Knowledge and Attitude about Vegetarianism Saudi Population

Knowledge and Attitude about Vegetarianism Saudi Population Wedad Azhar Umm al-Qura University Sanaa Aljabiri Umm al-Qura University Taqwa Bushnaq Taif University Firas S. Azzeh Umm al-Qura University Reema A. Alyamani Umm al-Qura University Sarah O. Alkholy Umm al-Qura University Walaa E. Alhassani Umm al-Qura University Wafaa F. Abusudah Umm al-Qura University Alaa Qadhi Umm al-Qura University Hassan M. Bukhari Umm al-Qura University Khloud Ghafouri (  [email protected] ) Umm al-Qura University Research Article Keywords: Vegetarianism, Vegetarian Diet, Vegetarian Products, Dietary requirement, vegan, Saudi Arabia Posted Date: January 10th, 2023 DOI: https://doi.org/10.21203/rs.3.rs-2398786/v1 License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License Page 1/27 Abstract Background: In recent years, there has been a great interest in the dietary practices of vegetarians in addition to an increasing awareness of the potential bene ts of vegetarian diets. However, there is insu cient data on the spread of vegetarianism in Arab countries. The study aims to investigate knowledge and attitude about vegetarianism and associated factors in Saudi population and to understand reasons for its growing prevalence. Method: Participants in this cross-sectional study were aged 18–65. Participants were recruited primarily through social media. The electronic questionnaire compromised three sections: socio-demographic questions, reasons for following a vegetarian diet, and beliefs and knowledge about vegetarianism. Multivariate binary logistic regression was utilized to determine predictive factors for being a vegetarian. Results: Responses were 3,035 of which 80.2% were female and 19.8% were male. Vegetarians represented 37.5% (15.7% semi-vegetarians, 8.1% pesco-vegetarians, 64.3% lacto-ovo-vegetarians, and 11.3% vegans) and the rest were non-vegetarians. The majority of the vegetarian participants (92.9%) have a low knowledge level. Health issues, followed by ethical, then environmental concerns were the most common motivators for adopting a vegetarian diet; these reasons were cited by 72.5%, 59.3%, and 47.9% of participants, respectively. Factors associated with increased vegetarianism were having exercises for half an hour to two hours, while factors associated with decreased vegetarianism were male gender, aged 51–64 years, being married, having a higher education, working in the health sector, being a housewife, and having an income between 5,000–10,000 SR/month. Conclusion: Vegetarianism appears to be growing phenomenon among the Saudi population. Increased awareness of health issues and the desire to live a healthy lifestyle might be the strongest motive. This study offers an opportunity to better understand vegetarianism in Saudi Arabia along with the possibility of expanding vegetarian food choices to the general public. 1. Background Food choice is a complex behaviour based on many interacting variables related to person, product, and context. There are many physiological, psychological, biological, genetic and socio-cultural factors that in uence an individual’s food choices that should be considered when studying a speci c eating behaviour (1). Although the current trend in Europe is for the Western diet, which is based on the consumption of animal food products, re ned carbohydrates, and added sugars, vegetarianism is becoming more popular than before (2). Vegetarianism is a general term that refers to refraining from consuming one or more types of foods from animal sources, especially red meats (3). Vegetarians can be sub-classi ed into: lacto-ovo-vegetarians (who consume eggs and dairy but no meat, poultry, sh, or seafood), ovo-vegetarians (who consume eggs but not dairy), lacto-vegetarians (who consume dairy products but not eggs), pesco-vegetarians (who consume sh and seafood but not meat and poultry), and pollo-vegetarians (who consume poultry but not meat and sh) (4). Page 2/27 In recent years, there has been a global great interest in the dietary practices of vegetarians, both in terms of the nutritional content and its implications for overall health and mortality rates. Also, There is an increasing awareness of the potential bene ts of vegetarian diets (5). Number of vegetarians in Saudi Arabi is unknow, however it has been estimated in some countries such as 8% in Canada (6), 5% in the US (7), 4.3% in Germany (8), 8% in South Australia (9), 15% in Scandinavia (10), less than 2% in France (11), 6% in the UK (12), 1–2% in Argentina (13), 33% in South Asia (14), and 40% in India (15). The insu cient data on the spread of vegetarianism in might be because there is no widely accepted de nition of vegetarianism (16). There are many reasons why people follow a vegetarian diet: ethical reasons