Usage, knowledge and perception of the ketogenic diet and associated factors in Saudi adults: A cross-sectional study.

The ketogenic diet (KD) is a popular weight management method. However, knowledge, perceptions, and use of KD have not been studied in the Saudi population. This cross-sectional study aims to assess the knowledge, perceptions, and use of the KD in Saudi Arabia, to compare medical and nonmedical students in their awareness of KD, and to determine factors associated with knowledge and perception of KD. A total of 1071 Saudis aged ≥ 18 years old were included. Participants were excluded if they were younger than 18, non-Saudi, pregnant, breastfeeding, had chronic illnesses, were using any medication, or were diagnosed with psychiatric conditions. Knowledge, perception, and use of KD were collected between 2021 and 2022 in Saudi Arabia using a prevalidated tool and its scoring protocol; higher scores indicated higher level of knowledge or perception. Among Saudi adults, 24% (n = 253) and 55% of them (n = 138/253) followed the KD for 1 month or less, respectively. The KD knowledge score was mean ±â€…SD: 7.95 ±â€…3.97 and half of the participants (49.5%) had a low knowledge level. Students had a significantly lower knowledge score (mean ±â€…SD: 7.69 ±â€…3.85) compared to nonstudents (mean ±â€…SD: 8.68 ±â€…4.19). Students in medical majors had a higher knowledge score compared to nonmedical major students (P < .001). The KD perception score was mean ±â€…SD: 28.74 ±â€…4.83 and 76% of the participants had moderate perception level. Males had a significantly higher perception score compared to females (P < .001). Students in medical majors had a lower perception score compared to nonmedical major students. Age and body mass index had a significantly weak positive correlation with knowledge and perception scores. Half of the sample had low knowledge and moderate level of perception about KD. Students with medical majors had higher knowledge but lower perception scores compared to nonmedical majors. Dieticians may measure the knowledge and perception of the KD diet in outpatient clinics to lose weight. Educational institutions may increase students' knowledge and perception of the KD in all majors. Future experimental studies examining the efficacy of the KD are needed to provide recommendations of the KD as a strategy for weight loss.

Stress during Home Confinement Is Associated with Eating Misalignment among Adults during COVID-19 Lockdown.

BACKGROUND: The COVID-19 pandemic forced Saudi Arabia to implement several measures including mandatory home confinement, banning entry to many cities, and suspending religious activities. Studies have reported inconsistent findings of the effect of home confinement on lifestyle factors. This study aims to assess the psychological impact of COVID-19 during home confinement and explore its association with dietary habits and weight change. METHODS: A cross-sectional study was conducted among Saudi adults using an online survey between May and June 2020. Data on dietary habits, sleep quality, and stress were collected. RESULTS: A total of n = 503 participants responded. Of 254 analyzed, 87% were females, 49% were overweight/obese (body mass index (BMI) ≥ 25 kg/m2), and 79% were under lockdown for >40 days. In multiple linear regression, higher stress scores during confinement were associated with higher stress scores before confinement and poorer sleep quality. In multiple logistic regression, those who did not eat at the same time had higher stress scores compared to those who always ate at the same time, whereas consuming ≥three meals was associated with lower stress scores than consuming one-two meals. The odds of gaining weight during confinement were higher among married adults, those with lower sleep quality, and consuming ≥three meals. CONCLUSIONS: Stress during home confinement was associated with eating misalignment and the number of meals consumed. Although this study was limited by its cross-sectional design and reliance on self-reported data, it provides valuable insights into the dietary habits and weight-gain associated factors that need to be further explored and addressed in any future restrictions for improved well-being.

Identification of the Most Suitable Mobile Apps to Support Dietary Approaches to Stop Hypertension (DASH) Diet Self-Management: Systematic Search of App Stores and Content Analysis.

