Association between dietary pattern and risk of cardiovascular disease among adults in the Middle East and North Africa region: a systematic review

Figures & data

Fig. 1 The burden of CHD risk factors (%) in the Middle East and North Africa countries in 2010. Data adopted from World Health Organization (12).

Fig. 2 The selection process of the included articles.

Table 1 Quality criteria summary for RCTs studies on the association of dietary patterns with CHD, strokes, and associated risk factors

	Domains
Study	Study question	Study population	Randomisation	Blinding	Interventions	Outcomes	Statistical analysis	Results	Discussion	Funding/support
(24)	Yes	Yes	Yes	Partial	Yes	Yes	Yes	Yes	Yes	Yes
(28)	Yes	Yes	Yes	Partial	Yes	Yes	Yes	Yes	Yes	Yes

Adapted from the Research Triangle Institute–University of North Carolina, Evidence-based Practice Centre (RTI–UNC EPC) for randomized control trials (RCTs) (15).

Table 2 Domains and elements for RCTs studies

Domains	Elements
Study question	• Clearly focused and appropriate question
Study population	• Description of study population • Specific inclusion and exclusion criteria • Sample size justification
Randomisation	• Adequate approach to sequence generation • Adequate concealment method used • Similarity of groups at baseline
Blinding	• Double-blinding (e.g. of investigators, caregivers, subjects, assessors, and other key personnel as appropriate) to treatment allocation
Interventions	• Intervention(s) clearly detailed for all study groups (e.g. dose, route, timing for drugs, and details sufficient for assessment and reproducibility for other types of interventions) • Compliance with intervention • Equal treatment of groups except for intervention
Outcomes	• Primary and secondary outcome measures specified • Assessment method standard, valid, and reliable
Statistical analysis	• Appropriate analytic techniques that address study withdrawals, loss to follow-up, missing data, and intention to treat • Power calculation • Assessment of confounding • Assessment of heterogeneity, if applicable
Results	• Measure of effect for outcomes and appropriate measure of precision • Proportion of eligible subjects recruited into study and followed up at each assessment
Discussion	• Conclusions supported by results with possible biases and limitations taken into consideration
Funding or sponsorship	• Type and source of support for study

Elements appearing in italics are those with an empirical basis. Elements appearing in bold are those considered essential to give a system a Yes rating for the domain. Adapted from the Research Triangle Institute–University of North Carolina, Evidence-based Practice Centre (RTI–UNC EPC) for randomized control trials (RCTs) (15).

Table 3 Quality criteria summary for the observational studies on the association of dietary patterns with CHD, strokes, and associated risk factors in the MENA region

Study	Explicit aims	Sample size justification or adequate	Sample representative of population	Inclusion and exclusion criteria stated	Reliability and validity of measures justified	Response rate and drop out specified	Data adequately described	Statistical significance assessed	Discussion of generalisability
(17)	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	No
(16)	Yes	No	No	In part	No	Yes	Yes	Yes	No
(26)	Yes	Yes	No	Yes	Yes	No	Yes	Yes	No
(22)	Yes	Yes	No	Yes	Yes	No	Yes	Yes	Yes
(30)	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	Yes
(29)	Yes	Yes	Yes	No	Yes	No	Yes	Yes	No
(31)	Yes	Yes	No	Yes	No	No	Yes	Yes	No
(23)	Yes	Yes	No	Yes	No	Yes	Yes	Yes	In part
(27)	Yes	Yes	No	Yes	Yes	No	Yes	Yes	No
(25)	Yes	Yes	No	No	Yes	Yes	Yes	Yes	No
(18)	Yes	Yes	No	Yes	Yes	No	Yes	Yes	No
(19)	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	No
(20)	Yes	Yes	No	Yes	Yes	Yes	Yes	Yes	No

NA: Not applicable. Adapted from the hierarchies of evidence and critical appraisal check list (14).

