Development of the Saudi Healthy Eating Index

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Alzeer, Omar Alhumaidan, Sarah Alkhunein, Areej Alkhaldy This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6099915/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 30 Jul, 2025 Read the published version in BMC Nutrition → Version 1 posted 13 You are reading this latest preprint version Abstract Background: The present study aimed to develop the Saudi Healthy Eating Index (SHEI) to assess adherence to the 2024 version of the Saudi Healthy Plate (SHP) guide and to evaluate diet quality among the Saudi population. Methods: Twelve components were selected for the SHEI based on the key dietary recommendations of the SHP guide. All components are scored between zero and ten points, except for components measuring the same dietary aspect, which are assigned up to five points. The total adherence score ranges between zero (no adherence) and 100 (complete adherence). Results: Maximum scores and standards were assigned to each component as follows: fruits (ten points, ≥0.6 servings/1000 kcal), vegetables (ten points, ≥1.1 servings/1000 kcal), grains (five points, ≥3.5 servings/1000 kcal), whole grain ratio (five points, ratio of whole grains to total grains ≥ 0.5), protein foods (five points, ≥2.2 servings/1000 kcal), seafood and plant-based protein foods (five points, ≥0.9 servings/1000 kcal), dairy products (ten points, ≥0.8 servings/1000 kcal), beverages (ten points, only water or non-sweetened beverages consumed), fatty acid ratio (ten points, ratio of unsaturated to saturated fatty acids ≥ 2.6), saturated fats (ten points, ≤7% of energy intake), added sugar (ten points, ≤5% of energy intake), and sodium (ten points, ≤0.8 grams of sodium per 1000 kcal). Conclusion: The SHEI was designed to measure diet quality by determining adherence to the SHP guide recommendations. The SHEI has various potential applications, including research, evaluation of dietary interventions, and monitoring diet quality among the Saudi population. Healthy Eating Index Diet quality Diet quality index Diet indices Saudi Arabia 1. Background Healthy dietary patterns contribute to greater longevity[ 1 ]. For example, higher diet quality was found to be associated with a reduced risk of noncommunicable diseases and mortality[ 2 ], and a large systematic review and meta-analysis revealed that low diet quality was linked to diabetes, cardiovascular disease, cancer, and all-cause mortality[ 3 ]. Several dietary indices have been developed to assess diet quality by categorizing individuals according to their adherence to national dietary guidelines [ 4 ]. These dietary indices serve as valuable tools for monitoring the nutritional status of populations, estimating the influence of nutritional interventions, and conducting epidemiological studies to evaluate the association between dietary patterns and the risk of certain diseases[ 5 – 8 ]. Among the most validated and most used dietary indices are the Healthy Eating Index (HEI)[ 9 ], the Diet Quality Index-International (DQI-I)[ 10 ], and the Mediterranean Diet Score (MDS)[ 11 ]. In particular, the HEI stands out as one of the leading indices for assessing the adherence of individual and population dietary intakes with dietary guidelines[ 11 ]. The HEI has several features and advantages, including (a) its adoption of a continuous (not discrete) scoring system, which facilitates various statistical analyses and related interpretations; (b) its application of the density approach to separate diet quality from quantity by calculating components as the amount of each food group per 1000 calories, which helps to overcome challenges associated with individual caloric requirements[ 9 , 12 , 13 ]; and (c) its explicit testing of validity and reliability[ 14 ]. Owing to these characteristics, several countries worldwide, such as Brazil[ 15 ], Malaysia[ 16 ], and China[ 17 ], have adopted the methodology introduced by Guenther et al.[ 12 ] and customized the HEI to develop their own national HEIs. In Saudi Arabia, there is a gap in standardized diet quality assessment tools designed to measure adherence to Saudi dietary guidelines. This gap could limit nutrition research and hinder evaluations of nutrition policies and interventions aiming to explore associations between diet quality and health-related outcomes among the Saudi population. The first set of dietary guidelines developed in Saudi Arabia, the Healthy Food Palm introduced by the Saudi Ministry of Health in 2012, portrayed food groups in the shape of a palm tree[ 18 , 19 ]. However, since its publication, only four studies have assessed adherence to the Healthy Food Palm. Halawani et al.[ 19 ] reported poor adherence of only 26% among Saudi adults. Alfreeh et al.[ 20 ] also found low adherence of 43% among Saudi female college students. Alkhaldy et al.[ 21 ] reported an adherence score of 26.5/60 among Saudi males with cardiovascular disease and a slightly higher score of 28/60 among healthy participants, while another study by Alkhaldy et al.[ 22 ] found similar adherence scores of approximately 24/50 among Saudis with and without colorectal polyps. In 2020, the National Nutrition Committee (NNC), a scientific advisory body operating under the Saudi Food and Drug Authority, released the first version of the Saudi Healthy Plate (SHP) guide in 2020[ 23 ], which was followed by an updated version in 2024[ 24 ]. Similar to the Eatwell Guide[ 25 ], both sets of guidelines emphasize five primary food groups, namely, grains and starches, fruits and vegetables, protein foods, dairy products, and fats and oils, and have sections for added sugar, sodium, and beverages[ 23 , 24 ]. Population adherence to either set of guidelines has yet to be measured. In recent years, Saudi Arabia has witnessed rapid urbanization and significant lifestyle changes, particularly in terms of dietary habits, which have seen a trend towards Westernization. This transition has contributed to an increase in the prevalence of obesity among individuals aged fifteen years and above, with rates reaching 24.1% for males and 33.5% for females[ 26 , 27 ]. A nationwide health survey revealed low intakes of fruits, vegetables, fish, nuts, and dairy products, alongside high intakes of meat and sugar-sweetened beverages[ 28 ]. Therefore, in line with the international practice of developing diet quality measurement tools to evaluate adherence to national dietary guidelines, the aim of this study was to describe the development of the Saudi Healthy Eating Index (SHEI) as a measure of diet quality for adults in terms of their adherence to the recommendations set in the 2024 version of SHP guide and present the strengths, limitations, and potential applications of the SHEI. The next phase of this research includes comprehensive validation and reliability testing of the SHEI to evaluate its efficacy in assessing diet quality among Saudi adults. These findings will be reported in subsequent publications. 2. Methods 2.1 Development of the SHEI The purpose of the SHEI is to measure adherence to the recommendations set in the SHP for Saudi adults aged eighteen years and above, with higher scores representing greater adherence (higher diet quality). The SHP was purposely designed to be direct and simple. It focuses on five main food groups: grains and starches, fruits and vegetables, protein foods, dairy products, and fats and oils. For each food group, the SHP guide presents the recommended servings, examples of a single serving, and some dos and don’ts related to cooking and preparation. Furthermore, it contains sections dedicated to added sugar and salt/sodium describing their recommended intake limits, possible substitutes, and their uncommon nomenclature found on food labels, plus a section on water and beverages. There is also an exemplary one-day menu, advice on healthy grocery shopping, detailed instructions on how to read food labels, and an exchange list of items from the main food groups[24]. Given the SHEI’s focus on dietary intake quality, sections of the SHP guide addressing nutritional behaviours or practices are not considered. 2.2 Components of the SHEI Table 1 lists the twelve SHEI components (fruits, vegetables, grains, whole grain ratio, protein foods, seafood and plant-based protein foods, dairy products, beverages, fatty acid ratio, saturated fats, added sugar, and sodium) selected to reflect the corresponding recommendations of the SHP guide. All quotations in this manuscript are translations from the original Arabic version of the 2024 SHP guide, translated by the first author and revised by the co-authors. 2.3 Weighting the SHEI components On the basis of the recommendations of the SHP guide, which emphasize the importance of a balanced intake of all food groups and nutrients to maintain a healthy and nutritious diet, the twelve components were each weighted at either ten points (fruits, vegetables, dairy products, beverages, fatty acid ratio, saturated fats, added sugar, and sodium) or five points if assessing the same dietary aspect (protein foods, seafood and plant-based protein foods, grains, and whole grain ratio), yielding a maximum total score of 100. 2.4 Scoring of the SHEI components After careful examination of several national HEIs, the least restrictive approach used in the HEI iterations developed by Guenther et al.[12] was adopted as the main guide for developing the SHEI. The scoring of the SHEI components was based on the density approach, expressed as amounts per 1000 calories of intake, except for ratio-based components (e.g. beverages). The recommended amounts of each food group according to the SHP guide were thus quantified in amounts per 1000 kcal at seven caloric patterns ranging from 2000 to 3200 kcal at 200 kcal intervals to meet the nutrient recommendations for adults aged eighteen years and above[29], as listed in Table 2 and Table 3 . The caloric patterns from 1000 to 1800 kcal were not considered because the SHP guide was designed for the adult population. The least restrictive or easiest-to-achieve recommendation was selected as the standard for the maximum score cut-off value for all components, except for the whole grain ratio, beverages, and sodium components. The recommended amounts of whole grain ratio and beverages were based on the literal recommendations in the SHP guide. A strong correlation exists between sodium and energy intake; thus, setting cut-off values for the absolute intake of sodium (per gram) is not ideal[30]. This indicates that the thresholds for sodium should be associated with energy intake. Calculating scores for adequacy components is simple because none of the components result in a logical zero score, and intakes within the minimum and maximum cut-off ranges for adequacy components are scored proportionately and calculated as follows[16]: Calculating scores for moderation components is not as straightforward because increased intakes equal lower scores, there is no obvious zero to set the minimum scores at, and there is no established evidence to indicate at which intake a zero should be set. This may lead to a floor or ceiling effect, wherein most of the sample scores are either too low or too high[12]. Hence, to mitigate this problem, national HEIs typically use population intake data to set the thresholds (e.g. the 90th percentile of the population intake for one day)[9, 16, 17, 31]. However, a comprehensive national nutrition survey has never been conducted in Saudi Arabia, making it impossible to determine cut off values based on the percentiles of population intake. Therefore, cut-off values for moderation components were set based on Saudi nutrition experts' judgment and compared with values in other national HEIs to check for feasibility and practicality. Intakes within the minimum and maximum cut-off ranges for moderation components are scored proportionately and calculated as follows[16]: 3. Results 3.1 SHEI components and scoring standards Table 4 lists the SHEI components, maximum score points, and the standards for attaining maximum and minimum scores. 