such as animal welfare, health concerns, shape and weight reasons, economic reasons, social reasons (including the in uence of family and friends), sensory preferences and taste, food safety concerns, and philosophical and religious beliefs (such as those espoused by members of the Seventh-day Adventist Church)(4, 17–20). Feeling disgust toward meat is another reason for choosing a vegetarian lifestyle (21). Recent Western studies indicate that ethical reasons are the most common motivation for adopting a vegetarian diet, followed by health concerns, and then environmental concerns (22–25). The practice of vegetarianism in India tends to be based on religious and traditional reasons rather than health beliefs. Therefore, India ranks rst among countries with the largest number of vegetarians, estimated at 300–400 million (15). To our knowledge, the prevalence of vegetarians and the attitude toward vegetarianism and the motivations for vegetarianism have not yet been studied in Saudi Arabia nor the Gulf countries. Therefore, the aim of this study is to investigate knowledge and attitude about vegetarianism and associated factors in Saudi population and to understand reasons for its growing prevalence. 2. Methodology 2.1. Participants This cross-sectional study began in May 2020 and ended in September 2020. Participants were residents of Saudi Arabia aged 18–65 years. Participants were recruited primarily through social media: Twitter, LinkedIn, and WhatsApp. The study was performed in accordance with the Declaration of Helsinki and approved by the Biomedical Ethics Committee in Umm Al-Qura University (HAPO-02-K-012-2020-10-447). 2.2 Sample Size Raosoft sample size calculator (http://www.raosoft.com/samplesize.html) was used to calculate the sample size needed for this study. The total population of the Saudi Arabia is approximately 30.000.000 citizens. The predetermined margin of error was 5% and the con dence level was 95%.. The target sample size was 385 to minimize erroneous results and increase study reliability. The total responses were 3,265 responses. 2.3. Questionnaire Page 3/27 The questionnaire was released on SurveyHero. All questionnaire results were downloaded from the website for analysis. The questionnaire was written in both Arabic and English. Participation in the survey was voluntary. The introduction to the questionnaire included an explanation of the purpose of the research and a consent form. The questionnaire contained three sections. The rst section consisted of 14 questions, 13 of which were about socio-demographic data. Question 14 asked whether the participant was a vegetarian or a non-vegetarian. The participants were also asked about the reasons that led them to choose a vegetarian diet and the obstacles of adhering to this diet. Their nutritional knowledge and attitude were also assessed through a group of agree–disagree statements. BMI was calculated for all participants. To assess participants’ knowledge, four questions were asked. Each correct answer was given one point, and the total sum of the discrete scores of the different items was calculated. Participants who correctly answered two questions or less were classi ed were classi ed as having a “low knowledge level”, while participants who correctly answered more than two questions were classi ed as having a “moderate to high knowledge level”. Restrictions were put in place to ensure that participants completed the survey only once. Incomplete answers and answers that were deemed to be typos or were clearly false were excluded. 2.4 Pilot Study To ensure the signi cance and simplicity of the study questions, the questionnaire was sent to specialists, including nutritionist and academic researchers. A pilot study on 30 participants was conducted to validate the questionnaire and test the simplicity of the questions, in addition to determining the duration of the interview. Cronbach’s alpha for all tested knowledge and attitude domains was more than .7, indicating acceptable reliability. 2.5. Statistics Data analysis was performed using the Statistical Package for the Social Sciences (SPSS) (IBM SPSS Statistics for Windows, Version 23.0. Armonk, NY: IBM Corp). Frequencies and rates were used to present categorical variables. The Chi-square test was used to test for correlations between categorical variables. Multivariate binary logistic regression was utilized to determine predictive factors for being a vegetarian; the following variables were entered into the model: gender, age, marital status, educational level, job, income, smoking habits, presence of chronic diseases, and exercise frequency. The model’s goodness-oft was tested using the Omnibus test and the Hosmer and Lemeshow test. The level of signi cance was set at P ≤ 0.05. 