Nutrition and Dietary Supplements
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Fruit and vegetable consumption among adults
in Saudi Arabia, 2013
This article was published in the following Dove Press journal:
Nutrition and Dietary Supplements
20 February 2015
Number of times this article has been viewed
Charbel El Bcheraoui 1
Mohammed Basulaiman 2
Mohammad A AlMazroa 2
Marwa Tuffaha 1
Farah Daoud 1
Shelley Wilson 1
Mohammad Y Al Saeedi 2
Faisal M Alanazi 2
Mohamed E Ibrahim 2
Elawad M Ahmed 2
Syed A Hussain 2
Riad M Salloum 2
Omer Abid 2
Mishal F Al-Dossary 2
Ziad A Memish 2
Abdullah A Al Rabeeah 2
Ali H Mokdad 1
Institute for Health Metrics and
Evaluation, University of Washington,
Seattle, WA, USA; 2Ministry of Health
of the Kingdom of Saudi Arabia,
Riyadh, Saudi Arabia
1
Background: Dietary risks were the leading risk factors for death worldwide in 2010. However,
current national estimates on fruit and vegetable consumption in the Kingdom of Saudi Arabia
(KSA) are nonexistent. We conducted a large household survey to inform the Saudi Ministry of
Health (MOH) on a major modifiable risk factor: daily consumption of fruits and vegetables.
Methods: The Saudi Health Interview Survey is a national multistage survey of individuals
aged 15 years or older. It includes questions on sociodemographic characteristics, tobacco
consumption, diet, physical activity, health care utilization, different health-related behaviors,
and self-reported chronic conditions. We used a backward elimination multivariate logistic
regression model to measure association between the Centers for Disease Control and Prevention
(CDC)-recommended daily consumption of fruits and vegetables and different factors.
Results: Between April and June 2013, a total of 10,735 participants completed the survey.
Overall, 2.6% of Saudis aged 15 years or older met the CDC guidelines for daily consumption
of fruits and vegetables. The likelihood of meeting the CDC guidelines increased with age;
among women; among persons who graduated from elementary or high school or had a higher
education; among residents of Makkah, Al Sharqia, Ha’il, or Jizan; among those who consumed
at least two servings of meat or chicken per day; among those who visited a health care facility
for a routine medical exam within the last 3 years; and among those who have been diagnosed
with hypertension.
Conclusion: We have showed that KSA is in dire need of improving the diet of its ­population.
Our findings call for urgent research to understand the reasons for low fruit and vegetable consumption, focusing on price or preference in order to develop and implement culturally and
country-relevant solutions to increase the consumption of fruits and vegetables.
Keywords: Kingdom of Saudi Arabia, fruits, vegetables, dietary risks, diet
Introduction
Correspondence: Ali H Mokdad
Institute for Health Metrics and
Evaluation, University of Washington,
2301, 5th Avenue, Suite 600, Seattle,
WA 98121, USA
Tel +1 206 897 2849
Fax +1 206 897 2899
Email [email protected]
Dietary risks were the leading risk for death, years of life lost, and disability-adjusted
life years worldwide in 2010.1 The sociocultural evolution of the last century led to
increased access to food, specifically in the Gulf region where oil revenues increased
wealth.2 People of the Gulf region traditionally did not consume much fruits and
vegetables, except for dates, due to the harsh desert environment. The main source of
energy was meat, dairy products, and carbohydrates. As wealth and imports made all
kinds of fruits and vegetables available, we would expect a change in diet from the
traditional low levels of consumption to more consumption of fruits and vegetables.
Several recommendations by the World Health Organization, the US Department
of Agriculture, and the Department of Health and Human Services exist to improve
41
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http://dx.doi.org/10.2147/NDS.S77460
El Bcheraoui et al
diet and increase the intake of fruits and vegetables.3,4 The
5 a day program started in 19905 and has evolved based on
scientific evidence.4 Specifically, an increased intake of fruits
and vegetables has been associated with decreased weight
and risk of cardiovascular disease morbidity and mortality.6–13
Currently, the US Centers for Disease Control and Prevention
(CDC) recommend consuming a certain number of servings
of fruits and vegetables (recommendations vary based on
sex and age).14
The Kingdom of Saudi Arabia (KSA) has witnessed a
demographic shift over the last 20 years; this was accompanied
by major behavioral changes such as an increase in caloric,
fat, and carbohydrate intake.15 The Saudi Ministry of Health
(MOH) issued its dietary guidelines for Saudis as part of its
fight against obesity in 2013, as 28.7% of Saudis aged 15 years
or older are obese.16,17
Current national data on fruit and vegetable consumption in KSA are nonexistent, and the most recent estimates
date from 2005.18 To assess the current daily consumption
of fruits and vegetables in KSA, and provide the MOH with
an evidence base on the predictors of this major modifiable
risk factor, we conducted a large household survey.