3.1.1 Fruits and vegetables The SHP guide recommends the following: “It is preferable to eat more vegetables than fruits”. Thus, fruits and vegetables are split into two separate components with cut-off values reflecting the recommendation (i.e. ≥0.6 servings/1000 kcal for fruits and ≥1.1 servings/1000 kcal for vegetables). These components include whole, juiced, frozen, dried, and canned fruits and vegetables, irrespective of their cooking method (e.g. frying) or preparation method (e.g. salting), because the saturated fat, added sugar, and sodium contents are accounted for later in their respective components. 3.1.2 Grains and whole grain ratio Adherence to grain-related recommendations is assessed using two components: grains and whole grain ratio. Whole grains include any food with a whole grain as the first ingredient, while total grains include any food with any grain as the first ingredient. The first component focuses on the quantity of grains consumed, and its maximum score cut-off value is defined as ≥3.5 servings/1000 kcal based on the least restrictive method. The second component focuses on the quality of grains consumed, and its maximum score cut-off value is defined as whole grains (servings)/total grains (servings) ≥0.5 based on the following SHP guide recommendation: “Ensure that at least half of your grain intake is from whole grain foods”. The numerator includes all consumed servings of foods with a whole grain as the first ingredient, and the denominator includes all consumed servings of foods with any grain as the first ingredient[31]. The ten points are split between the two components to prevent the maximum points being attained when the recommended servings are consumed but not from the optimal source. As for the minimum score cut-off values, a score of zero is assigned for both when the corresponding component is not consumed. 3.1.3 Protein foods and seafood and plant-based protein foods Adherence to protein-related recommendations is assessed using two components. The first component is protein foods at ≥2.2 servings/1000 kcal, which focuses on the quantity of protein foods consumed. The second component is seafood and plant-based protein foods at ≥0.9 servings/1000 kcal, which focuses on the quality of the protein foods consumed and is derived from the following SHP guide recommendation: “Consume protein from a variety of sources”. The ten points are split between the two components to prevent the maximum points being attained when the recommended servings are consumed but not from a variety of protein sources. Irrespective of the cooking and preparation methods, the protein foods component includes seafood, eggs, poultry, meat, and plant-based protein foods, whereas the complementary component only includes seafood and plant-based protein (i.e. beans and legumes, nuts, and seeds). Beans and legumes are accounted for in both the vegetable and protein-related components because of their unique nutritional composition[9].To determine the servings for the seafood and plant-based protein foods component, initially, all consumed servings of seafood per 1000 kcal are counted. Subsequently, servings of beans and legumes per 1000 kcal are included until the maximum five points are achieved (i.e. at ≥0.9 servings/1000 kcal). Any servings of beans and legumes exceeding this threshold should then be accounted for in the vegetables component. 3.1.4 Dairy products The maximum score cut-off value for the dairy products component is defined as ≥0.8 servings/1000 kcal based on the least restrictive method. This component includes dairy-based beverages (e.g. milk and laban), yogurt, cheese, labneh, and other dairy products, irrespective of their fat, added sugar, and sodium contents. Plant-based dairy alternatives (e.g. coconut milk and soy yogurt) are not mentioned in the SHP guide as they are not widely consumed in Saudi Arabia[32]. Nevertheless, plant-based dairy alternatives are included in this component if their protein content is >2.2 g/100 g[33]. 3.1.5 Beverages The beverages component is derived from the following SHP recommendations: “Make sure to drink 3.7 litres for males and 2.7 litres for females of beverages per day” and “Limit consumption of sugary and caffeine-containing beverages”, where the latter highlights water and non-sweetened beverages as the preferred beverages of choice. The numerator includes the millilitres of water and non-sweetened beverages consumed (e.g. non-sweetened milk, tea, and coffee), and the denominator includes all beverages consumed including non-sweetened, sweetened, and artificially sweetened beverages. Artificially sweetened beverages are not included in the numerator because dietary recommendations generally advise replacing sweetened beverages with non-sweetened ones, rather than artificially sweetened alternatives[34]. The fat and sodium contents of dairy drinks (e.g. milk and laban) are not considered because these are accounted for in their respective components. Fruit or vegetable juice is not included in this component and is accounted for in either the fruit or vegetable components. The maximum score cut-off value of one is achieved when all beverages consumed are non-sweetened, whereas the minimum score of zero is assigned when all beverages consumed are sweetened. 3.1.6 Saturated fats and fatty acid ratio Fat-related recommendations focus on limiting saturated fat intake and ensuring a balanced unsaturated fat intake. They consist of two components: fatty acid ratio and saturated fats. The fatty acid ratio is an adequacy component reflecting the consumed ratio of unsaturated fatty acids to saturated fatty acids, with a maximum score cut-off value of ≥2.6 based on the least restrictive approach. The minimum score cut-off value is set at half of the maximum cut-off value (i.e. ≤1.3) based on expert judgement. We recognize that other countries have based their values on population intake data; however, because comprehensive nutrition survey data are not available for the Saudi population, it was necessary to implement an alternative. Notably, the present values are comparable to those of ≥2.6 and ≤1.1 defined in the 2015 version of the HEI (HEI-2015), based on the Dietary Guidelines for Americans[9]. Saturated fats is a moderation component measuring the alignment with the following SHP guide recommendation: “A healthy adult should not consume more than 10% of calories from saturated fat per day”. The maximum score cutoff value is at ≤7% of energy intake, which is rounded up from ≤6.7% of energy intake, set using the least restrictive approach. For the minimum score, the cut-off value is set at double the maximum cut-off value (i.e. ≥14% of energy intake) based on expert judgement, as done in other indices[9]. The HEI-2015 used the 85th percentile of saturated fat intake as a percentage of energy from the results of population-level nutrition surveys, corresponding to ≥16% of energy intake[9]. Following the saturated fats recommendation of ≤10% of energy intake defined in the SHP guide results in a score of approximately 6/10 in the SHEI, reflecting the recommendation to not exceed it. Each of the two components is allocated a score of ten points, reflecting their substantial yet distinct roles in diet quality and health. 3.1.7 Added sugar Another moderation component is added sugar, which measures alignment with the following SHP guide recommendation: “A healthy adult should not consume more than 50 grams (i.e. 10% of calories) of added sugar per day”. The maximum score cut-off value of ≤5% of energy intake is set based on the least restrictive approach as adopted in the HEI-2015[9]. Coincidentally, ≤5% of energy intake corresponds to the World Health Organization (WHO)’s conditional recommendation for free sugar intake[35]. Meanwhile, the minimum score cut-off value is set at five times the maximum cut-off value (i.e. ≥25% of energy intake) based on expert judgement. The HEI-2015 used the 90th percentile of added sugar intake as a percentage of energy for the maximum score cut-off value based on the results of population-level nutrition surveys, which corresponded to ≤6.5% of energy intake, and the minimum was set at four times that (i.e. 26% of energy intake)[9]. The recommended intake limit of 10% of energy intake results in a score of approximately 8/10 in the SHEI, reflecting the recommendation to not exceed it. 3.1.8 Sodium The strong correlation between sodium and energy intake suggests that maximum and minimum thresholds should be established based on energy intake. The SHP guide recommendation for sodium, based on WHO guidelines, is to consume less than 2000 milligrams per day[30]. The HEI-2015 set the maximum threshold for sodium at 2300 mg/2150 kcal, equivalent to approximately 1100 mg/1000 kcal. This is based on the average energy intake for young and middle-aged adults (i.e. 2150 kcal) used in the dietary reference intake for sodium, and the minimum threshold was calculated based on 17% of the one-day population intake levels (2000 mg/1000 kcal)[12]. As previously mentioned, comprehensive nutrition survey data are not available for the Saudi population, so determining the average population energy intake or specific percentiles is not possible. Instead, the cut-off values are derived from the median value of the adult energy requirement range, 2000–3200 kcal (i.e. 2600 kcal), in conjunction with the SHP guide recommendation for sodium intake. This approach mirrors the methodology used in the Chinese HEI by Yuan et al., which utilized the median value of the energy requirement range for the included age groups, 1000–3000 kcal (i.e., 2000 kcal), rather than population energy intakes, despite the availability of the latter[17]. Consequently, the maximum score cut-off value is set at the ratio of the recommended sodium intake to the median energy requirement for adults, 2000 mg/2600 kcal, equivalent to approximately 800 mg/1000 kcal, while the minimum score cut-off value is set at 2000 mg/1000 kcal, approximately two and a half times the maximum score cut-off value. 