Awareness of the Mediterranean Diet and its Perceived Effect on Cardiovascular Health in the Western Region, Saudi Arabia

Summary

Objective:

To increase awareness of mediterranean diet (MD) and its perceived effects on cardiovascular health, enhance knowledge and inform public health efforts aimed at improving the population's health outcomes of. The MD comprises heart-healthy eating patterns high in vegetables, legumes, nuts and seeds, and fruits.

Methods:

This cross-sectional study involved adult participants who were living in the Western region of the Kingdom of Saudi Arabia. The data were collected online through social media platforms, then cleaned, coded, and analyzed using Statistical Package for the Social Sciences, version 21 to generate key insights.

Results:

A total of 390 participants were included in the study. The study noted gender differences in the awareness of core MD components, with females showing better knowledge than males (p = 0.009). Compared to other age groups, participants aged 18–29 years demonstrated significantly higher awareness of the diet (p = 0.008) and cardiovascular risk factors (p = 0.009). Common foods cited as good sources of dietary fiber include oats (302, 48.5%) and legumes (199, 31.9%).

Conclusion:

The study demonstrated a lack of awareness of the MD among the participants, but female and young adults demonstrated better awareness of the diet and its perceived effects on cardiovascular health. The research identified critical deficiencies in knowledge and awareness regarding the importance of MD in cardiovascular health. These findings call for greater public education and awareness regarding healthy lifestyle and dietary choices, aimed at encouraging healthy practices and enhancing overall wellbeing.

Introduction

Mediterranean diet (MD) emphasizes the intake of fresh, minimally processed, plant-derived foods, primarily including fruits, vegetables, whole grains, and various other plant-based items [1,2]. This dietary approach intentionally limits the intake of dairy products, red and processed meats, and sugars while allowing for moderate consumption of fish and poultry [3]. Research by Martínez-González et al. [4] indicates that following the MD plays a substantial role in enhancing cardiovascular health by lowering significant risk factors like cholesterol levels, hypertension, and obesity.

Research shows that the MD not only prevents overall cardiovascular events but also significantly reduces susceptibility to specific cardiovascular diseases (CVDs) like acute coronary syndrome (ACS) and hypertension [5]. These benefits are not necessarily associated with any particular component of the MD; rather, the benefits come from a holistic interaction of the different components that make up the MD.

Kingdom of Saudi Arabia (KSA) has experienced significant socioeconomic growth over recent decades, resulting in substantial changes to lifestyles. As a result, the prevalence of cardiovascular disease (CVD) among the Saudi population has reached unprecedented levels, making it 1 of the primary causes of death in the nation [6]. A systematic review of research conducted in KSA identifies 4 key factors contributing to the heightened risk of CVD: physical inactivity, obesity, poor dietary habits, and smoking [7]. In parallel with this rapid socioeconomic advancement, there has been a notable rise in the intake of processed foods that are high in calories, fats, and sugars [7]. Fast foods have progressively replaced the traditional local diet that characterized Saudi food. Research has consistently advocated consumption of the MD which helps people attain maximum nutritional benefits while minimizing caloric intake [8,9].

Despite the health benefits associated with the MD, little research has assessed the Saudi population's knowledge and awareness of the MD and its associated health benefits. Given the distinct cultural context of dietary habits in KSA, and the fact that the MD originates from countries bordering the Mediterranean Sea rather than from traditional Saudi cuisine, it is important to examine the extent to which modern-day Saudis are aware of this dietary pattern and its connection to cardiovascular health. Thus, this study seeks to assess the knowledge and awareness of the MD and its potential cardiovascular health benefits among adults in the Western Region of KSA. The results of this study will help to inform public health policy, particularly with regards to cardiovascular health.

Method

This research, conducted between November 2024 and December 2025, utilized a cross-sectional design conducted among the adult population in the Western region of KSA. An online survey was distributed among the target population, which included individuals aged 18 years and above. Exclusion criteria were age under 18 years, living outside the specified region, and age over 65 years.

