Risk Perception of Cardiovascular Diseases Among Saudi Women

Introduction

Across the globe, cardiovascular diseases remain to be the leading cause of death among women. According to World Health Organization (2010), CVD accounts for one-third of deaths among women in the world. In developed countries such as the US, more women than men succumb to CVD every year (WHO, 2004). The trend of high death is also experienced in the emerging economies and the developing world. Saudi Arabia is one of the countries that have experienced an unprecedented increase in CVD among women (Al-Hazzaa, 2004). The economic impact and the toll of CVD among women in Saudi Arabia are very high. Culturally, women are mandated with food preparation for the family. Furthermore, many Saudi women are currently engaged in active employment; hence, morbidity and mortality among the women have negative implications for the social and economic sectors (Mobaraki & Soderfeldt, 2007). Changes in dietary patterns, cooking styles, and reduced physical exercise are the main risk factors for CVD among Saudi women (Al-Hazzaa, Musaiger, Abahussain, 2010). The following literature review provides an overview of CVD and its implication and provides recommendations that relate to risk perception of cardiovascular disease among Saudi women in relation to home cooking and intentions to low-fat cooking.

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Overview of Cardiovascular Diseases and the Implications for Saudi Women

Cardiovascular diseases present a significant health challenge in the Kingdom of Saudi Arabia. According to WHO (2004), the risk factors for cardiovascular diseases in Saudi are similar to those in developed countries. Hypertension, atherosclerosis, diabetes and ischemic heart diseases are common in Saudi (Khan, 1997). Unfortunately, the etiology presents a trend in which women show high prevalence compared to their male counterparts. Extensive studies conducted by Yahya, Muhammad and Yussof (2014), identified the risk factors and pointed to possible primary prevention care programs based on the peoples’ attitudes and perceptions. Even though CVD among Saudi women are preventable, the changing lifestyle and dietary patterns have been a significant impediment and hence high morbidity and mortality.

A study conducted by Kumosani, Alama & Iyer (2011) categorized cardiovascular risk factors into modifiable and non-modifiable risk factors. According to Kumosani, Alama & Iyer (2011), the modifiable risk factors comprise of the changeable risk factors. Examples of modifiable risk factors include unhealthy diet, use of tobacco, inadequate physical exercise, overweight and hypercholesterolemia (Khatib, 2004). The non-modifiable risk factors include sex, the history of the family, socio-economic status and the social history. The non-modifiable and modifiable factors in Saudi Arabia have been a leading cause of CVD among women. However, Kumosani, Alama and Iyer pointed that the modifiable factors are the major risk factors accounting for over 80% of CVD among women. Khatib (2004), indicated that lifestyle education, change in perception, and monitoring the risk factors contribute significantly to prevention of the CVDs.

The changes in lifestyle have significantly influenced females than the males. Akram, Yacoub, Saedi and Raheem (2011) noted that many women find it more fashionable to engage in sedentary lifestyles. For instance, teenage females find junk foods, smoking shisha as more prestigious than adapting to a healthy diet and avoiding shisha smoking. In a study conducted by Al Qauhiz (2010) to determine the college female lifestyle, it was found that the lifestyle adopted by the teenage females early in life normally translate to the dietary practices they adopt in their early adulthood. In relation to the lifestyle, women in Saudi Arabia have the mandate to prepare foods for the family. Thus, they will adopt cooking styles and foods that relate to what they perceive to be fashionable in cooking for their families and hence transferring the risk factors to the whole family. The practices coupled with the sex predisposing factors such as reduced exercise during pregnancy and subsequent weight gain contributes to the increased prevalence of CVD among the Saudi women (Rasheed, 1998).

A cross-sectional study carried out by Mahmood, Jahan, Habibullar (2004), in Saudi Arabian city of Jeddah to examine the prevalence of smoking among the females established that the students were aware of the dangers of smoking and its connection to CVD. Despite the findings, the smoking prevalence was 11%. A similar study conducted by Osman and Al-Nozha (2000) in Eastern Saudi Arabia to determine the dietary practices and cooking choices among women reported similar trend. The women were aware of the risk factors of high-fat diets. However, majority of the women still prepared foods that were energy dense, low fiber and high fat content. Benner et al. (2004) attributed the findings to lifestyle changes. Pharaon (2004) noted that despite the Islamic teaching of a healthy diet and advocacy of physical exercise, the socio-economic changes and the food influences from outside cultures were responsible for adoption of the high fat foods presumed to be healthy. A study conducted by Pharaon (2004) pointed that there was significant changes in eating behaviors of people in Saudi Arabia. The study indicated that many people engage in consumption of foods that have high sugar and fats. In addition, a case study to examine the perception of body weight and eating behaviors among Saudi women, found that there was misconception about eating habits, cooking methods that led to major effects on the weight status of women (Yahya, Muhammad and Yossof, 2002).