4. Discussion The purpose of this study is to outline the development of the SHEI, an index designed to measure adherence to the dietary recommendations provided in the SHP guide. The SHP guide focuses on five main food groups, namely, grains and starches, fruits and vegetables, protein foods, dairy products, and fats and oils, and it also contains sections for added sugar, sodium, and beverages, which are included in the SHEI as main components or utilized to derive other components. The index scoring is continuous, ranging from zero to 100, and the maximum and minimum cut-off values were generally derived based on the least restrictive approach; otherwise, they were chosen based on expert judgment or taken as defined in the SHP guide. Variations in national dietary guidelines necessitate tailored development processes for diet quality assessment tools[ 36 ]. This may include adopting and/or modifying existing methods or constructing new ones to ensure alignment with specific dietary guidelines, and it typically involves three key aspects. Firstly, variations in dietary patterns between populations must be considered when selecting the components of a given diet quality assessment tool. Protein foods, vegetables, fruits, and grains are the basic components of most tools, but their incorporation may vary depending on the national dietary guidelines they are based on. For instance, protein sources could be broadly grouped, such as into animal-based and plant-based categories[ 16 , 31 , 37 , 38 ]. In other cases, protein components may be further divided to afford up to five distinct components, including fish and seafood, red meat, poultry, soybeans, and eggs[ 17 ]. Taking into account religious practices, a tool designed for the Indian population featured only plant-based protein foods[ 39 ]. In the case of vegetables, subcomponents such as dark leafy vegetables and starchy vegetables may be considered[ 15 , 17 , 40 ]. In the case of fruits, one component may be used to assess total fruit intake (including whole, juiced, and canned fruit)[ 16 , 17 , 39 , 41 ] or additional subcomponents may be included to further evaluate the consumption of specific forms of fruit, such as whole fruit[ 9 , 15 , 42 ]. Furthermore, some tools may incorporate specialized components such as alcohol[ 17 , 37 , 38 , 42 , 43 ], coffee[ 42 ], processed meat[ 42 , 43 ], and unhealthy snacks/sugar-sweetened beverages[ 37 , 38 , 44 ]. Secondly, adjustments to the weighting criteria may be required to prioritize components effectively. For instance, the allocation of weights between certain food groups may be divided to emphasize quality over quantity. This is frequently demonstrated by the addition of whole grains as a separate component, alongside the total grains component[ 9 , 15 – 17 , 31 , 43 ]. By contrast, some tools may combine distinct components within a group, such as classifying dairy products under the total protein foods component[ 31 ] or grouping seafood with plant-based protein foods in a single component[ 9 ], thereby minimizing their contribution to the assessed diet quality because they will lack a designated weight[ 31 ]. Thirdly, quantitatively assessing adherence to specific dietary recommendations relies on establishing accurate maximum and minimum scoring standards. This process varies depending on whether the scoring standard is based on the density approach or presented in absolute values for components derived from food groups. Components representing specific nutrients are typically added as a percentage of energy intake[ 12 ]. As an alternative, the proportions from Canada’s Food Guide 2019 plate snapshot were utilized to establish the scoring standards in the 2019 Healthy Eating Food Index[ 31 ]. Overall, the development of such tailored tools involves establishing the food and nutrient components, weighting criteria, and scoring standards to align with national dietary recommendations and nutritional priorities. The potential variations in these aspects highlight the importance of careful consideration when comparing and interpreting the results of each tool[ 36 ]. Developing a national HEI typically requires access to dietary data from comprehensive national nutrition surveys. However, in instances where such information is not available, dietary guidelines can be utilized. In this study, we elected to employ the latter approach for practicality and the potential for future refinement to estimate adequate intakes based on nutrient reference values. Determining diet quality scores has numerous applications, such as the surveillance and monitoring of diets across geographical regions, sociodemographic characteristics, population subgroups, and time, establishing country-specific diet-related targets, and evaluating the impact of proposed interventions (e.g. nutrition policy and programs)[ 5 – 7 , 45 ]. Another notable application is the use of predictive statistical methods to explore the relationship between diet quality and the probability of developing certain diseases or their risk factors[ 8 , 46 – 48 ]. Diet quality assessment tools can also be customized for purposes extending beyond diet quality, as already done for the Infant and Child Feeding Index (ICFI)[ 49 ] and the Probability of Adequate Nutrient Intake score (PANDiet)[ 50 ]. For the most part, the SHEI scoring standards reflect the SHP guide dietary recommendations, with some exceptions. For the beverages component, the SHP guide recommends reducing the consumption of sweetened beverages; however, the maximum score can only be achieved if no sweetened beverages are consumed. In the SHP guide, nuts are listed under the fats and oils food group, but in the SHEI they are regarded as plant-based protein foods. Furthermore, in the SHP guide, starchy vegetables fall under the grains and starches food group and are excluded from the fruits and vegetables group, whereas starchy vegetables are included in the total servings of vegetables in the SHEI, as are beans and legumes, despite them being listed only under protein foods in the SHP guide. In addition, the SHP guide promotes food choices that are low in and/or free from fat/saturated fat, sodium, and added sugar (e.g. low-fat cheeses and lean meats). By contrast, the SHEI includes all foods irrespective of their nutrient contents. To use the SHEI, dietary intake data must first be collected using any appropriate tool (e.g. 24-hour recall or food frequency questionnaire), then each food and beverage should be categorized into its respective components, and the intake should be translated to the designated units (i.e. intake as ratio to energy, percent of energy intake). These outputs are then used to quantify the scores for each component, which are summed to reach a final score out of 100. Diet analysis software and food composition databases can be employed for these steps. If the total energy intake is available, separate components can be scored to evaluate compliance with specific SHP guide recommendations. The resulting total SHEI score is reported quantitatively as a numerical value (e.g. 65) or qualitatively as a grade (e.g. grade A). The grading approach proposed in the HEI-2015 can be adapted to grade SHEI scores as follows: grade A for scores of 90–100, grade B for scores of 80–89, grade C for scores of 70–79, grade D for scores of 60–69, and grade F for scores of 0–59. These grades are intended as a means to explain the numerical scores and should not replace them, as relying solely on the classification of numerical values may overlook some finer details[ 9 ]. This study has several strengths. Firstly, to the best of our knowledge, this is the first healthy eating index based on the density standard for an Arab country. This suggests that the SHEI could be beneficial for use in neighboring countries, especially those comprising the Gulf Cooperation Council, which share many sociocultural characteristics with Saudi Arabia. Secondly, the SHEI uses continuous rather than discrete scoring to precisely measure dietary changes. The intake cut-off values are adjusted for energy (per 1000 kcal), except for the ratio components. This was implemented to avoid obtaining higher scores simply because the total energy intake is high, thus distinguishing diet quality from diet quantity. However, the SHEI has some limitations. Firstly, it is not suitable for all age groups or adults with special dietary requirements (e.g. pregnant women). The sensitivity of the SHEI to intakes beyond the cut-off values is limited, which could compromise surveillance and monitoring efforts. In addition, some cut-off values were set based on expert judgment as opposed to population intake data. The SHEI should be revised when population intake data become available. 5. Conclusions While this paper presents the developmental framework of the SHEI, validation and reliability studies have been initiated to confirm its usability and enhance its applicability in nutrition research and public health interventions. The SHEI has been designed to measure diet quality by determining adherence to the SHP guide, effectively filling an existing gap for an updated diet quality assessment tool for the Saudi population. The SHEI is anticipated to assist in evaluating diet quality within the Saudi population and provide valuable information to promote healthier eating habits, which could significantly reduce the incidence of diseases associated with poor diet quality. Abbreviations The following abbreviations are used in this manuscript: HEI Healthy Eating Index SHEI Saudi Healthy Eating Index SHP Saudi Healthy Plate NNC National Nutrition Committee DQI-I Diet Quality Index-International MDS Mediterranean Diet Score ICFI Infant and Child Feeding Index PANDiet Probability of Adequate Nutrient Intake Declarations Ethics approval and consent to participate: Not applicable. Consent for publication: Not applicable. Clinical trial number: Not applicable. Availability of data and materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This research received no external funding. Authors' contributions : H.M.A: Conceptualization, Methodology, Writing – original draft; O.A.: Methodology, Formal analysis, Writing – review & editing; S.A.: Writing – review & editing; A.A.: Supervision, Writing – review & editing. All authors read and approved the final manuscript. Author disclaimer: The views expressed in this study are those of the authors(s) and do not necessarily reflect those of the SFDA or its stakeholders. Guaranteeing the accuracy and validity of the data was the sole responsibility of the research team. Acknowledgments: Not applicable. References Hu FB. Diet strategies for promoting healthy aging and longevity: An epidemiological perspective. J Intern Med. 2023. https://doi.org/10.1111/joim.13728. Reedy J, Krebs-Smith SM, Miller PE, Liese AD, Kahle LL, Park Y, et al. Higher diet quality is associated with decreased risk of all-cause, cardiovascular disease, and cancer mortality among older adults. J Nutr. 2014;144:881–9. Schwingshackl L, Hoffmann G. 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Halawani R, Jaceldo‐Siegl K, Heskey C, Bahjri K. Saudi Population’s Adherence to the Healthy Food Palm: A Cross‐sectional Study. The FASEB Journal. 2019;33. Alfreeh L, Alomar S, Aljuraiban GS. Association of diet quality with serum high-sensitivity C-reactive protein level and the adherence to the Saudi dietary guidelines among female college students. J King Saud Univ Sci. 2022;34:101765. Alkhaldy AA, Alamri RS, Magadmi RK, Elshini NY, Hussein RAEH, Alghalayini KW. Dietary adherence of saudi males to the Saudi dietary guidelines and its relation to cardiovascular diseases: A preliminary cross-sectional study. J Cardiovasc Dev Dis. 2019;6. Alkhaldy AA, Aljahdli ES, Mosli MH, Jawa HA, Alsahafi MA, Qari YA. Adherence to the Saudi dietary guidelines and its relation to colorectal polyps: A university hospital-based study. J Taibah Univ Med Sci. 2020;15:25–31. Saudi Food and Drug Authority. Saudi Healthy Plate Guide. National Nutrition Committee. 