The study included a total of 390 adult residents from the Western region. Participants were recruited using a convenience sampling method. The sample size was calculated based on an estimated population of 5,000,000, a hypothesized outcome frequency of 50%, a 5% margin of error, and a 95% confidence level, yielding a minimum required sample of 385 participants. To account for potential incomplete responses, a total of 390 participants were included in the final analysis.

Data was collected using the Mediterranean Diet Nutrition Knowledge Questionnaire (Med-NKQ), a pre-validated, self-administered tool. The original Med-NKQ is a 20-item instrument that was developed and validated to assess awareness of the MD and its effect on cardiovascular health in an Australian population [10]. For this study, the questionnaire was culturally and linguistically adapted for the Saudi context. This process involved forward translation from English to Arabic by a professional translator, followed by a review and validation of the translated version by a panel of experts, including a professor of English language and nutrition specialists, to ensure conceptual accuracy, clarity, and cultural appropriateness. A pilot study involving 40 participants (10% of the total sample) was conducted to assess feasibility, clarity, and internal consistency (Cronbach's alpha) of the adapted Arabic instrument. The finalized Arabic questionnaire was developed using an online Google forms platform and distributed electronically to participants across the major cities of the Western region.

After collecting the data, the information was input into a Microsoft excel spreadsheet for initial cleaning. This process involved removing duplicate entries, dealing with unusual data points, and excluding responses that were incomplete. Once the data was cleaned, it was coded and transferred into Statistical Package for the Social Sciences, version 21, for further analysis. A Kolmogorov-Smirnov test was used to check if the data followed a normal distribution. For descriptive statistics, categorical data was shown as frequencies (n) and percentages (%). To examine the relationships between socio-demographic factors (independent variables) and knowledge scores regarding cardiovascular risk factors and core MD foods (dependent variables), non-parametric tests were used. The Mann-Whitney U test was applied to compare 2 groups, such as gender-based, while the Kruskal-Wallis H test was used for comparisons among more than 2 groups, such as age, city, income, and education. To categorize participants into low, moderate, and high awareness levels of MD, the following procedure was applied. First, a total knowledge score was calculated for each participant. The arithmetic mean of the total scores was 31.4 (SD = 5.3). Using the mean and standard deviation, the distribution was transformed into 3 ordinal levels: low awareness was defined as a score below the mean minus 1 standard deviation (≤26); high awareness was defined as a score above the mean plus 1 standard deviation (≥37); and moderate awareness was defined as scores falling between these 2 thresholds (27–36). Subsequently, the total awareness variable was recorded into these 3 categories. To examine associations between socio-demographic characteristics (gender, age, city, monthly income, educational level) and these 3 awareness levels (low, moderate, high), a Chi-square test was used, as it is appropriate for comparing categorical and ordinal descriptive variables. A p - value of less than 0.05 was considered statistically significant.

The study received ethical approval from the appropriate Institutional Review Board before it began. Each participant provided their consent electronically before completing the questionnaire. Everyone was free to choose whether to take part, and there were no rewards given. The privacy and anonymity of all participants were carefully protected during the entire research process, and the information gathered was used only for academic purposes.

Results

The study included a total of 390 participants (Table 1). Most respondents were males (67.9%) and within the age group of 18–29 years (60.5%). The majority resided in Al-Madina Al-Munawwarah (50.2%), while smaller proportions were from Jeddah (19.2%), Taif (10.3%), Yanbu (10.3%), and Makkah Al-Mukarramah (9.7%). A large proportion held a bachelor's degree (65.9%), followed by those with secondary education (25.1%); only a small percentage had only primary or intermediate education. More than half of the participants reported a monthly income of less than 5000 Saudi Riyals (SAR) (51%).

Table 1.

Socio-demographic characteristics of participants (N = 390).