Table 4 Summary of characteristics and main findings from the included studies examined the dietary patterns among CHD and stroke patients in the MENA countries

Reference, country and survey year	Sample size and gender proportion	Age groups	Study design and sampling methods	Factors studied	Diagnostic criteria	Dietary assessment methods	Main findings	Strength and limitations of included studies
(20)/Iran/2008	Stroke patients: 195 M: 60% and F: 40% Control group: 195 M: 49% and F: 51%	Stroke patients (66.9 years) Control subjects (60.8 years)	Case–control study/convenience non-random sample selection for cases and control subjects	The association between the intake of SSBs and risk of stroke	Ischaemic stroke defined as an episode of focal neurologic deficit with acute onset due to a vascular cause and lasting more than 24 h	A validated semi-quantitative FFQ with 168 food items	• There were no statistical differences between stroke patients and control group in the mean consumption of sugar-sweetened beverages (48.2 vs. 47.2 g/day, p=0.90) even after the adjustment of confounding factors.	• Noted limitations were the failure to match stroke patients and the control group, as the latter group was older. Further, because of the inability of stroke patients to remember their food intake, the family members of the patients completed the FFQ. • However, it was the first study among stroke patients in the Middle East and had a high response rate (93%)
(19)/Iran/2008				The association between potato consumption and risk of stroke			• The mean consumption of whole-fat dairy, pulses, potato and fruits was significantly higher among stroke patients in comparison to the control group, (132.2 vs. 73.6 g/day, p<0.001), (34.6 vs. 25 g/day, p<0.001), (31.1 vs. 23.4 g/day, p<0.05), and (358.6 vs. 280.5 g/day, p<0.05). • The mean consumption of low-fat dairy and vegetable oils was significantly lower among stroke patients than the control group, (270.3 vs. 339.9 g/day, p<0.05) and (10.4 vs. 19.2 g/day, p<0.001) respectively. • A significant positive association between the consumption of potatoes and the risk of strokes has been proved after an adjustment for confounding factors (OR=1.9, 95% CI: 1.0–3.6)
(18)/Iran/2004–2006	CHD patients: 108 M: 53% and F: 47%	CHD patients (51.5 years)	Case–control study/random selection of CHD and control subjects	The comparison in dietary pattern between CHD	CHD patients (more than 70% stenosis in each of the main coronary vessels or subjects	A semi-quantified validated FFQ with 41 food items	• The consumption of hydrogenated fats and whole-fat yoghurt was significantly associated with the increased risk of CHD (OR=2.12, 95% CI: 1.23–3.64) and (OR=2.35, 95% CI: 1.32–4.18) respectively.	• The limitation was the risk of bias in selecting the control subjects.
	Control: 108 M: 52% and F: 48%	Control (50.8 years)	from the catheterisation wards from two hospitals	patients and control group	with myocardial infarction). Control group (subjects with atypical chest pain and had normal angiography)		• The consumption of fish, vegetable oils and black tea on the daily basis was significantly associated with a decreased risk of CHD (OR=0.55, 95% CI: 0.31–0.91), (OR=0.23, 95% CI: 0.13–0.42), and (OR=0.3, 95% CI: 0.15–0.65) respectively.
							• There were no significant associations between the risk of CHD and the consumption of red meat, chicken and eggs on the weekly basis as well as the consumption of fruits and vegetables on the daily basis.

M: male; F: females; CHD: coronary heart disease; FFQ: food frequency questionnaire; g: gram; NR: not reported.

Table 5 Summary of characteristics and main findings from the included studies examined the association between diet and CVD risk factors in the MENA countries

