Food-Based Dietary Guidelines around the World: Eastern Mediterranean and Middle Eastern Countries

Abstract

In Eastern Mediterranean countries, undernutrition and micronutrient deficiencies coexist with overnutrition-related diseases, such as obesity, heart disease, diabetes and cancer. Many Mediterranean countries have produced Food-Based Dietary Guidelines (FBDGs) to provide the general population with indications for healthy nutrition and lifestyles. This narrative review analyses Eastern Mediterranean countries’ FBDGs and discusses their pictorial representations, food groupings and associated messages on healthy eating and behaviours. In 2012, both the WHO and the Arab Center for Nutrition developed specific dietary guidelines for Arab countries. In addition, seven countries, representing 29% of the Eastern Mediterranean Region population, designated their national FBDGs. At the moment several of these guidelines are available only in the English language. In summary, Eastern Mediterranean FBDGs mainly focus on food safety, not all are available in the local Arabic language, and they do not provide specific suggestions for the large number of foreign workers and migrants.

Full text

nutrients
Review
Food-Based Dietary Guidelines around the World:
Eastern Mediterranean and Middle Eastern Countries
Concetta Montagnese 1, *, Lidia Santarpia 2,3, Fabio Iavarone 2, Francesca Strangio 2,
Brigida Sangiovanni 2, Margherita Buonifacio 2, Anna Rita Caldara 2, Eufemia Silvestri 2,
Franco Contaldo 2,3 and Fabrizio Pasanisi 2,3
1Epidemiology Unit, IRCCS Istituto Nazionale Tumori “Fondazione G. Pascale”, 80131 Napoli, Italy
2Internal Medicine and Clinical Nutrition, Department of Clinical Medicine and Surgery, Federico II
University, 80131 Naples, Italy; lidia.santarpia@unina.it (L.S.); dr.fabioiavarone@gmail.com (F.I.);
franstrangio@libero.it (F.S.); brigidasangiovanni@gmail.com (B.S.); margheritabuonifacio@libero.it (M.B.);
arcaldara@libero.it (A.R.C.); miasilvestri@libero.it (E.S.); contaldo@unina.it (F.C.); pasanisi@unina.it (F.P.)
3Interuniversity Center for Obesity and Eating Disorders, Department of Clinical Nutrition and Internal
Medicine, Federico II University, 80131 Naples, Italy
*Correspondence: c.montagnese@istitutotumori.na.it; Tel.: +0039-081-746-2333
Received: 28 April 2019; Accepted: 10 June 2019; Published: 13 June 2019
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Abstract:
In Eastern Mediterranean countries, undernutrition and micronutrient deficiencies coexist with
overnutrition-related diseases, such as obesity, heart disease, diabetes and cancer. Many Mediterranean
countries have produced Food-Based Dietary Guidelines (FBDGs) to provide the general population with
indications for healthy nutrition and lifestyles. This narrative review analyses Eastern Mediterranean
countries’ FBDGs and discusses their pictorial representations, food groupings and associated messages
on healthy eating and behaviours. In 2012, both the WHO and the Arab Center for Nutrition developed
specific dietary guidelines for Arab countries. In addition, seven countries, representing 29% of the
Eastern Mediterranean Region population, designated their national FBDGs. At the moment several
of these guidelines are available only in the English language. In summary, Eastern Mediterranean
FBDGs mainly focus on food safety, not all are available in the local Arabic language, and they do not
provide specific suggestions for the large number of foreign workers and migrants.
Keywords:
dietary guidelines; Eastern Mediterranean countries; healthy diet; non-communicable
diseases; food safety; public health
1. Introduction
Food and nutrition play a key role in the prevention and treatment of undernutrition and
over-nutrition, diet-related non-communicable diseases (NCDs), such as obesity, cardiovascular
diseases, diabetes, and some types of cancer [
1
,
2
]. In several Eastern Mediterranean countries, in
the last few decades, several social health determinants such as political instability, low income,
urbanization, demography, local conflicts, and migration have dramatically affected food availability
and choices and consequently the nutritional status of certain populations [
3
,
4
]. In particular, inadequate
intake of some nutrients is responsible for undernutrition and micronutrient deficiencies, whilst the
increased consumption of processed (added sugars, saturated fat or trans fatty acids, NaCl- and
calorie-rich) foods has played a key role in the increased incidence of NCDs [
5
–
14
]. Currently,
two contrasting nutrition-related conditions co-exist: undernutrition and micronutrient deficiencies,
especially among children, and overnutrition-related NCDs claiming over 2.2 million lives in 2012 and
over 57% of all deaths in these countries [
5
–
8
]. In 2012, the Food and Agricultural Organization (FAO)
and the World Health Organization (WHO), which pay particular attention to this issue worldwide,
Nutrients 2019,11, 1325; doi:10.3390/nu11061325 www.mdpi.com/journal/nutrients

Nutrients 2019,11, 1325 2 of 16
published Food-Based Dietary Guidelines (FBDGs) for the Eastern Mediterranean Region (EMRO)
to provide the general population with indications for healthy nutrition and lifestyles. The aim
of our study was to collect all the available national FBDGs of Eastern Mediterranean countries to
identify differences and common points and to compare the suggested guidelines with European and
American FBDGs.
2. Materials and Methods
All FBDGs from Eastern Mediterranean countries, as identified according to the WHO regional
classification, were collected. The sources of information included the Internet, the FAO website, the
Embassies cultural office in Italy and the National Ministries of Health of these countries. Countries
with fewer than 100,000 inhabitants (according to the WHO website) were excluded. The data concerned
the FBDG format, additional texts (such as leaflets, booklets providing further information and advice
on the types and quantities to be consumed for each food group) and additional tips regarding fluids,
alcohol, physical activity and body weight advice and individual healthy behaviours.
3. Results
3.1. Geographic Distribution of the Studied Countries
The WHO identifies 22 Eastern Mediterranean countries (Table 1, Figure 1), corresponding to a
total of 684,561,000 inhabitants, about 9% of the world population [9].
Nutrients 2019, 11, x FOR PEER REVIEW
Figure 1. WHO Regions: WHO Member States are grouped into six regions. Each region has a
regional office. The map shows the WHO regions and the location of the regional offices
(https://www.who.int/about/regions/en/).
The WHO classification includes Iran, Afghanistan and Pakistan, which are not Arab countries,
and does not include Algeria, which is an Arab country. Palestine, i.e., the territories of the Gaza
Strip and West Bank, is included in the WHO EMR classification, whilst Turkey and Cyprus are
considered to belong to the European Region, and have been discussed elsewhere [15]. All countries
have more than 100,000 inhabitants. Twelve countries (Djibouti, Egypt, Jordan, Iraq, Libya, Morocco,
Pakistan, Palestine, Somalia, Sudan, Syrian Arab Republic and Tunisia) had no specific official data,
whilst Afghanistan, Iran, Lebanon, Oman, and Qatar (in the Near East region) have FBDG data
available on the FAO website (Table S1). Food-based dietary guidelines were available for Saudi
Arabia and Yemen on the National Ministries of Health website (Table S1). Our narrative analysis
will start with a description of the general guidelines produced by the WHO in collaboration with
the other UN agencies and experts from the region, aimed to guide the national guidelines: the
“Promoting a healthy diet for the WHO Eastern Mediterranean Region (EMRO): user-friendly
guide” [13]. Thereafter, the “Food Dome Dietary Guidelines for Arab Countries” [11], the
“Food-Based Dietary Guidelines for Arab Gulf Countries” [12] and finally national guidelines,
available for several countries, will be analysed to identify similarities and differences. Tables 2 and
3 give a comparison of the dietary recommendations and non-dietary recommendations,
respectively, for EMR countries’ FBDGs.
Figure 1.
WHO Regions: WHO Member States are grouped into six regions. Each region has a
regional office. The map shows the WHO regions and the location of the regional offices (https:
//www.who.int/about/regions/en/).