Subjects and methods
The Saudi Health Interview Survey is a national multistage
survey of individuals aged 15 years or older. Households of
Saudi citizens were randomly selected from a national sampling frame maintained and updated by the Census Bureau.
The MOH divides KSA into 13 health regions, each with its
own health department. We divided each region into subregions and blocks used by the KSA Department of Statistics.
All regions were included, and a probability proportional
to size was used to randomly select subregions and blocks.
Households were randomly selected from each block. We
collected a roster of household members and randomly
selected an adult aged 15 or older to be surveyed. If the randomly selected adult was not present, our surveyors made an
appointment to return, and a total of three visits were made
before the household was considered as a nonresponse.
The survey included questions on sociodemographic
characteristics, tobacco consumption, diet, physical activity,
health care utilization, different health-related behaviors, and
self-reported chronic conditions (hypertension, diabetes, and
hypercholesterolemia).
Consumption of fruits and vegetables was measured using
a frequency questionnaire. Daily fruits consumption was
assessed by asking the following two questions: “In a typical
week, on how many days do you eat fruit? Please include
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fresh, frozen, or canned fruit, for example, figs, grapes,
oranges, bananas, or apples. Do not include juices, blended
fruits, or dried fruits” and “How many servings of fruit do
you eat on one of those days?” Daily fruit juices consumption was assessed by asking the following two questions: “In
a typical week, on how many days do you drink 100% fruit
juices, including blended fruits? Do not include nectars”
and “How many servings of 100% fruit juices do you drink
on one of those days?” Daily vegetables consumption was
assessed by asking the following two questions: “In a typical week, on how many days do you eat vegetables? Please
include raw, cooked, canned, or frozen vegetables. Please
do not include rice, potatoes, or cooked dried beans such as
kidney beans, pinto beans, or lentils” and “How many servings of vegetables do you eat on one of those days?” We then
computed the numbers of fruits and vegetables consumed per
day as the sum of the average daily consumption of fruits,
fruit juices, and vegetables.
Our survey included questions on sodas, red meat, processed meat, chicken, dark-meat fish, other types of fish,
shrimp, processed food, milk, laban (yogurt), ayran (yogurt
beverage mixed with salt), labneh (traditional spreadable
cheese), cheese, nuts, and eggs. These were assessed using a
methodology similar to the one of fruit, juice, and vegetable
consumption. We assessed the type of bread the respondents
usually consume by asking: “What type of bread do you usually eat?” Respondents could choose between white, brown,
and Saudi traditional bread.
Although our survey did not include questions on carbohydrates such as pasta and rice, we calculated the caloric
intake from all available food items using the National
­Nutrient Database for Standard Reference from the US
Department of Agriculture. This is an underestimate of the
total caloric intake in the Kingdom, as rice is a staple there,
but we felt the estimate of total caloric intake was still important to include in our analysis.
Respondents were considered to be current smokers if
they reported currently smoking. We used the International
Physical Activity Questionnaire19 to classify respondents
into four groups of physical activity: 1) vigorous physical
activity, 2) moderate physical activity, 3) insufficient physical
activity, and 4) none.
To assess diagnosed blood pressure, diabetes, and
hypercholesterolemia status, respondents were asked three
separate questions: “Have you ever been told by a doctor,
nurse, or other health professional that you had: 1) hypertension, otherwise known as high blood pressure; 2) diabetes
mellitus, otherwise known as diabetes, sugar diabetes, high
Nutrition and Dietary Supplements 2015:7
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blood glucose, or high blood sugar; 3) hypercholesterolemia,
otherwise known as high or abnormal blood cholesterol?”