3. Results 3.1. Participants A total of 3,265 responses were collected, 230 of which were excluded because they were incomplete. Completed responses were 3,035 (response rate equals 93%). 80.2% (n = 2,434) of respondents were female and 19.8% (n = 601) were male. The respondents were from all regions of the Kingdom (Table 1). Page 4/27 Table 1 Socio-Demographic Pro le of the Participants (N = 3,035) Demographical Characteristics N (%) Gender Female 2,434 (80.2) Male 601 (19.8) Age 18–39 2,772 (91.3) 40–50 192 (6.3) 51–64 65 (2.1) 65 years and older 6 (0.2) Nationality Saudi 2,852 (94) Non-Saudi 183 (6) Place of Residency Makkah Region 1,099 (36.2) Madinah Region 220 (7.2) Riyadh Region 754 (24.8) Qasim Region 162 (5.3) Baha Region 100 (3.3) Tabuk Region 47 (1.5) Northern Borders Region 53 (1.7) Eastern Region 410 (13.5) Jouf Region 30 (1) Jazan Region 50 (1.6) Najran Region 14 (0.5) Other 96 (3.2) Marital Status Single 2,127 (70.1) Engaged 72 (2.4) Page 5/27 Demographical Characteristics N (%) Married 743 (24.5) Widowed 10 (0.3) Divorced 71 (2.3) Separated 12 (0.4) Educational Level Intermediate or less 57 (1.9) High school 813 (26.8) Diploma 161 (5.3) Bachelor’s degree 1,686 (55.6) Higher Education 318 (10.5) Job In the public sector 263 (8.7) In the health sector 274 (9) In the health sector but not a health practitioner 42 (1.4) In the private sector 287 (9.5) In the army / police 44 (1.4) Self-employed 91 (3) Unemployed 774 (25.5) Housewife 163 (5.4) Student 1053 (34.7) Retired 31 (1) Unable to work 13 (0.4) Income Less than 5,000 SR/month 2095 (69) 5,000–10,000 SR/month 419 (13.8) 10,000–15,000 SR/month 264 (8.7) 15,000–20,000 SR/Month 122 (4) More than 20,000 SR/month 135 (4.4) Page 6/27 Demographical Characteristics N (%) BMI Underweight 195 (6.4) Normal BMI 1,751 (57.7) Overweight 638 (21) Obese 1 256 (8.4) Obese 2 132 (4.3) Obese 3 63 (2.1) Smoking Habits Smokers 257 (8.5) Non-smokers 2,534 (83.5) Occasional Smokers 244 (8) Exercising Do not exercise 1,256 (41.4) Half an hour/day 929 (30.6) An hour/day 634 (20.9) Two hours/day 173 (5.7) More than two hours/day 43 (1.4) 3.2. Medical History of Participants The majority of the participants (59.1%) did not suffer from any disease. Whereas,12% had gastrointestinal diseases, 10.2% had anaemia, 7.8% had depression, 7.8% had anxiety, 6.6% had pulmonary diseases, 5.4% had food intolerance, 3% had thyroid disorders, 2.3% had cardiovascular disease and hypertension, 2.2% had diabetes, 1.9% had an abnormal lipid pro le, 1.6% had immune diseases, 0.7% had gout, 0.5% had skin diseases, 0.2% had favism disease, 0.2% had epilepsy, and 1.4% had other diseases. 3.3. Prevalence of Vegetarianism Among Participants The total number of participants who self-identi ed as vegetarians was 1,197; of which 188 (15.7%) were semi-vegetarians, 98 (8.1%) were pesco-vegetarians, 777 (64.3%) were lacto-ovo-vegetarians, and 134 (11.3%) were vegans. The number of non-vegetarians was 1,898 (62.5%). Regarding the duration of following a vegetarian diet, 117 (9.8%) of the participants said they had done so for a month or less, 162 Page 7/27 (13.5%) for six months or less, 176 (14.7%) for a year or less, 570 (47.6%) for one to ve years, and 172 (14.4%) for ve years and more. 3.4. Reasons for Following a Vegetarian Diet Table 2 explains the reasons for following a vegetarian diet. Health reasons, followed by ethical reasons, and then environmental concerns were the most common motivators to adopt a vegetarian diet; these reasons were cited by 72.5%, 59.3%, and 47.9% of participants, respectively. Table 2 Reasons for Following a Vegetarian Diet (N = 1,197) Question N % Because I think a vegetarian diet is healthier 868 72.5 Because I care about animal rights 710 59.3 Because I want to preserve the ecosystem by reducing animal farming that increases the problem of global warming 573 47.9 I do not like to eat meat 403 33.7 Meats are injected with hormones and this causes diseases 442 36.9 To enhance mood 221 18.5 Weight loss 194 16.2 Spiritual reasons 194 16.2 To get rid of acne 164 13.7 Psychological reasons (trauma related to animal slaughter) 155 12.9 Because I was in uenced by a celebrity who follows the vegetarian diet 94 7.9 Because my friends are vegetarians 50 4.2 Because vegetarian products are more available in the environment than animal products 37 3.1 Because plant products are less expensive than non-plant products 34 2.8 Because someone in my family is following a vegetarian diet 29 2.4 Religious reasons 26 2.2 Other 5 0.4 3.5. Sources of Information about Vegetarianism among Vegetarian Participants Page 8/27 Vegetarian participants relied on different sources of information about their diet. 751 (62.7%) of the vegetarian participants depended on social media, 476 (39.8%) got information from vegetarian dietitians on social media, 450 (37.6%) relied on online sources (Wikipedia, journals, and forms), and 399 (33.3%) relied on scienti c research. There were 153 participants (12.8%) who reported getting information from social media in uencers and 5 (0.4%) who reported that they rely on YouTube. 