Al-Alwan et al. (2013) examined the predisposing factors to CVD among Saudi women. The study established that Saudi women were more obese compared to average European women. The increased obesity was due adoption of new eating habits and the changes in socio-economic status, changes in traditional food styles and the sedentary lifestyle. The study established that Saudi women have the responsibility to prepare food for their family. The preparation includes different types of food that are rich in fat, meat, sugar, and spices. The food preparation practices were found to be influenced by Western food culture that eroded the healthy cooking practiced in traditional Arabian cuisine. Vanhecke, Miller, Franklin, Weber and McCullough (2006) noted that such practices that have been regarded as the right way bar Saudi Arabian women from the intentions to cook healthy foods because they have to ensure food is agreeable to the whole family.

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Obesity is one of the risk factors for CVD; in Saudi Arabia, the prevalence of obesity has significantly increased (Alhyas, McKay, Balasanthiran & Majeed, 2011). Alhyas, McKay, Balasanthiran & Majeed (2011) attributed the increased prevalence to the socio-economic and lifestyle changes. For instance, there are significant changes in dietary practices in Gulf countries signified by shift from the consumption of traditional foods rich in fiber to consumption of foods rich in sugar, western fast foods and foods with high fat (Musaiger, Takruri, Hassan & Tarboush, 2010). In a study to determine a typical diet for Saudi Arabians, Hawazen, Patsy and Robyn (2012) noted that the modern Saudi diet is characterized by high intake of red meat, high intake of carbohydrates, sugar and fat. According to Shara (2010), the average daily intake of fat in Saudi was 143.3%. In an earlier study conducted by WHO (2010), the prevalence of obesity among Saudi women was 43.8%. The study established that 7.6% were severely obese. The high levels of obesity implied the risk of cardiovascular diseases that have been on upward surge.

The adoption of the lifestyle that is characterized by high intake of calories, decreased physical activity contribute to the high incidence and prevalence rate of CVD marked by transition from communicable diseases to non-communicable diseases in Saudi Arabia (Mosca et al., 2007). Sadly, women have been worse hit by the transition. Evidently, the literature review pointed to lifestyle changes and unhealthy diets as having had great implication on the CVD status of the Saudi women. The different studies carried in Saudi Arabia established that women are more exposed to CVD due to the sedentary lifestyle they have adopted and the cooking habits such as high sugar, high fat, intake of a lot of carbohydrate diet, and western fast foods.

Nutrition Recommendations for Saudi Women and Fat Diet in Relation to CVD

Fats form an essential component of a healthy diet because they are major energy sources in a diet after the carbohydrates (El-Sayed, Elsanhoty, & Ramadan, 2014). Despite their essentiality, the excessive intake of fats and sugar among the Saudi women coupled with the sedentary lifestyle has remained to be key risk factor for CVD (Al-Nuaim, 2012). The acquired dietary habits characterized by excessive intake of animal proteins, sugar, saturated fat have led to nutrition imbalances leading to CVD in Saudi Arabia (Lappalainen et al., 1997). According to Memish, El-Bscheraoui, Tuffaha, Robinson, Dauod and Jabber (2014), maintaining a diet that has low fat and ensuring good patterns of nutrient intake play a significant role in the prevention of CVD. Bearing in mind that Saudi women are tasked with food preparation, they should be at the forefront in ensuring a low-fat diet and healthy family eating habits.

The traditional dietary patterns of Saudi women and Saudi Arabians in general presented a situation of balanced nutrition intake (Littlewoods &Yousuf, 2000). The dietary patterns were substantially related to agricultural practices (Musaiger, 2002). However, over the past decades, Saudi Arabia experienced industrial revolution and developments in the socio-economic sectors that consequently changed the composition of the typical diet in Saudi Arabia. The implications of the changes have been the increased incidence and prevalence of CVD. The changes are not unique to Saudi Arabia; such transitions continue to be experienced in the developing economies (Al-Baghili, Al-Ghamdi, Khalid, Ahmad & Mahmood, 2010). The unbalanced diet of Saudi women is directly associated with the high the increase in degenerative diseases such as obesity, diabetes and hypertension (Crocco, Pervez, & Katz, 2009). Schimiduber and Shetty (2005) noted that promotion of appropriate diet and adoption of lifestyle that are healthy resembling the traditional lifestyle will significantly contribute to reduced morbidity and mortality of CVD.

In many developed countries, dietary guidelines and goals are set to improve the food consumption patterns and the individual wellbeing (Aljohara, Al-Quaiz, Salwa & Tayel, 2009).

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According to Al-Dkheel (2012), the Arab Gulf countries have experienced drastic changes in patterns of food consumptions both qualitatively and quantitatively. The shift has led to consumption of high energy density diet in which sugars and fats are added to the daily foods (Brunner, Rees, ward, Burke & Thorogood, 2007). As a result, Saudi Arabia has undertaken extensive comparison of internal visual graphics from USA, United Kingdom and Canada, Japan and India and developed dietary guidelines for Saudi Arabia. The dietary guidelines are based on nutrition message that a healthy diet is composed of balance, variety and moderation foods (Al-Dkheel, 2012). The guidelines include the Healthy Food Palm that includes the food groups as illustrated in table 1 and 2 below. Despite the provisions for fat intake as provided in the Saudi diet guidelines, Shara (2010) noted that the average daily intake of fat in Saudi was 143.3%, which is contrary to the guidelines provision of limiting fat and sugar intake as much as possible. The Healthy Food Palm should be supplemented by physical activity of 30-60 minutes every day depending on the individual health status (Al-Dkheel, 2012).