Smartphone apps might provide an opportunity to support the Dietary Approaches to Stop Hypertension (DASH) diet, a healthy diet designed to help lower blood pressure. This study evaluated DASH diet self-management apps based on their quality, likely effectiveness, and data privacy/security to identify the most suitable app(s). A systematic search and content analysis were conducted of all DASH diet apps available in Google Play and the Apple App Store in the UK in November 2022. Apps were included if they provided DASH diet tracking. A previous systematic literature review found some commercial apps not found in the app store search, and these were also included in this review. Three reviewers used the App Quality Evaluation Tool (AQEL) to assess each app's quality across seven domains: knowledge acquisition, skill development, behaviour change, purpose, functionality, and appropriateness for adults with hypertension. Domains with a score of 8 or higher were considered high-quality. Two reviewers assessed the apps' data privacy and security and then coded Behaviour change techniques (BCTs) linked to the Theoretical Domain Framework (TDF) underpinning the likely effectiveness of the apps. Seven DASH diet apps were assessed, showing the limited availability of apps supporting DASH diet self-management. The AQEL assessment showed that three apps scored higher than eight in most of the AQEL domains. Nineteen BCTs were used across the apps, linked to nine TDF action mechanisms that may support DASH diet self-management behaviours. Four apps met standards for privacy and security. All seven apps with self-monitoring functionality had sufficient theoretical basis to demonstrate likely effectiveness. However, most had significant quality and data security shortcomings. Only two apps, NOOM and DASH To TEN, were found to have both adequate quality and security and were thus deemed suitable to support DASH diet self-management.

A Review of Anthropometric Measurements for Saudi Adults and Elderly, Directions for Future Work and Recommendations to Establish Saudi Guidelines in Line with the Saudi 2030 Vision.

Body weight is a significant risk factor for the disease burden of noncommunicable diseases (NCDs). Anthropometric measurements are the first step in determining NCDs risk, and clinicians must have access to valid cutoffs. This study aims to review the literature of Saudi national guidelines and studies previously conducted in Saudi Arabia (SA) and to provide insights and recommendations to establish national guidelines in anthropometric measurements for Saudi adults/elderly in line with the Saudi 2030 Vision. In total, 163 studies were included, and 12 of them contributed to the development of specific anthropometric cutoffs. Cutoffs for metabolic syndrome, waist circumference, and body mass index were established in Saudi adults. However, limited studies were conducted in the elderly. This review warrants establishing standard cutoffs of Saudi adult anthropometrics to avoid over/underreporting of malnutrition and adiposity. This review will help policymakers and the Ministry of Health to establish national guidelines and standard cutoffs to be used in SA for anthropometric measurements that may assist in detecting malnutrition and NCDs.

Comparison of TCN-2 (776C>G) Gene Polymorphism and Vitamin B12 Status with Different Body Mass Index among Saudi Adults.