2020. https://sfda.gov.sa/en/node/86211. Accessed 11 May 2024. Saudi Food and Drug Authority. Saudi Healthy Plate Guide, Second Version. National Nutrition Committee. 2024. https://sfda.gov.sa/en/node/93352. Accessed 11 May 2024. Buttriss JL. The Eatwell Guide refreshed. Nutr Bull. 2016;41:135–41. World Health Organization: WHO. Obesity and overweight. 2021. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Accessed 24 Feb 2024. Memish ZA, El Bcheraoui C, Tuffaha M, Robinson M, Daoud F, Jaber S, et al. Obesity and Associated Factors — Kingdom of Saudi Arabia, 2013. Prev Chronic Dis. 2014;11:140236. Moradi-Lakeh M, El Bcheraoui C, Afshin A, Daoud F, AlMazroa MA, Al Saeedi M, et al. Diet in Saudi Arabia: findings from a nationally representative survey. Public Health Nutr. 2017;20:1075–81. Institute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington (DC): The National Academies Press; 2002. World Health Organization. Guideline: Sodium intake for adults and children. Geneva; 2012. Brassard D, Munene LAE, St-Pierre S, Guenther PM, Kirkpatrick SI, Slater J, et al. Development of the Healthy Eating Food Index (HEFI)-2019 measuring adherence to Canada’s Food Guide 2019 recommendations on healthy food choices1. Applied Physiology, Nutrition and Metabolism. 2022;47:595–610. AL-Mohaithef M. Prevalence of vegan/vegetarian diet and eating behavior among Saudi adults and its correlation with body mass index: A cross-sectional study. Front Nutr. 2022;9. Drewnowski A, Henry CJ, Dwyer JT. Proposed Nutrient Standards for Plant-Based Beverages Intended as Milk Alternatives. Front Nutr. 2021;8:761442. World Health Organization, Magali Rios-Leyvraz, Jason Montez. Health effects of the use of non-sugar sweeteners: a systematic review and meta-analysis. 2022. World Health Organization. Guideline: Sugars intake for adults and children. . Geneva; 2015. Trijsburg L, Talsma EF, de Vries JHM, Kennedy G, Kuijsten A, Brouwer ID. Diet quality indices for research in low- and middle-income countries: a systematic review. Nutr Rev. 2019;77:515–40. Kurotani K, Akter S, Kashino I, Goto A, Mizoue T, Noda M, et al. Quality of diet and mortality among Japanese men and women: Japan Public Health Center based prospective study. BMJ. 2016;:i1209. Bekele TH, de Vries JHM, Feskens EJM, de Weijer A, Brouwer ID, Covic N, et al. Development of the Ethiopian Healthy Eating Index (Et-HEI) and evaluation in women of reproductive age. J Nutr Sci. 2023;12:e9. Das M. Healthy Eating Index: Evidence from India. SSRN Electronic Journal. 2015. https://doi.org/10.2139/ssrn.2571173. Krebs-Smith SM, Pannucci TRE, Subar AF, Kirkpatrick SI, Lerman JL, Tooze JA, et al. Update of the Healthy Eating Index: HEI-2015. J Acad Nutr Diet. 2018;118:1591–602. Van DTT, Trijsburg L, Do HTP, Kurotani K, Feskens EJM, Talsma EF. Development of the Vietnamese Healthy Eating Index. J Nutr Sci. 2022;11:e45. Looman M, Feskens EJM, De Rijk M, Meijboom S, Biesbroek S, Temme EHM, et al. Development and evaluation of the Dutch Healthy Diet index 2015. Public Health Nutr. 2017;20:2289–99. Zarrin R, Ibiebele TI, Marks GC. Development and validity assessment of a diet quality index for Australians. Asia Pac J Clin Nutr. 2013;22:177–87. Yun S, Park S, Yook S-M, Kim K, Shim JE, Hwang J-Y, et al. Development of the Korean Healthy Eating Index for adults, based on the Korea National Health and Nutrition Examination Survey. Nutr Res Pract. 2022;16:233. Sotos-Prieto M, Bhupathiraju SN, Mattei J, Fung TT, Li Y, Pan A, et al. Changes in Diet Quality Scores and Risk of Cardiovascular Disease Among US Men and Women. Circulation. 2015;132:2212–9. Ertuglu LA, Demiray A, Afsar B, Ortiz A, Kanbay M. The Use of Healthy Eating Index 2015 and Healthy Beverage Index for Predicting and Modifying Cardiovascular and Renal Outcomes. Curr Nutr Rep. 2022;11:526–35. Artegoitia VM, Krishnan S, Bonnel EL, Stephensen CB, Keim NL, Newman JW. Healthy eating index patterns in adults by sex and age predict cardiometabolic risk factors in a cross-sectional study. BMC Nutr. 2021;7:30. Onvani S, Haghighatdoost F, Surkan PJ, Larijani B, Azadbakht L. Adherence to the Healthy Eating Index and Alternative Healthy Eating Index dietary patterns and mortality from all causes, cardiovascular disease and cancer: a meta-analysis of observational studies. J Hum Nutr Diet. 2017;30:216–26. Bork K, Cames C, Barigou S, Cournil A, Diallo A. A Summary Index of Feeding Practices Is Positively Associated with Height-for-Age, but Only Marginally with Linear Growth, in Rural Senegalese Infants and Toddlers. J Nutr. 2012;142:1116–22. Verger EO, Mariotti F, Holmes BA, Paineau D, Huneau J-F. Evaluation of a Diet Quality Index Based on the Probability of Adequate Nutrient Intake (PANDiet) Using National French and US Dietary Surveys. PLoS One. 2012;7:e42155. Tables Tables 1 to 4 are available in the Supplementary Files section Additional Declarations No competing interests reported. Supplementary Files Tables.docx Cite Share Download PDF Status: Published Journal Publication published 30 Jul, 2025 Read the published version in BMC Nutrition → Version 1 posted Editorial decision: Revision requested 22 May, 2025 Reviews received at journal 12 May, 2025 Reviews received at journal 10 May, 2025 Reviews received at journal 07 May, 2025 Reviewers agreed at journal 21 Apr, 2025 Reviewers agreed at journal 20 Apr, 2025 Reviewers agreed at journal 19 Apr, 2025 Reviewers agreed at journal 14 Apr, 2025 Reviewers invited by journal 11 Mar, 2025 Editor invited by journal 07 Mar, 2025 Editor assigned by journal 27 Feb, 2025 Submission checks completed at journal 27 Feb, 2025 First submitted to journal 24 Feb, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6099915","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":440129609,"identity":"9707f53a-a5af-40a1-ae79-ba8cf78081c8","order_by":0,"name":"Haya M. Alzeer","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAzUlEQVRIiWNgGAWjYBACgwNA4gGIxd4A4loQqSUBxOIBsQwkSNEiASGJ0HLtdOKHhD82cuYzn1/d8KNAgoG/vTsBrxb727mbJRJ40oxlbueU3ewBOkzizNkN+G25nbtBIkHicOIM6Zy0GzxALQYSuQS1bP6RYPC/fobkmbSbf4jUsk0iIeFAgoQE+7HbxNqyzSLhQLLhDJ4cttsyBhI8xPhl840Pf+zkJdiPP7v5Bhh0/O29+LUgAR4DMEmschBgf0CK6lEwCkbBKBhBAACYbUunmh68/wAAAABJRU5ErkJggg==","orcid":"","institution":"King Saud University","correspondingAuthor":true,"prefix":"","firstName":"Haya","middleName":"M.","lastName":"Alzeer","suffix":""},{"id":440129610,"identity":"baece821-6ec3-44f6-a952-bb8725fa6c86","order_by":1,"name":"Omar Alhumaidan","email":"","orcid":"","institution":"National Nutrition Committee (NNC), Saudi Food and Drug Authority (SFDA)","correspondingAuthor":false,"prefix":"","firstName":"Omar","middleName":"","lastName":"Alhumaidan","suffix":""},{"id":440129611,"identity":"73652d4a-2d05-4696-976b-e75bc21f34f7","order_by":2,"name":"Sarah Alkhunein","email":"","orcid":"","institution":"National Nutrition Committee (NNC), Saudi Food and Drug Authority (SFDA)","correspondingAuthor":false,"prefix":"","firstName":"Sarah","middleName":"","lastName":"Alkhunein","suffix":""},{"id":440129612,"identity":"15d9cf3a-1b25-4278-99a5-939d96ffe744","order_by":3,"name":"Areej Alkhaldy","email":"","orcid":"","institution":"King Abdulaziz University","correspondingAuthor":false,"prefix":"","firstName":"Areej","middleName":"","lastName":"Alkhaldy","suffix":""}],"badges":[],"createdAt":"2025-02-24 21:38:10","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6099915/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6099915/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40795-025-01140-z","type":"published","date":"2025-07-30T16:06:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":88268418,"identity":"9abc6604-889c-4ee3-af17-f676144db2eb","added_by":"auto","created_at":"2025-08-04 16:51:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":495028,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6099915/v1/0138c144-02d2-4c17-bc57-de945bda4c47.pdf"},{"id":80276255,"identity":"15de26f8-63e3-4150-ad29-d9665a81686f","added_by":"auto","created_at":"2025-04-10 05:04:09","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":209911,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6099915/v1/97ba5405643fdd5f93bddf91.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Development of the Saudi Healthy Eating Index","fulltext":[{"header":"1. Background","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eHealthy dietary patterns contribute to greater longevity[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. For example, higher diet quality was found to be associated with a reduced risk of noncommunicable diseases and mortality[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], and a large systematic review and meta-analysis revealed that low diet quality was linked to diabetes, cardiovascular disease, cancer, and all-cause mortality[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Several dietary indices have been developed to assess diet quality by categorizing individuals according to their adherence to national dietary guidelines [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. These dietary indices serve as valuable tools for monitoring the nutritional status of populations, estimating the influence of nutritional interventions, and conducting epidemiological studies to evaluate the association between dietary patterns and the risk of certain diseases[\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Among the most validated and most used dietary indices are the Healthy Eating Index (HEI)[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], the Diet Quality Index-International (DQI-I)[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], and the Mediterranean Diet Score (MDS)[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In particular, the HEI stands out as one of the leading indices for assessing the adherence of individual and population dietary intakes with dietary guidelines[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. The HEI has several features and advantages, including (a) its adoption of a continuous (not discrete) scoring system, which facilitates various statistical analyses and related interpretations; (b) its application of the density approach to separate diet quality from quantity by calculating components as the amount of each food group per 1000 calories, which helps to overcome challenges associated with individual caloric requirements[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]; and (c) its explicit testing of validity and reliability[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Owing to these characteristics, several countries worldwide, such as Brazil[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], Malaysia[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], and China[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], have adopted the methodology introduced by Guenther et al.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and customized the HEI to develop their own national HEIs.