in Relation to Heart Disease Risk

Thesis submitted for the degree of Doctor of philosophy

By:

Noha Moalla D. Al Moraie

School of Agriculture, Food and Rural Development
Newcastle University

June 2014
Abstract

The food situation in Saudi Arabia has markedly changed during the last two decades. A
nutrition transition is taking place in the country in which traditional foods are being
replaced by fast foods high in fat, sugar, and salt. Since one important modifiable risk
factor of cardiovascular disease (CVD) is dietary intake is important to monitor these
changes in order to estimate the potential effects of this dietary transition as CVD risk.
Saudi Arabia has a wide geographical variation with its two major cities located in
contrasting regions where local food availability is very different. Therefore, this study
was designed to investigate dietary intake in two samples of adults living in different
geographic locations (coastal and internal areas) of Saudi Arabia and also, those living
abroad (in this case, in Newcastle, UK). 308 Saudi men and women aged 18 - 65 years
were recruited from King Abdul-Aziz University, in the coastal city of Jeddah (50 men, 50
women), Umm Al Qura University, in the inland city of Makkah (73 men, 56 women) and
those living abroad in Newcastle, UK (32 men, 47 women). All participants completed
detailed three consecutive day food records and an assessment questionnaire that included
question on lifestyle practices and socioeconomic status. Height and weight, waist and hip
circumference were measured in order to calculate body mass index (kg/m2), and waist/hip
ratio. The mean (SD) ages of women and men were 31.1 years (7.35) and 32.2 years
(8.27), respectively. BMI was lower in men and women from the coastal region 25.1
(2.76) than the inland region 26.3 (3.21), and for Saudis in Newcastle it was 25.6 (4.36) (P
< 0.05). Smoking was more prevalent in the internal area (63%) than coastal area (34%)
and (26%) in Saudi immigrants (P < 0.001). Men were more physically active than women
in three cities. Dietary intake data across the three locations demonstrate that subjects from
the coastal city had a significantly lower energy intake and SFA intake but higher intakes
of MUFA and PUFA, fibre, selenium and vitamin A (P < 0.05). In contrast they ate
significantly less carbohydrates, calcium, magnesium, sodium, potassium and zinc (P <
0.05). Altogether, the diet of internal city resembled the samples in Newcastle more than
the coastal city diet because the levels of key nutrient and food intakes, such as energy,
SFA, carbohydrates, calcium, magnesium, potassium and vitamin A, were similar. On the
other hand, MUFA and PUFA intakes were different between the three cities (P < 0.001).
Fatty acids intakes differed markedly between locations, with the coastal diet higher in
omega 3 fatty acids 1.3 vs. 0.37 vs. 0.78 g/day compared with internal diet and Saudi
immigrants diet, respectively (P < 0.001), while internal area had highest in trans fatty
acids intake (P < 0.001). It is concluded that, the results indicate that the prevalence of
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CVD risk factors in Saudi adults seems to be high. Food intake was statistically
significantly correlated with CVD risk factors for the whole study population. There were
differences between each location: people living close to the coastal area consumed more
fish and therefore more total omega 3 fatty acids relative to individuals living in the
internal areas of Saudi Arabia, in Makkah. This higher intake of total omega 3 fatty acids
by individuals living in the coastal city of Jeddah may be one of the reasons for the city’s
lower rates of CVD. Nutrition education among internal residents is needed for improving
diet quality and for increasing consumption of omega 3 fatty acids.

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Declaration

I hereby declare that this thesis is of my own composition and has not been accepted in
any previous application for a degree. All sources of information have been specifically
acknowledged by means of referencing. All data were collected and analysed by the
author.

Noha Al Moraie

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Acknowledgement

Firstly, all my thanks are to Allah who has provided me with the strength and capacity to
complete this thesis.

I would like to take this opportunity to express my sincere thanks to my supervisors,
Professor Chris Seal and Dr Georg Lietz for their continual support, supervision,
encouragement and guidance throughout my thesis. Thanks also go to Professor Paula
Moynihan for her relevant contributions during the annual assessments of the project.