Nutrients 2019,11, 1325 3 of 16
Table 1. EMR countries identified according to WHO classification and divided into six geographic sub-regions.
North Africa
(4)
Inhabitants
(n)
Central East
Africa
(1)
Inhabitants
(n)
Horn of
Africa (2)
Inhabitants
(n)
South Asia
(3)
Inhabitants
(n)
Western
Middle East
(5)
Inhabitants
(n)
Arabian Peninsula
(7)
Inhabitants
(n)
Egypt 192,115,000 Somalia 112,316,000 Sudan 140,783,000 Afghanistan 29,200,000 Syria 122,422,000 Saudi Arabia 32,552,000
Libya 16,545,000 Djibouti 1860,000 Pakistan 1213,707,000 Lebanon 4,421,000 Yemen 27,426,000
Tunisia 111,446,000 Iran 79,926,000 Jordan 110,053,000 Oman 4,560,000
Morocco 134,852,000 Iraq 137,140,000 Un. Arab Emirates 9,121,000
Palestine 14,706,000 Qatar 2,725,000
Bahrain 1,501,000
Kuwait 4,184,000
Total inhabitants
per sub-region 144,958,000 12,316,000 41,643,000 322,833,000 78,742,000 82,069,000
1No data available on FBDGs.

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Seven countries (Afghanistan, Iran, Yemen, Lebanon, Oman, Qatar and Saudi Arabia) have their
own official FBDGs, reaching a total of 195,616,000 citizens (29% of the entire Eastern Mediterranean
population) according to WHO documents [
9
]. Afghanistan published its national guidelines in 2015.
Specifically, Afghanistan lacks a functioning healthcare system because it is one of the world’s most
fragile and conflict-affected countries.
The WHO classification includes Iran, Afghanistan and Pakistan, which are not Arab countries,
and does not include Algeria, which is an Arab country. Palestine, i.e., the territories of the Gaza Strip
and West Bank, is included in the WHO EMR classification, whilst Turkey and Cyprus are considered
to belong to the European Region, and have been discussed elsewhere [
15
]. All countries have more
than 100,000 inhabitants. Twelve countries (Djibouti, Egypt, Jordan, Iraq, Libya, Morocco, Pakistan,
Palestine, Somalia, Sudan, Syrian Arab Republic and Tunisia) had no specific official data, whilst
Afghanistan, Iran, Lebanon, Oman, and Qatar (in the Near East region) have FBDG data available
on the FAO website (Table S1). Food-based dietary guidelines were available for Saudi Arabia and
Yemen on the National Ministries of Health website (Table S1). Our narrative analysis will start with
a description of the general guidelines produced by the WHO in collaboration with the other UN
agencies and experts from the region, aimed to guide the national guidelines: the “Promoting a healthy
diet for the WHO Eastern Mediterranean Region (EMRO): user-friendly guide” [
13
]. Thereafter, the
“Food Dome Dietary Guidelines for Arab Countries” [
11
], the “Food-Based Dietary Guidelines for Arab
Gulf Countries” [
12
] and finally national guidelines, available for several countries, will be analysed to
identify similarities and differences. Tables 2and 3give a comparison of the dietary recommendations
and non-dietary recommendations, respectively, for EMR countries’ FBDGs.