BACKGROUND: Overweight and obesity (OO) are significant public health issues, and many elements, including genetics, epigenetics, sedentary lifestyle, comorbid conditions, psychological and environmental pressures, have been linked to OO. More than 2 billion people are presently impacted by the global obesity epidemic, which is still advancing relentlessly. It is a significant public health concern and a major contributor to healthcare costs, because it increases the chance of developing conditions such as heart disease, stroke, type 2 diabetes, and chronic kidney disease (CKD). Using the ranges of 18.5-25 for normality, 25-30 for overweight, and 30 for obesity, BMI (in kg/m2) is used to identify obesity. Vitamin deficiency is one of the causative factors associated with the increasing trend of obesity. Altered vitamin B12 status is a multifactorial trait; changes in B12 status are produced by several single nucleotide polymorphisms (SNPs) in various genes that interact with the environment. They also support coordinated efforts to alter the built environment that is causing the obesity pandemic. Therefore, the present study aimed to evaluate the TCN-2 (776C>G) gene alteration and vitamin B12 levels with respect to different body mass index, as well as associating BMI with other biochemical parameters. METHODS: 250 individuals were involved in the study; among them, 100 were in the healthy weight range category (BMI: 18.5 to <25 kg/m2), 100 were overweight (BMI: 25.0 to <30 kg/m2), and 50 were obese (BMI: >30 kg/m2). Participants visited during the screening program were subjected to blood pressure measurement, and further peripheral blood samples were drawn from all the participants in plain as well as in EDTA vials for biochemical (lipid profile and vitamin B12 level) analysis and single nucleotide polymorphism studies. Extracted DNA from whole blood collected in EDTA vials using kit protocol was used for genotyping by PCR-RFLP. RESULTS: The levels of systolic (p < 0.0001) and diastolic blood pressures (p < 0.0001), HDL (p < 0.0001), LDL (p = 0.04), TG (p < 0.0001), cholesterol (p < 0.0001), and VLDL (p < 0.0001) showed significant differences between healthy controls, overweight, and obese groups. The healthy control TCN-2 (776C>G) genotypes were compared with those of overweight and obese participants, and compared to the healthy controls it was observed that overweight (p = 0.01) and obese (p = 0.002) subjects had significant differences in TCN-2 (776C>G) genotypes. For genotypes CG and GG, the odds ratio was 1.61 (0.87-2.95; p = 0.12), and 3.81 (1.47-9.88; p = 0.005) for overweight participants, respectively, and obese participants' calculated odds ratios were 2.49 (1.16-5.36; p = 0.01) and 5.79 (1.93-17.35; p = 0.001), respectively. The relative risk for genotypes CG and GG, was 1.25 (0.93-1.68; p = 0.12), 2.17 (1.12-4.17; p = 0.02) for overweight participants, while the obese participants' calculated relative risks were 1.31 (1.03-1.68; p = 0.01) and 2.02 (1.12-3.65; p = 0.001), respectively. Vitamin B12 levels were analyzed, and it was observed that a significant difference existed among overweight (305.5 pmol/L, p < 0.0001) and obese patients (229 pmol/L, p < 0.0001), respectively, as compared to healthy controls (385.5 pmol/L). Correlation analysis showed a significant association of vitamin B12 level with TG, cholesterol and VLDL; it showed a negative correlation, suggesting that decreases in B12 levels may impact the lipid profile. CONCLUSION: The study concluded that a predisposition to the GG genotype of TCN-2 gene polymorphism (776C>G) may increase susceptibility to obesity and the related complications, and higher odds and relative risk for the GG genotype may increase the risk of having obesity and further related complications. Lower vitamin B12 levels were linked with obesity and overweight, and impaired lipid parameters suggested that lower vitamin B12 may impact the altered lipid profile.

Change in Growth Status and Obesity Rates among Saudi Children and Adolescents Is Partially Attributed to Discrepancies in Definitions Used: A Review of Anthropometric Measurements.

Anthropometric measurements are the first step in determining the health status in children and adolescents. Clinicians require standardized protocols for proper assessment and interpretation. Therefore, this study aims to review the literature of international and Saudi national guidelines and studies previously conducted in Saudi children and adolescents to provide recommendations to establish Saudi guidelines in line with the Saudi 2030 Vision. Systematic search was conducted in several databases: Medline, PubMed, Saudi Digital Library and Google Scholar from January 1990 to January 2021. Further, 167 studies measured anthropometrics in Saudi children/adolescents; 33 of these studies contributed to the establishment/adjustment of Saudi growth charts or specific cutoffs or studied the trend of growth in representative samples or adjusted the international curves to be used in Saudis. This review warrants updating growth charts and establishing the standard cutoffs of Saudi adolescent anthropometrics to avoid over/underreporting. This review provides insights and recommendations regarding the resources that can be used to establish national guidelines in anthropometric measurements for Saudi children/adolescents. This review will help policymakers and the Ministry of Health to establish standardized protocols to be used in Saudi Arabia for anthropometric measurements that may assist in detecting malnutrition.

Effect of Intermittent Fasting on Body Image Satisfaction and Appreciation Among Saudi Adults.

