The palm or the plate? An assessment of dietary guideline promotion, awareness, and preferences among Saudis: cross-sectional survey

Food-based dietary guidelines (FBDGs) are specific guidelines established by countries in order to provide citizens with recommendations on how to eat healthily [1]. Generally, FBDGs are composed of science-based messaging, easily translated for the general public’s benefit, along with simple infographics and resources to ensure the messages can be easily understood [2]. The framework for FBDGs has been laid out by organizations like the World Health Organization (WHO) and the Food and Agriculture Organization (FAO) [3]. These groups suggest that FBDGs should be realistic, attainable, and culturally sensitive [4].

Since the FAO and WHO provided guidelines for implementing FBDGs in the 1990s [3], many countries have created various dietary guidelines and recommendations based on the FAO and WHO FBDG framework. Indeed, the WHO and FAO suggested that FBDGs need to be culturally sensitive and developed within the context of a specific country [5].

In Saudi Arabia, the Ministry of Health first issued the Healthy Food Palm dietary guideline in 2012 [6, 7] to provide dietary guidance to Saudi population. Graphically represented as an easily recognizable palm tree, the Healthy Food Palm presents food groupings and associative servings, similar to the USDA Food Guide Pyramid [8]. Subsequently, and contrastingly, in 2020, the Saudi Food and Drug Authority (SFDA) issued the Saudi Healthy Plate dietary guideline [9]. The Saudi Healthy Plate visually depicts five food groups, similar to the Eatwell Plate UK [10]. Both Saudi dietary guidelines encourage healthy and diverse eating options. Since the inception of both the Healthy Food Palm and the Saudi Healthy Plate, however, little research has focused on or ascertained public awareness of and adherence to either guideline and their effects on improving Saudis’ diets.

In fact, a literature review of post-2012 research revealed that few studies have assessed adherence to or awareness of the Healthy Food Palm and the Saudi Healthy Food Plate guidelines. Two cross-sectional studies conducted in 2019 [11, 12] did measure adherence to the Healthy Food Palm among Saudis. Results from Halawani et al. [11] showed that Saudis “do not adhere” to the Healthy Food Palm, and in general, the dietary intake of normal BMI, undergraduate, and single participants were lower than the recommended range comparatively. Another study [12] measured adherence to the Healthy Food Palm among Saudi males with and without cardiovascular diseases (CVD). They found that the non-CVD individuals consumed more fruit, olive oil, and non-alcoholic beer compared to individuals with CVD. In terms of guideline awareness, a survey study [13] that explored the views of Saudi male teachers on teaching nutrition in public high schools discovered that a majority of participants (73%) were aware of the American Food Pyramid, yet only 36% were aware of the Saudi Healthy Food Palm guideline.

A recent literature survey [14] investigated the awareness or use of dietary guidelines among Saudi mothers. Interestingly, the study assessed participant knowledge of American dietary guidelines, not Saudi dietary guidelines. To the best of our knowledge, there has been a dearth of studies assessing what differing effects, if any, the Healthy Plate versus the Healthy Palm has had on Saudi dietary habits. Given this, the aim of this survey study is to assess Saudi awareness, perceptions, and preferences in terms of the Healthy Palm and the Saudi Healthy Plate dietary guidelines.

Although FBDGs have been implemented across multiple countries, data surrounding their influence and success rate is limited. One literature review assessing FBDGs across four diverse countries found that nutritional surveys were not sufficient to determine the impact of FBDGs on dietary habits within a population [27]. As well as the overall lack of published research on the evaluation of FBDGs, many factors impede the success of FBDGs across various populations. Although some countries with FBDGs have an official body responsible for the implementation of these guidelines, some lacked a plan, strategy, or budget for guideline implementation. Further, in countries where FBDGs have been implemented for several years, there is a noticeable lack of monitoring or evaluation data [5].

This study revealed that approximately 15% of the participants recognize the Healthy Food Palm and the Saudi Healthy Plate guidelines by name. This is slightly lower than the results obtained by Tagtow and Raghavan in 2017, which found that 20.2% of 6,464 participants recognized the USDA’s MyPlate guidelines by name [20]. Like this study, a majority of studies [20, 27, 28] in this field use visual images of the FBDGs to ascertain participant familiarity with the guidelines. As Rong et al. [29] note, graphics help “people better understand the semi-quantitative information about each food group and apply dietary guidelines recommendations into practice in their daily lives.”[29], p. 220].Thus, focusing on image recognition, in this study 15.9% and 30.3% of respondents indicated that they had previously seen the Healthy Food Palm and Saudi Healthy Plate images, respectively.