\u003c/p\u003e \u003cp\u003eIn Saudi Arabia, there is a gap in standardized diet quality assessment tools designed to measure adherence to Saudi dietary guidelines. This gap could limit nutrition research and hinder evaluations of nutrition policies and interventions aiming to explore associations between diet quality and health-related outcomes among the Saudi population. The first set of dietary guidelines developed in Saudi Arabia, the Healthy Food Palm introduced by the Saudi Ministry of Health in 2012, portrayed food groups in the shape of a palm tree[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, since its publication, only four studies have assessed adherence to the Healthy Food Palm. Halawani et al.[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] reported poor adherence of only 26% among Saudi adults. Alfreeh et al.[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] also found low adherence of 43% among Saudi female college students. Alkhaldy et al.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] reported an adherence score of 26.5/60 among Saudi males with cardiovascular disease and a slightly higher score of 28/60 among healthy participants, while another study by Alkhaldy et al.[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] found similar adherence scores of approximately 24/50 among Saudis with and without colorectal polyps. In 2020, the National Nutrition Committee (NNC), a scientific advisory body operating under the Saudi Food and Drug Authority, released the first version of the Saudi Healthy Plate (SHP) guide in 2020[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], which was followed by an updated version in 2024[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Similar to the Eatwell Guide[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], both sets of guidelines emphasize five primary food groups, namely, grains and starches, fruits and vegetables, protein foods, dairy products, and fats and oils, and have sections for added sugar, sodium, and beverages[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Population adherence to either set of guidelines has yet to be measured.\u003c/p\u003e \u003cp\u003eIn recent years, Saudi Arabia has witnessed rapid urbanization and significant lifestyle changes, particularly in terms of dietary habits, which have seen a trend towards Westernization. This transition has contributed to an increase in the prevalence of obesity among individuals aged fifteen years and above, with rates reaching 24.1% for males and 33.5% for females[\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. A nationwide health survey revealed low intakes of fruits, vegetables, fish, nuts, and dairy products, alongside high intakes of meat and sugar-sweetened beverages[\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Therefore, in line with the international practice of developing diet quality measurement tools to evaluate adherence to national dietary guidelines, the aim of this study was to describe the development of the Saudi Healthy Eating Index (SHEI) as a measure of diet quality for adults in terms of their adherence to the recommendations set in the 2024 version of SHP guide and present the strengths, limitations, and potential applications of the SHEI. The next phase of this research includes comprehensive validation and reliability testing of the SHEI to evaluate its efficacy in assessing diet quality among Saudi adults. These findings will be reported in subsequent publications.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"2. Methods","content":"\u003cp\u003e2.1\u0026nbsp; \u0026nbsp;\u0026nbsp;Development of the SHEI\u003c/p\u003e\n\u003cp\u003eThe purpose of the SHEI is to measure adherence to the recommendations set in the SHP for Saudi adults aged eighteen years and above, with higher scores representing greater adherence (higher diet quality). The SHP was purposely designed to be direct and simple. It focuses on five main food groups: grains and starches, fruits and vegetables, protein foods, dairy products, and fats and oils. For each food group, the SHP guide presents the recommended servings, examples of a single serving, and some dos and don\u0026rsquo;ts related to cooking and preparation. Furthermore, it contains sections dedicated to added sugar and salt/sodium describing their recommended intake limits, possible substitutes, and their uncommon nomenclature found on food labels, plus a section on water and beverages. There is also an exemplary one-day menu, advice on healthy grocery shopping, detailed instructions on how to read food labels, and an exchange list of items from the main food groups[24]. Given the SHEI\u0026rsquo;s focus on dietary intake quality, sections of the SHP guide addressing nutritional behaviours or practices are not considered.\u003c/p\u003e\n\u003cp\u003e2.2\u0026nbsp; \u0026nbsp;\u0026nbsp;Components of the SHEI\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1\u003c/strong\u003e lists the twelve SHEI components (fruits, vegetables, grains, whole grain ratio, protein foods, seafood and plant-based protein foods, dairy products, beverages, fatty acid ratio, saturated fats, added sugar, and sodium) selected to reflect the corresponding recommendations of the SHP guide. All quotations in this manuscript are translations from the original Arabic version of the 2024 SHP guide, translated by the first author and revised by the co-authors.\u003c/p\u003e\n\u003cp\u003e2.3\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Weighting the SHEI components\u003c/p\u003e\n\u003cp\u003eOn the basis of the recommendations of the SHP guide, which emphasize the importance of a balanced intake of all food groups and nutrients to maintain a healthy and nutritious diet, the twelve components were each weighted at either ten points (fruits, vegetables, dairy products, beverages, fatty acid ratio, saturated fats, added sugar, and sodium) or five points if assessing the same dietary aspect (protein foods, seafood and plant-based protein foods, grains, and whole grain ratio), yielding a maximum total score of 100.\u003c/p\u003e\n\u003cp\u003e2.4\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Scoring of the SHEI components\u003c/p\u003e\n\u003cp\u003eAfter careful examination of several national HEIs, the least restrictive approach used in the HEI iterations developed by Guenther et al.[12] was adopted as the main guide for developing the SHEI. The scoring of the SHEI components was based on the density approach, expressed as amounts per 1000 calories of intake, except for ratio-based components (e.g. beverages). The recommended amounts of each food group according to the SHP guide were thus quantified in amounts per 1000 kcal at seven caloric patterns ranging from 2000 to 3200 kcal at 200 kcal intervals to meet the nutrient recommendations for adults aged eighteen years and above[29], as listed in \u003cstrong\u003eTable 2\u003c/strong\u003e and \u003cstrong\u003eTable 3\u003c/strong\u003e. The caloric patterns from 1000 to 1800 kcal were not considered because the SHP guide was designed for the adult population.\u003c/p\u003e\n\u003cp\u003eThe least restrictive or easiest-to-achieve recommendation was selected as the standard for the maximum score cut-off value for all components, except for the whole grain ratio, beverages, and sodium components. The recommended amounts of whole grain ratio and beverages were based on the literal recommendations in the SHP guide. A strong correlation exists between sodium and energy intake; thus, setting cut-off values for the absolute intake of sodium (per gram) is not ideal[30]. This indicates that the thresholds for sodium should be associated with energy intake. Calculating scores for adequacy components is simple because none of the components result in a logical zero score, and intakes within the minimum and maximum cut-off ranges for adequacy components are scored proportionately and calculated as follows[16]:\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\n\u003cp\u003eCalculating scores for moderation components is not as straightforward because increased intakes equal lower scores, there is no obvious zero to set the minimum scores at, and there is no established evidence to indicate at which intake a zero should be set. This may lead to a floor or ceiling effect, wherein most of the sample scores are either too low or too high[12]. Hence, to mitigate this problem, national HEIs typically use population intake data to set the thresholds (e.g. the 90th percentile of the population intake for one day)[9, 16, 17, 31]. However, a comprehensive national nutrition survey has never been conducted in Saudi Arabia, making it impossible to determine cut off values based on the percentiles of population intake. Therefore, cut-off values for moderation components were set based on Saudi nutrition experts\u0026apos; judgment and compared with values in other national HEIs to check for feasibility and practicality. Intakes within the minimum and maximum cut-off ranges for moderation components are scored proportionately and calculated as follows[16]:\u003c/p\u003e\n\u003cp\u003e\u003cimg 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\"\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003e3.1\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;SHEI components and scoring standards\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u0026nbsp;\u003c/strong\u003elists the SHEI components, maximum score points, and the standards for attaining maximum and minimum scores.\u003c/p\u003e\n\u003cp\u003e3.1.1\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Fruits and vegetables\u003c/p\u003e\n\u003cp\u003eThe SHP guide recommends the following: \u0026ldquo;It is preferable to eat more vegetables than fruits\u0026rdquo;. Thus, fruits and vegetables are split into two separate components with cut-off values reflecting the recommendation (i.e. \u0026ge;0.6 servings/1000 kcal for fruits and \u0026ge;1.1 servings/1000 kcal for vegetables). These components include whole, juiced, frozen, dried, and canned fruits and vegetables, irrespective of their cooking method (e.g. frying) or preparation method (e.g. salting), because the saturated fat, added sugar, and sodium contents are accounted for later in their respective components.\u003c/p\u003e\n\u003cp\u003e3.1.2\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Grains and whole grain ratio\u003c/p\u003e\n\u003cp\u003eAdherence to grain-related recommendations is assessed using two components: grains and whole grain ratio. Whole grains include any food with a whole grain as the first ingredient, while total grains include any food with any grain as the first ingredient. The first component focuses on the quantity of grains consumed, and its maximum score cut-off value is defined as \u0026ge;3.5 servings/1000 kcal based on the least restrictive method. The second component focuses on the quality of grains consumed, and its maximum score cut-off value is defined as whole grains (servings)/total grains (servings) \u0026ge;0.5 based on the following SHP guide recommendation: \u0026ldquo;Ensure that at least half of your grain intake is from whole grain foods\u0026rdquo;. The numerator includes all consumed servings of foods with a whole grain as the first ingredient, and the denominator includes all consumed servings of foods with any grain as the first ingredient[31]. The ten points are split between the two components to prevent the maximum points being attained when the recommended servings are consumed but not from the optimal source. As for the minimum score cut-off values, a score of zero is assigned for both when the corresponding component is not consumed.