Nutrients 2019,11, 1325 5 of 16
Table 2. EMR countries’ FBDGs dietary recommendations.
Food Groups WHO-EMR: User Friendly Guide
Food Dome Dietary
Guidelines for Arab
Countries
Kingdom of Saudi
Arabia Lebanese Dietary Guidelines Qatar Dietary Guidelines Omani Guide to Healthy Eating Afghanistan Islamic Republic of Iran
Cereals/Grain
Products and
Tubers
180 g/day:
90 g whole grain; 90 g “other”
grains
30 g equivalent =1 slice bread; 1
2
cup cooked pasta, rice, bulgar, or
cereal;
1 cup dry cereal
6–11 servings/day:
≥
5.5 servings whole grain
1 serving =1 slice bread;
1
4Arabic bread;
1
2cup cooked cereals;
30 g dry cereal
6–11 servings/day
1 serving =1 slice
bread (25 g),
1
2cup of cereals,
1 slice of toast
6 servings/day
(with at least 1
2being whole grain)
based on 2000 kcal diet
1 serving =1
4big loaf of Arabic
whole-wheat pita bread;
1 slice bread; 1
2cup rice, pasta, or
noodles;
1 cup dry cereal (unsweetened)
≥6 servings/day
Substitute refined with whole
and high-fibre grains.
Choose grains prepared with
little or no added fat, sugar or
salt, read labels Avoid
hydrogenated or trans-fat.
6–11 servings/day
1 slice bread;
1
2cup cooked rice, pasta, or cereal;
prefer whole wheat, brown rice
6 servings/day for a 2200
Kcal diet.
1 serving =~140 kcal.
~1
4Naan (50 g piece);
~2/3 cup (125 g) cooked
brown or white rice;
1 small potato boiled (160
g boiled weight), etc.
All types of bread
(preferably whole), rice
(brown, if available),
macaroni, spaghetti,
other pasta, barley
Fruits
4 servings/day or 2 cups/day
1 serving =1 medium fruit;
1
2cup fresh fruit;
1 cup fruit juice
3–5 servings/day
1 serving =1 medium
fruit;
3
4cup fruit juice
2–4 servings/day
1 serving =1medium
fruit;
1
2cup juice;
1
2cup dried fruit
2 servings/day
1 serving =1 small fruit;
1 cup fruit juice;
1
2cup dried fruit
2–4 servings per day
1 serving =1 medium fruit;
1
2cup cut fruit;
1
2fruit juice;
1
4cup dried fruit.
Favour whole fruit over juices,
choose often as snacks
2–4 servings/day
1 serving =1 cup raw or cooked;
1
2
cup fruit juice.
Choose vitamin C-, vitamin A- and
potassium-rich fruits.
3 servings/day for a 2200
kcal diet. 1 serving =~80
kcal
Apples, pears, citrus fruit,
peaches, grapes; dried
fruits; fruit juices
Vegetables
5 servings/day or 2 1
2cups per day
1 serving =1
2cup raw or cooked;
1 cup leafy vegetable;
1
2cup vegetable juice
3–5 servings/day
1 serving =1 cup raw;
3
4cup vegetable juice
3–5 servings/day
1 serving =1 cup raw
or cooked;
1 cup juice
2–3 servings/day
1 serving =1 cup raw or cooked;
2 cup leafy vegetables;
1cup vegetable juice
3–5 servings/day
1 serving =1
2cup cooked, fresh,
raw, or canned;
1 cup green leafy vegetables
3–5 servings/day
Chose vegetables prepared with
little or no added fat and salt.
Choose vitamin C-, vitamin A- and
iron/folic acid-rich vegetables.
2.5 servings/day for a
2200 Kcal diet.1 serving =
~35 kcal
Green leafy and non-leafy
vegetables
Milk & Dairy
Products
3 cup equivalent/
day
1 cup equivalent =1 cup low-fat
milk or yoghurt; 45 g low-fat
natural cheese;
60 g processed cheese;
8 tbsp labneh
2–3 servings/day
1 serving =1 cup milk;
45 g cheese;
1 tbsp cream cheese
2–4 servings/day
1 serving =1 cup milk
or labneh;
30 g cheese
3 servings/day
1 serving =1 cup low fat milk or dairy
products to supply the daily
recommended intake of calcium of
1000 mg/day based on 2000 kcal diet;
3 tbsp powdered milk;
45 g cheese;
8 tbsp labneh
2 cup equivalents/day
1 cup eq. =1 cup milk or
yoghurt;
50 g cheese;
14 tbsp labneh
Daily consumption of r low fat
milk and dairy products.
Choose vitamin D fortified milk
1 serving/day
1 serving =1 cup long-life, fresh,
pasteurized, powdered milk or
yoghurt;
45 g natural cheese;
60 g oz processed cheese, laban
and kushk
3.5 servings/day for a
2200 Kcal diet. 1 serving
=~70 kcal
Milk, cheese, yoghurt,
yoghurt drink (doogh),
kashk (a traditional dry
milk product), ice cream
Meat & Vegetal
Proteins
160 g per day
1 serving =30 g lean meat, poultry,
or fish;
1 egg;
1
4cup cooked dry beans;
15 g nuts or seeds
2–4 servings per day
1 serving =50–80 g meat,
chicken, or fish;
1 egg;
1
2
cup legumes and
nuts
2–3 servings per day
1 serving =60–90 g
red meat, chicken, or
fish;
1
2cup cooked
legumes
5–6.5 servings per day
1 serving =30 g meat, poultry,or fish;
1 egg;
1 cup legumes;
15 g nuts or seeds
Eat a variety of fish at least 2
times a week. Chose skinless
poultry and lean cuts of meat.
Avoid processed meats.
Chose legumes, nuts and seeds
as alternative protein sources.
Eat legumes daily.
Choose legumes prepared with
little or no added fat or salt
Meat: 1–2 servings/day
1 serving =30 g red lean beef, lamb
and camel, poultry,chicken. All
fishes;
1 egg;
15 g oz nuts or seeds Legumes: 1
serving per day;
1
2
cup cooked lentils, beans or peas;
1
4cup cooked dry beans or tofu
Meat: 2 servings/day for
a 2200 Kcal diet. 1
serving =~70 kcal.
Legumes: 1.5
servings/day for a 2200
Kcal diet. 1 serving =
~140 kcal.
Beef, veal, lamb, chicken,
fish, canned tuna, shrimp,
eggs
Legumes, nuts including
walnuts, almonds,
pistachios, peanuts,
hazelnuts
Oils 6 tsp per day None provided “least amount per
day” Limited consumption Limited Consumption None provided None provided None provided
Salt, Fats & Sugars
Salt: no more
2,3 g/day.
Use iodized salt for growth and
brain development
Fat: 18 g/day
Sugar: 8 tsp/day
None provided
Use iodized salt,
especially in cities
that are not on the sea
coast “Least amount
per day”
Salt: no more
2.3 g/day for healthy people and to
less than 1.5 g for people with
hypertension, type 2 diabetes, chronic
kidney disease, or over 50 years.
Fat: 56–78 g per day
Sugar: <10 tsp per day
Salt: <5 g/day
Additional information on how
to check food labels for the
words salt or sodium.
Distinguish “Foods high in salt”
and “Foods low in salt”
Fat: <3 g per 100 g
Sugar: <5 g per 100 g
Salt: <5 g/day;
Fat: 59 g per day
Sugar: <10% total
calories sugar
Salt: <5 g/day;
Reduce simple sugars
and substitute sweets
with fruits.
Remove visible fat from
meat. Reduce processed
meat consumption.
None provided
Water & Fluids Men: 3.7 L/day
Women: 2.7 L/day “Sufficient quantity” 1.5 L per day 2–3 L per day 2–3 L per day Daily Daily Daily
Tbsp: tablespoon; tsp: teaspoon.