Also, I would like to thank the Saudi government (King Abdul Aziz University) for
providing me with a full time research grant. I would like to thank the staff of the Saudi
Arabian Cultural Bureau in London for their assistance and cooperation. Also, I give
special thanks to all Saudi who participated in this study without the cooperation of those
people this project could not have been possible. The cooperation of the staff of both King
Abdul Aziz University and Umm Al Qura University is gratefully acknowledged and also
for the students and their families in Newcastle, UK thank you.

Finally, I am grateful to my family: to my parents who have always supporting me. I hope
that they are proud of me. To my husband Naif, who assisted and encouraged me in many
ways, my children Layan and Thamer for their unconditional love, my brothers and sisters
especially my sister Manal due to her support to me in various ways. I present my thanks
and gratitude from all my heart to all my colleagues and friends.

Thank you
Noha

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Table of Contents
Abstract ....................................................................................................................................... i
Acknowledgement ..................................................................................................................... v
List of Tables ........................................................................................................................... xii
List of Figures ........................................................................................................................ xvii
List of Abbreviations ............................................................................................................... xx
Chapter 1 Introduction.............................................................................................................. 1
Chapter 2 Literature Review .................................................................................................... 4
2.1 CVD in Saudi Arabia ....................................................................................................... 4
2.1.1 Demographic and geographical background ............................................................ 4
2.1.2 Economic and cultural in Saudi Arabia .................................................................... 5
2.1.3 Prevalence of CVD in Saudi Arabia ......................................................................... 6
2.2 CVD risk factors .............................................................................................................. 7
2.2.1 Age and gender ......................................................................................................... 8
2.2.2 Obesity ...................................................................................................................... 8
2.2.3 Diabetes mellitus ....................................................................................................... 9
2.2.3 Hypercholesterolemia ............................................................................................. 10
2.2.5 Hypertension ........................................................................................................... 11
2.2.6 Cigarette smoking ................................................................................................... 11
2.2.7 Physical activity ...................................................................................................... 12
2.2.8 Socioeconomic status .............................................................................................. 14
2.3 Diet and CVD ................................................................................................................ 15
2.3.1 Fat and fatty acids intake ........................................................................................ 15
2.3.2 Minerals .................................................................................................................. 18
2.3.3 Vitamins .................................................................................................................. 19
2.3.4 Fibre ........................................................................................................................ 19
2.3.5 Food groups intake .................................................................................................. 20
2.3.5.1 Nuts and seeds.................................................................................................. 20
2.3.5.2 Fish ................................................................................................................... 20
2.3.5.3 Fruits & vegetables .......................................................................................... 21
2.3.5.4 Fast food........................................................................................................... 22
2.3.5.5 Diet in Saudi Arabia ......................................................................................... 23
2.4 Impact of relocation on dietary habits of Saudis living abroad ..................................... 25
2.5 Assessment of dietary intake ......................................................................................... 28
2.5.1 Twenty-four hour recall .......................................................................................... 28
2.5.2 Dietary record ......................................................................................................... 29
2.5.3 Food frequency questionnaires (FFQ) .................................................................... 29
2.5.4 Diet history.............................................................................................................. 30
2.6 Aims, Objectives and Hypotheses of the Study ................................................................. 33
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2.6.1 Aims ............................................................................................................................ 33
2.6.2 Objectives ................................................................................................................... 33
2.6.3 Hypotheses .................................................................................................................. 34
Chapter 3 Overall Study Methodology .................................................................................. 37
3. Study design ......................................................................................................................... 37
3.1 Ethical approval ............................................................................................................. 37
3.2 Statistical power of the study and sample size ............................................................... 37
3.3 Study participants........................................................................................................... 38
3.4 Questionnaire design ...................................................................................................... 39
3.4.1 Demographic details ............................................................................................... 39
3.4.2 Social habits ............................................................................................................ 39
3.4.3 Dietary habits .......................................................................................................... 39
3.4.4 Piloting the questionnaire ....................................................................................... 40
3.4.5 Study procedure for questionnaire .......................................................................... 40
3.5 Anthropometric measurement ........................................................................................ 40
3.6 Assessment of dietary intake ......................................................................................... 42
3.6.1 Interview ..................................................................................................................... 43
3.6.2 Dietary analysis ....................................................................................................... 44
