RESEARCH

Original Research: Brief

Dietary Patterns Associated with the Prevalence

of Cardiovascular Disease Risk Factors in
Kuwaiti Adults
Badreya Al-Lahou, MS; Lynne M. Ausman, DSc, RD; José L. Peñalvo, PhD; Gordon S. Huggins, MD; Suad Al-Hooti, MS;
Sameer Al-Zenki, PhD; Fang Fang Zhang, MD, PhD

ARTICLE INFORMATION ABSTRACT

Article history:
Submitted 17 January 2019
Accepted 6 September 2019
Available online 18 November 2019
Keywords:
Kuwait
Dietary pattern
Factor analysis
Cardiovascular disease risk factors
2212-2672/Copyright ª 2020 by the Academy of
Nutrition and Dietetics.
https://doi.org/10.1016/j.jand.2019.09.012
Background Kuwaiti adults have experienced a rapid increase in cardiovascular disease
(CVD) and its risk factors. Dietary patterns in the Kuwaiti diet associated with the
increasingly higher CVD burden have not been adequately evaluated.
Objective The objective of this study was to identify the major dietary patterns in
Kuwaiti adults and examine their associations with CVD risk factors.
Design This cross-sectional study examined data from the 2008-2009 National Nutri-
tion Survey of the State of Kuwait.
Participants/setting The study included 555 Kuwaiti adults aged
20 years who
completed a 24-hour dietary recall.
Main outcome measures The outcome measures included CVD risk factors such as
obesity (body mass index), abdominal obesity (waist circumference), elevated blood
pressure, dyslipidemia (blood lipid levels), diabetes (glucose and glycated hemoglobin
levels), and metabolic syndrome.
Statistical analysis Dietary patterns were identified using principal component anal-
ysis. The associations between dietary patterns and CVD risk factors were analyzed
using survey-weighted multivariable linear and logistic regression models.
Results Three dietary patterns were identified: vegetable-rich, fast food, and refined
grains/poultry. Younger adults had higher adherence to the fast-food or refined-grains/
poultry dietary patterns, whereas older adults had higher adherence to the vegetable-
rich dietary pattern. The fast-food dietary pattern was positively associated with body
mass index (b¼.94, 95% CI 0.08 to 1.79), waist circumference (b¼2.05, 95% CI 0.20 to 3.90
cm), and diastolic blood pressure (b¼1.62, 95% CI 0.47 to 2.77 mm Hg). The refined
grains/poultry dietary pattern was positively associated with plasma glucose levels
(b¼1.02, 95% CI 1.002 to 1.04 mg/dL [0.056 to 0.058 mmol/L]). Individuals in the highest
tertile of the fast-food or refined-grains/poultry dietary patterns had higher odds of
metabolic syndrome than those in the lowest tertile.
Conclusions The fast-food and refined grains/poultry dietary patterns were associated
with high prevalence of CVD risk factors among Kuwaiti adults. The current findings
underscore the need for prospective studies to further explore dietary pattern and CVD
risk factor relationships among at-risk Kuwait adults.
J Acad Nutr Diet. 2020;120(3):424-436.

D
IET PLAYS AN IMPORTANT ROLE IN PREVENTING
cardiovascular disease (CVD).1 Traditional ap-
proaches of examining one or a few nutrients or
foods in isolation have failed to consider the syn-
ergistic effects of nutrients and foods.2 A dietary pattern
approach has potential to better account for the complexity
of the human diet and represents a better approach to eval-
uate the role of diet in chronic disease.3 The 2015-2020
Dietary Guidelines for Americans4 have explicitly recom-
mended healthy dietary patterns for chronic disease pre-
vention, moving away from the recommendations on
individual nutrients or foods.
Although dietary patterns have been well characterized in
Western populations, very few studies have examined dietary
patterns among Middle East region populations.5-7 The
Middle East region is composed of countries that are diverse
in economic status, demographic characteristics, and eating
habits.8 The Gulf Cooperation Council (GCC) countries, such
as Kuwait, Saudi Arabia, Qatar, Bahrain, United Arab Emirates,
and Oman, are high-income Middle East region countries.9
The introduction of Western foods in the GCC region may
have shaped the traditional diet to resemble more of a
Western-style diet.10 In parallel, the GCC countries have
experienced a rapid increase in obesity and other CVD risk

424 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS ª 2020 by the Academy of Nutrition and Dietetics.