3.6. Challenges Vegetarians Face to Maintain a Vegetarian Diet There were many challenges that in uenced the participants’ adherence to a vegetarian diet. The top challenge they faced was the di culty in nding meat and dairy substitutes, followed by the culture of the surrounding society; these challenges were reported by 209 (17.5%) and 178 (14.9%) of the participants, respectively. Unavailability of vegetarian dishes at parties and social events was common among 160 participants, 156 (13%) reported laziness and a lack of cooking skills, 140 (11.7%) reported that they did not know what to eat, 136 (11.4%) mentioned the high cost, 133 (11.1%) reported the lack of vegetarian dishes in cafes and restaurants, 84 (7%) reported peer pressure, 76 (6.3%) reported a lack of diversity in their diet, 51 (4.3%) reported a fear of nutrient de ciencies, 28 (2.3%) reported missing meat and meat products, 16 (1.3%) reported food allergies, and 11 (0.9%) reported health problems. 30 (2.5%) reported that they did not have challenges. When asked about the ease of following a vegetarian diet, 611 (51%) of the vegetarian participants responded that it was generally easy. 3.7. Beliefs and Knowledge About Vegetarianism Among Vegetarian and Non-Vegetarian Participants Knowledge of vegetarianism was measured by asking a set of questions as shown in Table 3. Participants who correctly answered two questions or less were classi ed as having a low knowledge level. Participants who correctly answered more than two questions were classi ed as having a moderate to high knowledge level. Using these criteria, 92.9% of vegetarian participants were considered to have a low knowledge level. Page 9/27 Table 3 Beliefs and knowledge about vegetarianism among vegetarian participants (N = 1,197) Beliefs Section Agree Disagree n (%) n (%) I do not know n (%) Vegetarian products are more expensive than non-vegetarian products 129 (10.8) 418 (34.9) 650 (54.3) A vegetarian diet is healthy 95 (7.9) 54 (4.5) 1,048 (87.6) It is hard for a vegetarian diet to be balanced 144 (12) 783 (65.4) 270 (22.6) Non-vegetarian products are more available than vegetarian products 138 (11.5) 709 (59.2) 350 (29.2) Vegetarians need supplements 175 (14.6) 702 (58.6) 320 (26.7) A vegetarian diet does not have enough protein 94 (7.9) 1,009 (84.3) 94 (7.9) Vegetarians are more vulnerable to de ciencies in vitamins and minerals such as vitamin B12, iron, and calcium 195 (16.3) 720 (60.2) 282 (23.6) Fermented soya products are a good source of vitamin B12 621 (51.9) 103 (8.6) 473 (39.5) Knowledge Section Table 4 shows the believes, perception and knowledge toward vegetarianism among non-vegetarian participants. Participants who correctly answered two questions or less were classi ed as having a low knowledge level. Participants who correctly answered more than two questions were classi ed as having a moderate to high knowledge level. Using these criteria, 1182 (64.30%) had low knowledge level and 656 (35.7%) had moderate to high knowledge level. Page 10/27 Table 4 Beliefs and knowledge about vegetarianism among non-vegetarian participants (n = 1838) Beliefs Section Agree Disagree n (%) n (%) I do not know n (%) The vegetarian diet is healthy. 308 (16.8) 683 (37.2) 847 (46.1) It is hard for a vegetarian diet to be balanced 340 (18.5) 411 (22.4) 1087 (59.1) Non-vegetarian products are more available than vegetarian products. 359 (19.5) 882 (48) 597 (32.5) Vegetarians need supplements 379 (20.6) 305 (16.6) 1154 (62.8) All vegetarian diets do not have enough protein 381 (20.7) 777 (42.3) 680 (37) Vegetarians are more vulnerable to have vitamin and mineral de ciency such as vitamin B12. iron and calcium 583 (31.7) 312 (17) 943 (51.3) Fermented soya products are good source of vitamin B12 1280 (69.6) 133 (7.2) 425 (23.1) Yes No n (%) n (%) 1507 (82) 331 (18) Knowledge Section Perception Section Would you like to incorporate more vegetarian food in your diet? 3.9 Factors Associated with Being Vegetarian There was a signi cant association between being a vegetarian and gender, age, residence, marital status, educational level, job, income, BMI, smoking and exercising habits (all P < 0.005), and nationality (P < 0.05). Vegetarians were more likely to be female, young, residence of Jouf Region, single, holding high school certi cation, students, exercising more than two hours a day and Saudis (Table 5). Page 11/27 Table 5 Association Between Socio-Demographic Variables and Being Vegetarian (N = 3,035) Demographic Characteristics Are you Vegetarian? Yes No n = 1,197 n = 1,838 Gender < 0.001** Female 1,079 (44.3%) 