Nutrients 2019,11, 1325 6 of 16
Table 3. EMR countries’ FBDGs non-dietary recommendations.
Non Dietary
Recommendations
WHO EMRO: User
Friendly Guide
Food Dome Dietary
Guidelines for Arab
Countries
Kingdom of Saudi
Arabia
Lebanese Dietary
Guidelines
Qatar Dietary
Guidelines
Omani Guide to Healthy
Eating Afghanistan Islamic Republic
of Iran
Physical Activity
30 min/day of moderate PA
30 min/day of moderate
PA 30–60 min/day 30 min, 5 days a week 30 min moderate PA, 5
days a week
Moderate PA: 30 min 5
days/week, Vigorous PA:20
min 3 days/week
20–30 min PA/day 30–40 min PA/day
Language English English, Arabic English English English, Arabic English English English
Food guide illustration
shape Plate (circle) Food Dome Healthy Food Palm Lebanese Cedar (pyramid) Tablecloth Healthy Plate (circle) Tablecloth Pyramid
Food safety/Hygiene Five keys for safer foods.
Eat clean and safe food.
Ensure Safety of Food
Eaten
Proper cleaning practices
and food handling.
Microbiological aspects of
food safety, and practical
matters related to safety
precautions
Mothers and family
members should practice
hand washing-with soap
and water at critical times
Wash your hands before
handling food and often
during food preparation,
after going to the toilet.
Wash and sanitize all
surfaces and equipment
used for food preparation.
Protect kitchen areas and
food from insects, pests
and other animals
Mothers and family
members should
practice hand
washing with soap
and water at critical
times
Washing hands and
keeping chopping
boards, plates,
knives, etc. clean
Safe water Drink lots of clean water
Get your home tap water
checked for microbial and
mineral contamination. If it
is not safe for drinking,
drink safe bottled-water
Use clean and safe water
for hand washing,
drinking and food
preparation
Untreated water from
rivers and canals is not
safe! Rainwater collected in
clean tanks is safe as long
as the tanks are protected
from contamination from
birds or other animals
Use clean and safe
water for hand
washing, drinking
and food
preparation
Healthy body weight Maintain a healthy body
weight
Maintain proper weight
for height
Maintain an
appropriate weight
for your height
Enjoy and maintain a
healthy body weight
Exercising regularly can
help maintain a healthy
body weight and high
quality of life
Maintain a normal
weight and stay
healthy; you should
eat adequately and
have sufficient
physical activity
Recommendations for
specific population
subgroups
Women of childbearing age,
lactating women, strict
vegetarians, lactose
intolerance, elderly
Pregnant and lactating
women, infants and
preschool children,
school children and
adolescents, people
aged 50 years
Pregnant, breastfeeding
women, menopause,
elderly, lactose intolerant,
Vegetarians and strict
vegans. Population groups
most susceptible to
food-borne illnesses
(individuals with
weakened immune
systems, e.g., HIV-infected)
Pregnant, breastfeeding
women, children,
adolescents, vegetarians
Pregnant, breastfeeding
women, children,
adolescence, elderly
Pregnant,
breastfeeding
women, children,
adolescence
Recommendations for
specific diseases
Coronary heart disease,
stroke, cancers, type 2
diabetes mellitus, cataract
and macular degeneration,
hypertension; dental caries
Diet-related diseases
(heart disease, type 2
diabetes, hypertension,
osteoporosis, obesity
and cancer),
undernutrition and
micronutrient
deficiencies
Obesity; CVD;
hypertension,
diabetes, dental
caries, osteoporosis,
rickets, micronutrient
deficiencies
Obesity; CVD; diabetes,
hypertension, obesity,
cancer, dental caries,
osteoporosis, nutrient
deficiencies
Obesity; CVD; diabetes,
hypertension, cancer,
nutrient deficiencies,
COPD
Obesity; CVD;
hypertension, diabetes,
obesity, cancer, dental
caries, osteoporosis,
nutrient deficiencies
Obesity; CVD;
hypertension,
BPCO,
micronutrient
deficiencies
Obesity; CVD;
hypertension,
diabetes, cancer,
nutrient deficiencies
PA: Physical Activity; CVD: Cardiovascular Diseases; COPD: Chronic obstructive pulmonary disease.

Nutrients 2019,11, 1325 7 of 16
3.2. Promoting a Healthy Diet for the WHO EMRO: User-Friendly Guide
Based on the FAO/WHO Technical Consultation on National Food-Based Dietary Guidelines for
countries in the Near East held in 2004, the WHO authored the “Promoting a healthy diet for the WHO
EMRO: user-friendly guide” project to provide recommendations for an overall healthy pattern of
eating to be adopted by the general population in EMRO countries to reduce the risk of major chronic
diseases through diet and physical activity [
13
]. These recommendations are tailored to the dietary
needs, food choices and preferences of the population of these regions and take into account the
availability and cultural acceptance of foods in different countries. The guideline is available in English
but not in the local language (Arabic), and, similarly to the USDA’s My Plate and Dietary Guidelines
for Americans [
16
], a circle is used as a food guide pictorial representation. The plate is divided into
five different sections, each representing a food group (bread, cereals, potatoes and rice; fruit and
vegetables; meat, poultry, fish, dried beans and eggs; milk and dairy products; foods containing fat
and foods and drinks containing sugar), with an area proportional to the recommended amounts to
be consumed. A glass of water on the left of the plate encourages non-caloric fluid intake. A set of
14 recommendations (Table 4) suggests choosing a variety of healthy foods each day, describes the
potential health benefits and negative disease outcomes related to each food category, and exhaustively
discusses the recommendations for the respective food group.
Table 4.
Promoting a healthy diet for the WHO Eastern Mediterranean Region: user-friendly guide—
key recommendations.
1. Maintain a healthy body weight
2. Be active
3. Limit intake of fats and oils
4. Limit intake of sugars, especially sweetened foods and beverages
5. Limit salt intake
6. Eat a variety of foods every day
7. Eat cereals, preferably whole grains, as the basis of most meals
8. Eat more vegetables and fruit every day
9. Eat legume-based dishes regularly and choose unsalted nuts and seeds
10. Eat fish at least twice a week
11. Consume milk/dairy products daily (preferably low-fat)
12. Choose poultry and lean meat
13. Drink lots of clean water
14. Eat clean and safe food
A section on the glycaemic index and some tips to increase vegetable and fruit intake are
included. It is suggested that people choose predominantly unsaturated vegetable oils (such as
olive, sunflower, canola, corn and soy oils) rather than animal fats, lard, palm or coconut oil, hard
margarine or clarified butter (ghee, samna). It is also recommended that people regularly consume
legume-based dishes and at least two portions of fish per week to achieve adequate intake of omega-3
fatty acids, low-fat milk and dairy products, and to select lean meat cuts, with examples of local
and traditional Arabic foods. The consumption of fresh or dried fruits (e.g., dates, apricots and
raisins) as snacks instead of processed foods high in added sugars, of cereal-based snacks instead
of cakes, biscuits, baklava, knafeh and confectionery and of fresh fruit juice instead of soft drinks
and sweetened beverages (e.g., jellab, tamirhindi or sweetened lemonade) is suggested. Limits on
added sugars, particularly in the form of sweetened beverages and sweets, salty snacks, and fatty
foods are advised, while the importance of consuming dietary fat from unsaturated fat sources and
omega-3 fatty acids from foods such as nuts, flaxseed and fish is emphasized. A list of foods and drinks
containing added sugar is also included. Recommendations to consume less than 2.3 g of sodium per
day and to use iodized salt for growth and brain development are included. Fresh foods are more
frequently depicted than manufactured/packaged (processed) foods (such as yoghurt, butter, sweets,
salty snacks, corn syrup and canned fish); oil is represented by a bottle. No recommendations on

