Association of two types of dietary pattern scores with cardiovascular disease risk factors and serum 25 hydroxy vitamin D levels in Saudi Arabia

  • Najlaa Aljefree Food and Nutrition Department, Faculty of Human Sciences and Design, King Abdulaziz University, Jeddah, Saudi Arabia
  • Noha M. Almoraie Food and Nutrition Department, Faculty of Human Sciences and Design, King Abdulaziz University, Jeddah, Saudi Arabia
  • Israa M. Shatwan Food and Nutrition Department, Faculty of Human Sciences and Design, King Abdulaziz University, Jeddah, Saudi Arabia
Keywords: vitamin D deficiency, diet score, high-fat dietary pattern, Mediterranean diet, cardiovascular disease, obesity, low-density lipoprotein


Background: Cardiovascular disease (CVD) is a main cause of mortality and disability worldwide. One of the key factors in the soaring prevalence of CVD globally has been nutrition transitions and changes in dietary patterns.

Objective: This study investigated the association between two diet scores, namely, a high-fat dietary (HFD) pattern score and a Mediterranean diet (MedDiet) score, and CVD risk factors (obesity, hypertension, total cholesterol, and blood glucose) and serum 25 hydroxy vitamin D (25[OH]D) levels.

Methods: Three hundred twenty-one participants were included in this study. Fasting blood tests were collected from all participants for biochemical measurements. Blood pressure and anthropometric measurements were also taken. A validated, semi-quantitative food frequency questionnaire was used to collect data on participants’ dietary intake. Dietary scores for the HFD pattern were calculated based on recommended food groups. MedDiet scores were calculated based on a previously validated method that contains 14 questions related to MedDiet. Both diet scores were classified into tertiles. Linear regression analyses were performed to assess the statistical significance of the tertile groups.

Result: A significant association was found between HFD score and obesity when comparing the lowest tertile (27.3±4.6 kg/m2) of HFD scores with the medium tertile (29.2±5.7 kg/m2; P = 0.02). A higher HFD score was significantly associated with lower 25(OH)D levels (P = 0.02). In addition, a significant association was observed between MedDiet scores and 25(OH)D levels, with an increase in MedDiet score resulting in an increase in 25(OH)D levels (P = 0.01). Furthermore, a significant negative association between MedDiet scores and low-density lipoprotein levels was reported only in participants with CVD (P = 0.03).

Conclusion: The results of this study revealed that HFD and MedDiet scores might have a role in the development of CVD and vitamin D deficiency among the Saudi Arabian population. Further studies are required using diet scores to assess the quality of dietary patterns and their association with an increased risk of diseases in Saudi Arabians.


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  1. World Health Organization. World health statistics 2017: monitoring health for the SDGs, sustainable development goals. Geneva: World Health Organization. 2017. Available from:

  2. Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, Al-Harthi SS, Arafah MR, Khalil MZ, et al. Diabetes mellitus in Saudi Arabia. Saudi Med J 2004; 25(11): 1603–10.

  3. Al-Nozha MM, Al-Mazrou YY, Al-Maatouq MA, Arafah MR, Khalil MZ, Khan NB, et al. Obesity in Saudi Arabia. Saudi Med J 2005; 26(5): 824–9.

  4. Aljefree N, Ahmed F. Prevalence of cardiovascular disease and associated risk factors among adult population in the Gulf region: a systematic review. Adv Public Health 2015; 2015: 235101. doi: 10.1155/2015/235101

  5. Afshin A, Forouzanfar MH, Reitsma MB, Sur P, Estep K, Lee A, et al. Health effects of overweight and obesity in 195 countries over 25 years. New Engl J Med 2017; 377(1): 13–27. doi: 10.1056/NEJMoa1614362

  6. Hamley S. The effect of replacing saturated fat with mostly n-6 polyunsaturated fat on coronary heart disease: a meta-analysis of randomised controlled trials. Nutrition J 2017; 16(1): 30. doi: 10.1186/s12937-017-0254-5

  7. Tindall AM, Kris-Etherton PM, Petersen KS. Replacing saturated fats with unsaturated fats from walnuts or vegetable oils lowers atherogenic lipoprotein classes without increasing lipoprotein(a). J Nutr 2020; 150(4): 818–25. doi: 10.1093/jn/nxz313

  8. Qian F, Korat AA, Malik V, Hu FB. Metabolic effects of monounsaturated fatty acid-enriched diets compared with carbohydrate or polyunsaturated fatty acid-enriched diets in patients with type 2 diabetes: a systematic review and meta-analysis of randomized controlled trials. Diabetes Care 2016; 39(8): 1448–57. doi: 10.2337/dc16-0513

  9. Schwingshackl L, Hoffmann G. Diet quality as assessed by the healthy eating index, the alternate healthy eating index, the dietary approaches to stop hypertension score, and health outcomes: a systematic review and meta-analysis of cohort studies. J Acad Nutr Diet 2015; 115(5): 780–800.e5. doi: 10.1016/j.jand.2014.12.009