1,355 (55.7%) Male 118 (19.6%) 483 (80.4%) Age < 0.001** 18–39 1,158 (41.8%) 1,614 (58.2%) 40–50 30 (15.6%) 162 (84.4%) 51–64 5 (7.7%) 60 (92.3%) 65 years and older 4 (66.7%) 2 (33.3%) Nationality 0.04* Saudi 1,138 (39.9%) 1,714 (60.1%) Non-Saudi 59 (32.2%) 124 (67.8%) Place of Residency < 0.001** Makkah Region 364 (33.1%) 735 (66.9%) Madinah Region 85 (38.6%) 135 (61.4%) Riyadh Region 321 (42.6%) 433 (57.4%) Qasim Region 79 (48.8%) 83 (51.2%) Baha Region 48 (48%) 52 (52%) Tabuk Region 20 (42.6%) 27 (57.4%) Northern Boarders Region 23 (43.4%) 30 (56.6%) Eastern Region 181 (44.1%) 229 (55.9%) Jouf Region 21 (70%) 9 (30%) Jazan Region 13 (26%) 37 (74%) Najran Region 6 (42.9%) 8 (57.1%) * Signi cant at level P ≤ 0.05 ** Signi cant at level P ≤ 0.005 P-Value Page 12/27 Other 36 (37.5%) 60 (62.5%) Marital Status < 0.001** Single 1,017 (47.8%) 1,110 (52.2%) Engaged 22 (30.6%) 50 (69.4%) Married 125 (16.8%) 618 (83.2%) Widowed 5 (50%) 5 (50%) Divorced 24 (33.8%) 47 (66.2%) Separated 4 (33.3%) 8 (66.7%) Educational Level < 0.001** Intermediate or less 24 (42.1%) 33 (57.9%) High school 395 (48.6%) 418 (51.4%) Diploma 56 (34.8%) 105 (65.2%) Bachelor’s degree 659 (39.1%) 1,027 (60.9%) Higher Education 63 (19.8%) 255 (80.2%) Job < 0.001** In the public sector 51 (19.4%) 212 (80.6%) In the health sector 52 (19%) 222 (81%) In the health sector but not a health practitioner 13 (31%) 29 (69%) In the private sector 90 (31.4%) 197 (68.6%) In the army / police 7 (15.9%) 37 (84.1%) Self-employed 39 (42.9%) 52 (57.1%) I do not work 347 (44.8%) 427 (55.2%) Housewife 24 (14.7%) 139 (85.3%) Student 560 (53.2%) 493 (46.8%) Retired 8 (25.8%) 23 (74.2%) Unable to work 6 (46.2%) 7 (53.8%) Income < 0.001** * Signi cant at level P ≤ 0.05 ** Signi cant at level P ≤ 0.005 Page 13/27 Less than 5,000 SR/month 982 (46.9%) 1,113 (53.1%) 5,000–10,000 SR/month 101 (24.1%) 318 (75.9%) 10,000–15,000 SR/month 60 (22.7%) 204 (77.3%) 15,000–20,000 SR/Month 25 (20.5%) 97 (79.5%) More than 20,000 SR/month 29 (21.5%) 106 (78.5%) BMI < 0.001** Underweight 97 (49.7%) 98 (50.3%) Normal BMI 821 (46.9%) 930 (53.1%) Overweight 173 (27.1%) 465 (72.9%) Obesity 1 64 (25%) 192 (75%) Obesity 2 21 (15.9%) 111 (84.1%) Obesity 3 21 (33.3%) 42 (66.7%) Do you smoke? < 0.001** Yes 55 (21.4%) 202 (78.6%) No 1,032 (40.7%) 1,502 (59.3%) Occasionally 110 (45.1%) 134 (54.9%) If you exercise, how much time do you usually spend daily? < 0.001** I do not exercise 371 (29.5%) 885 (70.5%) Half an hour 388 (41.8%) 541 (58.2%) An hour 314 (49.5%) 320 (50.5%) Two hours 105 (60.7%) 68 (39.3%) More than two hours 19 (44.2%) 24 (55.8%) * Signi cant at level P ≤ 0.05 ** Signi cant at level P ≤ 0.005 3.10. Association Between Vegetarianism and Chronic Disease A signi cant difference was observed between vegetarians and non-vegetarians in the prevalence of diseases. Vegetarians were having higher incidence of depression (P ฀ 0.001), anxiety (P ฀ 0.001) compared to non-vegetarians. Whereas non-vegetarians had signi cantly higher prevalence of anaemia Page 14/27 (P ฀ 0.001), thyroid disorders (P = 0.002), diabetes (P = 0.033), CVD and hypertension (P = 0.017), and abnormal lipid pro le (P ฀ 0.001) compared to vegetarians. 3.11. Association Between Knowledge Level and Demographic Variables Among Vegetarians There was no association between age (P = 0.49), educational level (P = 0.31), or presence of disease (P = 0.5) and the knowledge level of vegetarians. 3.13. Factors that Predict Being Vegetarian A multivariate logistic regression included the following variables: gender, age, marital status, educational level, job, income, smoking habits, presence of chronic diseases, and exercising. Participants with the following characteristics were signi cantly (P < 0.05) more likely to be vegetarian: exercising for half an hour, exercising for an hour, and exercising for two hours. Presence of the following characteristics was signi cantly (P < 0.05) correlated with lower chances of being a vegetarian: male gender, being aged 51– 64, being married, having a higher education, working in the health sector, being a housewife, and having an income between 5,000–10,000 SR/month, as shown in Table 6. Page 15/27 Table 6 Factors that Predict Being Vegetarian Demographics P-Value Odds Ratio Con dence Interval Gender (Female vs Male) < 0.001** 0.336 0.259–0.434 40–50 0.062 0.641 0.401–1.022 51–64 0.004** 0.204 0.068–0.61 65 years and older 0.16 4.712 0.541–41.03 Engaged 0.087 0.621 0.36–1.072 Married < 0.001** 0.45 0.341–0.592 Widowed 0.366 2.055 0.431–9.792 Divorced 0.589 0.858 0.491–1.497 Separated 0.673 1.323 0.361–4.85 Age (18–39 is the Referent) Marital Status (Single is the Referent) Educational Level (Intermediate or less is the Referent) High school 0.702 0.89 0.489–1.618 Diploma 0.583 0.825 0.415–1.641 Bachelor’s Degree 0.376 0.766 0.424–1.384 Higher