Table 1: Daily recommended food servings according to age groups

Food group
Age group
Cereals and Bread Vegetables and Fruits Milk and Products Meat and Substitutes Sugar and fat
Minimal amount
Children 2-3 years 3 4 3 1
Children 4-8 years 4 5 2 1
Children 9-13 years 6 6 3-4 1-2
Adolescents 14-18 years, Females 6 7 3-4 2
Adolescents 14-18 years, Males 7 8 3-4 3
Adults 19-50 years
females
6 7-8 2 2
Adults 19-50 years
Males
8 8-10 2 3
Adults >50 years
Females
6 7 3 2
Adults>50 years
Males
7 7 7 7
Pregnant women 8 8-10 4 3
Lactating mothers 8 8-10 4 3

Table 2: Rations allowable daily food groups in The Healthy Food Palm

No. Food groups Serving numbers The amount of serving size
1 Cereals & Bread 6-11 =25 grams of bread
=1/4 Arabic bread medium size
=one slice of toast
=½ cup of cereals such as rice
2 Vegetables 3-5 1 cup of raw leafy vegetables
=1/2 cup of other vegetables, cooked or chopped raw
¾ cup of vegetables juice
3 Fruits 2-4 = 1 medium apple, banana, orange.
=1/2 cup of chopped or canned fruits.
=medium dates
¾ cup of vegetable juice
4 Milk and products 2-4 = 1 cup of milk or laban or yogurt
= spoons of milk powder
=60 gram of processes cheese
5 Meat & substitutes 2-3 =60=90 grams of cooked lean meat, poultry or fish.
= 1 egg
=1/2 of cooked dry beans
=4-6 tablespoon of peanut butter
6 Fat & sugar Lower amount possible
7 Water 6 At least 6 cups daily.

According to Khanan & Costarelli (2008), many Saudi women have adopted diets with saturated fats, high sugar and red meat. Despite the awareness of the implication of the unhealthy diets, Al Dhereri, Al-Mawalil, Laleye and Washi (2014) pointed that the adopted diets are presumed as the best lifestyle that matches the current socio-economic status of Saudi women. Notably, CVD in Saudi Arabia are etiologically linked with the practices of cooking food and dietary patterns that that affect women (Mahmood, Johan & Habibullar, 2014). Sibai et al. (2010) noted that public health interventions should leverage on perception and intentions of the Saudi women to adopt low fat diets. The unhealthy diets combined with physical inactivity among Saudi women contribute to the increasing CVD. Al-Hazzaa (2004) found that 53.4% of adults in Saudi Arabia are exposed to chronic heart diseases due to unhealthy diet and reduced physical exercise. In a follow-up study by Shara (2010), Saudi women were found to have lower physical activity compared to women from other countries. Shara (2010) noted that the reason behind the lower activity is attributable to the social roles that further predispose them to CVD. Similarly, studies conducted in Saudi Arabia by Al Nozha, Al-Mazrou, Al-Maatauq, Arafah and Khalil (2005) pointed to a high prevalence of cardiovascular diseases among women. The findings were attributed to transition in nutrition marked by abandonment of traditional diets that were high in fiber and the modern adoption of diets high in sugar, salt and fat (Al Nozha et al., 2005).

The increased obesity among Saudi women is due to adoption of new eating habits and the changes in socio-economic status, changes in traditional food styles and the sedentary lifestyle (Al-Alwan et al., 2013). A cross-sectional study carried out in European Union (EU) established that information on the difficulties that relate to eating healthier diets is imperative in helping the public health people designing nutrition interventions device programs that are effective (Kearney & McElhone, 1999). The study participants were interviewed in the study cited common barrier for healthy eating was time, taste and the socio-economic changes. Lack of knowledge was not mentioned during the study. Such a study though not carried in Saudi Arabia points to a common trend in the developed world. The same finding could be generalized to the Saudi women who have the intention to low fat diets but the socio-economic factors, taste and time factors may be the main barrier to healthy eating as pointed out in the teenage female study (Brug, Assema, Kok, 1994). Therefore, a comprehensive study on the risk perception of cardiovascular diseases and intentions to low diet could provide real data on the actual barriers to a healthy diet and subsequently help in drawing informed recommendations for Saudi Arabian diets.

Conclusion

Studies on CVD carried in Saudi indicate that lifestyle changes are the leading causes of cardiovascular diseases among the women population. The studies point to a significant level of awareness of unhealthy diets. The awareness stems from the religious teaching that may inform the intention to low fat diets and regularly exercising. However, diets high in fats, sugar, and excessive consumption of red meat and adoption of fast foods remain to be prevalent. Thus, there is need for nutrition education that touches on attitude and lifestyle change in relation to eating. The change in attitude and perception to achieve the ultimate goal of healthy diet and cooking practices should be guided by informed campaigns that target women. The studies should be evidence backed and hence the necessity for the research on risk perception of cardiovascular disease among Saudi women in relation to home cooking and intentions to low fat cooking.

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