factors such as diabetes and hypertension.11 For example, in
Kuwait, more than three-fourths of the adult population is
overweight or obese,12 nearly half of adults have pre-
hypertension or hypertension,13 and 40% have prediabetes or
diabetes.14
Although the association between dietary patterns and
CVD and its related risk factors has been evaluated in other
regions of the world,15,16 it is important to evaluate how di-
etary intake patterns contribute to the CVD burden in pop-
ulation of Middle East region countries given the alarmingly
high CVD risk factors in this population. Evidence generated
directly from Middle East region countries can play important
roles in informing evidence-based priorities for imple-
mentation trials and prevention policies to reduce CVD
burden in these countries as well as to reduce the global CVD
burden.
The aim of this study was to identify the major dietary
patterns of the Kuwaiti adult population using dietary data
collected from a national nutrition survey, and to further
investigate the associations between dietary patterns and
CVD risk factors, including obesity, abdominal obesity,
elevated blood pressure (BP), dyslipidemia, and diabetes.
METHODS
Study Design and Population
The present study used data of adult participants aged 20
years or older in the National Nutrition Survey of the State of
Kuwait (NNSSK). The NNSSK is a cross-sectional household-
based cluster survey that was conducted during 2008-2009
by the Kuwait Institute for Scientific Research and the
Kuwaiti Ministry of Health.10 Based on the proportion to
population size method, Kuwait was stratified into 54 local-
ities considering the number of households and the per-
centage of Kuwaiti households. Of these, 82 clusters were
identified with 20 households per cluster, including 1,640
households and 7,547 individuals. From these households,
545 agreed to participate, resulting in total of 1,830 in-
dividuals who participated in the survey (response
rate¼24.25%). We included 1,021 adult participants aged 20
years or older. Pregnant (n¼27) or lactating (n¼5) women
and participants with missing dietary information (n¼2) or
unreliable reporting (n¼7), defined as total  3 standard
deviations of the log-scale daily total energy intake, were
excluded. Because of the concern that having chronic health
conditions may result in change in dietary patterns, 425
participants with one or more diagnosed conditions of dia-
betes, hypertension, hypercholesterolemia, or heart problem,
or were currently taking medications to treat these condi-
tions were further excluded. These exclusions resulted in 555
adult participants included for the current analysis. The study
was approved by the Ethics Committee of the Ministry of
Health in Kuwait, and a written consent form was obtained
from all participants.
Dietary Data
An interview-based 24-hour dietary recall was administered
by NNSSK-trained dietitians who asked participants about
their food and beverage consumption in the previous 24
hours. Dietitians used a food instruction booklet developed
by Kuwait Institute for Scientific Research on the basis of the
US Department of Agriculture five-step multiple pass method
March 2020 Volume 120 Number 3
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RESEARCH SNAPSHOT
Research Question: What are the major dietary patterns of
the Kuwaiti adult population? Are there any associations
between the identified dietary patterns and cardiovascular
disease risk factors?
Key Findings: In this cross-sectional study that included 555
Kuwaiti adults aged 20 years or older, three major dietary
patterns were identified: vegetable-rich pattern, fast-food
pattern, and refined grains/poultry pattern. Higher
adherence to the fast-food dietary pattern was positively
associated with body mass index, waist circumference, and
blood pressure. Higher adherence to the refined grains/
poultry dietary pattern was associated with higher glucose
levels.
to help participants recall the type and amount of food
eaten.17 Dietitians also used food pictures and household
measures to help participants estimate the amount of food
consumed. Dietary data were analyzed using the ESHA Food
Processor software version 10.318 that was uploaded with
more than 100 recipes of traditional dishes and foods in the
Kuwait market.10 Intakes of nutrients and total energy were
derived from the ESHA software. Built-in recipes in ESHA
were used to disaggregate traditional dishes into their
ingredients.
CVD Risk Factors
Weight, height, and waist circumference were measured
based on standard protocols using a body composition
analyzer (model TBF 310; Tanita), a vertical stadiometer
(model 214; Seca), and a measuring tape, respectively.10 BP
was measured using a sphygmomanometer or an electronic
professional blood pressure monitor (Pro M, Spengler Elec-
tronic). Two measurements were taken, at least 10 minutes
apart, while subjects were seated with their feet flat on the
floor.13 All measurements were taken twice, and the average
was used. Blood samples were collected at the cubital fossa
after an overnight fast. Plasma glucose (PG), high-density li-
poprotein (HDL) cholesterol, total cholesterol, and triglycer-
ide (TG) levels were analyzed on a Dimension RxL automated
clinical chemistry analyzer (DadeBehring [Siemens]) using
the manufacturer’s kits.13 The bichromatic end point method
was used to measure PG, HDL cholesterol, and TG levels and
the interassay coefficients of variation ranged from 1.5% to
3.5%, 2% to 6%, and 1% to 1.5%, respectively. Total cholesterol
level was measured by the trichromatic end point method
and interassay coefficient of variation was <2%. Glycated
hemoglobin (HbA1c) was measured on a Roche Cobas Integra
400 and the interassay coefficient of variation was 2.5%.
Body mass index (BMI) was calculated as weight in kilo-
grams divided by height in meters squared. Obesity was
defined as BMI
25.19 Abdominal obesity was defined as
waist circumference
94 cm in men and
80 cm in
women.20 Low-density lipoprotein (LDL) cholesterol level
was calculated using the Friedewald equation: LDL choles-
terol (mg/dL)¼total cholesterol (mg/dL)eHDL cholesterol
(mg/dL)eTG (mg/dL)/5, for those with TG 400 mg/dL (4.4
mmol/L).21 Dyslipidemia was defined as LDL cholesterol level
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 425
RESEARCH

Food or food Food or food

group Food item group Food item

Sugar-sweetened Regular soft drinks, fruit drinks Refined grains White rice, white bread, toast, bun,
beverages cereal, pasta, croissant
Nuts and seeds Any kind of nuts, seeds, nuts/seeds Full-fat dairy Full fat milk (white or chocolate),
butter products buttermilk, yogurt or flavored
Dark green Lettuce, spinach, broccoli, parsley, yogurt, labna (creamy cheese made
vegetables arugula from strained yogurt), cheese

Red and orange Carrots, pumpkin, sweet potatoes, Low-fat dairy Skim (fat-free) or low-fat milk (white or
vegetables red/orange bell peppers products chocolate), buttermilk, yogurt or
flavored yogurt, labna (creamy
Tomatoes Tomatoes (fresh, cooked, sauce, paste,
cheese made from strained yogurt),
dried, pickled)
cheese
Starchy vegetables Corn, green peas
Burgers and Burgers, sandwiches, meat and
Other vegetables Cucumber, eggplant, zucchini, green sandwiches chicken patties
peppers, cabbage, cauliflower,
Pizza Pizza
onion, garlic, mushrooms, zucchini
Sweet condiments Sugar, honey, molasses, syrup, jam,
White potatoes White potatoes
jelly
French fries French fries, hash brown
Western sweet Cookies, chocolate, cake, doughnut,
Snacks Potato chips, corn chips, tortilla chips, cinnamon roll, Danish pastry, ice
crackers, popcorn cream

Whole fruit Apples, pears, berries, banana, citrus Traditional sweet All kinds of traditional sweets,
fruits, papaya, mango, pineapple, including balaleet, khabees, alba,
grapes, raisins, kiwifruit, fruit salads, crème caramel, mehalabia, tamreia,
figs, apricot, peach, watermelon, rangena, rehash, lugamat, darabeel,
pomegranate gours egalee, zalabya, aseeda,
ghourayba, baklava, kunafa, gatayef,
100% Fruit juice 100% fruit juice
halwa, semsemya
Dates All kinds of dates (fresh, immature,
Arabic coffee Arabic coffee
and mature)
Western coffee French, espresso, cappuccino, latte,
Legumes Lupin bean, fava bean, chickpea,
mocha, Frappuccino,a instant coffee
hummus, lentil
Black tea Black tea
Fish and shellfish Fish, shrimp, tuna, salmon
Herbal Tea Green, herbal teas
Poultry Chicken, turkey
a
Starbucks Corporation.
Unprocessed red Lamb, cow, and camel meat, organ
meat meats such as liver, brain, kidney Figure. (continued) Food groups included in the dietary pattern
analysis among Kuwaiti adults, 2008-2009 National Nutrition
Processed meat Nuggets, mortadella, hot dogs, Survey of the State of Kuwait.
sausages
Egg Eggs