Nutrients 2019,11, 1325 8 of 16
alcoholic beverage consumption are included. The WHO EMRO guidelines also provide advice to
improve the nutritional status of specific population subgroups (hypertensive subjects, middle-aged
and older adults, women of childbearing age, lactating women, strict vegans and vegetarians and
lactose-intolerant individuals). These guidelines are intended for use not only by policy-makers, health
care providers and nutritionists, but also by people involved in food distribution, food service and
various nutrition programs. Unfortunately, they are not available in the Arabic language.
3.3. Food Dome Dietary Guidelines for Arab Countries
The Food Dome Dietary Guidelines proposed by the Arab Center for Nutrition [
11
] is focused on
the prevention of the most prevalent diet-related diseases in Arabic countries and takes into account
local habits and traditional food consumption patterns, lifestyle and health status. These guidelines
are available both in the local language (Arabic) and in English. The Dome illustration used for the
dietary guidelines reflects the culture and religious background of Arab people: the dome is part of
most mosques and churches and is widely used in many buildings in the EMRO (Figure 2).
Nutrients 2019, 11, x FOR PEER REVIEW 10 of 18
frequently depicted than manufactured/packaged (processed) foods (such as yoghurt, butter, sweets,
salty snacks, corn syrup and canned fish); oil is represented by a bottle. No recommendations on
alcoholic beverage consumption are included. The WHO EMRO guidelines also provide advice to
improve the nutritional status of specific population subgroups (hypertensive subjects, middle-aged
and older adults, women of childbearing age, lactating women, strict vegans and vegetarians and
lactose-intolerant individuals). These guidelines are intended for use not only by policy-makers,
health care providers and nutritionists, but also by people involved in food distribution, food service
and various nutrition programs. Unfortunately, they are not available in the Arabic language.
3.3. Food Dome Dietary Guidelines for Arab Countries
The Food Dome Dietary Guidelines proposed by the Arab Center for Nutrition [11] is focused
on the prevention of the most prevalent diet-related diseases in Arabic countries and takes into
account local habits and traditional food consumption patterns, lifestyle and health status. These
guidelines are available both in the local language (Arabic) and in English. The Dome illustration
used for the dietary guidelines reflects the culture and religious background of Arab people: the
dome is part of most mosques and churches and is widely used in many buildings in the EMRO
(Figure 2).
Figure 2. The Food Dome: dietary guidelines for Arab countries.
The Food Dome is divided into different sections, each representing a food group, proportional
to the recommended amounts. A wide variety of foods commonly consumed by Arab people are
Figure 2. The Food Dome: dietary guidelines for Arab countries.
The Food Dome is divided into different sections, each representing a food group, proportional
to the recommended amounts. A wide variety of foods commonly consumed by Arab people are
represented, including traditional foods, such as Arabic flatbread and macaroni as cereals; cream cheese
and laban in the milk and dairy food group; and seeds, nuts and peanut butter in the protein-rich

Nutrients 2019,11, 1325 9 of 16
food group. The graphical format is characterized only by fresh foods; milk is represented by a bottle.
No recommendations on water and beverages, or on salt, sugar and fat intake, are reported. At the
base of the Dome people are engaged in physical activity. In general, the Food Dome reflects the
recommendations of promoting a healthy diet for the WHO EMRO: User-Friendly Guide [
13
] while
adhering to regional and cultural food practices and access. Specific recommendations for vulnerable
groups are also included: women of reproductive age, pregnant or lactating women, infants and
preschool children (under six years of age), schoolchildren and adolescents, and people aged over
50 years. Advice is also included on alcohol consumption during pregnancy and its negative effects on
children’s development and behaviour. Finally, recommendations for the prevention of cataracts and
macular degeneration, and on adequate vitamin D intake and sunlight exposure to reduce risk factors
for osteoporosis after menopause are included.
3.4. Food-Based Dietary Guidelines for Arab Gulf Countries
In 2012, the Arab Center for Nutrition developed Food-Based Dietary Guidelines for the Arab
Gulf Countries (namely Bahrain, Kuwait, Oman, Qatar, Saudi Arabia, and United Arab Emirates, also
part of the Gulf Cooperation Council (GCC) [
12
]. These countries are located in or connected to the
Arabian Peninsula and have an overall population of nearly 50 million people, with the majority in
Saudi Arabia (31 million) and the fewest in Bahrain (1.3 million).
The FBDGs for the Arab Gulf countries consist of 14 simple and practical recommendations,
taking into account the socio-cultural status and nutritional problems shared by these countries.
These guidelines lack a graphical representation and are available only in English [
12
]. It is suggested
that people satisfy their energy requirements mainly from plant-related foods (grains, legumes, seeds,
and nuts) and replace meat with fish wherever possible. It is also recommended that people eat grains
fortified with iron, folic acid, calcium and vitamin D to compensate for deficiencies. The consumption
of milk and low-fat dairy products is encouraged, particularly for their high calcium content and
beneficial effects on bone density. Practical advice is also provided to reduce salt intake (no more
than 5 g sodium chloride/day) and the consumption of salty food such as processed meat products
(e.g., sausages and mortadella), salted fish and fish sauce, such as mihiyawa (mishawa) and tareeh,
as well as giblets, due to their high cholesterol content. The use of spices, vinegar and herbs as salt
substitutes, as well as of iodized salt, is recommended. Some practical advice to avoid contamination
during food storage and/or preparation and alcohol abuse and smoking is also included.
3.5. Food Guide Illustration Shapes
In total, 6/7 (86%) EMR countries (Afghanistan, Iran, Lebanon, Oman, Qatar and Saudi Arabia)
have visual aids for food guide illustrations (Figure 3).
Saudi Arabia, Iran and Lebanon use a pyramid as the food guide representation. The Iranian
pyramid has four layers, accompanied by a list of 13 recommendations. The pyramid shape for
Lebanon and Saudi Arabia adopts a graphical format that conveys aspects of local culture, like settings
and crops. The Lebanese Cedar Food Guide has the crown/foliage shaped like a pyramid and is
divided into six sections placed in four layers. Each section represents a food group, with the serving
sizes according to the daily recommended amounts. A glass of water in the trunk of the cedar tree
indicates the importance of consumption of safe water. A young man and a woman jogging on a beach
suggest regular physical activity. The Lebanese manual “Fourteen Food-Based Dietary Guidelines for
Lebanese Adults” deals with diet-related public diseases and the eating patterns of the Lebanese adult
population. The Saudi Arabian “Healthy Food Palm” distributes food groups in the palm trunk (seven
layers) and leaves according to the daily suggested amounts. At the bottom of the trunk a glass of
water with recommendations on its consumption underscores the importance of water intake, mostly
due to the very hot weather. Food groups on the leaves are symmetrically distributed according to
the daily recommended amounts. At the base of the “Healthy Food Palm” people are shown playing
football, swimming and cycling, recommending regular physical exercise. The palm tree symbolizes