Women diagnosed with diabetes or hypertension during
pregnancy were not counted as having these conditions.
To assess time since last routine medical checkup,
respondents were asked, “In which year did you last visit a
doctor or other health professional for a routine checkup? A
routine checkup is a general physical exam, not an exam for
a specific injury, illness, or condition.”
We compared the distribution of respondents who met the
Saudi and the CDC guidelines for daily consumption of fruits
and vegetables to those who did not by sociodemographic,
behavioral, and health characteristics. The Saudi guidelines
recommend consuming at least two servings of fruits and
three servings of vegetables per day. The CDC guidelines
recommend consuming at least 1) two servings of fruits and
three servings of vegetables for men aged 15–18 years or
21–60 years; 2) two servings of fruits and three-and-a-half
servings of vegetables for men aged 19–20 years; 3) two
servings of fruits and two-and-a-half servings of vegetables
for men older than 20 years and women aged 19–25 years; 4)
one-and-a-half servings of fruits and two-and-a-half servings
of vegetables for women aged 15–18 years or 26–50 years;
and 5) one-and-a-half servings of fruits and two servings of
vegetables for women older than 50 years.
We used a backward elimination multivariate logistic
regression model to measure association between adequate
consumption of fruits and vegetables per day, based on the
CDC recommendations, and associated factors. All factors
were included in the model. Then variables were eliminated
based on a Wald χ2 test for analysis of effect. Variables
were removed one by one based on the significance level
of their effect on the model, starting with the variable with
the highest P-value .0.5, until all variables retained had a
P-value #0.5 in the analysis of effect. The logistic regression excluded cases with missing data. Out of the 10,735
completed interviews, the regression analysis excluded 266
observations missing self-reported hypercholesterolemia
status, 115 missing self-reported diabetes status, 212 missing
fruit and vegetable consumption, 173 missing meat and
chicken consumption, 29 missing smoking status, 33 missing
marital status, and 20 missing educational level. In total,
9,993 observations were used in our regression analyses. Data
were weighted to account for the probability of selection,
and age and sex post-stratification, based on census data for
age and sex distribution of the Saudi population. We used
SAS 9.3 for the analyses and to account for the complex
sampling design.
Nutrition and Dietary Supplements 2015:7
Fruit and vegetable consumption in Saudi Arabia
Ethics
The Saudi MOH and its institutional review board (IRB) have
approved the study protocol. The University of Washington
IRB has deemed the study as IRB exempt, since the Institute
for Health Metrics and Evaluation received de-identified
data for this analysis. All respondents consented and agreed
to participate in the study. We used verbal consent that was
captured by our computer program, since it is commonly used
and accepted in KSA. Two verbal consents were obtained:
one for the household roster (obtained from the head of the
household or the most knowledgeable person in the house) and
another obtained from the randomly selected respondent. The
KSA MOH and the University of Washington IRB approved
the verbal consents that were obtained in this study.
Results
Between April and June 2013, a total of 12,000 households
were contacted, and a total of 10,735 participants completed
the survey (response rate of 89.4%).
The majority of our participants consumed less than
two servings of fruits and vegetables per day (Table 1).
Overall, 2.6% of Saudis aged 15 years or older met both
the Saudi and the CDC guidelines for daily consumption of
fruits and vegetables. The largest variations in consumption
were observed between regions and number of daily servings consumed of meat and chicken. While 0.2% of Al Jawf
residents met the CDC guidelines for daily consumption of
fruits and vegetables, 9.6% of ‘Asir residents did so. Also,
the proportion of people meeting the guidelines increased
from 0.9% among those who consumed between 0–0.9 and
1.0–1.9 servings of meat and chicken per day to 3.3% and
8.4% among those who consumed 2.0–2.9 and 3.0+ servings
of meat and chicken per day, respectively (Table 1).
In the multivariate analysis, several factors were associated with the likelihood of meeting the CDC guidelines for
daily consumption of fruits and vegetables. This likelihood
increased with age and among women, persons who graduated from elementary or high school or had a higher education, and residents of Makkah, Al Sharqia, Ha’il, and Jizan. It
also increased with increased daily caloric intake, and among
individuals who consumed at least two servings of meat or
chicken per day, those who last visited a health care facility
for a routine medical exam less than 3 years ago, and those
who had been diagnosed with hypertension (Table 2).