Reference, country and survey year	Sample size and gender proportion	Age groups	Study design, sampling methods and response rate (%)	Factors studied	Diagnostic criteria	Dietary assessment methods	Main findings	Strength and limitations of included studies
(23)/Lebanon/2009–2010	T2D patients: 58 Control: 116 M: 60.3% and F: 39.7% in both groups	T2D (56.5 years) Control (55.9 years)	Case–control study/convenience non-random sample selection for cases and random selection for control/89% for cases and 82% for control	The association between dietary patterns and the odds of T2D among newly diagnosed patients	NR	Semi-quantitative FFQ with 97 food items	• 4 main dietary patterns identified using factor analysis: Refined grains and desserts (rich in pastas, pizza, white bread, and desserts), Traditional Lebanese (rich in olives oil, fruits and vegetables, whole wheat bread, and traditional dishes), fast food (rich in French fries, fast-food sandwiches, mixed nuts, and whole fat diary), and Meat and alcohol pattern (rich in eggs, alcohol, read meats, and sweetened beverages). • The refined grains and desserts pattern and the fast-food pattern were associated with the increase risk of type 2 diabetes (OR=3.85, 95% CI: 1.13–11.23) and (OR=2.80, 95% CI: 1.41–5.59) respectively after adjustment of confounding factors • The traditional Lebanese dietary pattern was associated with decrease risk of type 2 diabetes (OR=0.46, 95% CI: 0.22–0.97). • The refined grains and desserts, the fast food, and the meat and alcohol patterns were positively associated with BMI and WC • The refined grains and desserts pattern had the highest variance (13.68%) followed by the traditional Lebanese (10.8%) and fast food (9.13%).	• The FFQ used in this survey was not validated; however it was completed by a qualified dietician and not self-reported. • The risk of recall bias and the possibility of changing the food intake because of medical advice and relatively small sample size were the limitations
(24)/Iran/2009	31 T2D patients M: 13 and F: 18	NR	Randomised crossover design/random selection	The effect of DASH diet on the metabolic risk in T2D patients	T2D defined as FPG ≥126 mg/dl or on medication	The 3-day food diaries	• After 8 weeks period, DASH diet was significantly associated with the reduction in weight and WC. • the mean changes for fasting blood glucose, LDL cholesterol, TC, systolic blood pressure (SBP) and diastolic blood pressure (DBP) were reduced after DASH eating pattern (−29.4 mg/dl), (−17.2 mg/dl), (−22.1 mg/dl), (−13.6 mmHg), and (−9.5 mmHg) respectively. • The mean change for HDL cholesterol was increased (4.3 mg/dl) after DAH diet.	• major strength is the use of RCT design and thus provided strongest evidence
(22)/Iran/2003–2008	425 IGT subjects M and F: NR	35–55 years	Cross-sectional study/convenience sampling	The association between dietary patterns and MetS among subjects with IGT	MetS defined according to ATP III criteria	FFQ with 39 food items	• 5 dietary patterns were identified: Western pattern, prudent pattern, vegetarian pattern, high-fat dairy pattern, and chicken and plant pattern. • After adjustment for the confounding variables, the Western pattern (rich in sugar, butter, soda, sweets, eggs, hydrogenated fat, and mayonnaise) was significantly associated with increased levels of triacylglycerol and blood pressure (OR=1.76, 95% CI: 1.01–3.07) and (O=2.62, 95% CI: 1.32–5.23) respectively. • The vegetarian pattern (rich in green leafy vegetables, fruits, potatoes and legumes) was associated with increased plasma glucose levels (OR=2.26, 95% CI: 1.25–4.06).	• A noted limitation was the use of a short FFQ with 39 food items • The FFQ did not separate the questions regarding refined from whole grain; thus the dietary analysis did not separate the consumption of refined and whole grain.
(27)/Iran	827 M: 357 and F: 470	18–74 years	Cross-sectional study/multistage cluster random sampling	The association between dairy consumption and MetS	MetS defined according to ATP III criteria	Semi quantitative FFQ with 168 food items	• Subjects in quartile 4 (highest) of the dairy intake (milk, yoghurts, and cheese) had significantly lower mean WC, SBP and DBP than subjects in quartiles 1 (lowest), (76 vs. 81 cm), (112 vs. 128 mmHg), and (83 vs. 89 mmHg) respectively. • After adjustment for the confounding variables, subjects in the highest quartile of dairy intake had lower odds of getting MetS (OR by quartile: 1, 0.83, 0.74, 0.69, P<0.02).	• The survey used a population-based sample; however, it was representative of a large city (Tehran) in Iran but not the entire population in Iran.