Nutrients 2019,11, 1325 10 of 16
vitality, growth and prosperity and has a huge cultural influence in the Arab world; it is also part of
the national flag of Saudi Arabia. Oman and Qatar use a circle as a food guide pictorial representation.
The Omani Healthy Plate is the visual representation of the “Omani Guide to Healthy Eating.” The
Omani FBDGs are set as nine Key Guidelines addressing people older than two years and focusing on
adequate nutrition and NCD prevention. The plate is divided into six different coloured sections whose
area is proportional to the recommended consumption. A bottle of water encourages non-caloric fluid
intake. The Qatar food guide is a shell-shaped plate containing six food groups. The area of each food
section is proportional to the recommended amount for a healthy diet; a drop of water symbolizes
the importance of water consumption and hydration. Afghanistan uses a tablecloth with seven food
plates. The largest plate at the centre represents the main food group, consisting of cereals and tubers.
Nutrients 2019, 11, x FOR PEER REVIEW 12 of 18
symmetrically distributed according to the daily recommended amounts. At the base of the
“Healthy Food Palm” people are shown playing football, swimming and cycling, recommending
regular physical exercise. The palm tree symbolizes vitality, growth and prosperity and has a huge
cultural influence in the Arab world; it is also part of the national flag of Saudi Arabia. Oman and
Qatar use a circle as a food guide pictorial representation. The Omani Healthy Plate is the visual
representation of the “Omani Guide to Healthy Eating.” The Omani FBDGs are set as nine Key
Guidelines addressing people older than two years and focusing on adequate nutrition and NCD
prevention. The plate is divided into six different coloured sections whose area is proportional to the
recommended consumption. A bottle of water encourages non-caloric fluid intake. The Qatar food
guide is a shell-shaped plate containing six food groups. The area of each food section is
proportional to the recommended amount for a healthy diet; a drop of water symbolizes the
importance of water consumption and hydration. Afghanistan uses a tablecloth with seven food
plates. The largest plate at the centre represents the main food group, consisting of cereals and
tubers.
Figure 3. Food guide illustration shapes used for some Eastern Mediterranean FBDGs. (a) Qatar; (b)
Afghanistan; (c) Iran; (d) Oman; (e) Kingdom of Saudi Arabia; (f) Lebanon.
(a)
(c)
(e)
(b)
(d)
(f)
Figure 3.
Food guide illustration shapes used for some Eastern Mediterranean FBDGs. (
a
) Qatar;
(b) Afghanistan; (c) Iran; (d) Oman; (e) Kingdom of Saudi Arabia; (f) Lebanon.

Nutrients 2019,11, 1325 11 of 16
3.6. Language Used
The Food Dome FBDGs for Gulf countries and the WHO EMRO guidelines were available only in
English, whereas the Food Dome Dietary Guidelines for Arab countries were available both in the local
language (Arabic) and in English. Five out of seven countries (Afghanistan, Iran, Lebanon, Oman and
Saudi Arabia) have data and supportive information (web pages, leaflets and booklets) available in
English, but not in the local languages. Qatari FBDGs are available both in the local language (Arabic)
and in English.
3.7. Additional Information
Qatari FBDGs include ecological recommendations to protect the environment while eating a
healthy diet; for example: reduce leftovers and waste; and choose fresh, home-made foods over highly
processed foods and fast foods, preferably those produced locally and regionally. Due to possible
microbial food contamination, all FBDGs include advice on food safety, proper cleaning practices
and handling of food and contain additional text on personal hygiene measures. The Afghanistan,
Lebanon and Oman FBDGs recommend using clean, safe water for hand washing, drinking and
food preparation and suggest boiling water or using bottled water to avoid microbial and mineral
contamination. In particular, the Omani FBDGs recommend not using untreated water from rivers and
canals, as well as rainwater, which is prone to contamination. Recommendations on healthy cooking
are present in the Iran, Lebanon, Oman, Qatar and Saudi Arabia FBDGs. Most FBDGs encourage
consumers to check food labels to choose foods with fewer calories and low saturated fat (including
trans fatty acids), sugar and sodium content. Five FBDGs (Afghanistan, Iran, Lebanon, Oman and
Qatar) contain additional text on micronutrient intake for normal metabolic growth and physical
well-being. Lebanon and Afghanistan suggest consuming fortified foods, such as vitamin D-fortified
foods (e.g., milk and yoghurt), iron-fortified flour, vitamin A-fortified oil and iodine-fortified salt.
Afghanistan FBDGs provide tables on the number of servings of each of the food groups needed for
“three energy levels” to achieve and maintain a healthy body weight and overall health.
Five out of seven FBDGs recommend limiting the consumption of caloric beverages. Oman and
Lebanon recommend limiting not only added-sugar soft drinks, to less than 10% of daily calories,
but also sugar-free soft drinks. Some FBDGs recommend drinking natural fruit juice (e.g., orange,
grapefruit, strawberry), a yoghurt drink or kefir instead of sweetened beverages and local syrup-based
drinks (e.g., jellab, tamirhindi or sweetened lemonade).
3.8. Foods Pictured in the Graphics
Regarding the frequency of the food pictures represented in the FBDGs: cereals, fruit, vegetables,
milk, dairy, fish, meat and legumes are reported in all countries (100%). In the analysed countries, fresh
foods (85–98%) were depicted more frequently than manufactured/packaged foods (2–15%). Frozen
okra and frozen mixed vegetables are also depicted in the Qatari shell food graphic because they
are commonly consumed food products. Some countries (e.g., Lebanon, Oman, and Qatar) include
local food preparations: Arabic bread and Arab flatbread, ghee (clarified butter), cheese, laban, Arab
sweets and dates, among others. Water is part of the food graph for Lebanon, Oman, Qatar and Saudi
Arabia, but absent in the Iran and Afghanistan FBDGs graphics. Salt consumption is graphically
represented only in the Lebanese FBDGs, at the top of the cedar tree. Alcoholic beverages are absent in
all graphic representations.
3.9. Food Grouping
The Lebanon, Saudi Arabia, Oman and Qatar FBDGs classify foods into six groups; water, generally
is represented separately. “Milk and dairy products” are a food group in all FBDGs. Traditional
dairy products, such as laban (a yoghurt-based drink), soy milk, kefir, Akkawi and Kashkaval (hard
cheese), labneh and Kashta (a cooking cream cheese), are suggested. The Afghanistan and Lebanon