Discussion
Our manuscript is the first to report on national consumption of fruits and vegetables in the KSA. Our results showed
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199 (7.21; 5.83–8.59)
298 (6.93; 5.86–7.99)
241 (9.78; 8.19–11.38)
369 (12.00; 10.38–13.62)
513 (9.09; 8.01–10.17)
386 (13.93; 12.11–15.76)
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Abbreviation: CI, confidence interval.
1,010 (28.38; 26.23–30.54)
1,732 (35.07; 33.18–36.96)
877 (33.74; 31.12–36.35)
1,110 (36.72; 34.31–39.13)
1,348 (31.99; 30.07–33.91)
527 (24.40; 21.93–26.87)
528 (15.68; 13.86–17.51)
890 (16.93; 15.47–18.39)
478 (18.15; 16.07–20.23)
532 (8.40; 7.53–9.28)
152 (6.60; 5.31–7.88)
52 (8.63; 5.42–11.83)
916 (12.52; 11.49–13.55)
277 (9.29; 7.94–10.63)
76 (9.69; 6.95–12.43)
2,387 (34.15; 32.68–35.63)
923 (32.11; 29.87–34.35)
309 (31.72; 27.52–35.93)
1,742 (27.40; 25.98–28.82)
942 (35.83; 33.50–38.16)
295 (33.83; 29.23–38.43)
1,274 (17.53; 16.35–18.70)
484 (16.18; 14.42–17.93)
138 (16.13; 12.56–19.70)
129 (6.63; 5.24–8.01)
173 (7.41; 5.98–8.83)
189 (8.54; 7.02–10.06)
131 (9.28; 7.39–11.17)
63 (8.67; 5.80–11.53)
53 (7.51; 4.70–10.32)
223 (8.86; 7.45–10.28)
343 (11.85; 10.19–13.52)
304 (12.78; 10.93–14.63)
193 (12.65; 10.47–14.83)
108 (12.17; 9.24–15.11)
98 (11.25; 8.33–14.17)
808 (31.89; 29.49–34.30)
935 (34.79; 32.33–37.25)
838 (35.03; 32.47–37.59)
507 (33.48; 30.41–36.56)
286 (32.19; 27.98–36.40)
252 (28.91; 24.71–33.10)
783 (36.17; 33.64–38.70)
713 (28.68; 26.30–31.06)
569 (26.76; 24.34–29.19)
389 (27.44; 24.45–30.43)
235 (30.28; 25.92–34.63)
303 (34.96; 30.62–39.31)
403 (16.45; 14.51–18.38)
533 (17.27; 15.45–19.08)
399 (16.89; 14.90–18.89)
273 (17.15; 14.71–19.58)
140 (16.70; 13.30–20.09)
150 (17.37; 13.90–20.84)
398 (7.18; 6.22–8.14)
340 (8.00; 6.86–9.13)
673 (11.14; 10.00–12.28)
596 (10.61; 9.45–11.77)
944 (17.61; 16.15–19.06)
954 (16.03; 14.65–17.42)
1,723 (33.19; 31.38–35.01)
1,903 (32.97; 31.18–34.75)
Sex
Male
Female
Age (years)
15–24
25–34
35–44
45–54
55–64
65+
Marital status
 Currently married
Never married
Separated, divorced, or widowed
Education
Primary school or less
 Elementary or high school completed
 College degree or higher education
N (weighted %; 95% CI)
N (weighted %; 95% CI)
1,420 (30.88; 29.03–32.74)
1,572 (32.39; 30.56–34.22)
N (weighted %; 95% CI)
N (weighted %; 95% CI)
1 to ,2
,1
Servings of fruits and vegetables consumed daily
2 to ,3
3–5
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Sociodemographic characteristics
Table 1 Distribution of daily consumption of fruits and vegetables by sociodemographic characteristics
44
N (weighted %; 95% CI)
5+
El Bcheraoui et al
very low consumption of fruits and vegetables in the country
among all segments of the population. This is an alarming
finding and calls for immediate programs to encourage intake
of fruits and vegetables to prevent diseases and reduce burden
on families and the health system.