130 mg/dL (3.37 mmol/L).22 Elevated BP was defined as
Whole grains Brown bread, toast, bun, shabura diastolic BP
80 mm Hg and/or systolic BP
120 mm Hg.23
(rusk), brown rice Prediabetes/diabetes was defined as fasting PG
100 mg/dL
(5.6 mmol/L) or HbA1c
5.7%.24 Metabolic syndrome was
(continued) defined as meeting any three of the five criteria: waist
Figure. Food groups included in the dietary pattern analysis circumference
94 cm in men and
80 cm in women, TG
among Kuwaiti adults, 2008-2009 National Nutrition Survey of
150 mg/dL (1.7 mmol/L); HDL cholesterol <40 mg/dL (1.0
the State of Kuwait. mmol/L) in men and <50 mg/dL (1.3 mmol/L) in women,

426 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS March 2020 Volume 120 Number 3

systolic BP
130 mm Hg and/or diastolic BP
85 mm Hg, and
fasting PG
100 mg/dL (5.6 mmol/L).20
Covariates
Sociodemographic information was collected using an
interview-based questionnaire by trained interviewers. In-
formation collected included date of birth, education level
(less than high school, completed high school, some college,
and completed college or beyond), and family monthly in-
come in Kuwaiti dinar (KD) (<1,000 KD [$3,300], 1,000 to
2,000 KD [$3,300 to 6,600], and
2,000 KD [$6,600]).
Smoking status and physical activity were assessed through a
series of questions in a self-reported questionnaire. In-
dividuals who had never smoked tobacco were defined as
nonsmokers, individuals who had ever smoked were defined
as former smokers, and individuals who were smoking at the
time of the survey were defined as current smokers. For
physical activity, individuals were asked to report their
duration of moderate (defined as any activity that increases
breathing to some extent) and strenuous physical activities
(defined as any activity that requires great effort that caused
sweating and difficulty in breathing, such as running, weight
lifting, and strenuous activity). Participants who engaged in
at least 150 minutes/week of moderate physical activity, 75
minutes/week of strenuous activity, or an equivalent combi-
nation of moderate and strenuous activities were classified as
active.25
Identification of Dietary Patterns
Food items were combined into 32 food groups based on
nutrient profile. Food items with distinct characteristics or
consumption, such as Arabic coffee and dates, constituted
their own group (Figure). Intakes of food groups were
adjusted for total energy intake using the density method as
grams per 2,000 kcal, to account for individual differences in
metabolic efficiency, body size, and physical activity and to
reduce measurement error.26
Principal component analysis was conducted to identify
the dietary patterns using the PROC FACTOR procedure in SAS
version 9.4.27 Eigenvalues >1, evaluation of the scree plot, as
well as interpretability were used to determine the common
components to be retained. Retained components were
rotated using orthogonal rotation method (VARIMAX pro-
cedure) to facilitate interpretability while keeping uncorre-
lated components. For each retained component, a score was
estimated using the SCORE option in PROC FACTOR state-
ment. Higher scores correspond to greater adherence to a
specific dietary pattern.
Statistical Analysis
Participants’ characteristics and intake of food groups and
nutrients were compared by tertile of component scores for
each dietary pattern using analysis of variance for continuous
variables and c2 test for categorical variables. Logistic
regression models were conducted to estimate the odds ratio
(OR) and 95% CI of the association between dietary patterns
and CVD risk factors, after adjustment of age (continuous),
sex (men and women), total energy intake (continuous),
place of living (six governorates), education (less than high
school, completed high school, some college, and completed
college and beyond), family income (<1,000 KD, 1,000 to
March 2020 Volume 120 Number 3
RESEARCH
<2,000 KD, and
2,000 KD), cigarette smoking (current,
former, and nonsmoker), physical activity (active or seden-
tary), BMI (continuous), and multivitamin supplement use
(yes or no). The three dietary patterns were adjusted in the
same model to assess its independent effect. Further adjust-
ment was made for family history of high cholesterol levels or
hypertension (yes or no) when dyslipidemia or elevated BP
was evaluated as the outcome, respectively. Significance of
trend was examined by modeling diet quality tertile as an
ordinal variable in the logistic regression models. Multivari-
able linear regression analyses were further conducted to
estimate b coefficients and 95% CI of the association between
dietary pattern scores (standardized component scores) and
CVD risk factors as continuous variables after adjusting for
the same confounding variables included in the logistic
models. Skewed dependent variables such as PG and HbA1c
were natural log-transformed before analyses.
All statistical analyses were performed using SURVEY pro-
cedures in SAS version 9.4,27 to account for the complex sam-
pling design of the NNSSK. Sampling weights have been
adjusted for nonrespondents and matched to the 2005 Kuwaiti
census. P values <0.05 was considered statistically significant.
RESULTS
The meanstandard error of age of study participants was
34.50.65 years and 51.3% were women. The meanstandard
error BMI was 28.90.59, and two-thirds were overweight
(30.5%) or obese (36.8%). Three major dietary patterns were
identified: the vegetable-rich dietary pattern loaded high in
all subcategories of vegetables except for white potato; the
fast-food dietary pattern loaded high in burgers/sandwiches,
french fries, and sugar-sweetened beverages (SSBs); the
refined-grains/poultry dietary pattern loaded high in refined
grains and poultry and low in whole grains (Table 1). These
three dietary patterns accounted for 2.5%, 2.5%, and 1.7% of
the variance, respectively, and represent a total of 6.7% of the
variance explained. Compared with those with a lower score,
participants with a higher score for the vegetable-rich dietary
pattern were older and more likely to be women and non-
smokers and those with a higher score of the fast-food di-
etary pattern were younger, more likely to be women, and
receive higher levels of education. Participants with a higher
score of the refined grains/poultry dietary pattern were
younger compared with those with a lower score (Table 2).
In multivariable logistic regression models, participants in
the highest tertile of the fast-food dietary pattern scores had
nearly twofold odds of being obese (OR 1.94, 95% CI 1.07 to
3.52) and having elevated BP (OR 2.38, 95% CI 1.13 to 4.99)
and approximately three-fold odds of having metabolic syn-
drome (OR 2.66, 95% CI 1.29 to 5.47) compared with those in
the lowest tertile (Table 3). Those with greater adherence to
the refined grains/poultry dietary pattern also had higher
odds of having dyslipidemia (OR 2.14, 95% CI 1.04 to 4.40) or
metabolic syndrome (OR 1.95, 95% CI 0.99 to 3.84) than those
with the lowest adherence. When the outcomes were
analyzed in multivariable linear regression models, a 1
standard deviation increase in the fast-food dietary pattern
score was associated with a 1.62 mm Hg increase in diastolic
BP (b¼1.62, 95% CI 0.47 to 2.77 mm Hg), 0.94 increase in BMI
(b¼.94, 95% CI 0.08 to 1.79), and 2.05 cm increase in waist
circumference (b¼2.05, 95% CI 0.20 to 3.90 cm) (Table 4).
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428