\u003c/p\u003e\n\u003cp\u003e3.1.3\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Protein foods and seafood and plant-based protein foods\u003c/p\u003e\n\u003cp\u003eAdherence to protein-related recommendations is assessed using two components. The first component is protein foods at \u0026ge;2.2 servings/1000 kcal, which focuses on the quantity of protein foods consumed. The second component is seafood and plant-based protein foods at \u0026ge;0.9 servings/1000 kcal, which focuses on the quality of the protein foods consumed and is derived from the following SHP guide recommendation: \u0026ldquo;Consume protein from a variety of sources\u0026rdquo;. The ten points are split between the two components to prevent the maximum points being attained when the recommended servings are consumed but not from a variety of protein sources. Irrespective of the cooking and preparation methods, the protein foods component includes seafood, eggs, poultry, meat, and plant-based protein foods, whereas the complementary component only includes seafood and plant-based protein (i.e. beans and legumes, nuts, and seeds). Beans and legumes are accounted for in both the vegetable and protein-related components because of their unique nutritional composition[9].To determine the servings for the seafood and plant-based protein foods component, initially, all consumed servings of seafood per 1000 kcal are counted. Subsequently, servings of beans and legumes per 1000 kcal are included until the maximum five points are achieved (i.e. at \u0026ge;0.9 servings/1000 kcal). Any servings of beans and legumes exceeding this threshold should then be accounted for in the vegetables component.\u003c/p\u003e\n\u003cp\u003e3.1.4\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Dairy products\u003c/p\u003e\n\u003cp\u003eThe maximum score cut-off value for the dairy products component is defined as \u0026ge;0.8 servings/1000 kcal based on the least restrictive method. This component includes dairy-based beverages (e.g. milk and laban), yogurt, cheese, labneh, and other dairy products, irrespective of their fat, added sugar, and sodium contents. Plant-based dairy alternatives (e.g. coconut milk and soy yogurt) are not mentioned in the SHP guide as they are not widely consumed in Saudi Arabia[32]. Nevertheless, plant-based dairy alternatives are included in this component if their protein content is \u0026gt;2.2 g/100 g[33].\u003c/p\u003e\n\u003cp\u003e3.1.5\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Beverages\u003c/p\u003e\n\u003cp\u003eThe beverages component is derived from the following SHP recommendations: \u0026ldquo;Make sure to drink 3.7 litres for males and 2.7 litres for females of beverages per day\u0026rdquo; and \u0026ldquo;Limit consumption of sugary and caffeine-containing beverages\u0026rdquo;, where the latter highlights water and non-sweetened beverages as the preferred beverages of choice. The numerator includes the millilitres of water and non-sweetened beverages consumed (e.g. non-sweetened milk, tea, and coffee), and the denominator includes all beverages consumed including non-sweetened, sweetened, and artificially sweetened beverages. Artificially sweetened beverages are not included in the numerator because dietary recommendations generally advise replacing sweetened beverages with non-sweetened ones, rather than artificially sweetened alternatives[34]. The fat and sodium contents of dairy drinks (e.g. milk and laban) are not considered because these are accounted for in their respective components. Fruit or vegetable juice is not included in this component and is accounted for in either the fruit or vegetable components. The maximum score cut-off value of one is achieved when all beverages consumed are non-sweetened, whereas the minimum score of zero is assigned when all beverages consumed are sweetened.\u003c/p\u003e\n\u003cp\u003e3.1.6\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Saturated fats and fatty acid ratio\u003c/p\u003e\n\u003cp\u003eFat-related recommendations focus on limiting saturated fat intake and ensuring a balanced unsaturated fat intake. They consist of two components: fatty acid ratio and saturated fats. The fatty acid ratio is an adequacy component reflecting the consumed ratio of unsaturated fatty acids to saturated fatty acids, with a maximum score cut-off value of \u0026ge;2.6 based on the least restrictive approach. The minimum score cut-off value is set at half of the maximum cut-off value (i.e. \u0026le;1.3) based on expert judgement. We recognize that other countries have based their values on population intake data; however, because comprehensive nutrition survey data are not available for the Saudi population, it was necessary to implement an alternative. Notably, the present values are comparable to those of \u0026ge;2.6 and \u0026le;1.1 defined in the 2015 version of the HEI (HEI-2015), based on the Dietary Guidelines for Americans[9].\u003c/p\u003e\n\u003cp\u003eSaturated fats is a moderation component measuring the alignment with the following SHP guide recommendation: \u0026ldquo;A healthy adult should not consume more than 10% of calories from saturated fat per day\u0026rdquo;. The maximum score cutoff value is at \u0026le;7% of energy intake, which is rounded up from \u0026le;6.7% of energy intake, set using the least restrictive approach. For the minimum score, the cut-off value is set at double the maximum cut-off value (i.e. \u0026ge;14% of energy intake) based on expert judgement, as done in other indices[9]. The HEI-2015 used the 85th percentile of saturated fat intake as a percentage of energy from the results of population-level nutrition surveys, corresponding to \u0026ge;16% of energy intake[9]. Following the saturated fats recommendation of \u0026le;10% of energy intake defined in the SHP guide results in a score of approximately 6/10 in the SHEI, reflecting the recommendation to not exceed it. Each of the two components is allocated a score of ten points, reflecting their substantial yet distinct roles in diet quality and health.\u003c/p\u003e\n\u003cp\u003e3.1.7\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Added sugar\u003c/p\u003e\n\u003cp\u003eAnother moderation component is added sugar, which measures alignment with the following SHP guide recommendation: \u0026ldquo;A healthy adult should not consume more than 50 grams (i.e. 10% of calories) of added sugar per day\u0026rdquo;. The maximum score cut-off value of \u0026le;5% of energy intake is set based on the least restrictive approach as adopted in the HEI-2015[9]. Coincidentally, \u0026le;5% of energy intake corresponds to the World Health Organization (WHO)\u0026rsquo;s conditional recommendation for free sugar intake[35]. Meanwhile, the minimum score cut-off value is set at five times the maximum cut-off value (i.e. \u0026ge;25% of energy intake) based on expert judgement. The HEI-2015 used the 90th percentile of added sugar intake as a percentage of energy for the maximum score cut-off value based on the results of population-level nutrition surveys, which corresponded to \u0026le;6.5% of energy intake, and the minimum was set at four times that (i.e. 26% of energy intake)[9]. The recommended intake limit of 10% of energy intake results in a score of approximately 8/10 in the SHEI, reflecting the recommendation to not exceed it.\u003c/p\u003e\n\u003cp\u003e3.1.8 \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Sodium\u003c/p\u003e\n\u003cp\u003eThe strong correlation between sodium and energy intake suggests that maximum and minimum thresholds should be established based on energy intake. The SHP guide recommendation for sodium, based on WHO guidelines, is to consume less than 2000 milligrams per day[30]. The HEI-2015 set the maximum threshold for sodium at 2300 mg/2150 kcal, equivalent to approximately 1100 mg/1000 kcal. This is based on the average energy intake for young and middle-aged adults (i.e. 2150 kcal) used in the dietary reference intake for sodium, and the minimum threshold was calculated based on 17% of the one-day population intake levels (2000 mg/1000 kcal)[12]. As previously mentioned, comprehensive nutrition survey data are not available for the Saudi population, so determining the average population energy intake or specific percentiles is not possible. Instead, the cut-off values are derived from the median value of the adult energy requirement range, 2000\u0026ndash;3200 kcal (i.e. 2600 kcal), in conjunction with the SHP guide recommendation for sodium intake. This approach mirrors the methodology used in the Chinese HEI by Yuan et al., which utilized the median value of the energy requirement range for the included age groups, 1000\u0026ndash;3000 kcal (i.e., 2000 kcal), rather than population energy intakes, despite the availability of the latter[17]. Consequently, the maximum score cut-off value is set at the ratio of the recommended sodium intake to the median energy requirement for adults, 2000 mg/2600 kcal, equivalent to approximately 800 mg/1000 kcal, while the minimum score cut-off value is set at 2000 mg/1000 kcal, approximately two and a half times the maximum score cut-off value.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eThe purpose of this study is to outline the development of the SHEI, an index designed to measure adherence to the dietary recommendations provided in the SHP guide. The SHP guide focuses on five main food groups, namely, grains and starches, fruits and vegetables, protein foods, dairy products, and fats and oils, and it also contains sections for added sugar, sodium, and beverages, which are included in the SHEI as main components or utilized to derive other components. The index scoring is continuous, ranging from zero to 100, and the maximum and minimum cut-off values were generally derived based on the least restrictive approach; otherwise, they were chosen based on expert judgment or taken as defined in the SHP guide.