Our findings showed little or no improvement from a
previous STEPS survey and after efforts of the MOH to
increase the consumption of fruits and vegetables. In 2005,
5.5% of Saudis aged 15–64 years reported consuming at least
five servings of fruits and vegetables per day.18 This increased
to only 7.3% in our survey for the same age group. These
findings call for a review of current programs, barriers, and
determinants of a healthy diet, especially because current
guidelines for fruit and vegetable consumption are only met
by 2.6% of Saudis.
Despite this low intake of fruits and vegetables overall,
it is noteworthy that this consumption increased with the
educational level. Emphasizing the importance of a healthy
diet rich with fruits and vegetables at schools is one way to
increase such consumption.
Our data showed regional variation in fruit and vegetable
consumption in KSA. However, none of the regions had high
levels of intake, with ‘Asir, where consumption is the highest,
having only 9.6% of residents meeting the current guidelines
for daily consumption of fruits and vegetables. While our data
cannot provide an explanation on this regional variation, it
would be relevant for future studies to investigate the factors
behind the higher consumption of fruits and vegetables in
some regions for policy formulation.
Our findings could be explained by several factors. Due
to the climate, KSA traditionally had no major production of
fruits and vegetables. Hence, Saudis did not consume many
fruits and vegetables, except for dates that are produced in
abundance. However, the recent wealth from oil revenues
allowed for tremendous development of the agricultural sector in the region.2 Recent advances in agriculture, especially
in areas bordering Yemen and Oman where there is enough
rainfall to sustain agriculture, allowed the production of
4.7 million tons of fruits and vegetables in 2005, making
the country 65% and 85% self-sufficient for fruits and vegetables, respectively, based on consumption patterns.2 Dates
and tomatoes were the top fruits and vegetables produced.
However, given our findings on the low consumption of fruits
and vegetables in KSA, this production would be less than
the reported percentages if Saudis were to meet the guidelines for fruit and vegetable consumption. There would also
be a need for a higher production and import of fruits and
vegetables. To address the current unmet needs, KSA imports
Nutrition and Dietary Supplements 2015:7
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Fruit and vegetable consumption in Saudi Arabia
Table 2 Distribution of different levels of daily fruit and vegetable consumption, and association between daily consumption of fruits
and vegetables based on the CDC dietary guidelines and sociodemographic, behavioral, and health characteristics of Saudis aged 15
years or older in Kingdom of Saudi Arabia in 2013
Sociodemographic,
behavioral, and health
characteristics
Meeting the Saudi
dietary guidelines
Meeting the CDC
dietary guidelines
Backward elimination
multivariate logistic
regression for
meeting the CDC
dietary guidelines
N
Weighted %
(95% CI)
N
Weighted %
(95% CI)
AOR (95% CI)
2.47 (1.97–2.97)
2.71 (2.08–3.34)
123
161
1.99 (1.53–2.44)
3.15 (2.50–3.81)
Ref
2.48 (1.61–3.81)
1.43 (1.18–1.74)
1.29 (0.76–1.83)
2.35 (1.57–3.14)
3.66 (2.58–4.75)
4.60 (3.20–5.99)
4.53 (2.27–6.79)
3.52 (1.45–5.59)
29
65
72
63
32
23
1.20 (0.67–1.72)
2.43 (1.64–3.21)
3.58 (2.51–4.65)
4.40 (3.05–5.75)
4.77 (2.46–7.08)
3.97 (1.84–6.11)
3.66 (3.03–4.29)
1.35 (0.85–1.86)
3.32 (1.29–5.36)
216
41
26