Education 0.011** 0.419 0.214–0.819 In the health sector 0.012* 0.542 0.337–0.872 In the health sector but not a health practitioner 0.748 1.14 0.512–2.538 In the private sector 0.401 1.213 0.773–1.905 In the army / police 0.795 0.884 0.347–2.247 Self-employed 0.266 1.398 0.775–2.52 I do not work 0.743 1.077 0.691–1.678 Housewife 0.028* 0.507 0.277–0.931 Student 0.138 1.397 0.898–2.174 Job (In the public sector is the Referent) * Signi cant at level P ≤ 0.05 ** Signi cant at level P ≤ 0.005 Page 16/27 Demographics P-Value Odds Ratio Con dence Interval Retired 0.063 2.864 0.944–8.687 Unable to work 0.765 1.211 0.346–4.244 Income (Less than 5000 SR/month is the Referent) 5,000–10,000 SR/month 0.003** 0.637 0.472–0.86 10,000–15,000 SR/month 0.477 0.87 0.593–1.276 15,000–20,000 SR/month 0.987 1.005 0.588–1.716 More than 20,000 SR/month 0.712 1.102 0.657–1.85 No 0.617 1.096 0.766–1.569 Occasionally 0.026 1.647 1.062–2.556 Do you have any disease? (No vs Yes) 0.745 1.028 0.872–1.211 Do you smoke? (Yes is the Referent) If you exercise, how much time do you usually spend daily? (I do not exercise is the Referent) Half an hour < 0.001** 1.714 1.414–2.077 An hour < 0.001** 2.321 1.872–2.877 Two hours < 0.001** 2.321 2.742–5.662 More than two hours 0.202 1.543 0.793–3.003 * Signi cant at level P ≤ 0.05 ** Signi cant at level P ≤ 0.005 4. Discussion To our knowledge, this is the rst study to investigate knowledge and attitude about vegetarianism and associated factors in Saudi population and to understand reasons for its growing prevalence.. Despite the strong in uence of a tradition of meat-based consumption, ndings from this study prove that there is a signi cant number of vegetarians and vegans in Saudi Arabia. The prevalence of self-reported vegetarians among the general Saudi population found in the current study was 37.5%. This study does not claim that this is an accurate gure for the prevalence of vegetarianism in the country; it is to be expected that people with an interest in vegetarianism would self-select for participation. Comments indicated that participants were pleased to be asked about their diet, as this was the rst opportunity they had had to share their views. Page 17/27 The majority of our sample were female, thus might be due many factors. Female tend to care more about food and body shape and weight loss (26–29). Additionally, women are more likely to answer online survey and to spend more time in social media in Saudi Arabia (30). It’s possible that the recruitment process (through social media) resulted in an overrepresentation of young people. However, this number may be due to an increased awareness of the health risks of consuming large amounts of meat. Health reasons were observed among the strongest motives for adopting a vegetarian diet among Saudis, whereas Heiss, Hormes and Alix Timko (2017), found that moral motives were most prominent in Western societies. Studying vegetarianism is challenging for researchers due to the di culty in identifying vegetarians, differentiating between types of vegetarianism, and interpreting the discrepancy between self-reported identi cation and self-reported behaviour (10, 28, 32). The non-vegetarian has low knowledge and recognition of vegetarian diet. This might be due to the lack of understanding and awareness of vegetarianism in Saudi. The current study found interesting results regarding vegetarians’ beliefs about vegetarianism. Vegetarians indicated that vegetarian products are easily available and are not expensive. This may also help to explain the spread of vegetarianism in Saudi Arabia. Some studies have indicated that vegetarian products are often described as expensive in Western societies, which reduces the chance of people adopting the diet (33, 34). On the other hand, Lusk and Norwood (2016) found that vegetarians reported lower food expenditures than meat eaters. While other studies have found that most vegetarians believe that a vegetarian diet is healthy, a neutral attitude was observed of vegetarians regarding this belief in the current study (36–38). Most of studies indicated that they did not know whether this belief was valid (36–38). In general, the knowledge level of vegetarians was low, contrary to expectation. Although many studies have found that vegetarians with a higher educational level have a higher level of knowledge about vegetarianism (36–38), this relationship was not found in the current study or in some others (39, 40). There is no doubt that there are social and psychological factors that affect an individual’s dietary behaviour, preferences, and taste. These socio-psychological in uences may either support or inhibit a healthy lifestyle (41, 42). In the current study, vegetarians indicated that social norms constitute a barrier to adherence to a vegetarian diet. These