Table 1. Factor loadings and energy-adjusted intakes of key food groups and nutrients by tertile (T) of the dietary pattern among Kuwaiti adults aged
20 years in the
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

2008-2009 National Nutrition Survey of the State of Kuwait (N¼555)

Vegetable-Rich Pattern Fast-Food Pattern Refined-Grains/Poultry Pattern

Factor Factor Factor
Food group/nutrient loadinga T1 T3 loading T1 T3 loadinga T1 T3

meanstandard errorb meanstandard errorb meanstandard errorb

Fruit (g/d)
Whole fruit 0.17 48.99.7 99.817.0** e0.12 10716.8 65.114.2 e0.33 13518.1 28.25.4***
Dates e0.09 19.65.6 13.21.9 e0.38 36.36.4 3.81.1*** e0.38 39.36.5 5.91.4***
100% fruit juice e0.02 34.016.4 32.89.0 e0.08 44.619.2 17.86.3 e0.17 68.120.8 28.416.2
Vegetables (g/d)
Dark green vegetables 0.76 4.81.6 79.89.3*** e0.03 29.54.0 39.08.5 e0.20 51.97.9 28.25.4*
Tomatoes 0.69 23.13.8 1197.4*** e0.10 76.75.6 56.97.0* 0.004 64.07.6 74.54.6
Other vegetables 0.76 26.63.7 1639.4*** e0.17 10510.8 73.89.2* e0.11 91.89.4 84.37.1
White potatoes 0.10 7.81.6 18.62.7*** e0.18 18.52.6 9.31.9** 0.23 5.51.2 20.13.0***
Grains (g/d)
Whole grains 0.09 21.54.1 46.37.2** e0.10 40.77.7 23.55.0 e0.41 82.911.5 11.45.1***
Refined grains e0.01 1096.4 1369.9* e0.14 1287.7 1119.5 0.71 60.94.4 1979.5***
Protein foods (g/d)
Poultry 0.22 30.47.4 11912.3*** e0.12 88.213.1 64.18.6 0.42 18.93.9 13512.1***
Unprocessed red meat e0.13 46.48.0 25.25.0* e0.25 63.39.3 11.23.0*** 0.06 22.94.6 36.06.5
Processed meat e0.07 8.53.1 3.91.7 0.21 0.30.2 12.43.1*** 0.05 3.51.5 4.82.1
Fish/shellfish 0.04 15.64.7 18.55.5 0.04 12.54.5 25.76.6 e0.31 48.69.4 1.80.8***
Legumes 0.02 10.13.3 10.62.1 e0.03 6.31.3 7.72.7 0.10 6.02.8 18.23.9*
Dairy products (g/d)
Full fat e0.03 15022.0 13017.9 e0.41 24430.0 48.26.0*** e0.19 16924.7 11717.1
March 2020 Volume 120 Number 3

Low fat 0.06 37.611.3 56.120.4 e0.01 37.314.2 44.017.0 e0.15 57.715.6 22.47.4
Fast food (g/d)
Burgers/sandwiches e0.13 49.47.7 10.33.1*** 0.63 1.81.6 61.49.7*** e0.20 40.57.7 9.32.8***
French fries e0.15 25.13.3 9.82.4*** 0.62 1.10.6 39.24.2*** e0.08 19.04.0 9.62.0*
Sugar-sweetened beverages e0.19 38550.7 18826.2*** 0.61 74.516.0 50941.0*** e0.05 33938.2 21021.1**

(continued on next page)

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Table 1. Factor loadings and energy-adjusted intakes of key food groups and nutrients by tertile (T) of the dietary pattern among Kuwaiti adults aged
20 years in the
2008-2009 National Nutrition Survey of the State of Kuwait (N¼555) (continued)

Vegetable-Rich Pattern Fast-Food Pattern Refined-Grains/Poultry Pattern

Factor Factor Factor
Food group/nutrient loadinga T1 T3 loading T1 T3 loadinga T1 T3

meanstandard errorb meanstandard errorb meanstandard errorb

Sweets/snacks (g/d)
Snacks e0.08 7.32.3 1.90.8* 0.19 1.30.6 11.62.7*** e0.01 7.22.2 5.11.7
Western sweets e0.13 38.45.1 24.14.6* 0.19 13.81.8 50.26.8*** e0.17 37.55.4 16.54.7**
Sweet condiments e0.14 21.83.0 12.01.3** e0.46 28.12.7 7.91.5*** e0.04 18.42.9 13.41.5
Nutrients
Protein (% of energy) 14.80.5 18.20.6*** 17.90.5 14.90.5*** 15.10.5 18.20.5***
Carbohydrates (% of energy) 52.51.0 50.30.9 51.71.2 52.60.9 56.31.1 51.11.1***
Fat (% of energy) 32.60.9 31.50.9 30.40.9 32.50.7 28.60.9 30.81.0
Saturated fats (% of energy) 11.40.5 10.50.4 11.40.5 10.00.4* 9.30.4 10.30.4
Sodium (mg/d) 2,81776.3 3,655160*** 3,225157 3,222130 3,05499.0 3,271103
Fiber (g/d) 14.00.9 31.72.2*** 25.21.7 20.22.0 25.11.6 20.91.4
Calcium (mg/d) 70237.5 79740.2 83246.8 59833.7*** 82849.0 64131.3***
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Potassium (mg/d) 1,98893.1 2,659104*** 2,636102 2,01490.1*** 2,728112 2,09368.5***

Vitamin D (mg/d) 1.80.2 2.30.7 2.10.3 1.20.2*** 2.20.3 1.80.7
a
Factor loadings with absolute value
0.40 are in boldface type.
b
Values are energy-adjusted meanstandard error using a density method as a percentage of energy (carbohydrates, fat, and protein) or as amount per 2,000 kcal/day (food groups and micronutrients).
*Significant difference between T1 and T3 at P<0.05.
**Significant difference between T1 and T3 at P<0.01.
***Significant difference between T1 and T3 at P<0.0001.