Variable	Category	Frequency (n)	Percentage (%)
Gender	Male	265	67.9
	Female	125	32.1
Age (in years)	18–29	236	60.5
	30–39	48	12.3
	40–49	58	14.9
	50–65	48	12.3
City	Makkah Al-Mukarramah	38	9.7
	Jeddah	75	19.2
	Al-Madina Al-Munawwarah	197	50.2
	Taif	40	10.3
	Yanbu	40	10.3
Monthly Income	Less than 5000	199	51
	5000–10000	78	20
	More than 10000	113	29
Educational Level	Primary	2	0.5
	Intermediate	5	1.3
	Secondary	98	25.1
	Bachelor	257	65.9
	Postgraduate	28	7.2

N: total number.

In Table 2 percentages are calculated based on multiple-response items. Participants were allowed to select more than 1 answer for several questions; therefore, percentages do not sum to 100% and may exceed the total number of participants (N = 390). Percentages reflect the proportion of participants who selected each response option. Therefore Table 2 (awareness of cardiovascular risk factors), shows most of the participants were aware of the importance of dietary fiber in lowering cholesterol levels (302, 57.3%) and of butter in increasing cholesterol levels (317, 61.2%). The participants knew that common foods containing healthy fats include unsalted nuts (289, 38.6%), salmon (275, 36.7%), and dark chocolate (146, 19.5%). Fewer than half of the participants identified correct practices to lower blood pressure, including salt reduction (318, 40.3%) and losing weight if overweight (294, 39.1%).

Table 2.

Participant knowledge and awareness of cardiovascular risk factors and heart-healthy practices.

Question	N	%
Which of the following statements are true for lowering blood pressure? (Select all that apply.)
Eating more fruits and vegetables.	178	22.5
Eating more foods containing whole grains such as wheat and barley.	69	8.7
Reducing consumption of foods high in processed fats and sugars.	201	25.4
Eating more legumes.	24	3
Reducing salt in food.	318	40.3
Which of the following options can help lower blood pressure? (Multiple options)
If overweight, try to lose weight.	294	39.1
Eating more leafy green vegetables.	202	26.9
When choosing canned foods, select those with lower salt content.	239	31.8
Eating more white bread.	16	2.1
Which of the following statements is correct? (Multiple options)
Fruits and vegetables are beneficial solely because of the vitamins and minerals they contain.	123	23.3
Fats are unhealthy in all cases and should be avoided whenever possible.	102	19.4
Dietary fibre plays an important role in reducing cholesterol levels.	302	57.3
Which of the following foods is most likely to raise cholesterol levels? (Multiple options)
Extra virgin olive oil	87	16.8
Butter	317	61.2
Whole grain bread	114	22
What is the recommended daily intake of vegetables?
(One serving equals half a cup of cooked vegetables or 1 cup of raw vegetables/salad)
2 servings	192	49.2
3 servings	146	37.4
5 servings	46	11.8
7 servings	6	1.5
Which of the following foods contains healthy fats? (Multiple options)
Unsalted nuts	289	38.6
Dark chocolate	146	19.5
Salmon fillet	275	36.7
Butter	39	5.2
Which of the following foods is considered a good source of dietary fiber? (Multiple options)
Cornflakes	78	12.5
Oats	302	48.5
Rice crackers (Japanese rice crackers)	44	7.1
Legumes (such as chickpeas, kidney beans, lentils)	199	31.9
Which of the following foods contains a high percentage of salt? (Multiple options)
Smoked salmon	142	28.3
Boiled eggs	43	8.6
Canned tuna	317	63.1
Which of the following pasta dishes reflects the concept of the Mediterranean diet for heart health?
Pasta with tomato sauce	187	47.9
Pasta with mushrooms and cream sauce	203	52.1
By what percentage does following the Mediterranean diet reduce the risk of heart attacks?
0%	10	2.6
10%	30	7.7
30%	76	19.5
60%	32	8.5
I don't know	242	62.1
Looking at the 2 products below, which 1 contains the highest percentage of salt per 100 grams?
Option 1	275	70.5
Option 2	115	29.5
Looking at the bread contents of products 1 and 2, which 1 is healthier for the heart?
Bread No. 1	214	54.9
Bread No. 2	176	45.1

N: total number, %: percentage.