BACKGROUND: Obesity remains a public health concern, and intermittent fasting (IF) is a popular strategy for weight loss that has gained considerable scientific and popular attention. However, weight control can affect body image. Poor body image and its impact on psychological well-being are linked to obesity in many individuals. Body appreciation is a crucial characteristic of positive body image. However, there is a lack of studies assessing these relationships in Saudi adults. AIM:  To evaluate the associations between IF diet, body image satisfaction, and body appreciation in Saudi adults. METHOD:  A web-based cross-sectional study was done with healthy Saudi adults aged 18 to 50 years old who followed the IF diet. The questionnaire had five sections: a brief study introduction, sociodemographic variables, adherence to the diet, modified body image scale, and body appreciation scale. Ethical approval was obtained. RESULTS: A total of 190 participants were included in this study, including 59 (31.1%) males and 131 (68.9%) females. Comparing before and after IF, the body mass index (BMI) significantly decreased after IF (p < 0.001). After IF, a significant decrease in the body image dissatisfaction score was observed (p < 0.001). A significant increase was noted in the body appreciation score (p < 0.001).  Conclusion: IF is significantly associated with better body image satisfaction and body appreciation. These results may help weight loss studies and may have public health implications.

Morning individuals in Saudi Arabia have higher self-regulation of eating behavior compared to evening types.

Chronotype is a manifestation of an individual's circadian system, which can be presented as a preference for morningness or eveningness. Evening chronotype has been linked to unhealthy dietary habits. These habits are partially from poor self-regulation of eating behavior (SREB). SREB is a goal-directed process that helps resist food temptation and achieve desired dietary outcomes. It is unclear whether chronotype is associated with SREB. This study aims to investigate the association between chronotypes and SREB. A total of 599 adults (18-50 years) enrolled in this cross-sectional study. Participants received an online questionnaire that collected sociodemographic, anthropometrics, chronotype through the validated reduced Morningness-Eveningness Questionnaire (rMEQ) and SREB using the SREB Questionnaire. ANOVA, Chi-square and multivariate logistic regression were used. In adjusted models, morning types had 85% higher SREB compared to evening types (p = 0.003, OR = 1.85). Evening types found fried foods (p = 0.003), chips (p = 0.005) and French fries (p = 0.018) more tempting than morning types. These findings show a link between chronotype and SREB. Strategies focusing on SREB may help evening types improve dietary habits. Further studies are required to clarify the underlying mechanisms for these associations. This may have important implications for lifestyle and behavioral change policy.

Bridging the Reciprocal Gap between Sleep and Fruit and Vegetable Consumption: A Review of the Evidence, Potential Mechanisms, Implications, and Directions for Future Work.

A substantial burden of disease and mortality globally is attributable to both sleep disruption and low intakes of fruit and vegetable (FV) and there is increasing mechanistic and epidemiological evidence to support a reciprocal relationship between the two. This review provides an overview of experimental and observational studies assessing the relations between sleep and FV consumption from 52 human adult studies. Experimental studies are currently limited and show inconsistent results. Observational studies support a non-linear association with adults sleeping the recommended 7-9 hours/day having the highest intakes of FV. The potential mechanisms linking sleep and FV consumption are highlighted. Disrupted sleep influences FV consumption through homeostatic and non-homeostatic mechanisms. Conversely, FV consumption may influence sleep through polyphenol content via several potential pathways. Few human experimental studies have examined the effects of FV items and their polyphenols on sleep and there is a need for more studies to address this. An appreciation of the relationship between sleep and FV consumption may help optimize sleep and FV consumption and may reduce the burden of chronic diseases. This review provides implications for public health and directions for future work.

Fruit and Vegetable Consumption and Their Polyphenol Content Are Inversely Associated with Sleep Duration: Prospective Associations from the UK Women's Cohort Study.

This study aims to investigate the prospective associations between fruit and vegetable (FV) intakes and their polyphenol content with subsequent sleep duration in UK women. In this study, 13,958 women with ~4 years of follow-up in the UK Women's Cohort Study were included in the analyses. FV intakes were assessed at baseline using a food frequency questionnaire (FFQ), and average hours of sleep per day were self-reported in follow-up. Polyphenol intake was calculated by matching FV items from the FFQ with the Phenol-Explorer database. Linear regression models, adjusting for confounders, were used for the analyses. Consuming an additional portion of apples, kiwi, oranges, pineapple, and 100% pure juice were associated with shorter sleep. Similarly, an additional portion of cabbage, celery, aubergine, olives, and peppers were inversely associated with sleep duration. An additional gram of total polyphenols was associated with shorter sleep by 18 min (99% CI -31 to -4, p < 0.001). FV consumption and total polyphenol content were inversely associated with sleep duration; however, effect sizes were small, and polyphenol classes from FV intakes were not associated with sleep duration. Future intervention studies considering the time of FV consumption in relation to sleep are needed to clarify the underlying mechanisms.