Nutrients 2019,11, 1325 12 of 16
FBDGs recommend the consumption of calcium- and vitamin D-enriched milk. The Qatari FBDGs
include a “Milk, Dairy Products & Alternatives” food group that includes milk and dairy products and
other calcium and vitamin D-rich foods (e.g., fortified soy drinks, almonds, chickpeas) as alternatives
for people who do not drink milk or dairy products. Three countries (Afghanistan, Iran and Oman)
classify animal (meat, fish and eggs) and plant-based protein-rich foods (legumes, seeds and nuts) as
two different food groups. Some FBDGs include traditional meats, such as goat, sheep, rabbit, turkey,
camel, lamb and liver as part of their food habits. The Omani FBDGs include animal protein-rich
foods, both fresh and processed meat, and typical high-fat animal products (e.g., canned meats,
sausages, shawarma—mixed meats placed on a vertical spit and grilled kebab, chicken nuggets and
fingers). “Meats and Legumes” are reported as a unique protein-rich food group in the Saudi Arabian
FBDGs. The Lebanese Food Guide lists fruit and vegetables by colour and nutrients: red for lycopene;
orange and yellow for beta-carotene; green and purple for polyphenols; and white for allyl sulphides.
The Omani FBDGs list fruit and vegetables by nutrients: vitamin C-, vitamin A-, iron- and folic
acid-rich foods. In particular, they include the mulukhiya leaves of Corchorus olitorius in the iron/folic
acid-rich vegetables group. The FBDGs of Afghanistan and Qatar recommend okra consumption
(a local plant cultivated in tropical, subtropical and warm regions).
3.10. Salt Intake
Recommendations on salt intake are present in all FBDGs. The Afghanistan, Oman, Qatar and
Lebanon FBDGs recommend no more than 5 g/day of salt, corresponding to 2.3 g/day sodium, whereas
Saudi Arabia limits salt intake to less than 2.3 g/day. The Qatari FBDGs include additional information
on how to check food labels for the words salt or sodium and distinguish “Foods high in salt” (more
than 1.5 g of salt (0.6 g sodium)/100 g) and “Foods low in salt” (0.3 g of salt—or 0.1 g sodium—or
less/100 g). The Saudi Arabia and Yemen FBDGs recommend using iodized salt, especially in cities
that are not on the sea coast. The Lebanese FBDGs recommend limiting sodium intake to less than
2.3 g per day for healthy people and to less than 1.5 g for people with hypertension, type 2 diabetes,
chronic kidney disease or over 50 years.
3.11. Lifestyle, Physical Activity and other Healthy Behaviours
Some FBDGs recommend maintaining a healthy body weight (6/7, 86%), eating a variety of foods,
preferring vegetables to animal products (5/7, 71%), having a healthy breakfast (3/7, 43%), eating at
regular times (2/7, 29%) and having some snacks based on fresh fruit and vegetables, unsalted nuts
and seeds, whole cereal products or low-fat yoghurt (6/7, 86%). All FBDGs include physical activity as
part of the format or as a key topic in the supporting information. Yemen FBDGs include the message:
“Keep a better lifestyle: quit smoking and chewing qat.” Khat chewing is part of Yemeni culture, as well
as in the Horn of Africa and the Arabian Peninsula, where the Catha edulis plant is widely cultivated.
The chewing of khat leaves releases chemicals structurally related to amphetamines. Even if khat is
not considered by the WHO a “seriously addictive drug,” its consumption can affect sleep, leading to
rebound effects, such as late awakening, decreased productivity and daytime sleepiness, as well as
increased heart rate and blood pressure. The Afghanistan, Lebanon, Oman and Qatar FBDGs include
advice on sun exposure to maintain high vitamin D levels. Moreover, it is advised that people avoid
excess sun exposure due to the risk of skin cancer.
3.12. Specific Population Subgroups
All EMR FBDGs include recommendations for the prevention of obesity, and some countries include
recommendations for the prevention of diet-related diseases: CVD and hypertension (5 countries:
Afghanistan, Iran, Lebanon, Oman, Qatar), diabetes (6 countries: Afghanistan, Iran, Lebanon, Qatar,
Oman, Saudi Arabia), cancer (3 countries: Oman, Qatar, Iran) and dental caries (2 countries: Lebanon
and Oman). The Qatar and Afghanistan FBDGs include advice on the prevention of obesity-related
diseases, such as respiratory disease (BPCO), sleep apnoea, hernia, reproductive and mental health

Nutrients 2019,11, 1325 13 of 16
disorders. Moreover, the nutritional status of pregnant (Afghanistan, Lebanon, Oman, Saudi Arabia
and Yemen) and breastfeeding women (Afghanistan, Lebanon, Oman, Qatar, Saudi Arabia, Yemen),
as well as of children, adolescents (4/6) and the elderly (4/7), is considered. The Saudi Arabia and
Afghanistan FBDGs include recommendations to prevent micronutrient deficiencies (such as iron,
vitamins A and D, and iodine) in children. The Saudi Arabian FBDGs include recommendations to
prevent osteoporosis and rickets. Specific dietary guidelines for vegetarians are also included in the
FBDGs of Lebanon and Qatar; in addition, the Lebanese FBDGs include advice for strict vegans and
for lactose-intolerant people.
4. Discussion
Eastern Mediterranean countries are experiencing a socioeconomic—either positive or negative
—transition in health and nutritional status in the last decades [
17
,
18
]. In these regions, undernutrition
and micronutrient deficiencies coexist with an alarming increase in obesity and NCDs associated with
overnutrition [
17
–
20
]. Recently an International Commission has been instituted by The Lancet (The
Lancet Commission) in order to regularly monitor and report on nutritional status around the world.
The Commission’s last report [
21
] introduced the new concept of Global Syndemic to underscore the
strict relationship between obesity, undernutrition and climate change. For example, in these countries,
the epidemic of obesity is associated with iron deficiency anaemia and vitamin D deficiency, which,
despite the sunny environment, remain two important nutritional issues and, in some countries, specific
fortification policies are being considered. Many Arab governments have established a Nutrition
Plan of Action for the prevention and control of nutrition-related diseases, as recommended by the
WHO/FAO [
19
], but political instability, local persisting conflicts and migration make it difficult, or
often impossible, to implement any nutritional or lifestyle advice.
According to the FAO and WHO recommendations, individual countries have developed simple
dietary guidelines based on their specific public health concerns and relevant to people of different
ages, lifestyles and cultures. Some countries (Oman, Qatar, Kingdom of Saudi Arabia) also detailed the
process, involving many experts for development of FBDGs. Both Food-Based Dietary Guidelines
for Arab Gulf Countries and Food Dome Dietary Guidelines for Arab Countries reported all steps for
the Developing Food-Based Dietary Guidelines [
11
,
12
]. They described the review of their current
nutrition problems and lifestyle patterns associated with diet-related diseases. Mainly, FBDGs focused
on the remarkable economic and social transformations of the past few decades, which unavoidably
influenced dietary habits.
Unfortunately, but understandably due to their instabilities, 12 out of 22 countries of this WHO
region still do not have national FBDGs. Despite these limitations, Qatar is one of the few countries
(along with Brazil, Germany and Sweden) to develop “environmentally sustainable and eating patterns
that ensure food security, improve diet quality and respond to climate change challenges” [21,22].
4.1. Specific Nutritional Characteristics of EMRO FBDGs
The national food guidelines recorded in this review are comparable to the Mediterranean-style
diet outlined by the WHO’s Regional Office for EMRO. These dietary recommendations focus on the
predominant consumption of whole grains, fruits and vegetables and healthy plant-based oils, with
a strong limitation on the consumption of red meats, animal-based proteins and fat, dairy products,
added sugars and refined starchy foods. Indications on regular physical exercise, attention to food
preparation, maternal health and diet during pregnancy and food hygiene support a healthy diet.
No recommendations are given to limit the consumption of processed and ultra-processed (ready to
heat, or ready to eat) foods, nor specific recommendations to avoid the excess consumption of added
sugar drinks, in particular in younger groups. On the other hand, the suggestion to select vitamin- and
mineral-rich or fortified foods is common. Another Arabic FBDG limitation that mainly regards the
Gulf Cooperation Council is that, despite the prevalence of immigration, there is no specific advice
targeted to the numerous foreigners living and working locally.