Survey results indicated that 48.5% of participants (n = 302) correctly identified oats as a good source of dietary fiber, and 31.9% (n = 199) correctly identified legumes. Additionally, nearly one-quarter of the participants correctly identified smoked salmon (142, 28.3%) as containing high sodium. About half, 187 (47.9%) of the participants correctly identified pasta with tomato sauce as a food reflecting the concept of MD for heart health, but only 76 participants (19.5%) were aware that the diet reduces the risk of heart attack by 30%.

Percentages in Table 3 are calculated based on multiple-response items. Participants were allowed to select more than 1 answer for several questions; therefore, percentages do not sum to 100% and may exceed the total number of participants (n = 390). Percentages reflect the proportion of participants who selected each response option. Therefore, Table 3 shows the varying levels of awareness regarding the core components of the MD. Fewer than a third of participants (26.0%, n = 171) were aware of the role of extra virgin olive oil as a core component. More respondents correctly identified leafy green vegetables (45.6%, n = 282) and unsalted nuts (35.6%, n = 220). Nearly one-third 205 (35%) of the participants correctly reported grilling as the most common cooking method in the MD. When asked to identify common flavors in the MD, participants most frequently gave correct answers for lemon (40.4%, n = 280), oregano (27.4%, n = 190), and garlic (25.7%, n = 178). A majority (304, 77.9%) were aware that water is the beverage most often consumed in the MD; and more than half (199, 51%) knew that vegetable and lentil soup with whole grain bread and olive oil is an excellent meal choice for heart health. Only 142 participants (36.4%) knew the most suitable diet for breakfast. The results showed a significant statistical relationship between age and awareness of CVD risk factors (p = 0.009). Participants aged 18–29 years demonstrated better general awareness of CVD risk factors than other age groups. Other socio-demographic variables were not statistically significant (Table 4).

Table 3.

Participant knowledge of core components, cooking methods, and food choices in the mediterranean diet.

Question	n	%
Which of the following foods are recognized as key components of the Mediterranean diet? (Multiple options)
White rice	132	20.1
Chicken breast	191	29
Legumes (chickpeas, kidney beans, lentils)	164	24.9
Extra virgin olive oil	171	26
Which of the following foods are recognized as key components of the Mediterranean diet? (Multiple options)
Unsalted nuts	220	35.6
Leafy green vegetables	282	45.6
Blue cheese	70	11.3
Salami	46	7.4
Which of the following is used to add flavor to foods in the Mediterranean diet?
(You may select more than 1 option)
Lemon	280	40.4
Bouillon cubes (Maggi)	45	6.5
Oregano	190	27.4
Garlic	178	25.7
Which of the following food preparation techniques are typically practiced in the Mediterranean diet?
(Multiple options)
Deep frying at high temperatures	60	10.2
Moist-heat cooking (such as boiling or steaming)	284	48.5
Grilling	205	35
Eating only raw foods	37	6.3
Which of the statements below correctly reflect the principles and characteristics of the Mediterranean diet?
(Multiple options)
Making extra-virgin olive oil the main fat source in daily meals	264	41.1
Drinking fruit juice with all meals	96	15
Eating red meat 3–4 times a week	99	15.4
A dietary pattern that is mainly plant-based	183	28.5
Which beverage is most commonly consumed as part of the Mediterranean diet?
Water	304	77.9
Fruit juice	60	15.4
Coffee	26	6.7
Which of the following meals is the best choice for heart health when following the Mediterranean diet?
Vegetable and lentil soup with whole grain bread and olive oil	199	51
Oven-baked fish with potatoes	51	13.1
Carbonara pasta	27	6.9
Grilled beef steak with green salad and fat-free dressing	113	29
For breakfast, which of the following is most suitable for the Mediterranean diet?
Eggs with smoked salmon on a slice of toast	248	63.6
Cooked fava beans with tomatoes and onions, served on a slice of toast	142	36.4

Table 4.

Association between socio-demographic characteristics and knowledge of cardiovascular disease risk factors (mean rank, p - value).