Validity of an online 24-h recall tool (myfood24) for dietary assessment in population studies: comparison with biomarkers and standard interviews.

BACKGROUND: Online dietary assessment tools can reduce administrative costs and facilitate repeated dietary assessment during follow-up in large-scale studies. However, information on bias due to measurement error of such tools is limited. We developed an online 24-h recall (myfood24) and compared its performance with a traditional interviewer-administered multiple-pass 24-h recall, assessing both against biomarkers. METHODS: Metabolically stable adults were recruited and completed the new online dietary recall, an interviewer-based multiple pass recall and a suite of reference measures. Longer-term dietary intake was estimated from up to 3 × 24-h recalls taken 2 weeks apart. Estimated intakes of protein, potassium and sodium were compared with urinary biomarker concentrations. Estimated total sugar intake was compared with a predictive biomarker and estimated energy intake compared with energy expenditure measured by accelerometry and calorimetry. Nutrient intakes were also compared to those derived from an interviewer-administered multiple-pass 24-h recall. RESULTS: Biomarker samples were received from 212 participants on at least one occasion. Both self-reported dietary assessment tools led to attenuation compared to biomarkers. The online tools resulted in attenuation factors of around 0.2-0.3 and partial correlation coefficients, reflecting ranking intakes, of approximately 0.3-0.4. This was broadly similar to the more administratively burdensome interviewer-based tool. Other nutrient estimates derived from myfood24 were around 10-20% lower than those from the interviewer-based tool, with wide limits of agreement. Intraclass correlation coefficients were approximately 0.4-0.5, indicating consistent moderate agreement. CONCLUSIONS: Our findings show that, whilst results from both measures of self-reported diet are attenuated compared to biomarker measures, the myfood24 online 24-h recall is comparable to the more time-consuming and costly interviewer-based 24-h recall across a range of measures.

The relationship between sleep duration and fruit/vegetable intakes in UK adults: a cross-sectional study from the National Diet and Nutrition Survey.

OBJECTIVES: There is increasing evidence to suggest an association between sleep and diet. The aim of the present study was to examine the association between sleep duration and fruit/vegetable (FV) intakes and their associated biomarkers in UK adults. DESIGN: Cross-sectional. SETTING: Data from The National Diet and Nutrition Survey. PARTICIPANTS: 1612 adults aged 19-65 years were included, pregnant/breastfeeding women were excluded from the analyses. OUTCOME MEASURES: Sleep duration was assessed by self-report, and diet was assessed by 4-day food diaries, disaggregation of foods containing FV into their components was conducted to determine total FV intakes. Sleep duration was divided into: short (<7 hours/day), reference (7-8 hours/day) and long (>8 hours/day) sleep periods. Multiple regression adjusting for confounders was used for analyses where sleep duration was the exposure and FV intakes and their associated biomarkers were the outcomes. Restricted cubic spline models were developed to explore potential non-linear associations. RESULTS: In adjusted models, long sleepers (LS) consumed on average 28 (95% CI -50 to -6, p=0.01) g/day less of total FV compared to reference sleepers (RS), whereas short sleepers (SS) consumed 24 g/day less (95% CI -42 to -6, p=0.006) and had lower levels of FV biomarkers (total carotenoids, ß-carotene and lycopene) compared to RS. Restricted cubic spline models showed that the association between sleep duration and FV intakes was non-linear (p<0.001) with RS having the highest intakes compared to SS and LS. The associations between sleep duration and plasma total carotenoids (p=0.0035), plasma vitamin C (p=0.009) and lycopene (p<0.001) were non-linear with RS having the highest levels. CONCLUSIONS: These findings show a link between sleep duration and FV consumption. This may have important implications for lifestyle and behavioural change policy.