\u003c/p\u003e \u003cp\u003eVariations in national dietary guidelines necessitate tailored development processes for diet quality assessment tools[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. This may include adopting and/or modifying existing methods or constructing new ones to ensure alignment with specific dietary guidelines, and it typically involves three key aspects. Firstly, variations in dietary patterns between populations must be considered when selecting the components of a given diet quality assessment tool. Protein foods, vegetables, fruits, and grains are the basic components of most tools, but their incorporation may vary depending on the national dietary guidelines they are based on. For instance, protein sources could be broadly grouped, such as into animal-based and plant-based categories[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. In other cases, protein components may be further divided to afford up to five distinct components, including fish and seafood, red meat, poultry, soybeans, and eggs[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Taking into account religious practices, a tool designed for the Indian population featured only plant-based protein foods[\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. In the case of vegetables, subcomponents such as dark leafy vegetables and starchy vegetables may be considered[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e]. In the case of fruits, one component may be used to assess total fruit intake (including whole, juiced, and canned fruit)[\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e] or additional subcomponents may be included to further evaluate the consumption of specific forms of fruit, such as whole fruit[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Furthermore, some tools may incorporate specialized components such as alcohol[\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], coffee[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e], processed meat[\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], and unhealthy snacks/sugar-sweetened beverages[\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e, \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Secondly, adjustments to the weighting criteria may be required to prioritize components effectively. For instance, the allocation of weights between certain food groups may be divided to emphasize quality over quantity. This is frequently demonstrated by the addition of whole grains as a separate component, alongside the total grains component[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e]. By contrast, some tools may combine distinct components within a group, such as classifying dairy products under the total protein foods component[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] or grouping seafood with plant-based protein foods in a single component[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], thereby minimizing their contribution to the assessed diet quality because they will lack a designated weight[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Thirdly, quantitatively assessing adherence to specific dietary recommendations relies on establishing accurate maximum and minimum scoring standards. This process varies depending on whether the scoring standard is based on the density approach or presented in absolute values for components derived from food groups. Components representing specific nutrients are typically added as a percentage of energy intake[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. As an alternative, the proportions from Canada\u0026rsquo;s Food Guide 2019 plate snapshot were utilized to establish the scoring standards in the 2019 Healthy Eating Food Index[\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Overall, the development of such tailored tools involves establishing the food and nutrient components, weighting criteria, and scoring standards to align with national dietary recommendations and nutritional priorities. The potential variations in these aspects highlight the importance of careful consideration when comparing and interpreting the results of each tool[\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDeveloping a national HEI typically requires access to dietary data from comprehensive national nutrition surveys. However, in instances where such information is not available, dietary guidelines can be utilized. In this study, we elected to employ the latter approach for practicality and the potential for future refinement to estimate adequate intakes based on nutrient reference values. Determining diet quality scores has numerous applications, such as the surveillance and monitoring of diets across geographical regions, sociodemographic characteristics, population subgroups, and time, establishing country-specific diet-related targets, and evaluating the impact of proposed interventions (e.g. nutrition policy and programs)[\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Another notable application is the use of predictive statistical methods to explore the relationship between diet quality and the probability of developing certain diseases or their risk factors[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan additionalcitationids=\"CR47\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e]. Diet quality assessment tools can also be customized for purposes extending beyond diet quality, as already done for the Infant and Child Feeding Index (ICFI)[\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] and the Probability of Adequate Nutrient Intake score (PANDiet)[\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor the most part, the SHEI scoring standards reflect the SHP guide dietary recommendations, with some exceptions. For the beverages component, the SHP guide recommends reducing the consumption of sweetened beverages; however, the maximum score can only be achieved if no sweetened beverages are consumed. In the SHP guide, nuts are listed under the fats and oils food group, but in the SHEI they are regarded as plant-based protein foods. Furthermore, in the SHP guide, starchy vegetables fall under the grains and starches food group and are excluded from the fruits and vegetables group, whereas starchy vegetables are included in the total servings of vegetables in the SHEI, as are beans and legumes, despite them being listed only under protein foods in the SHP guide. In addition, the SHP guide promotes food choices that are low in and/or free from fat/saturated fat, sodium, and added sugar (e.g. low-fat cheeses and lean meats). By contrast, the SHEI includes all foods irrespective of their nutrient contents.\u003c/p\u003e \u003cp\u003eTo use the SHEI, dietary intake data must first be collected using any appropriate tool (e.g. 24-hour recall or food frequency questionnaire), then each food and beverage should be categorized into its respective components, and the intake should be translated to the designated units (i.e. intake as ratio to energy, percent of energy intake). These outputs are then used to quantify the scores for each component, which are summed to reach a final score out of 100. Diet analysis software and food composition databases can be employed for these steps. If the total energy intake is available, separate components can be scored to evaluate compliance with specific SHP guide recommendations. The resulting total SHEI score is reported quantitatively as a numerical value (e.g. 65) or qualitatively as a grade (e.g. grade A). The grading approach proposed in the HEI-2015 can be adapted to grade SHEI scores as follows: grade A for scores of 90\u0026ndash;100, grade B for scores of 80\u0026ndash;89, grade C for scores of 70\u0026ndash;79, grade D for scores of 60\u0026ndash;69, and grade F for scores of 0\u0026ndash;59. These grades are intended as a means to explain the numerical scores and should not replace them, as relying solely on the classification of numerical values may overlook some finer details[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThis study has several strengths. Firstly, to the best of our knowledge, this is the first healthy eating index based on the density standard for an Arab country. This suggests that the SHEI could be beneficial for use in neighboring countries, especially those comprising the Gulf Cooperation Council, which share many sociocultural characteristics with Saudi Arabia. Secondly, the SHEI uses continuous rather than discrete scoring to precisely measure dietary changes. The intake cut-off values are adjusted for energy (per 1000 kcal), except for the ratio components. This was implemented to avoid obtaining higher scores simply because the total energy intake is high, thus distinguishing diet quality from diet quantity. However, the SHEI has some limitations. Firstly, it is not suitable for all age groups or adults with special dietary requirements (e.g. pregnant women). The sensitivity of the SHEI to intakes beyond the cut-off values is limited, which could compromise surveillance and monitoring efforts. In addition, some cut-off values were set based on expert judgment as opposed to population intake data. The SHEI should be revised when population intake data become available.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"5. Conclusions","content":"\u003cp\u003e \u003cdiv class=\"BlockQuote\"\u003e \u003cp\u003eWhile this paper presents the developmental framework of the SHEI, validation and reliability studies have been initiated to confirm its usability and enhance its applicability in nutrition research and public health interventions. The SHEI has been designed to measure diet quality by determining adherence to the SHP guide, effectively filling an existing gap for an updated diet quality assessment tool for the Saudi population. The SHEI is anticipated to assist in evaluating diet quality within the Saudi population and provide valuable information to promote healthier eating habits, which could significantly reduce the incidence of diseases associated with poor diet quality.\u003c/p\u003e \u003c/div\u003e \u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eThe following abbreviations are used in this manuscript:\u003c/p\u003e\n\u003cdiv align=\"Left\"\u003e\n \u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"524\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eHEI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eHealthy Eating Index\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSHEI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSaudi Healthy Eating Index\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eSHP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eSaudi Healthy Plate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eNNC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNational Nutrition Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eDQI-I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eDiet Quality Index-International\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eMDS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eMediterranean Diet Score\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eICFI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eInfant and Child Feeding Index\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003ePANDiet\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eProbability of Adequate Nutrient Intake\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u0026nbsp;\u003c/strong\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u0026nbsp;\u003c/strong\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis research received no external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors' contributions\u003c/strong\u003e: H.M.A: Conceptualization, Methodology, Writing – original draft; O.A.: Methodology, Formal analysis, Writing – review \u0026amp; editing; S.A.: Writing – review \u0026amp; editing; A.A.: Supervision, Writing – review \u0026amp; editing. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor disclaimer:\u003c/strong\u003e The views expressed in this study are those of the authors(s) and do not necessarily reflect those of the SFDA or its stakeholders. Guaranteeing the accuracy and validity of the data was the sole responsibility of the research team.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e Not applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eHu FB. Diet strategies for promoting healthy aging and longevity: An epidemiological perspective. J Intern Med. 2023. https://doi.org/10.1111/joim.13728.\u003c/li\u003e\n \u003cli\u003eReedy J, Krebs-Smith SM, Miller PE, Liese AD, Kahle LL, Park Y, et al. Higher diet quality is associated with decreased risk of all-cause, cardiovascular disease, and cancer mortality among older adults. 