(17)/Iran	984 F: 100%	30–50 years	Cross-sectional study/systematic random sampling/(95.9%)	The association between diet (components of various food groups) and MetS among middle aged women	MetS defined according to ATP III criteria	Validated FFQ	• By comparing females with MetS (n=284) with females without MetS (n=632), females with MetS showed a significantly lower consumption of meat, fruits, vegetables, cereals, dairy products, oil and butter and a significantly higher consumption of bread and grains than females without MetS. • Carbohydrates rather than fats contributed a lot more to the total energy intake of females with MetS compared to females without MetS. • 4 food components identified: 1 a healthy food pattern, 2 a high glycaemic index and high-fat pattern, 3 a pattern include the intake of pasta, 4 the dairy products and eggs, 5 the pattern include the intake of sweets. • Food component 1 and 4 were associated with the reduce risk of MetS, while food component 3 was positively associated with increased blood lipids.	• The main strength of the survey was the systematic random sampling used to select the study subjects; however, they were only derived from an urban population
(16)/Lebanon/2008–2009	323 M: 160 F:163	≥18 years	Cross-sectional study/multistage random sampling/(24.3%)	The association between various dietary patterns and risk of MetS	MetS defined according to the International Diabetes Federation	FFQ with 61 food items	• 3 dietary patterns identified using factor analysis: fast-food and desserts pattern, traditional Lebanese pattern, and high-protein pattern. • The variance of the fast-food and desserts pattern was the highest compared to the traditional and high-protein patterns (13.11, 9.71, and 7.8% respectively). • The fast-food and desserts pattern (rich in fast-food sandwiches, pizzas, desserts, soft drinks) was associated with an increased risk of MetS (OR=3.13, 95% CI: 1.36–7.22) and hyperglycaemia (OR=3.81, 95%CI: 1.59–9.14). • The high-protein pattern (rich in chicken, fish, low-fat dairy products, meats) was associated with an increased risk of high blood pressure (OR=2.98, 95% CI: 1.26–7.02). • There was no association between the traditional Lebanese pattern (rich in olives, fruits, legumes, vegetable oil, grains) and the risk of MetS.	• The main limitation was the low response rate (24.3%). • The FFQ used in the study was not validated; however, the data was collected by a qualified dietician and no self-reported
(26)/Iran	827 M: 357 and F: 470	18–74 Years	Cross-sectional study/multistage cluster random sampling	The association between whole-grains intake and HW in adults	The WC cut-offs values used were 80 cm for males and 79 cm for females. For the serum triacylglycerol concentrations, the triacylglycerol ≥150 mg/dl used as the cut-off based on the NCEP ATP III recommendations.	Semi quantitative FFQ with 168 food items	• Subjects in the highest quartile of the consumption of whole-grains (including all dark breads such as Iranian bread Tafton, barbari and sangak breads as well as barley bread, popcorn and Iranian whole grain cornflakes) had significantly lower rates of HW (29%) than subjects in the lowest quartile (44%). • Subjects in the highest quartile of the consumption of refined grains (biscuits, white breads, French bread, noodles, pasta and rice) had significantly higher rates of HW (45%) than subjects in the lowest quartile (27%). • After adjustment for the confounding variables, a significant negative association between whole-grains intake and WC was found, while the association between refined-grains and WC was positive but not significant. • Participants who consumed large amounts of whole-grain products were also consumed large amounts of fruits, vegetables and fibre, and less consumed meat and cholesterol.	• A noted limitation was the accurate separation between whole-grains and refined grains was difficult because of the fixed food categories in the FFQ used
(28)/Iran	116 MetS patients M: 34 and F: 82	41.2 years	Randomised controlled trial	The effect of DASH diet on patients with MetS	MetS defined according to the International Diabetes Federation	The 3-day food diaries	• After a 6 month intervention, the DASH diet had more positive effects on the reduction of the metabolic risks in MetS patients compared to the weight-reducing diet. • The mean change in WC (M: 98, F: 90; M: 100, F: 91 cm), weight (M: 71, F: 57; M: 73, F: 58 kg), triglycerides (M: 185, F: 217; M: 187, F: 216 mg/dl), SBP (M: 133, F: 132; M: 136, F: 141 mmHg), and DBP (M: 81, F: 78; M: 87, F: 83 mmHg) was significantly lower among male and female subjects on the DASH diet than those on the weight-reducing diet respectively.	• Strength of evidence is strong as the study used RCT design.
(25)/Lebanon/2005	787 M: 52%, F: 48%/ R 100%	40–60 years	Cross-sectional study/random selection/(85%)	The relation between Mediterranean diet and obesity among rural population	Overweight and obesity defined according to the WHO criteria	Non-quantitative FFQ and a 24-h recall	• A low adherence to Mediterranean diet was found among the study population as it partly matched the traditional Mediterranean diet. • The Mediterranean diet score (MDS) was inversely associated with WC but not BMI in both genders. • The compound Mediterranean score for both positive factors of the Mediterranean pattern (fruits, vegetables, legumes, olive oil and whole cereals) as well as negative factors adopted by the study subjects (pastries, liquid sweets and refined cereals) was negatively associated with WC and BMI in both genders.	• Noted limitations were the limited sample size and use of a qualitative FFQ, however, it was combined with 24-h recall