3.6.3 Collection of food samples ..................................................................................... 44
3.6.4 Estimation of food portion sizes ............................................................................. 45
3.6.5 Coding, using WinDiets .......................................................................................... 46
3.6.6 Derived outcome variables from dietary assessment .............................................. 46
3.6.7 Food groups intake .................................................................................................. 47
3.6.8 Validation of dietary assessment ............................................................................ 49
3.7 Socioeconomic factors ................................................................................................... 49
3.8 Statistical analysis .......................................................................................................... 51
Chapter 4 ................................................................................................................................ 53
Study1: Dietary Patterns and Risk of Heart Disease in Male and Female living in Coastal
City (Jeddah) ............................................................................................................................ 53
4.1 Introduction .................................................................................................................... 53
4.2 Study aims and objectives .............................................................................................. 53
4.2.1 Aims ........................................................................................................................ 53
4.2.2 Objectives ............................................................................................................... 54
4.3 Methods.......................................................................................................................... 54
4.3.1 Study subjects ......................................................................................................... 54
4.3.2 Demographic and anthropometric information ....................................................... 55
4.3.3 Dietary assessment .................................................................................................. 55
4.3.4 Statistical analysis ................................................................................................... 55
4.4 Results ............................................................................................................................ 56
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4.4.1 Demographic and anthropometric data ................................................................... 56
4.4.2 Socioeconomic factor .............................................................................................. 56
4.4.3 Comparison of cardiovascular risk factors between genders .................................. 58
4.4.4 Dietary data ............................................................................................................. 60
4.4.5 Validation of dietary data ........................................................................................ 64
4.4.6 Comparison with UK Dietary Reference Values for food energy and nutrients
(DRV) .............................................................................................................................. 65
4.4.7 Relationship between nutrient intake and other factors .......................................... 72
4.4.7.1 Relationship between nutrient intake and socioeconomic status ..................... 72
4.4.7.2 Relationship between nutrient intake and CVD risk factors ............................ 72
4.4.8 Intake by food groups ............................................................................................. 77
4.4.9 Relationship between intake by food group and other factors ................................ 77
4.4.9.1 Relationship between intake by food group and socioeconomic status ........... 77
4.4.9.2 Relationship between intake by food group and CVD risk factors ................. 78
4.5 Discussion ...................................................................................................................... 79
4.6 Summary and Conclusions ............................................................................................ 82
Chapter 5 ................................................................................................................................ 84
Study 2: Dietary Patterns and Risk of Heart Disease in Male and Female living in internal
City (Makkah) .......................................................................................................................... 84
5.1 Introduction .................................................................................................................... 84
5.2 Study aims and objectives .............................................................................................. 84
5.2.1 Aims ........................................................................................................................ 84
5.2.2. Objectives .............................................................................................................. 85
5.3 Methods.......................................................................................................................... 85
5.3.1 Study subjects ......................................................................................................... 85
5.3.2 Demographic and anthropometric information ....................................................... 86
5.3.3 Dietary assessment .................................................................................................. 86
5.3.4 Statistical analysis ................................................................................................... 86
5.4 Results ............................................................................................................................ 87
5.4.1 Demographic and anthropometric data ................................................................... 87
5.4.2 Socioeconomic factor .............................................................................................. 87
5.4.3 Comparison of cardiovascular risk factors between genders .................................. 90
5.4.4 Dietary data ............................................................................................................. 91
5.4.5 Validation of dietary data ........................................................................................ 96
5.4.6 Comparison with UK Dietary Reference Values for food energy and nutrients
(DRV) .............................................................................................................................. 97
5.4.7 Relationship between nutrient intake and other factors ........................................ 104
5.4.7.1 Relationship between nutrient intake and socioeconomic status ................... 104
5.4.7.2 Relationship between nutrient intake and CVD risk factors .......................... 104
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5.4.8 Intake by food groups ........................................................................................... 108
5.4.9 Relationship between intake by food group and other factors .............................. 108
5.4.9.1 Relationship between food group intake and socioeconomic status .............. 108
5.4.9.2 Relationship between intake by food group and CVD risk factors ............... 109
5.5 Discussion .................................................................................................................... 110
5.6 Summary and conclusions ........................................................................................... 113
Chapter 6 .............................................................................................................................. 115
Study 3: Dietary Patterns and Risk of Heart Disease in Male and Female Saudi Arabians
living in UK (Newcastle upon Tyne) ..................................................................................... 115