The Saudi Healthy Plate guidelines were established in Saudi Arabia in 2020, while the Healthy Food Palm guidelines were established back in 2012. It is plausible that the more recent release of the Saudi Healthy Plate guidelines is a key factor in explaining why almost twice as many participants recognized images from the Saudi Health Plate as compared to the Healthy Food Palm image. However, in a study of dietary guidelines in Arabic-speaking countries, Coats et al. [30], found that “Graphical representation of culturally appropriate food choices and servings sizes,” which the Saudi Healthy Palm uses, “is a useful education tool for clinicians and registered dietitians” [30], p. 1130].

In contrast to these findings, a 2018 study of the USDA MyPlate guidelines found that almost two-thirds of 23,343 American participants were able to recognize the MyPlate icon [31]. This number is significantly higher than the findings established here and may be worth investigation and inquiry into the factors that contributed to a higher guideline recognition rate. It is important to note, however. that recognition of the guidelines, either by name or by image, does not necessarily correlate to knowledge of or an understanding of the guidelines themselves. In a systematic of 1,765 articles, Boylan et al., [32] found that “recognition of [dietary] guidelines did not signify understanding.” [32], p. 1].

In this study, 53% of respondents were able to correctly identify the number of food groups within the Healthy Food Palm guidelines, despite only 15.9% of respondents indicating that they had previously seen the corresponding image. This may indicate that the fundamental message of the guidelines is being heard, regardless of how frequently and in what media the associated image is shared or used. Similarly, 54% of participants gave the correct answer when asked how many food groups were in the Saudi Healthy Plate guidelines.

Approximately half of the respondents were able to correctly identify which foods should be consumed at which levels for both the Healthy Food Palm guidelines and the Saudi Healthy Plate guidelines. Comparatively, a 2013 study in the United States found that 45% of participants recognized the USDA's MyPlate guidelines [33].

Despite the fact that approximately half of the subjects in the current study comprehended the Healthy Food Palm and the Saudi Healthy Plate guidelines, a far lower proportion of respondents reported actually adhering to the guidelines. Among participants who expressed that using the Healthy Food Palm or the Saudi Healthy Plate guidelines was helpful, only approximately 4% self-reported eating five portions of fruits and vegetables a day. This aligns with findings from other countries which have reported low overall adherence to FBDGs [34]. Similarly, a more recent study of adults in the United Kingdom reports low adherence to the government’s Eatwell guidelines [35]. The aforementioned study performed in the United Kingdom indicated that less than 0.1% of the sample adhered to all 9 of the Eatwell guidelines, and approximately 26% of the sample adhered to the fruit and vegetable guideline, which, like the Saudi Healthy Plate guidelines, recommends five portions of fruits and vegetables per day [35].

The findings from the present study demonstrate a preference for the Saudi Healthy Plate guidelines as compared to the Healthy Food Palm. However, approximately 25% of the sample reported that they preferred neither the Healthy Food Palm nor the Saudi Healthy Plate guidelines. This may shed light on the need to include stakeholder perspectives on the concept of dietary guidelines to find “appropriate national dietary advice” [36]. Additionally, further understanding why 53.6% of respondents preferred the Saudi Healthy Plate guidelines, compared to 21.4% who preferred the Healthy Food Palm, could help identify the components of dietary guidelines that the public could more easily comprehend and adhere to. Understanding the popularity of the Saudi Healthy Plate could help to further optimize FBDGs and improve adherence throughout the population. Indeed, much remains to be understood regarding the factors required for successful FBDG creation and implementation.

Overall, findings from the present study indicate that awareness of the current Saudi dietary guidelines is lacking among the general population. Among the participants who were aware of the guidelines, a majority could accurately identify the correct number of food groups and servings recommended by each set of guidelines. However, this did not translate into adherence, with only 10% of respondents indicating that they were following the Saudi Healthy Plate guidelines. Surprisingly, neither social media campaign promotions nor the presence of an influencer was identified by participants as factors that would affect their dietary choices. Rather, participants indicated that food availability and convenience and the state and quality of their own health were the most influencing factors in terms of their dietary choices.

Given the study’s findings, unique opportunities exist for dietary guideline promotion and positive changes in dietary behavior, particularly when a broad spectrum of influencing factors is considered. Future research should not only consider demographic factors but should also look at environmental influences, housing and economic status and stability, and the presence and availability of food, or lack thereof as in a “food desert” [40].

As well, while social media campaigns and influencers may change dietary behaviors for some, making healthy foods more available and convenient, and dietary guideline promotion that shows a stronger nexus between BMI, weight, energy levels, for example, and other markers of personal health, might create more optimal public health engagement.

While the current study offers preliminary insights into the two dominant FBDGs in Saudi Arabia, more research is required to better understand how Saudis view and use the Saudi Healthy Plate and Healthy Palm dietary guidelines. In general, although it is possible that FBDGs can contribute to better health outcomes and a reduction in non-transmissible chronic diseases, more research needs to be conducted to better understand dietary choice and behaviors and to more comprehensively understand how to optimize FBDGs.