**1. Introduction**

Cardiovascular disease (CVD) is considered a major public health problem in Saudi Arabia [1,2]. with an estimated 46% of all deaths attributed to CVD, and a 36% higher death rate in men compared to women [1]. The risk factors of CVD are characterized as modifiable factors such as diet, physical activity, obesity, and smoking, or non-modifiable factors such as aging, family history, and ethnicity [3–5]. The most important modifiable risk factor for CVD is diet [6–9]. Studies showed that a diet high in fruits, vegetables, whole grains as the major source of carbohydrates, and non-hydrogenated unsaturated fats as the main form of dietary fat, with adequate omega-3 fatty acids (monounsaturated fatty acid and polyunsaturated fatty acid), may reduce the risk of CVD [9–13]. Vitamins, minerals, fiber, and phenolic compounds are the main protective components found in fruit, vegetables, and whole grains with a functional role in reducing oxidative stress, inflammation, blood pressure, and improving insulin sensitivity and the lipoprotein profile [14–16]. In contrast, a diet containing a high intake of saturated

fats, and refined and processed carbohydrates is linked with an increased CVD risk as a result of raised levels of blood glucose, total cholesterol, and low-density lipoprotein (LDL) cholesterol [17–22].

However, it is important to note that most of these nutritional studies evaluated the intake of a single nutrient, or small number of nutrients or food items in relation to risk of CVD. As individuals do not eat a single food or isolated nutrient, many researchers argued the importance of considering a holistic approach, investigating dietary patterns (combination of nutrients) rather than nutrient-based studies, when assessing health consequences [23–25]. Moreover, diet has a synergistic effect as it is a complex mixture of nutrients (within-food or across-food combinations), which could induce antagonistic effects on optimal health [23–25].

Dietary guidelines are a useful tool in public health policy, which can help reduce risk and prevent non-communicable diseases. Studies on dietary guideline adherence demonstrated their effectiveness in reducing the risk of disease, including CVD in multiple countries [24,26,27].

Current CVD research is dominated by studies that were conducted on Western populations with a paucity of research investigating the link between CVD and diet in Saudi Arabia [28,29]. Furthermore, to our knowledge no study used a holistic approach to consider the association of adherence to Saudi dietary guidelines with risk of CVD. We hypothesized that the non-adherence to the Saudi dietary guidelines could increase the risk of CVD in Saudi males.

#### **2. Material and Methods**

#### *2.1. Study Design and Participants*

A cross-sectional design study was performed at King Abdulaziz University Hospital (KAUH) in Jeddah, Saudi Arabia. Patients were recruited from the medical ward, surgical ward, and coronary care unit at KAUH. The inclusion criteria for CVD patients consisted of male cardiac patients, aged between 30–80 years old, as the prevalence of CVD among Saudi population increases after 30 years old [30]. The inclusion criteria for the non-CVD patients included male patients, in the same age range, who were free of CVD and had been admitted to the hospital for minor clinical conditions, including abdominal pain, eye surgery, and fever. Patients with liver, kidney, or respiratory disease, or any type of cancer diagnosis were excluded from recruitment to either group. Ethical approvals were obtained from the Faculty of Medicine Research Committee at King Abdulaziz University (Reference no. 307-14). All patients gave informed written consent.

#### *2.2. The Saudi Dietary Guidelines*

The message of the Saudi dietary guidelines is to follow a healthy diet including variety, balance, and moderation [31]. The main goals of these guidelines are (1) to improve health by promoting healthy eating options and encouraging physical activities; (2) to promote valuable food that high in nutrients such as foods rich in protein, fiber, vitamins, and minerals, and reduce foods of poor nutritional value such as foods high in salt, sugars, saturated fats, and hydrogenated fat; (3) to support the normal growth and development of infants, children, and adolescents; (4) to decrease the diseases related to diet in the Saudi community; and (5) to support physical activity.

To communicate the recommended food groups and serving sizes, the Saudi dietary guidelines are graphically represented in the form of a palm tree with the food groups distributed in the trunk and leaves of the palm in proportion to their recommended level of intake. The largest food group of bread and cereals was placed in the bottom big leaf of the palm and represents the most important source of carbohydrates (6–11 servings/day). Vegetables (3–5 servings/day) and fruits (2–4 servings/day) come next as they are high in vitamins and minerals. Milk and its products (2–4 servings/day) are the third largest group, which are essential sources of protein and calcium. The smallest group constitutes meat and beans (2–4 servings/day), and they are considered as sources of protein. Fat and sugar were in the smallest upper leaves of the palm (representing lower quantities); this shows the need to minimize their intake. Water was also added to the healthy food palm, due to the hot weather of Saudi Arabia. As regular physical activity is essential, together with a balanced diet, the healthy food palm also recommends individuals to exercise for 30–60 min daily according to the individual's health status [31].