3.60 (2.97–4.22)
1.27 (0.77–1.76)
4.29 (2.13–6.44)
2.13 (1.42–2.85)
2.26 (1.72–2.80)
4.02 (3.01–5.04)
76
108
100
2.52 (1.76–3.28)
2.05 (1.53–2.57)
3.93 (2.93–4.94)
0.58 (0.22–0.94)
1.60 (0.93–2.27)
0.69 (0.00–1.57)
0.95 (0.11–1.80)
6.75 (4.86–8.64)
9.59 (7.52–11.67)
1.09 (0.08–2.09)
2.46 (1.18–3.73)
1.40 (0.36–2.43)
1.58 (0.75–2.40)
1.26 (0.54–1.98)
1.34 (0.23–2.45)
0.07 (0.00–0.19)
14
32
3
6
56
98
8
18
5
18
14
10
2
0.60 (0.22–0.98)
1.52 (0.90–2.15)
0.55 (0.00–1.40)
0.95 (0.11–1.80)
6.63 (4.76–8.51)
9.56 (7.50–11.63)
0.87 (0.19–1.55)
2.53 (1.21–3.85)
0.75 (0.05–1.44)
1.74 (0.88–2.59)
1.48 (0.59–2.36)
1.89 (0.54–3.24)
0.21 (0.00–0.52)
2.67 (2.22–3.12)
1.57 (0.00–3.37)
2.39 (1.49–3.29)
250
4
30
2.76 (2.31–3.21)
1.12 (0.00–2.83)
1.71 (0.97–2.44)
0.99 (0.54–1.44)
0.87 (0.53–1.21)
3.54 (2.42–4.65)
8.17 (6.41–9.93)
32
42
63
141
0.86 (0.46–1.26)
0.86 (0.51–1.20)
3.34 (2.32–4.36)
8.36 (6.57–10.16)
2.40 (1.72–3.08)
2.91 (2.08–3.74)
2.96 (1.69–4.22)
2.35 (1.65–3.04)
96
83
41
64
2.41 (1.75–3.08)
2.99 (2.16–3.83)
2.85 (1.63–4.08)
2.19 (1.50–2.89)
6.60 (5.11–8.10)
3.76 (2.29–5.24)
1.69 (1.29–2.10)
107
38
139
6.18 (4.75–7.60)
4.32 (2.65–5.98)
1.69 (1.29–2.09)
Sex
 Male
153
 Female
127
Age (years)
 15–24
33
 25–34
62
 35–44
74
 45–54
63
 55–64
29
19
 65+
Marital status
 Currently married
217
 Never married
45
 Separated, divorced, or widowed
17
Education
 Primary school or less
62
 Elementary or high school completed 116
 College degree or higher education
102
Region
 Riyadh
13
 Makkah
30
 Al Madinah
4
 Al Qasim
6
 Al Sharqia
57
 ‘Asir
97
 Tabuk
7
 Ha’il
19
 Al Hudud ash Shamaliyah
8
 Jizan
16
 Najran
14
 Al Bahah
8
 Al Jawf
1
Smoking status
 Never
233
 Ex-smoker
7
 Current smoker
40
Daily consumption of red meat and chicken (servings)
 0–0.9
31
 1.0–1.9
42
 2.0–2.9
60
143
 3.0+
Levels of physical activity
 None
87
 Low
79
 Moderate
41
 Vigorous
73
Time since last routine medical exam
 Within the last year
109
 1–3 years ago
36
134
 4+ years ago
Ref
0.67 (0.34–1.29)
1.12 (0.52–2.40)
Ref
2.25 (1.27–3.98)
3.38 (1.77–6.48)
Ref
2.59 (1.12–5.99)
1.00 (0.11–8.75)
2.10 (0.68–6.46)
6.38 (2.91–14.00)
10.56 (5.03–22.19)
2.30 (0.74–7.17)
5.17 (2.16–12.38)
1.17 (0.22–6.22)
3.98 (1.54–10.29)
2.18 (0.86–5.50)
1.79 (0.56–5.75)
0.14 (0.01–1.42)
Ref
1.08 (0.58–2.03)
2.84 (1.55–5.20)
2.81 (1.34–5.87)
1.86 (1.17–2.96)
1.90 (1.09–3.33)
Ref
(Continued)
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El Bcheraoui et al
Table 2 (Continued)
Sociodemographic,
behavioral, and health
characteristics
Daily caloric intake
Meeting the Saudi
dietary guidelines
Meeting the CDC
dietary guidelines
Backward elimination
multivariate logistic
regression for
meeting the CDC
dietary guidelines
N
N
AOR (95% CI)
Weighted %
(95% CI)
Mean =4,389.42;
SE =187.37
History of diagnosis of hypertension
 No
235
 Yes
44
History of diagnosis of diabetes
 No
229
 Yes
50
History of diagnosis of hypercholesterolemia
 No
242
 Yes
36
Weighted %
(95% CI)
1.06 (1.04–1.08)
Mean =4,423.16;
SE =187.29
2.28 (1.89–2.66)
6.88 (4.29–9.48)
235
47
2.23 (1.85–2.61)
7.07 (4.50–9.65)
2.35 (1.95–2.75)
5.45 (3.47–7.44)
231
51
2.32 (1.93–2.72)
5.38 (3.41–7.35)
2.35 (1.95–2.74)
7.45 (4.52–10.39)
245
37
2.37 (1.98–2.77)
6.62 (3.91–9.32)
Ref
2.37 (1.46–3.85)
Ref
1.37 (0.81–2.34)
Notes: Significant AOR are presented in a bolded font. AOR are calculated per 10-year and 100-calorie increases for age and daily caloric intake, respectively. Smoking status,
levels of physical activity, and history of diagnosis with hypercholesterolemia were included in the logistic regression but dropped out based on their effect on the model.