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The FASEB Journal. 2019;33.\u003c/li\u003e\n \u003cli\u003eAlfreeh L, Alomar S, Aljuraiban GS. Association of diet quality with serum high-sensitivity C-reactive protein level and the adherence to the Saudi dietary guidelines among female college students. J King Saud Univ Sci. 2022;34:101765.\u003c/li\u003e\n \u003cli\u003eAlkhaldy AA, Alamri RS, Magadmi RK, Elshini NY, Hussein RAEH, Alghalayini KW. Dietary adherence of saudi males to the Saudi dietary guidelines and its relation to cardiovascular diseases: A preliminary cross-sectional study. J Cardiovasc Dev Dis. 2019;6.\u003c/li\u003e\n \u003cli\u003eAlkhaldy AA, Aljahdli ES, Mosli MH, Jawa HA, Alsahafi MA, Qari YA. Adherence to the Saudi dietary guidelines and its relation to colorectal polyps: A university hospital-based study. J Taibah Univ Med Sci. 2020;15:25\u0026ndash;31.\u003c/li\u003e\n \u003cli\u003eSaudi Food and Drug Authority. Saudi Healthy Plate Guide. National Nutrition Committee. 2020. https://sfda.gov.sa/en/node/86211. Accessed 11 May 2024.\u003c/li\u003e\n \u003cli\u003eSaudi Food and Drug Authority. Saudi Healthy Plate Guide, Second Version. National Nutrition Committee. 2024. https://sfda.gov.sa/en/node/93352. Accessed 11 May 2024.\u003c/li\u003e\n \u003cli\u003eButtriss JL. The Eatwell Guide refreshed. Nutr Bull. 2016;41:135\u0026ndash;41.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization: WHO. Obesity and overweight. 2021. https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight. Accessed 24 Feb 2024.\u003c/li\u003e\n \u003cli\u003eMemish ZA, El Bcheraoui C, Tuffaha M, Robinson M, Daoud F, Jaber S, et al. Obesity and Associated Factors \u0026mdash; Kingdom of Saudi Arabia, 2013. Prev Chronic Dis. 2014;11:140236.\u003c/li\u003e\n \u003cli\u003eMoradi-Lakeh M, El Bcheraoui C, Afshin A, Daoud F, AlMazroa MA, Al Saeedi M, et al. Diet in Saudi Arabia: findings from a nationally representative survey. Public Health Nutr. 2017;20:1075\u0026ndash;81.\u003c/li\u003e\n \u003cli\u003eInstitute of Medicine. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington (DC): The National Academies Press; 2002.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Guideline: Sodium intake for adults and children. Geneva; 2012.\u003c/li\u003e\n \u003cli\u003eBrassard D, Munene LAE, St-Pierre S, Guenther PM, Kirkpatrick SI, Slater J, et al. Development of the Healthy Eating Food Index (HEFI)-2019 measuring adherence to Canada\u0026rsquo;s Food Guide 2019 recommendations on healthy food choices1. Applied Physiology, Nutrition and Metabolism. 2022;47:595\u0026ndash;610.\u003c/li\u003e\n \u003cli\u003eAL-Mohaithef M. Prevalence of vegan/vegetarian diet and eating behavior among Saudi adults and its correlation with body mass index: A cross-sectional study. Front Nutr. 2022;9.\u003c/li\u003e\n \u003cli\u003eDrewnowski A, Henry CJ, Dwyer JT. Proposed Nutrient Standards for Plant-Based Beverages Intended as Milk Alternatives. Front Nutr. 2021;8:761442.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization, Magali Rios-Leyvraz, Jason Montez. Health effects of the use of non-sugar sweeteners: a systematic review and meta-analysis. 2022.\u003c/li\u003e\n \u003cli\u003eWorld Health Organization. Guideline: Sugars intake for adults and children. . Geneva; 2015.\u003c/li\u003e\n \u003cli\u003eTrijsburg L, Talsma EF, de Vries JHM, Kennedy G, Kuijsten A, Brouwer ID. Diet quality indices for research in low- and middle-income countries: a systematic review. Nutr Rev. 2019;77:515\u0026ndash;40.\u003c/li\u003e\n \u003cli\u003eKurotani K, Akter S, Kashino I, Goto A, Mizoue T, Noda M, et al. Quality of diet and mortality among Japanese men and women: Japan Public Health Center based prospective study. BMJ. 2016;:i1209.\u003c/li\u003e\n \u003cli\u003eBekele TH, de Vries JHM, Feskens EJM, de Weijer A, Brouwer ID, Covic N, et al. Development of the Ethiopian Healthy Eating Index (Et-HEI) and evaluation in women of reproductive age. J Nutr Sci. 2023;12:e9.\u003c/li\u003e\n \u003cli\u003eDas M. Healthy Eating Index: Evidence from India. SSRN Electronic Journal. 2015. https://doi.org/10.2139/ssrn.2571173.\u003c/li\u003e\n \u003cli\u003eKrebs-Smith SM, Pannucci TRE, Subar AF, Kirkpatrick SI, Lerman JL, Tooze JA, et al. Update of the Healthy Eating Index: HEI-2015. J Acad Nutr Diet. 2018;118:1591\u0026ndash;602.\u003c/li\u003e\n \u003cli\u003eVan DTT, Trijsburg L, Do HTP, Kurotani K, Feskens EJM, Talsma EF. Development of the Vietnamese Healthy Eating Index. J Nutr Sci. 2022;11:e45.\u003c/li\u003e\n \u003cli\u003eLooman M, Feskens EJM, De Rijk M, Meijboom S, Biesbroek S, Temme EHM, et al. Development and evaluation of the Dutch Healthy Diet index 2015. Public Health Nutr. 2017;20:2289\u0026ndash;99.\u003c/li\u003e\n \u003cli\u003eZarrin R, Ibiebele TI, Marks GC. Development and validity assessment of a diet quality index for Australians. Asia Pac J Clin Nutr. 2013;22:177\u0026ndash;87.\u003c/li\u003e\n \u003cli\u003eYun S, Park S, Yook S-M, Kim K, Shim JE, Hwang J-Y, et al. Development of the Korean Healthy Eating Index for adults, based on the Korea National Health and Nutrition Examination Survey. Nutr Res Pract. 2022;16:233.\u003c/li\u003e\n \u003cli\u003eSotos-Prieto M, Bhupathiraju SN, Mattei J, Fung TT, Li Y, Pan A, et al. Changes in Diet Quality Scores and Risk of Cardiovascular Disease Among US Men and Women. Circulation. 2015;132:2212\u0026ndash;9.\u003c/li\u003e\n \u003cli\u003eErtuglu LA, Demiray A, Afsar B, Ortiz A, Kanbay M. The Use of Healthy Eating Index 2015 and Healthy Beverage Index for Predicting and Modifying Cardiovascular and Renal Outcomes. Curr Nutr Rep. 2022;11:526\u0026ndash;35.\u003c/li\u003e\n \u003cli\u003eArtegoitia VM, Krishnan S, Bonnel EL, Stephensen CB, Keim NL, Newman JW. Healthy eating index patterns in adults by sex and age predict cardiometabolic risk factors in a cross-sectional study. BMC Nutr. 2021;7:30.\u003c/li\u003e\n \u003cli\u003eOnvani S, Haghighatdoost F, Surkan PJ, Larijani B, Azadbakht L. Adherence to the Healthy Eating Index and Alternative Healthy Eating Index dietary patterns and mortality from all causes, cardiovascular disease and cancer: a meta-analysis of observational studies. J Hum Nutr Diet. 2017;30:216\u0026ndash;26.\u003c/li\u003e\n \u003cli\u003eBork K, Cames C, Barigou S, Cournil A, Diallo A. A Summary Index of Feeding Practices Is Positively Associated with Height-for-Age, but Only Marginally with Linear Growth, in Rural Senegalese Infants and Toddlers. J Nutr. 2012;142:1116\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eVerger EO, Mariotti F, Holmes BA, Paineau D, Huneau J-F. Evaluation of a Diet Quality Index Based on the Probability of Adequate Nutrient Intake (PANDiet) Using National French and US Dietary Surveys. PLoS One. 2012;7:e42155.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 to 4 are available in the Supplementary Files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Healthy Eating Index, Diet quality, Diet quality index, Diet indices, Saudi Arabia","lastPublishedDoi":"10.21203/rs.3.rs-6099915/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6099915/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e The present study aimed to develop the Saudi Healthy Eating Index (SHEI) to assess adherence to the 2024 version of the Saudi Healthy Plate (SHP) guide and to evaluate diet quality among the Saudi population.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eTwelve components were selected for the SHEI based on the key dietary recommendations of the SHP guide. All components are scored between zero and ten points, except for components measuring the same dietary aspect, which are assigned up to five points. The total adherence score ranges between zero (no adherence) and 100 (complete adherence).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e Maximum scores and standards were assigned to each component as follows: fruits (ten points, ≥0.6 servings/1000 kcal), vegetables (ten points, ≥1.1 servings/1000 kcal), grains (five points, ≥3.5 servings/1000 kcal), whole grain ratio (five points, ratio of whole grains to total grains ≥ 0.5), protein foods (five points, ≥2.2 servings/1000 kcal), seafood and plant-based protein foods (five points, ≥0.9 servings/1000 kcal), dairy products (ten points, ≥0.8 servings/1000 kcal), beverages (ten points, only water or non-sweetened beverages consumed), fatty acid ratio (ten points, ratio of unsaturated to saturated fatty acids ≥ 2.6), saturated fats (ten points, ≤7% of energy intake), added sugar (ten points, ≤5% of energy intake), and sodium (ten points, ≤0.8 grams of sodium per 1000 kcal).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion: \u003c/strong\u003eThe SHEI was designed to measure diet quality by determining adherence to the SHP guide recommendations. The SHEI has various potential applications, including research, evaluation of dietary interventions, and monitoring diet quality among the Saudi population.\u003c/p\u003e","manuscriptTitle":"Development of the Saudi Healthy Eating Index","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-10 05:04:05","doi":"10.21203/rs.3.rs-6099915/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-05-22T13:43:50+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-12T17:48:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-10T12:23:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-05-07T13:51:48+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140211465327500974761475579700168697210","date":"2025-04-21T16:56:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"267760108354554220330961891055813341564","date":"2025-04-20T07:44:47+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"233543029746297584193356151695173404821","date":"2025-04-19T19:18:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"230922595498981225176698802832446072030","date":"2025-04-14T18:00:18+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-11T15:43:51+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-07T13:54:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-02-28T00:36:37+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-02-28T00:35:31+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Nutrition","date":"2025-02-24T21:25:36+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-nutrition","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nutn","sideBox":"Learn more about [BMC Nutrition](http://bmcnutr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nutn/default.aspx","title":"BMC Nutrition","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"658d217f-17ca-4881-a50f-17e643694836","owner":[],"postedDate":"April 10th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-08-04T16:46:01+00:00","versionOfRecord":{"articleIdentity":"rs-6099915","link":"https://doi.org/10.1186/s40795-025-01140-z","journal":{"identity":"bmc-nutrition","isVorOnly":false,"title":"BMC Nutrition"},"publishedOn":"2025-07-30 16:06:11","publishedOnDateReadable":"July 30th, 2025"},"versionCreatedAt":"2025-04-10 05:04:05","video":"","vorDoi":"10.1186/s40795-025-01140-z","vorDoiUrl":"https://doi.org/10.1186/s40795-025-01140-z","workflowStages":[]},"version":"v1","identity":"rs-6099915","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6099915","identity":"rs-6099915","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}