Characteristics	Mean rank	P - Value
Gender
Male	196.97	0.706
Female	192.38
Age (in years)
18–29	208.87	0.009*
30–39	153.25
40–49	178.91
50–65	192.08
City
Makkah Al-Mukarramah	199.04	0.206
Jeddah	192.36
Al-Madina Al-Munawwarah	186.25
Taif	230.84
Yanbu	208.24
Monthly income
Less than 5000	197.43	0.113
5000–10000	213.60
More than 10000	179.60
Educational Level
Primary	55.25	0.236
Intermediate	228.20
Secondary	208.32
Bachelor	192.81
Postgraduate	179.50

As seen in Table 5, results showed a significant statistical relationship between gender, age, city, and monthly income, and the awareness of core MD foods (p = 0.009, p = 0.033, p < 0.001, p = 0.024). In a significant gender difference, females demonstrated higher awareness than males. A large proportion of participants aged 18–29 years, those who resided in Taif city, and those who had a monthly income of less than 5000 SAR showed better awareness compared with the rest. On the other hand, education level was not statistically significant (Table 5).

Table 5.

Association between socio-demographic characteristics and knowledge of core mediterranean diet components (mean rank, p - value).

Characteristics	Mean rank	P - Value
Gender
Male	185.34	0.009*
Female	217.05
Age (in years)
18–29	208.76	0.033*
30–39	170.06
40–49	182.09
50–65	171.94
City
Makkah Al-Mukarramah	211.58	0.000*
Jeddah	218.77
Al-Madina Al-Munawwarah	171.47
Taif	249.88
Yanbu	200.54
Monthly income
Less than 5000	209.61	0.024*
5000–10000	190.56
More than 10000	174.06
Educational level
Primary	199	0.848
Intermediate	146.70
Secondary	199.44
Bachelor	196.18
Postgraduate	183.93

There was a significant statistical relationship between age or city and the awareness of MD (p = 0.008, p = 0.025). A large proportion of participants aged 18–29 years and residents of Taif city demonstrated higher awareness of MD than other groups (Table 6).

Table 6.

Association between socio-demographic characteristics and awareness of mediterranean diet.

Distribution of awareness levels by socio-demographic variables
			Level
Socio-Demographic variables			Low	Moderate	High	P - Value
Gender	Male	Count	56	172	37	0.278
		%	21.1%	64.9%	14.0%
	Female	Count	22	78	25
		%	17.6%	62.4%	20.0%
Age	18–29	Count	37	156	43	0.008*
		%	15.7%	66.1%	18.2%
	30–39	Count	18	22	8
		%	37.5%	45.8%	16.7%
	40–49	Count	14	36	8
		%	24.1%	62.1%	13.8%
	50–65	Count	9	36	3
		%	18.8%	75.0%	6.2%
City	Makkah	Count	6	27	5
		%	15.8%	71.1%	13.2%
	Jeddah	Count	13	52	10
		%	17.3%	69.3%	13.3%
	Al-Madinah	Count	49	121	27
		%	24.9%	61.4%	13.7%
	Taif	Count	5	21	14
		%	12.5%	52.5%	35.0%
	Yanbu	Count	5	29	6
		%	12.5%	72.5%	15.0%
Monthly income	Less than 5000	Count	34	133	32	0.144
		%	17.1%	66.8%	16.1%
	From 5000 to 10000	Count	13	49	16
		%	16.7%	62.8%	20.5%
	More than 10000	Count	31	68	14
		%	27.4%	60.2%	12.4%
Educational level	Primary	Count	1	1	0	0.399
		%	50.0%	50.0%	0.0%
	Intermediate	Count	0	5	0
		%	0.0%	100.0%	0.0%
	Secondary	Count	18	61	19
		%	18.4%	62.2%	19.4%
	Bachelor	Count	50	169	38
		%	19.5%	65.8%	14.8%
	Postgraduate	Count	9	14	5
		%	32.1%	50.0%	17.9%

Discussion

The rising burden of CVD in KSA, driven by shifting lifestyles and dietary patterns, creates a need for preventive nutritional strategies like the MD [11,12]. A critical challenge is that, while the need for such interventions is growing, awareness of the MD among the adult population in Western, KSA remains low. Our findings show that the majority of participants demonstrated low to moderate awareness of the diet, a trend consistent with low adherence rates reported in KSA [13]. This gap shows that we must develop clear and targeted awareness campaigns that present the MD not as a foreign concept, but as a flexible and beneficial pattern that can include local foods and flavors.