#### *2.3. The Saudi Dietary Guideline Score*

The score of adherence was given according to the Saudi dietary guidelines [31]. The ratings of the consumption of each food group (from 0 to 5 or the reverse) was adapted from Panagiotakos et al. (2006) [24]. The dietary adherence score included non-refined cereals and bread (whole bread, rice, pasta, and other grains), fruit, vegetables, legumes, fish, olive oil, non-alcoholic beer, meat and meat products, poultry, full-fat dairy products, sweets, and oils.

For the intake of food items assumed to be close to the Saudi dietary guidelines or higher (non-refined cereals, fruits, vegetables), we allocated a score of 0 when the individual stated no consumption, a score of 1 when they stated consumption of 1–4 servings/month, a score of 2 for 5–8 servings/month, a score of 3 for 9–12 servings/month, a score of 4 for 13–18 servings/month, and a score of 5 for more than 18 servings/month. Moreover, we included legumes, fish, and olive oil in this group after separating them from the meat and oil groups. Originally excluded from the Saudi guidelines, non-alcoholic beer was also added due to its health benefits for heart disease [32]. In contrast, for the intake of food items assumed to be limited in Saudi dietary guidelines (i.e., rare or monthly intake; meat and meat products, poultry, and full-fat dairy products), we allocated the scores on a reverse scale (i.e., 5, when individuals stated no intake, to 0, when they stated almost daily intake). Hence, the scores ranged from 0 to 60. Higher values of score show better adherence to the Saudi dietary guidelines (Table 1).


**Table 1.** The Saudi dietary guideline score.

a Whole-grain bread, rice, pasta etc. b Fresh (e.g., apple, oranges, banana, grapes, etc.) and dried fruit, including dates.

#### *2.4. Procedure and Data Collection*

An interview-administered survey consisting of four sections (demographics, anthropometrics, medical history, and a dietary assessment by food frequency questionnaire (FFQ)) was completed for each patient.

#### *2.5. Demographics and Medical History*

Personal information, including date of birth, gender, marital status, any medical diagnoses, and family history of cardiovascular diseases (whether at least one first-degree relative had CVD) was collected from the hospital electronic system at KAUH. Data regarding the education level, employment status, and tobacco use was collected during the interview process.

## *2.6. Anthropometric Measurements*

The anthropometric measurements, including height, weight, waist circumference (WC), and body mass index (BMI) were performed according to standard procedures and carried out in the patient's ward. Patients were weighed in light clothing, without shoes, using a calibrated scale to the nearest 0.1 kg measured in kilograms. Height was measured to the nearest 0.1 cm. The BMI was computed as the fraction of weight to the squared height, with consideration for the cut-off for older adults (65 years old and older). The WC was taken at the level of the narrowest point between the lowest costal border and the iliac crest by the research team.

#### *2.7. Estimation of Habitual Dietary Intake*

The dietary intake was assessed using a 60-item food frequency questionnaire (FFQ). For each food item, patients were asked how frequently it was consumed during the last year on a daily, weekly, or monthly basis, along with the portion sizes. Food intake was grouped into food groups (milk and dairy products, fruits, vegetables, meats, rice, breads, beverages, legumes, and sweets). The average servings of each item consumed per week were calculated using Microsoft Excel version 1808 (Redmond, WA, USA).

#### *2.8. Assessment of Blood Variables*

Blood data were collected from the patients' records for the lipid profile (high-density lipoprotein (HDL), low-density lipoprotein (HDL), total cholesterol (TC), and triglycerides (TG)); blood glucose (fasting blood glucose (FBG) and glycated hemoglobin (HbA1c)); hemoglobin (HGB) and hematocrit (HCT); cardiac enzymes (aspartate aminotransferase (AST), creatine kinase (CK), lactate dehydrogenase (LDH), and cardiac troponin I (CTN-I)); and electrolytes (sodium (Na), potassium (K), and chloride (Cl)), according to the hospital policy.

#### *2.9. Sample Size Calculation*

This is a preliminary study to identify factors of interest and to develop a study protocol for a larger-scale study. No power calculation was conducted in this study due to the absence in Saudi literature of endpoints similar to the hypothesis proposed in this study. The data of this study serve as preliminary data to determine the needed sample size to achieve the aim of the study. We aimed to include 80 patients (40 with CVD and 40 without CVD disease).