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430JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

Table 2. Characteristics of Kuwaiti adults aged
20 years (N¼555) for the lowest tertile (T1) and highest tertile (T3) of the dietary patterns, 2008-2009 National Nutrition
Survey of the State of Kuwait

Vegetable-Rich Pattern Fast-Food Pattern Refined-Grains/Poultry Pattern

P value P value P value
Characteristic Total T1 T3 (T1 vs T3) T1 T3 (T1 vs T3) T1 T3 (T1 vs T3)

)meanstandard error/ )meanstandard error/ )meanstandard error/

Age, y 34.50.65 32.21.0 35.71.2 0.03 38.11.1 30.31.1 <0.0001 35.51.1 32.60.99 0.03
Body mass indexa 28.90.58 27.80.60 28.80.88 0.80 28.30.83 29.21.2 0.54 29.00.66 29.31.1 0.83
ƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒ! ƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒ! ƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒ!
Sex 0.005 0.02 0.50
Female 286 (51.3) 75 (40.4) 116 (63.7) 76 (40.0) 104 (55.1) 99 (53.8) 91 (46.5)
Male 269 (48.7) 110 (59.6) 69 (36.3) 109 (60.0) 81 (44.9) 86 (46.2) 94 (53.5)
Education level 0.59 0.0005 0.67
Less than high school 115 (35.7) 37 (32.3) 34 (33.1) 58 (52.7) 20 (21.3) 38 (33.8) 41 (39.8)
High school 115 (19.7) 41 (23.9) 42 (19.5) 33 (13.9) 51 (27.0) 35 (16.0) 44 (21.9)
Some college 144 (22.3) 46 (19.6) 51 (26.0) 43 (17.7) 54 (26.3) 49 (26.0) 46 (19.3)
College or beyond 181 (22.4) 61 (24.1) 58 (21.5) 51 (15.7) 60 (25.4) 63 (24.3) 54 (19.0)
Monthly family income 0.26 0.66 0.31
level (Kuwaiti dinarb)
<1,000 134 (26.2) 41 (23.7) 50 (23.7) 49 (25.6) 50 (29.2) 50 (28.3) 47 (28.8)
1,000-2,000 296 (49.9) 93 (51.2) 94 (47.1) 105 (55.2) 94 (46.4) 90 (50.2) 110 (51.9)

2,000 125 (23.9) 51 (25.1) 41 (29.2) 31 (19.2) 41 (24.4) 45 (21.5) 28 (19.2)
Governoratec 0.76 <0.0001 0.007
Al Ahmadi 86 (16.2) 26 (11.4) 25 (15.7) 40 (23.7) 24 (12.6) 28 (15.9) 30 (14.5)
Al Asimah 96 (16.4) 28 (16.2) 33 (15.5) 21 (7.1) 30 (18.2) 41 (18.8) 19 (13.5)
March 2020 Volume 120 Number 3

Al Farwaniyah 91 (21.3) 28 (19.1) 40 (23.7) 39 (23.4) 23 (15.0) 30 (22.4) 40 (27.0)

Al Jahrah 80 (9.3) 26 (7.6) 25 (10.0) 35 (13.4) 22 (7.6) 24 (8.7) 35 (13.1)
Hawalli 116 (20.2) 43 (24.9) 36 (19.0) 23 (10.7) 60 (34.4) 49 (26.9) 28 (14.1)
Mubarak Al Kabeer 86 (16.6) 34 (20.8) 26 (16.0) 27 (21.8) 26 (12.3) 13 (7.3) 33 (17.8)

(continued on next page)

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Table 2. Characteristics of Kuwaiti adults aged
20 years (N¼555) for the lowest tertile (T1) and highest tertile (T3) of the dietary patterns, 2008-2009 National Nutrition
Survey of the State of Kuwait (continued)

Vegetable-Rich Pattern Fast-Food Pattern Refined-Grains/Poultry Pattern

P value P value P value
Characteristic Total T1 T3 (T1 vs T3) T1 T3 (T1 vs T3) T1 T3 (T1 vs T3)

ƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒ! ƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒ! ƒƒƒƒƒƒƒn (%)ƒƒƒƒƒƒƒ!

Smoking status 0.0005 0.07 0.19
Nonsmoker 356 (63.9) 101 (51.2) 138 (78.5) 105 (55.6) 119 (63.1) 126 (69.3) 111 (57.0)
Former smoker 75 (12.5) 29 (16.3) 18 (8.0) 35 (18.5) 20 (10.4) 23 (9.1) 23 (13.2)
Current smoker 124 (23.6) 55 (32.5) 29 (13.5) 45 (25.9) 46 (26.5) 36 (21.5) 51 (29.8)
Physical activityd 0.40 0.21 0.33
Active 114 (21.0) 43 (24.9) 37 (16.7) 31 (18.6) 47 (26.7) 45 (24.3) 41 (22.0)
Sedentary 433 (79.0) 140 (75.1) 145 (83.3) 153 (81.4) 134 (73.3) 138 (75.7) 141 (78.0)
Weight statuse 0.33 0.47 0.74
Underweight/normal weight 163 (32.7) 59 (36.2) 46 (31.2) 58 (30.4) 55 (33.1) 50 (31.3) 60 (34.8)
Overweight 199 (30.5) 70 (35.0) 70 (30.9) 72 (36.7) 66 (30.3) 72 (32.1) 56 (25.6)
Obese 193 (36.8) 56 (28.9) 69 (38.0) 55 (32.9) 64 (36.6) 63 (36.6) 69 (39.6)
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a
Body mass index was calculated as weight in kilograms divided by height in meters squared and was used to define weight status (underweight/normal weight [<25], overweight [25 to 29.9], and obesity [
30]).
b
$1¼0.3 Kuwaiti dinar.
c
Kuwait is divided into six governorates or area of residence. Al Ahmadi is the most populated governorate (21.4%) followed by Al Asimah (19.1%), Hawalli (16.8%), Al Farwaniyah (16.7%), Al Jahrah (14.2%), and Mubarak Al Kabeer (11.7%). The
governorates have similar sex distributions (approximately 49% men and 51% women). For age distribution, Al Ahmadi and Al Jahra are the two governorates with largest proportion of people younger than age 20 years (50.5% and 49.9%,
respectively), and Al Asimah and Hawalli are the two governorates with largest proportion of people older than age 40 years (28.6% and 27.7%, respectively).44
d
Physical activity was categorized into active (who reported engaging in moderate physical activity for 150 minutes per week, strenuous activity for 75 minutes per week, or an equivalent combination of moderate and strenuous activity) and inactive.
e
Body mass index was calculated as weight in kilograms divided by height in meters squared and was used to define weight status (underweight/normal weight [<25], overweight [25 to 29.9], and obese [
30]).