Abbreviations: CDC, Centers for Disease Control and Prevention; CI, confidence interval; AOR, adjusted odds ratios; Ref, reference; SE, standard error.
$1.1 billion USD of fruits and vegetables.20 In 2013–2014,
the Kingdom imported the equivalent of $2.05 billion USD
of agriculturally produced food from India alone.21
The prices of fruits and vegetables in the Kingdom fluctuate greatly and increase around major holidays, especially
in the holy month of Ramadan, when demand increases by
up to 15%.20 Fruits and vegetables are relatively expensive,
which prevents large segments of the population from buying them on a regular basis. The average monthly income
in the Kingdom is 7,611 Saudi Riyal, about $2,030 USD.22
Housing in KSA is a major cost and consumes about 18.4%
of the general cost of living index.22 The monthly minimum
amount of money recommended for food per person is about
$163 per month,23 or $864 per household, since our survey
showed an average of 5.3 persons per household.
In the Kingdom, imported foods are subject to a 5%
import duty.24 Grain production was heavily subsidized in
an attempt to be self-sufficient,2 and gasoline is heavily subsidized and sold as low as $0.12 USD per liter.25 ­However,
fruits and vegetables are neither exempt from import taxes
nor subsidized. The findings of our study call for reviewing
the subsidies in KSA. It is important to extend subsidies to
fruit and vegetable production, similar to policies in the US
for certain products.26 Furthermore, it may be time to consider
supporting fruit and vegetable importers, while creating policies to protect the local producers. It is important to remember
that if Saudis were to increase their consumption of fruits and
vegetables to meet the CDC or MOH guidelines, the demand
and therefore the prices would increase. Government statistics
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show that currently 65% and 85% of fruits and vegetables
consumed are produced in KSA. To prevent an increase
in price, an increase in local production, or a government
support of imports, is needed. Hence, a major review of the
agricultural plans and subsidies is crucial.
Our study has some limitations. First, our data are
cross-sectional, and we cannot assess causality. Second,
variables included in this analysis are self-reported and
subject to recall bias. Third, individuals may have overestimated their consumption of fruits and vegetables as it is
a desirable behavior, and we may have overestimated the
true consumption in KSA. Finally, our dietary questionnaire
excludes questions on carbohydrates in a country where
rice consumption is common and therefore does not allow
us to compute a full caloric intake. However, our study
used standardized data collection methods and protocols.
Moreover, we had a large sample size, a high response rate,
and included all regions of KSA, and so our findings are
nationally representative.
Our study calls for qualitative work to understand why
Saudis do not consume fruits and vegetables, and whether it
is a taste or preference issue due to the nomadic and desert
history of the country or an issue of pricing. Each of these
issues has its own solution. We recommend group discussions to get a clear sense of what is driving this behavior.
The MOH should work with community elders and leaders
and with women’s groups to understand the barriers and
develop targeted programs to improve fruit and vegetable
consumption.
Nutrition and Dietary Supplements 2015:7
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Fruit and vegetable consumption in Saudi Arabia
The Arab and Saudi media has many cooking shows with
specialized TV channels.27 The MOH should use such venues
to introduce recipes for vegetarian cooking. The Kingdom
was once part of the spice route and buzzed with caravans
bringing this valuable merchandise from India to Damascus.28
These spices could be used to influence the Arab cuisine by
adding flavor to vegetarian dishes and making them more
appealing.