(29)/Saudi Arabia/1993–1998	1,764 females	30–70 years	Cross-sectional study/multistage stratified cluster sampling	The association between black tea consumption and serum lipids and lipoproteins	NR	Structured questionnaire	• The daily consumption of black tea was reported among 87.2% of the study subjects. • Saudi females who daily consumed more than six cups of tea (>480 ml) were significantly more likely than those who did not, to have lower rates of dyslipidaemia including, high (TC) (OR=0.63, 95% CI: 0.41–0.97), high triglycerides (OR=0.56, 95% CI: 0.35–0.86), high (LDL) (OR=0.70, 95% CI: 0.45–1.07), and high (VLDL) (OR=0.61, 95% CI: 0.39–0.93). • There was no association between black tea consumption and (HDL).	• Misclassification of the intake of beverage might be a limitation. • The large representative sample from the National survey was a strength of the study
(31)/Saudi Arabia/2008–2009	312 students M:132, F:180	21.1 years	Cross-sectional study/random selection/	The association between overweight and obesity and HTN and dietary habits	BMI defined according to the National Institute of Health. HTN defined according to the Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents.	Self-reported questionnaire (11 items)	• The proportion of total energy from carbohydrates and fats was very high especially from fats (38% vs. 39%) and (46.1% vs. 46.8%) in both males and females. • The proportion of total energy from protein was (17% vs. 15%) in males and females. • A high intake of mono-unsaturated fats and saturated fats was reported as 21 and 14% in both genders, whereas the mean intake of fibre was low in both genders. • Some unhealthy food habits were reported including a high consumption of snacks (daily) in almost 42.5%, a low consumption of vegetables (1 to 2 times weekly) in 30%, a high consumption of fatty foods (3–4 times weekly) in 36% of the females and 44% of the males, a high consumption of salty foods (daily) in 36% of the females and 43% of the males and a high consumption of sugar (daily) in 41% of the females and 38% of the males. • A significant association between the high intakes of energy derived from fatty foods and BMI and hypertension in both genders. Similarly, a significant association was found between the high consumption of salty foods and hypertension. • A negative association was found between the consumption of vegetables, grains and beans and BMI and hypertension in both genders.	• The study sample was derived from one university in Riyadh city, which makes it hard to generalise the results to wider population in Saudi Arabia.
(30)/Iran	486 F: 100%	40–60 years	Cross-sectional study/multistage cluster random sampling/(89%)	The association between dietary patterns and CVD risk factors	Dyslipidaemia was defined based on the third report of the National Cholesterol Education Program Expert Panel. HTN: SBP ≥ 140 mm Hg or DBP ≥ 90. T2D: fasting blood glucose ≥6.93 mmol/l	Validated semi-quantitative FFQ with 168 food items	• The study identified three main dietary patterns using principle component analysis: healthy pattern (rich in fruits, vegetables, legumes, fruit juices, poultry, whole grains), Western pattern (rich in red meat, high-fat dairy products, refined grains, hydrogenated fats, sweets, soft drinks, eggs, pizza), and Iranian pattern (rich in potato, tea, refined grains, whole grains, legumes, hydrogenated fats). • After controlling for confounders, the healthy dietary pattern was significantly associated with decreased levels of dyslipidaemia (OR=0.36, 95% CI: 0.19–0.53), HTN (OR=0.33, 95% CI: 0.17–0.60), and at least 2 risk factors (OR=0.39, 95% CI: 0.20–0.77).	• The main limitation of this survey was that it was conducted among only females and the sample derived from only Tehran city so it is difficult to generalise the results across all Iranian females.
							• The Western pattern was significantly associated with increased dyslipidaemia (OR=2.59, 95% CI: 1.41–4.76), HTN (OR=2.61, 95% CI: 1.27–5.19), and at least 2 risk factors (OR=2.65, 95% CI: 1.20–5.64). • The Iranian pattern was only significantly associated with increased dyslipidaemia (OR=1.73, 95% CI: 1.02–2.99). • There was no association between the three dietary patterns and T2D.

M: male; F: females; R: rural; CVD: cardiovascular disease; CHD: coronary heart disease; T2D: type 2 diabetes; BMI: body mass index; WC: waist circumference; FPG: fasting plasma glucose; LDL: low-density lipoprotein; HDL: high-density lipoprotein; VLDL: very low-density lipoprotein; TC: total cholesterol; HC: hypercholesterolemia; SBP: systolic blood pressure; DBP: diastolic blood pressure; Mets: metabolic syndrome; IGT: impaired glucose tolerance; HW: hypertriglyceridemia waist; HTN: hypertension; FFQ: food frequency questionnaire; g: gram; cm: centimetre; kg: kilogram; WHO: World Health Organization; DASH: dietary approaches to stop hypertension; NR: not reported.

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