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Table 3. Multivariable-adjusted odds ratios (ORs)a of cardiovascular disease (CVD) risk factorsb by tertile (T) of dietary pattern scores in Kuwaiti adults aged
20 years
(N¼555), 2008-2009 National Nutrition Survey of the State of Kuwait

Obesity Abdominal Obesity Dyslipidemia Elevated Blood Pressure Prediabetes/Diabetes Metabolic Syndrome
Score N (%) OR (95% CI) N (%) OR (95% CI) N (%) OR (95% CI) N (%) OR (95% CI) N (%) OR (95% CI) N (%) OR (95% CI)

Vegetable-rich dietary pattern score

T1 126 (63.8) 1.00 110 (54.8) 1.00 67 (40.0) 1.00 125 (67.7) 1.00 68 (34.9) 1.00 51 (21.9) 1.00
T2 127 (69.0) 0.94 (0.46-1.92) 119 (68.3) 1.37 (0.72-2.59) 67 (35.3) 0.63 (0.30-1.31) 126 (68.3) 0.71 (0.36-1.40) 91 (48.2) 1.48 (0.77-2.82) 66 (38.0) 1.44 (0.68-3.02)
T3 139 (68.8) 1.02 (0.54-1.90) 127 (62.7) 1.02 (0.60-1.74) 65 (32.4) 0.56 (0.32-0.99) 130 (76.4) 1.75 (0.81-3.79) 86 (45.4) 1.32 (0.66-2.65) 58 (31.4) 1.00 (0.39-2.56)
P value for trend 0.95 0.96 0.049 0.16 0.45 0.93
Fast-food dietary pattern score
T1 127 (69.6) 1.00 119 (62.2) 1.00 64 (35.6) 1.00 129 (71.2) 1.00 89 (44.8) 1.00 63 (31.5) 1.00
T2 135 (65.3) 1.18 (0.62-2.24) 127 (65.5) 1.21 (0.62-2.34) 74 (35.6) 1.22 (0.55-2.71) 132 (73.1) 2.71 (1.29-5.73) 90 (50.3) 1.86 (1.04-3.33) 58 (31.5) 1.41 (0.76-2.61)
T3 130 (66.9) 1.94 (1.07-3.52) 110 (58.3) 1.28 (0.64-2.58) 61 (36.1) 1.55 (0.71-3.41) 120 (68.7) 2.38 (1.13-4.99) 66 (33.7) 1.16 (0.58-2.35) 54 (28.6) 2.66 (1.29-5.47)
P value for trend 0.03 0.49 0.26 0.03 0.67 0.008
Refined-grains/poultry dietary pattern score
T1 135 (68.7) 1.00 126 (67.6) 1.00 55 (26.6) 1.00 133 (70.8) 1.00 77 (41.9) 1.00 55 (26.7) 1.00
T2 132 (68.1) 1.03 (0.50-2.12) 114 (59.1) 0.60 (0.33-1.12) 77 (44.7) 2.56 (1.20-5.47) 115 (67.3) 0.58 (0.29-1.13) 95 (51.8) 1.45 (0.76-2.79) 52 (27.5) 0.91 (0.44-1.88)
T3 125 (65.2) 0.96 (0.48-1.92) 116 (60.0) 0.72 (0.39-1.36) 67 (34.7) 2.14 (1.04-4.40) 133 (74.4) 0.90 (0.44-1.84) 73 (35.5) 0.77 (0.37-1.57) 68 (36.5) 1.95 (0.99-3.84)
P value for trend 0.91 0.33 0.03 0.75 0.43 0.04
a
Values were estimated from multivariable logistic models adjusted for age (years, continuous), sex (male vs female), place of living (six governorates), total energy intake (kcal/day, continuous), income level (<1,000 Kuwaiti dinars, 1,000 to <2,000
Kuwaiti dinars, and
2,000 Kuwaiti dinars), smoking status (current, former, and nonsmoker), education level (less than high school, high school, some college, and completed college and beyond), physical activity (active vs. sedentary), multivitamin
supplement use (yes vs. no), other dietary pattern, family history (yes vs no) of high cholesterol (dyslipidemia model) or hypertension (elevated blood pressure model), and body mass index (dyslipidemia, elevated blood pressure, and prediabetes/
diabetes models).
b
Definition of CVD risk factors: obesity was defined as body mass index
25; abdominal obesity was defined as waist circumference
94 cm (men) or
80 cm (women); dyslipidemia was defined as low-density lipoprotein
130 mg/dL (calculated
according to the Friedewald equation); elevated blood pressure was defined as diastolic blood pressure
80 mm Hg and/or systolic blood pressure
120 mm Hg; prediabetes/diabetes was defined as fasting plasma glucose
100 mg/dL [
5.55
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mmol/L] or glycated hemoglobin
5.7%; and metabolic syndrome was defined as having any three of the five criteria: abdominal obesity, triglycerides
150 mg/dL [
1.69 mmol/L], high-density lipoprotein <40 mg/dL [<1.04 mmol/L] (men) or
<50 mg/dL [<1.3 mmol/L] (women), systolic blood pressure
130 mm Hg and/or diastolic blood pressure
85 mm Hg, or fasting plasma glucose
100 mg/dL [
5.55 mmol/L].
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Table 4. Multivariable-adjusted b coefficientsa of cardiovascular disease risk factors and dietary pattern scores in Kuwaiti adults aged
20 years (N¼555), 2008-2009
National Nutrition Survey of the State of Kuwait

Systolic Diastolic
Body Waist LDL HDL Total blood blood
mass circumference cholesterolbc cholesterolcd cholesterolc pressure pressure Glucoseef
Variable index (cm) (mg/dL) (mg/dL) (mg/dL) (mm Hg) (mm Hg) (mg/dL) HbA1ce (%)

ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ b (95% CI)ƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒƒ!