6.1 Introduction .................................................................................................................. 115
6.2 Study aims and objectives ............................................................................................ 116
6.2.1 Aims ...................................................................................................................... 116
6.2.2. Objectives ............................................................................................................ 116
6.3 Methods........................................................................................................................ 117
6.3.1 Study subjects ....................................................................................................... 117
6.3.2 Demographic and anthropometric information ..................................................... 117
6.3.3 Dietary assessment ................................................................................................ 117
6.3.4 Statistical analysis ................................................................................................. 118
6.4 Results .......................................................................................................................... 118
6.4.1 Demographic and anthropometric data ................................................................. 118
6.4.2 Socioeconomic factor ............................................................................................ 118
6.4.3 Comparison of cardiovascular risk factors between genders ................................ 122
6.4.4 Dietary data ........................................................................................................... 123
6.4.5 Validation of dietary data ...................................................................................... 127
6.4.6 Comparison with UK Dietary Reference Values for food energy and nutrients
(DRV) ............................................................................................................................ 128
6.4.7 Relationship between nutrient intake and other factors ........................................ 135
6.4.7.1 Relationship between nutrient intake and socioeconomic status ................... 135
6.4.7.2 Relationship between nutrient intake and CVD risk factors .......................... 135
6.4.8 Intake by food groups ........................................................................................... 139
6.4.9 Relationship between intake by food group and other factors .............................. 139
6.4.9.1 Relationship between intake by food group and socioeconomic status ......... 139
6.4.9.2 Relationship between intake by food group and CVD risk factors ............... 139
6.5 Discussion .................................................................................................................... 141
6.6 Summary and conclusions ........................................................................................... 144
Chapter 7 .............................................................................................................................. 146
Comparison of the Dietary Patterns of Saudi Populations from different Geographical
locations (Coastal and Internal Cities) in the Western Region of Saudi Arabia .................... 146
7.1 Introduction .................................................................................................................. 146
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7.2 Study aims and objectives ............................................................................................ 147
7.2.1 Aims ...................................................................................................................... 147
7.2.2 Objectives ............................................................................................................. 147
7.3 Methods........................................................................................................................ 148
7.3.1 Study subjects ....................................................................................................... 148
7.3.2 Demographic and anthropometric information ..................................................... 148
7.3.3 Dietary assessment ................................................................................................ 148
7.3.4 Statistical analysis ................................................................................................. 149
7.4 Results .......................................................................................................................... 149
7.4.1 Demographic data ................................................................................................. 149
7.4.1.1 Age and gender .................................................................................................. 149
7.4.1.2 Education status ............................................................................................. 150
7.4.1.3 Monthly income ............................................................................................. 150
7.4.1.4 Marital status .................................................................................................. 150
7.4.2 Socioeconomic factor ............................................................................................ 151
7.4.3 Anthropometric data ............................................................................................. 153
7.4.4 Comparison of cardiovascular risk factors between cities .................................... 153
7.4.4.1 Obesity ........................................................................................................... 154
7.4.4.2 Personal medical history ................................................................................ 155
7.4.4.3 Family history ................................................................................................ 156
7.4.4.4 Smoking habits............................................................................................... 156
7.4.4.5 Physical activity ............................................................................................. 156
7.4.5 Dietary data ........................................................................................................... 158
7.4.5.1 Dietary habits ..................................................................................................... 158
7.4.5.2 Nutrient intake ............................................................................................... 159
7.4.5.2.1 Intake of energy, macronutrients, cholesterol and fibre ............................. 159
7.4.5.2.2 Intake of minerals ....................................................................................... 163
7.4.5.2.3 Intake of vitamins ....................................................................................... 163
7.4.5.2.4 Intake of fatty acids ..................................................................................... 165
7.4.6 Intake by food groups ........................................................................................... 168
7.4.7 Multivariate analysis of the association between nutrients intake and CVD risk
factors in between cities ................................................................................................. 169
7.5 Discussion .................................................................................................................... 171
7.6 Summary and conclusions ........................................................................................... 174
Chapter 8 .............................................................................................................................. 175
Comparison of the Dietary Patterns of Saudi Populations from Different Geographical
Locations in Saudi Arabia and the UK .................................................................................. 175
8.1 Introduction .................................................................................................................. 175
8.2 Study aims and objectives ............................................................................................ 176
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