social norms include the prevailing food culture (consumption of meat) on occasions, holidays, and family gatherings and showing generosity by providing meat on these special occasions. Moreover, refusing to eat what is given is considered impolite. Because of this, there may be many Saudis who are open to vegetarianism but who nd it di cult to adopt a vegetarian diet while surrounded by these rigid traditions. It has been proven that most omnivores describe vegetarians as virtuous but weak, more moral, and less masculine (43). In a survey conducted by Rosenfeld and Tomiyama (2020), many meat eaters indicated that the fear of feeling stigmatised was one of the main barriers that prevented them from adopting vegetarianism. nancial cost, sensory enjoyment of meat, inadequate cooking skills, and convenience (lack of vegetarian dish variety) were also reported as barriers in this study as well as others (44–46). Page 18/27 Today, with technology, it is easy to access detailed information on any topic and gain access to many cultures around the world. Accordingly, social networks have a clear effect on an individual’s behaviours, especially dietary behaviours (47, 48). In the current study, 62.7% of vegetarians reported relying on social media such as Twitter, Facebook, and Instagram to gain information about vegetarianism. Social media can be a useful tool for facilitating dietary and health knowledge. However, not all in uencers and accounts promote accurate health information. The current study found many factors that had a statistically signi cant associated with choosing a vegetarian lifestyle, including gender, age, income level, educational level, place of residence, BMI, marital status, job, and some health-related behaviours such as smoking and exercise. Men were less likely to be vegetarian compared to women. Many studies have found that most vegetarians are young women (26– 28). It has been observed that women are more likely to adopt a vegetarian diet for weight loss and body image reasons compared with men (49). Additionally, in Saudi Arabia feast and gathering are gender segregated and vegetarian food is widely more available for women. Typically, men are served meat based dish, whereas women are able to choose from a buffet. It was observed that with increasing age, it is di cult to change certain behaviours, including dietary pattern. The current study found that people aged 51–64 were less likely to be vegetarians compared to those aged 18–39, which is consistent with other studies that have found that more younger adults tend to adopt a vegetarian lifestyle than older adults (27, 50). A study conducted in the UK researched the attitudes concerning different reasons to be vegetarian across generations. The results showed that younger people (11–20) were broadly in agreement with the moral and environmental reasons. People aged 41–60 agreed with the health reasons (37). Although many studies have indicated that vegetarians have higher educational levels than meat eaters (26, 27, 50, 51), the current study found a different result in the current study; those with a higher educational level were less likely to be vegetarians. The explanation for this difference may be due to the explosion in online knowledge. The current study found that those with an income of between 5,000 and 10,000 SR were less likely to be vegetarians compared to those with an income of less than 5,000 SR. The prevalence of vegetarianism may vary according to income level. Rammohan et al. (2012) indicated that poverty and the high cost of meat were a reason for choosing a vegetarian diet, while some other studies have indicated that people with a higher income are more likely to be vegetarians for health and environmental reasons (53, 54). It is possible that people who are health conscious in general are more likely to exercise, avoid smoking, and adopt a vegetarian diet. The current study found that people who spent two hours exercising a day were 3.94 times more likely to be vegetarians than those who did not exercise. There are several studies that have indicated that exercising and avoiding smoking are closely associated with vegetarianism (55, 56). Regarding the potential risks or bene ts of a vegetarian diet for mental health, the current study found signi cant associations between vegetarianism, depression, and anxiety, which is consistent with a number of previous studies (57–59). On the other hand, a recent systematic review and meta-analysis of Page 19/27 observational studies concluded that there were no signi cant associations between a vegetarian diet and depression (60). Results are still contradictory as to whether a vegetarian diet is associated with positive or negative effects on mental health. For example, Jin et al (2019) concluded that vegetarianism was