Vegetable-rich dietary pattern score (per SDg)
b (95% CI) .57 1.61 e2.03 e.58 e3.46 0.45 .29 1.00 1.00
(e.43 to 1.58) (e.56 to 3.79) (e5.45 to 1.39) (e1.68 to 0.51) (e7.44 to 0.52) (e.86 to 1.76) (e.51 to 1.09) (.98 to 1.02) (.98 to 1.01)
P value 0.26 0.14 0.24 0.29 0.09 0.50 0.47 0.99 0.62
Fast-food dietary pattern score (per SD)
b (95% CI) .94 2.05 1.13 .37 .35 1.34 1.62 1.02 1.01
(.08 to 1.79) (.20 to 3.90) (e2.77 to 5.03) (e.74 to 1.47) (e3.40 to 4.11) (e.28 to 2.97) (.47 to 2.77) (1.00 to 1.04) (1.00 to 1.03)
P value 0.03 0.03 0.57 0.51 0.85 0.10 0.006 0.07 0.11
Refined grains/poultry dietary pattern score (per SD)
b (95% CI) e.30 .15 2.07 e.31 1.95 e.24 e.34 1.02 1.01
(e.94 to .35) (e1.18 to 1.47) (e1.14 to 5.29) (e1.58 to 0.96) (e1.60 to 5.50) (e1.87 to 1.38) (e1.57 to .90) (1.002 to 1.04) (0.99 to 1.02)
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS

P value 0.36 0.83 0.20 0.63 0.28 0.76 0.59 0.03 0.38
a
Values were estimated from multivariable linear regression models adjusted for age (years, continuous), sex (male vs female), place of living (six governorates), total energy intake (kcal/day, continuous), income level (<10,00 Kuwaiti dinars, 1,000 to
<2,000 Kuwaiti dinars, and
2,000 Kuwaiti dinars), smoking status (current, former, and nonsmoker), education level (less than high school, high school, some college, and completed college or beyond), physical activity (active vs sedentary),
multivitamin supplement use (yes vs no), other dietary patterns, family history (yes vs no) of high cholesterol (blood lipid models) or hypertension (blood pressure models), and body mass index (all models except when body mass index or waist
circumference is the outcome).
b
LDL¼low-density lipoprotein and was calculated according to the Friedewald equation.
c
To convert mg/dL cholesterol to mmol/L, mulitpy mg/dL by 0.026. To convert mmol/L to mg/dL, multiply mmol/L by 38.6. Cholesterol of 193 mg/dL¼5.00 mmol/L.
d
HDL¼high-density lipoprotein.
e
Glucose and HbA1c were log-transformed due to right skewness. b (95% CI) were converted back to its original unit, corresponding differences in glucose (mg/dL) and HbA1c (%) per 1 SD increase of dietary pattern scores.
f
To convert mg/dL glucose to mmol/L, multiply mg/dL by 0.0555. To convert mmol/L glucose to mg/dL, multiply mmol/L by 18.0. Glucose of 108 mg/dL¼6.0 mmol/L.
g
SD¼standard deviation.

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A 1 standard deviation increase in the refined grains/poultry
dietary pattern was associated with 1.02 mg/dL increase in
plasma glucose (b¼1.02, 95% CI 1.002 to 1.04 mg/dL [0.026 to
0.027 mmol/L]).
DISCUSSION
Among Kuwaiti adults who are at risk for CVD, three dietary
patterns were identified: a fast-food dietary pattern, a
refined-grains/poultry dietary pattern, and a vegetable-rich
dietary pattern. High adherence to a fast-food dietary
pattern among Kuwaiti adults was associated with elevated
BP, BMI, and waist circumference; high adherence to a
refined-grains/poultry dietary pattern was associated with
increased glucose levels.
Although dietary patterns can vary across populations due
to cultural influences and societal factors,3 the fast-food di-
etary pattern identified among Kuwaiti adults is similar in
food composition (eg, burgers, french fries, and SSBs) to the
Western dietary pattern identified among US adults.28,29
Such a Western/fast-food dietary pattern has been previ-
ously identified among populations of the Middle East such
as Iranian women5,6 and Lebanese adults,7 suggesting the
westernization of dietary patterns among countries in the
Middle East. As expected, the fast-food dietary pattern was
associated with CVD risk factors such as obesity and elevated
BP. The positive association between the fast-food dietary
pattern and prevalence of obesity observed among Kuwaiti
adults is in line with those reported by a meta-analysis of
studies conducted in Europe, North and South America, and
Asia.30 Participants with a high adherence to the fast-food
dietary pattern also consumed high levels of energy-dense
foods such as french fries and SSBs, and high consumption
of empty calories are known risk factors for obesity.31,32 In
addition, the fast-food dietary pattern was associated with
elevated BP among Kuwaiti adults. The positive association
between a Western dietary pattern and hypertension has
been previously reported among Iranian women.5 Although
sodium intake did not vary across tertiles of the fast-food
dietary pattern among Kuwait adults, individuals who fol-
lowed a fast-food dietary pattern also consumed low levels of
vegetables and fruits that are rich sources of potassium.33
Findings from prior studies suggest that the ratio of sodium
to potassium is more strongly associated with blood pressure
than either nutrient alone.34 Given the rapid urbanization
and increased availability of fast-food restaurants in
Kuwait,9,35 the association between fast-food consumption
and CVD risk and the potential mechanisms underlying this
need to be further evaluated. In the case that studies indicate
fast-food consumption results in increased CVD risk, policy
options need to be considered to reduce fast-food con-
sumption in Kuwait and other Middle Eastern countries for
primary prevention of CVD.
The refined-grains/poultry dietary pattern captured some
aspects of a traditional Kuwaiti diet such as high consump-
tion of refined grains and poultry, although other compo-
nents of the traditional Kuwaiti diet such as dates, vegetables,
and fish36 were negatively loaded. The refined-grains/poultry
dietary pattern was associated with higher levels of plasma
glucose among Kuwaiti adults. This finding may be explained
by the high glycemic index foods (eg, refined grains and
potatoes)37 characterized by this dietary pattern and the low
434 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
consumption of the low glycemic index foods (eg, whole
grains and whole fruits)37 by individuals with high adherence
to this dietary pattern. The positive association between the
refined-grains/poultry dietary pattern and plasma glucose
may contribute to the alarmingly high prevalence of predia-
betes (19.4%) and diabetes (18.8%) among Kuwaiti adults.14 It
is important to note that the refined-grains/poultry dietary
pattern maybe popular in Kuwait due to the subsidy of rice
and poultry to all Kuwaiti families by the government.38 In
the case that future longitudinal studies confirm the associ-
ation between a refined-grains/poultry dietary pattern and
plasma glucose, the current food subsidy policies may be
revisited by shifting toward subsidizing healthier food op-
tions such as replacing refined grains with whole grains.10
The vegetable-rich dietary pattern was associated with
lower odds of dyslipidemia but was not linked to CVD risk
factors as continuous outcomes. Although other evidence
suggests a high consumption of vegetables and fruits pro-
tecting against CVD risk factors,15,39 it is possible that among
Kuwaiti adults, the vegetable-rich dietary pattern did not
play as strong a role as the other two dietary patterns. Thus,
discouraging unhealthful dietary patterns such as fast-food
and refined-grains/poultry dietary patterns may be more
important in reducing CVD risk factors among Kuwaiti adults
than promoting a vegetable-rich dietary pattern. In Kuwait,
vegetables are most commonly consumed as part of mixed
dishes, in stews, soups, or salads. Further studies are needed
to evaluate the role of vegetables types and cooking methods
on CVD risk factors among Kuwaiti adults.
The prevalence of metabolic syndrome is nearly 40%
among Kuwaiti adults.13 Both the fast-food and refined-
grains/poultry dietary patterns that were identified in
Kuwaiti adults were associated with a higher prevalence of
metabolic syndrome. The positive association between con-
sumption of a Western dietary pattern and metabolic syn-
dromes has been reported in the literature.39-41 Such an
association identified among Kuwaiti adults who were at
high risk of metabolic syndrome and CVD underscore the
importance of improving the dietary pattern to reduce the
CVD burden in Kuwait. In line with our findings, the Global
Burden of Disease project estimated that a suboptimal diet
consisting of low intake of fruits, vegetables, whole grains,
nuts/seeds, seafood n-3 fats, and polyunsaturated fats and a
high intake of processed meats, unprocessed red meats, SSBs,
sodium, and trans fats contributes to a substantial burden of
CVD and diabetes in Kuwait and other GCC countries.42 In
Kuwait, an estimated of 1,540 CVD deaths and 108 diabetes
deaths were attributable to suboptimal diet, accounting for
57.1% of the total CVD and diabetes deaths that occurred in
Kuwait in 2010.42
The younger generation in Kuwait had a much higher
adherence to both the fast-food and refined-grains/poultry
dietary patterns compared with the older generation.
Indeed, Allafi and colleagues43 reported that among Kuwaiti
adolescents, about 30% reported consuming fast foods more
than 3 times a week, 60% reported consuming sweets and
SSBs >3 times a week, and approximately 70% did not
consume vegetables, fruits, and dairy products on a daily
basis.43 More than 75% of the Kuwaiti population are younger
than age 40 years.44 This highlights the importance of
nutrition policies and interventions targeting Kuwaiti youth
for reducing the CVD burden of the nation. In addition,
March 2020 Volume 120 Number 3