  10. Kris-Etherton PM, Etherton TD, Carlson J, Gardner C. Recent discoveries in inclusive food-based approaches and dietary patterns for reduction in risk for cardiovascular disease. Curr Opin Lipidol 2002; 13(4): 397–407. doi: 10.1097/00041433-200208000-00007

  11. Iqbal R, Anand S, Ounpuu S, Islam S, Zhang X, Rangarajan S, et al. Dietary patterns and the risk of acute myocardial infarction in 52 countries: results of the INTERHEART study. Circulation 2008; 118(19): 1929–37. doi: 10.1161/circulationaha.107.738716

  12. Hu FB. Dietary pattern analysis: a new direction in nutritional epidemiology. Curr Opin Lipidol 2002; 13(1): 3–9. doi: 10.1097/00041433-200202000-00002

  13. Sofi F, Macchi C, Abbate R, Gensini G, Casini A. Mediterranean diet and health. BioFactors (Oxford, England) 2013; 39(4): 335–42. doi: 10.1002/biof.1096

  14. Bach-Faig A, Berry EM, Lairon D, Reguant J, Trichopoulou A, Dernini S, et al. Mediterranean diet pyramid today. Science and cultural updates. Publ Health Nutr 2011; 14(12a): 2274–84. doi: 10.1017/s1368980011002515

  15. Misirli G, Benetou V, Lagiou P, Bamia C, Trichopoulos D, Trichopoulou A. Relation of the traditional Mediterranean diet to cerebrovascular disease in a Mediterranean population. Am J Epidemiol 2012; 176(12): 1185–92. doi: 10.1093/aje/kws205

  16. Ruiz-Canela M, Estruch R, Corella D, Salas-Salvadó J, Martínez-González MA. Association of Mediterranean diet with peripheral artery disease: the PREDIMED randomized trial. JAMA 2014; 311(4): 415–17. doi: 10.1001/jama.2013.280618

  17. Arvaniti F, Panagiotakos DB. Healthy indexes in public health practice and research: a review. Crit Rev Food Sci Nutr 2008; 48(4): 317–27. doi: 10.1080/10408390701326268

  18. Martinez-Gonzalez MA, Garcia-Arellano A, Toledo E, Salas-Salvado J, Buil-Cosiales P, Corella D, et al. A 14-item Mediterranean diet assessment tool and obesity indexes among high-risk subjects: the PREDIMED trial. PLoS One 2012; 7(8): e43134. doi: 10.1371/journal.pone.0043134

  19. Mertens E, Markey O, Geleijnse JM, Lovegrove JA, Givens DI. Adherence to a healthy diet in relation to cardiovascular incidence and risk markers: evidence from the Caerphilly Prospective Study. Eur J Nutr 2018; 57(3): 1245–58. doi: 10.1007/s00394-017-1408-0

  20. Roy R, Hebden L, Rangan A, Allman-Farinelli M. The development, application, and validation of a Healthy eating index for Australian Adults (HEIFA-2013). Nutrition 2016; 32(4): 432–40. doi: 10.1016/j.nut.2015.10.006

  21. Ardawi MS, Qari MH, Rouzi AA, Maimani AA, Raddadi RM. Vitamin D status in relation to obesity, bone mineral density, bone turnover markers and vitamin D receptor genotypes in healthy Saudi pre- and postmenopausal women. Osteoporos Int 2011; 22(2): 463–75. doi: 10.1007/s00198-010-1249-7

  22. Sadat-Ali M, AlElq A, Al-Turki H, Al-Mulhim F, Al-Ali A. Vitamin D levels in healthy men in eastern Saudi Arabia. Annals of Saudi Medicine 2009; 29(5): 378–82. doi: 10.4103/0256-4947.55168

  23. Elsammak MY, Al-Wossaibi AA, Al-Howeish A, Alsaeed J. High prevalence of vitamin D deficiency in the sunny Eastern region of Saudi Arabia: a hospital-based study. East Mediterr Health J 2011; 17(4): 317–22. doi: 10.26719/2011.17.4.317

  24. Tuffaha M, El Bcheraoui C, Daoud F, Al Hussaini HA, Alamri F, Al Saeedi M, et al. Deficiencies under plenty of sun: vitamin D status among adults in the Kingdom of Saudi Arabia, 2013. N Am J Med Sci 2015; 7(10): 467–75. doi: 10.4103/1947-2714.168675

  25. Martins D, Wolf M, Pan D, Zadshir A, Tareen N, Thadhani R, et al. Prevalence of cardiovascular risk factors and the serum levels of 25-hydroxyvitamin D in the United States: data from the Third National Health and Nutrition Examination Survey. Arch Intern Med 2007; 167(11): 1159–65. doi: 10.1001/archinte.167.11.1159