Nutrients 2019,11, 1325 14 of 16
This may be an important limitation for multi-ethnic societies in this region of the globalized
world. Migrants, in fact, represented approximately 51% of the region’s total population in 2016,
ranging from 37% in Saudi Arabia to 89% in the United Arab Emirates [23].
EMRO FBDGs offer many practical pieces of advice that are appropriate for local customs, dietary
patterns and daily lifestyles. Unfortunately, some of these FBDGs are only in English and not in
the local language, Arabic. Several EMRO FBDGs are only available in English (Afghanistan, Iran,
Lebanon, Oman, Saudi Arabia and Yemen), making their diffusion among middle- and lower-class
populations quite difficult.
4.2. Special Recommendations Addressed to Local Environmental and Hygiene Peculiarities
The importance of drinking an adequate amount of safe water or fluids and their crucial role for
proper hydration and thermoregulation are commonly reported in EMRO FBDGs because of the hot
and dry weather typical of the region. Similarly, some FBDGs advise using clean and safe water for
hand washing, drinking and food preparation, and caution against the use of untreated water from
rivers, canals or rainwater collected in unprotected tanks. Microbial food poisoning (mainly caused by
microbial agents, specifically salmonellosis, hepatitis A, shigellosis, and staphylococcus) is one of the
most common food-borne diseases in these countries as a result of contaminated foods, a consequence
of the diffuse practice of street food consumption. Nowadays about 20–25% people in developing
countries (e.g., people with no access to cooking facilities because of rapid urbanization, single workers
without families and people moving in and out of the city for work) depend on street food [4].
4.3. EMRO FBDGs Pictures and Food Grouping
The graphical representations used for FBDGs vary amongst EMR countries. The pyramid (Saudi
Arabia, Iran and Lebanon) and the circle (Oman and Qatar) remain the most commonly used formats,
while some other countries adopt icons inspired by national folklore and traditions. Moreover, by
comparing these guidelines with the European and American ones, an inverse correlation seems to
exist between industrialization, income and a simplified FBDG graphical representation. As a matter of
fact, a number of countries are currently switching to the plate because it facilitates the interpretation
of intake proportions of the food classes normally recommended. As far as food classes go, most
FBDGs classify foods into six groups. The use of food groups ensures the inclusion, in separate
“baskets,” of all basic foods and helps people make healthy food choices. In all countries, cereals, i.e.,
complex carbohydrates in different preparations, and vegetables occupy the largest proportion of the
graphical representation. There is agreement regarding food grouping: minimal differences could be a
result of the different emphasis given to the food nutritional properties or to local preferences and
to the local food availability. “Fruits and Vegetables” are generally considered separate food groups
in most countries (Afghanistan, Iran, Oman, Qatar and Saudi Arabia), but in the Lebanon FBDGs
they are considered a single food group. In our opinion, fruit and vegetables should be represented
separately, due to the different nutrient and caloric contents as well as the various distribution of
vitamins, minerals and plant chemicals. Moreover, despite their indisputable protective roles against
cancer, diabetes and cardiovascular diseases, the sugar content, in particular of fruit, must be carefully
counted in the daily caloric intake.
4.4. Messages on Healthy Lifestyles
Associated with the FBDGs, messages on healthy lifestyles include, in the Yemeni FBDGs, the
caution to not chew khat leaves (releasing chemicals structurally related to amphetamines) and in Gulf
countries’ FBDGs the suggestion of “not smoking and reducing the exposure to smoking environments.”
The smoking of Shisha (waterpipe tobacco smoking) is widely practiced by a considerable proportion
of the population (also women and adolescents), and people incorrectly believe that this practice is
not as harmful as smoking cigarettes. Alcoholic beverages are absent in all graphic representations,
possibly for religious reasons, and no recommendation on alcohol consumption is included with the

Nutrients 2019,11, 1325 15 of 16
exception of the FBDGs for Arab Gulf countries, which include the rather specific recommendation
“Avoid Drinking Alcoholic Beverages.” Nevertheless current economic open-market policies and
globalization have contributed to a rise in local drinking of alcohol.
5. Conclusions
To our knowledge, this study is the only one to widely analyse several EMR countries’ FBDGs and
compare them with European and American FBDGs. Specific features of Eastern Mediterranean and
Middle Eastern countries’ FBDGs include separating vegetables from animal sources in designating
protein-rich foods and preferring vegetable foods; attention to food safety and hygiene, particularly for
street food and drinking water; a suggestion to consume iron-, calcium- and vitamin D-rich or fortified
foods; and attention to tradition, inviting people to consume local foods and eventually reducing the
caloric content of traditional recipes. More attention should be paid to ongoing ethnic, social and
cultural evolution, giving adequate consideration to ethnic diversity.
Supplementary Materials:
The following are available online at http://www.mdpi.com/2072-6643/11/6/1325/s1,
Table S1: Food-Based Dietary Guidelines sources for EMR countries.
Author Contributions:
Conceptualization, F.C. and C.M.; methodology, F.C. and C.M.; formal analysis, C.M., F.I.,
F.S., M.B. and B.S.; data curation, E.S. and A.R.C.; writing—original draft preparation, C.M.; writing—review and
editing, L.S. and F.C.; supervision, F.P.
Funding: This research received no external funding.
Acknowledgments:
Raed Milad Nammouz, while an undergraduate student at the School of Medicine and
Surgery, University Federico II in Naples, kindly provided help with translating Arab FBDGs.
Conflicts of Interest: The authors declare no conflict of interest.
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