inversely related to the prevalence of depression in middle-aged South Asians in America. Beezhold et al (2015) conducted an online survey to investigate the moods of adult vegetarians and meat eaters, and they concluded that vegan males were less anxious than vegetarian and omnivorous males, while vegan females were less stressed than vegetarian and omnivorous females. In contrast to these studies, a study conducted on university students in the USA showed that vegetarians were more likely to suffer from neuroticism and depression than omnivores (62). A study found that the risk of depression among vegetarian men was 1.67 times higher than the risk for non-vegetarians (63). This might be due to an increased risk of de ciencies in certain nutrients, such as iron (64–66), zinc (67, 68), omega-3 (69–72), vitamin B12 (73–75), and vitamin D (76–78). These nutrients are mostly found in animal dietary sources. A signi cant association was found of CVD, hypertension, diabetes, and abnormal lipid pro les and not being vegetarians. A vegetarian diet has been associated with a reduced risk of some chronic diseases, such as hypertension, diabetes, and CVD (79–82). It has been shown that vegetarians have lower levels of total cholesterol, triglycerides, fasting glucose, and diastolic and systolic blood pressure compared to non-vegetarians (83). Vegetarianism is also inversely associated with fasting glucose, insulin resistance, total and LDL cholesterol, visceral fat, and fatty liver (84)(79)(58). The current study found a signi cant association between anaemia and non-vegetarians. This might be due to the large proportion of women in the study and women are most likely to have anaemia. There are some limitations of the current study to consider. Short-term vegetarians were included in the survey. The current study identi ed people who had adhered to a vegetarian diet for a month or less as being vegetarians. Another limitation was that dietary habits were self-reported; it is therefore di cult to know if this data is entirely accurate. It is known from previous studies that self-reported vegetarians do not always completely abstain from meat. No conclusions can be drawn regarding the causal relationship between diet and the individual variables examined because the study was a cross-sectional design. Additionally, the majority of the participants were female. We did not investigate the se of vitamin and supplements among the participants. Conducting an online survey instead of face-to-face or phone interviews can also be a source of bias for the study since it limits the results to the individuals who have internet access. On the other hand, the current study has many strengths. This study is rst to examine the prevalence of vegetarianism in Saudi as well as examine knowledge and perceptions of vegetarianism in the country. The sample size was large and can be considered representative of the general Saudi population. It would be interesting to follow up with participants in a cohort study. 5. Conclusion To conclude, this study can open doors for more research to be done in the eld of vegetarianism. A nationwide study of dietary preference should be conducted to estimate the actual number of vegetarians. The level of knowledge among our participants was a bit low and this needs governmental Page 20/27 effort to improve their knowledge though Ministry of Health rather than relying of uno cial sources. An educational programmes should be carried out to improve the knowledge about different diets and how to achieve optimal nutrition. Declarations Ethics approval and consent to participate The study was performed in accordance with the Declaration of Helsinki and approved by the Biomedical Ethics Committee in Umm Al-Qura University (HAPO-02-K-012-2020-10-447). All participants signed and informed consent forms prior to participate. Consent for publication Authors, give our consent for the publication of identi able details, which can include case history and/or details within the text to be published in the above Journal and Article. Availability of Data and Materials The raw data supporting the conclusions of this article will be made available by the authors, without undue reservation. Please contact Dr. Khloud Ghafouri [email protected] Competing Interests The authors declare that the research was conducted in the absence of any commercial or nancial relationships that could be construed as a potential con ict of interest. Funding The authors declare that the research was conducted in the absence of any funding. Author Contributions WA and KG conceived and designed the study. AQ, TB, RA and SA conducted research, provided research materials, and collected and organized data. FA, HB and SOA analysed and interpreted data. 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