  26. Lee JH, Gadi R, Spertus JA, Tang F, O’Keefe JH. Prevalence of vitamin D deficiency in patients with acute myocardial infarction. Am J Cardiol 2011; 107(11): 1636–8. doi: 10.1016/j.amjcard.2011.01.048

  27. Aljefree NM, Lee P, Alsaqqaf JM, Ahmed F. Association between Vitamin D status and coronary heart disease among adults in Saudi Arabia: a case-control study. Healthcare 2016; 4(4): 77. doi: 10.3390/healthcare4040077

  28. Shils ME, Shike M. Modern nutrition in health and disease. Philadelphia: Lip-pincott Williams & Wilkins; 2006.

  29. Laviolle B, Froger-Bompas C, Guillo P, Sevestre A, Letellier C, Pouchard M, et al. Relative validity and reproducibility of a 14-item semi-quantitative food frequency questionnaire for cardiovascular prevention. Eur J Cardiovasc Prev Rehabil 2005; 12(6): 587–95. doi: 10.1097/01.hjr.0000186625.98604.5d

  30. Mertens E, Mullie P, Deforche B, Lefevre J, Charlier R, Huybrechts I, et al. Cross-sectional study on the relationship between the Mediterranean diet score and blood lipids. Nutr J 2014; 13: 88. doi: 10.1186/1475-2891-13-88

  31. Ganji V, Martineau B, Van Fleit WE. Association of serum vitamin D concentrations with dietary patterns in children and adolescents. Nutr J 2018; 17(1): 58. doi: 10.1186/s12937-018-0365-7

  32. Mithal A, Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes B, Eisman JA, et al. Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int 2009; 20(11): 1807–20. doi: 10.1007/s00198-009-0954-6

  33. Geleijnse JM. Vitamin D and the prevention of hypertension and cardiovascular diseases: a review of the current evidence. Am J Hypertens 2011; 24(3): 253–62. doi: 10.1038/ajh.2010.199

  34. Aljefree NM, Lee P, Ahmed F. Knowledge and attitudes about vitamin D, and behaviors related to vitamin D in adults with and without coronary heart disease in Saudi Arabia. BMC Public Health 2017; 17(1): 266. doi: 10.1186/s12889-017-4183-1

  35. Gutiérrez-Pliego LE, Camarillo-Romero Edel S, Montenegro-Morales LP, De Garduño-García J. Dietary patterns associated with body mass index (BMI) and lifestyle in Mexican adolescents. BMC Public Health 2016; 16(1): 850. doi: 10.1186/s12889-016-3527-6

  36. Paradis AM, Godin G, Pérusse L, Vohl MC. Associations between dietary patterns and obesity phenotypes. Int J Obes 2009; 33(12): 1419–26. doi: 10.1038/ijo.2009.179

  37. Simunovic M, Supe-Domic D, Karin Z, Degoricija M, Paradzik M, Bozic J, et al. The Relationship of Vitamin D Status, Adherence to the Mediterranean Diet, and Physical Activity in Obese Children and Adolescents. Journal of Medicinal Food 2021; 24(4): 385–93. doi: 10.1089/jmf.2020.0032

  38. Grant W. Vitamin D and health in the Mediterranean countries. Hormones 2018; 18: 23–35. doi: 10.1007/s42000-018-0059-8

  39. Rees K, Hartley L, Clarke A, Thorogood M, Stranges S. ‘Mediterranean’ dietary pattern for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev 2012; (4): 1–44. doi: 10.1002/14651858.Cd009825

  40. Nordmann AJ, Suter-Zimmermann K, Bucher HC, Shai I, Tuttle KR, Estruch R, et al. Meta-analysis comparing Mediterranean to low-fat diets for modification of cardiovascular risk factors. Am J Med 2011; 124(9): 841–51.e2. doi: 10.1016/j.amjmed.2011.04.024

  41. Dai J, Jones DP, Goldberg J, Ziegler TR, Bostick RM, Wilson PW, et al. Association between adherence to the Mediterranean diet and oxidative stress. Am J Clin Nutr 2008; 88(5): 1364–70. doi: 10.3945/ajcn.2008.26528

  42. Schwingshackl L, Hoffmann G. Mediterranean dietary pattern, inflammation and endothelial function: a systematic review and meta-analysis of intervention trials. Nutr Metab Cardiovasc Dis 2014; 24(9): 929–39. doi: 10.1016/j.numecd.2014.03.003

  43. Nadtochiy SM, Redman EK. Mediterranean diet and cardioprotection: the role of nitrite, polyunsaturated fatty acids, and polyphenols. Nutrition 2011; 27(7–8): 733–44. doi: 10.1016/j.nut.2010.12.006

How to Cite
Aljefree, N., Almoraie, N. M., & Shatwan, I. M. (2021). Association of two types of dietary pattern scores with cardiovascular disease risk factors and serum 25 hydroxy vitamin D levels in Saudi Arabia. Food & Nutrition Research, 65.
Original Articles