The demographic patterns within our data offer crucial insights for designing these targeted awareness campaigns. The significantly higher awareness among young adults (aged 18–29) suggests that educational institutions are a key channel for sharing information. This group, often more exposed to global health trends and nutritional information in academic settings, can be leveraged as early adopters and peer influencers. Furthermore, the observed gender and geographical disparities—with females and residents of Taif city demonstrating better knowledge—highlight the role of social and cultural exposure. Taif's status as a tourist hub may facilitate a broad exchange of culinary practices, suggesting that an effective strategy could be promoting the MD through a lens of cultural variety, rather than health alone. A particularly revealing finding was the high MD awareness among lower-income groups, which may reflect the high proportion of students in our sample. This is a key opportunity; public health messaging should actively counter the idea that MD is expensive. Campaigns can focus on its affordable core components—like legumes, whole grains, and seasonal vegetables—and provide practical, budget-friendly cooking guides. Partnering with universities to offer workshops and affordable MD-based meals in cafeterias could directly reach this engaged but often budget-conscious group.

Beyond general awareness, our study identified specific knowledge deficits that need addressing. Although participants showed a basic understanding of certain heart-healthy concepts, considerable uncertainty existed about the core components of the MD, such as low recognition of extra virgin olive oil as a cornerstone of the diet. Healthcare providers can play a central role in improving this. During routine check-ups, doctors and nurses can give simple, clear advice about the proven benefits of the MD, such as its potential to reduce heart attack risk. Making this connection between the diet and a powerful health outcome can motivate people to learn more.

Most participants expressed uncertainty regarding basic questions about the MD, reflecting a widespread lack of knowledge about its health benefits. The findings strongly indicate a need for enhanced public awareness. By using targeted education programs, correcting misconceptions, empowering healthcare providers to give simple advice, and highlighting the diet's proven benefits, we can begin to close this knowledge gap. Enhancing understanding of the MD is crucial for promoting health dietary habits and lifestyle choices, which are essential for improving health outcomes of the population in KSA.

Study limitations

Firstly, the cross-sectional design permitted the examination of relationships among the variables, yet it fell short of establishing causal links. Secondly, the reliance on a self-administered online survey for data collection may have introduced bias, as there was no method to verify the accuracy of participants’ responses. Additionally, utilizing convenience sampling through social media platforms could limit the generalizability of the results, especially since those with greater digital literacy, internet access, and a heightened interest in health-related matters may be overrepresented. Finally, as the research focused solely on the Western region of KSA, its findings may not be relevant to other populations.

In conclusion, the study demonstrated a lack of awareness of the MD among the participants, but female and young adults demonstrated better awareness of the diet and its perceived effects on cardiovascular health. The research identified critical deficiencies in knowledge and awareness regarding the importance of MD in cardiovascular health. While some participants demonstrated knowledge of specific heart-healthy practices, overall understanding of the MD as a comprehensive dietary pattern remained limited. These findings call for greater public education and awareness regarding healthy lifestyle and dietary choices, aimed at encouraging healthy practices and enhancing overall wellbeing.

Disclosure statement

AI tools were utilized in the writing of this article for language editing and grammar enhancement purposes only. No AI tools were used in the creation of images, collection of data, or analysis of data. No part of this article has been presented in any conference proceedings or in any preprint servers.

Acknowledgement

We would like to thank Cambridge proofreading (www.proofreading.org) for the English language editing.

Disclosure

The authors have no conflict of interests to declare. The work was not supported or funded by any drug company or external source.