Ministry of Health
The Healthy Food Palm
an
Su
g
d
oils
dairy products gr
nd
lk a
i
M
p
ou
and legumes gr
ts
ou
ea
p
s
ar
M
For Kingdom of Saudi Arabia
Veg
eta
ble
s
oups
ls gr
rea
Ce
Brea
da
nd
Fr
ui
p
ou
gr
up
gro
ts
Oils and sugars
The least amount of
oils and sugars/day.
Meats and legumes
Serving =2–3 serving/day.
One exchange serving =60 to
90 grams of red meat, chicken
or fish, or 1/2 cup cooked
legumes.
Milk and dairy
products
Serving =2–4 serving/day.
One serving = one cup of milk
or Laban (240 mL) or 30 g
cheese.
Fruits
Serving =2–4 serving/day.
One serving = medium size of
fruit such as apples or oranges
or bananas, or kiwi, or half
a cup of juice (120 mL) or half a
cup of dry fruits.
Vegetables
Serving =3–5 serving/day.
One serving = cup
vegetables or cup of juice
or 1/2 cup cooked
vegetable.
Cereals and bread
Serving =6–11 serving/day.
One exchange serving = slice of
bread (25 grams) or a half cup of
cooked cereal or breakfast cereal
or 4–6 medium size biscuits.
Water
Drinking water per day
At least 6 Cups (240 mL)
Physical activity: of 30–60 minutes a day depending on health status
Ministry of Health – Undersecretary of Medical Assistance Services
General Directorate of Nutrition. Phone: 4640811 PO.B 5253 Riyadh 11422
Email: [email protected]
Figure 1 The Healthy Food Palm, Saudi Ministry of Health, 2012.
Note: Copyright © 2012. Figure reproduced courtesy of the Ministry of Health, Kingdom of Saudi Arabia; from Dietary Guidelines for Saudis. Riyadh: The Healthy Food Palm; 2012.32
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El Bcheraoui et al
KSA is a country deep in roots and culture, and solutions have to come from Saudis themselves. KSA is in need
of a group or a person to champion the healthy lifestyle
and promote healthy behaviors such as increase in fruit and
vegetable consumption and physical activity. We analyzed
our data according to two guidelines for fruit and vegetable
consumption: CDC and the Saudi MOH guidelines. We
wanted to show that the consumption is very low regardless
of what guidelines are used. We strongly believe that the
guidelines in KSA should be revised to include the local
diet and improve it. KSA has a food pyramid called Healthy
Food Palm (Figure 1) that is based on the US Food and Drug
Administration dietary guidelines for Americans.16 This food
pyramid should be reviewed and changed to put greater
emphasis on fruits and vegetables as opposed to consumption
of grains, which is not an issue in KSA.
Moreover, we feel that educating women on the benefits
of a healthy diet may lead to better uptake of fruits and vegetables at home and perhaps outside. The KSA MOH has done
a remarkable job in decreasing infectious diseases, especially
maternal and child health.29,30 The country employed a system
to educate and inform women about healthier behaviors and
disease prevention tools.31 Such a model would be very helpful to reach out to women and inform them of the benefits of
fruits and vegetables and ways to prepare them to the taste
of the community.
Our study provides important and timely findings.
We have showed that KSA is in dire need of improving
the diet of its population. Our findings call for urgent
research to understand the reasons for low consumption
of fruits and vegetables, focusing on price or preference
in order to develop and implement culturally and countryrelevant solutions to increase the consumption of fruits
and vegetables.
Acknowledgments
This study was financially supported by a grant from the
MOH of the KSA. We would like to thank Kate Muller at
the Institute for Health Metrics and Evaluation for editing
the manuscript.
Author contributions
All authors have contributed to the conception and design,
acquisition of data, and analysis and interpretation of data
of this manuscript. All authors have drafted or revised the
manuscript critically for important intellectual content. The
final version of the manuscript that is to be published has
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been approved by all the authors where they agree to be
accountable for all aspects of the work ensuring that questions
related to the accuracy or integrity of any part of the work
are appropriately investigated and resolved.
Disclosure
The authors would like to declare no conflict of interest.
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