women were more likely to adhere to the fast-food dietary
pattern and to the vegetable-rich dietary pattern than men
after controlling for age. In Kuwait, women also have a higher
obesity prevalence than men (44.0% vs 36.5%).12 In our study
population, education was positively associated with adher-
ence to the fast-food dietary pattern after controlling for age
and income. A possible explanation for the observed result is
that a high level of job involvement requires individuals to
work longer hours leaving scarce time for individual to pre-
pare or eat healthy food.45 The difference in dietary patterns
by sex and education and its role in determining the risk of
CVD in Kuwaiti warrant further investigation.
The present study has limitations. First, although principal
component analysis is widely used in nutritional epidemi-
ology research,16,46 it involves some arbitrary decisions
regarding combining food items into groups, determining the
number of factors to retain, and naming of factors. Second,
the cross-sectional design of this study precluded making
causal inferences about the observed associations and the
observed findings need to be confirmed in future prospective
studies. To minimize reverse causation, individuals who were
diagnosed by a physician as having diabetes, hypertension, or
dyslipidemia before the survey were excluded in this anal-
ysis. Third, the assessment of dietary intake was based on a
single 24-hour recall, which does not represent usual intake
at the individual level.47 Fourth, dietary intake patterns tend
to be correlated with socioeconomic status and lifestyle fac-
tors such as education and smoking.16 Although adjustments
for known potential confounders were included in all
regression models, residual confounding can still occur and
bias the observed associations. Last, although the NNSSK is a
national nutrition survey, only one-quarter of eligible par-
ticipants completed the survey and of these, participants
with pre-existing health conditions were excluded.
Compared with the census data of Kuwaiti adults, the par-
ticipants included in this study were younger and had a
higher level of education. Thus, our findings may not be
generalizable to the whole adult population in Kuwait.
Despite these limitations, to our best knowledge, this study is
among the first to evaluate associations between dietary
patterns and CVD risk factors among Kuwaiti adults who
have experienced a rapid increase in CVD diseases and risk
factors.11-14
CONCLUSIONS
Kuwait and other GCC countries have experienced rapid ur-
banization due to economic growth, and during the same
period the burden of diet-related diseases has been
increasing among all segments of the population in these
countries. In this study of Kuwaiti adults, adherence to the
fast-food and refined-grains/poultry dietary patterns was
associated with CVD risk factors and metabolic syndrome. In
the case that this is confirmed in future longitudinal studies,
these findings point to an urgent need for population-based
strategies to improve nutrition and reduce CVD burden in
Kuwait and other GCC countries.
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AUTHOR INFORMATION
B. Al-Lahou is a doctoral candidate, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA, and a research assistant,
Kuwait Institute for Scientific Research, Kuwait City, Kuwait. L. M. Ausman is a professor, and F. F. Zhang is an associate professor, Friedman
School of Nutrition Science and Policy, and G. S. Huggins is an associate professor, Sackler School of Graduate Biomedical Sciences, Tufts
University, Boston, MA. J. L. Peñalvo is an adjunct assistant professor, Friedman School of Nutrition Science and Policy, Tufts University, Boston,
MA, and a professor, Institute of Tropical Medicine Antwerp, Antwerpen, Belgium. S. Al-Hooti is retired; at the time of the study, she was a
researcher, Food and Nutrition Program, Kuwait Institute for Scientific Research, Kuwait City, Kuwait. S. Al-Zenki is a science and technology
director for Environment and Life Sciences Research Centers, Kuwait Institute for Scientific Research, Kuwait City, Kuwait.
Address correspondence to: Fang Fang Zhang, MD, PhD, Friedman School of Nutrition Science and Policy, Tufts University, 150 Harrison Ave,
Boston, MA 02111. E-mail: fang_fang.zhang@tufts.edu
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
This research was supported by Kuwait Institute for Scientific Research and supported partially by the Kuwait Foundation for the Advancement of
Science (grant no. 2003-1202-02).
AUTHOR CONTRIBUTIONS
B. Al-Lahou, L. M. Ausman, J. L. Peñalvo, G. S. Huggins, and F. F. Zhang designed this research; B. Al-Lahou analyzed data and performed statistical
analysis; B. Al-Lahou, L. M. Ausman, and F. F. Zhang wrote the manuscript; and all authors contributed to the manuscript revisions and read and
approved the manuscript.

436 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS March 2020 Volume 120 Number 3