Cardiovascular Disease (CVD) is the primary cause of disability and death worldwide CVDs include Myocardial Infarction (MI) [1]. Coronary Artery Disease (CAD) [2], coronary heart disease (CHD), cerebrovascular disease, peripheral arterial disease, rheumatic heart disease, congenital heart disease, deep vein thrombosis, and pulmonary embolism [3].

CVD is responsible for 45% of total mortality rates in Gulf Council Countries (GCC) [4]. Various researches done around the globe include INTERSTROKE, INTERHEART, Gulf Registry of acute coronary events (Gulf RACE), and African Middle East Cardiovascular Epidemiological (ACE) study summarizing mutual risk to CVD [4]. Of the risk factors identified where dyslipidemia, obesity, physical inactivity, and unhealthy diet [4], 94% of the risk factors are modifiable risk factors that can be prevented [4], of which diet and physical inactivity have a major role [4]. A study showed that people who sit for more than 10 hours have 38% higher risk to develop MI and 31% risk of death compared to people who sit for less than 6 hours per day [4].

NCDs are the cause of 70% of deaths worldwide [2]. NCD like CVD is a primary public concern and is responsible for almost half of the mortality rate in SA [8]. Male gender is more than one-third higher than female in developing a CVD [8]. CVDs are the main cause of hospitalization around the globe, affecting the economy and increasing the burden on individuals and society [19]. Consequently, identifying risk factors and implementing preventive interventions have a substantial beneficial effect on public health and the economy [19]. Risk factors can be modifiable or non-modifiable [19]. Modifiable risks include sedentary lifestyle, smoking, and poor diet [19]. Hypertension and diabetes are also modifiable risk factors for CVDs [20]. Non-modifiable risk factors include gender, age, and genetics [10]. The thyroid hormone has a great impact on CVD as it affects the cardiac system and function [19]. More than half of the Saudi population is either hypertensive or pre-hypertensive and one-fifth of the population is diabetic [20].

Risk factors like obesity and hypertension are among the main factors to develop CVD [10]. A Saudi survey conducted on a community-based national epidemiological health study on more than 17,000 adults between 30 and 70 years of age demonstrated the prevalence of obesity in more than 35% of the study group [21] ^. Various developed countries were able to reduce CVD by 50% when reducing the associated risk factors [10]. Notwithstanding the measures and success in reducing CVDs, CVDs remain the main cause of death in adults over 35 [2]. All treatment applied for CVDs is prescribed for life, which indicates the importance of setting preventive measures as it is the most effective intervention to reduce CAD-associated morbidities and death [2]. Intervention measures should include setting policies and procedures to draw attention to preventing CVD instead of treating CVD patients [10]. Preventive measures are more effective and require fewer resources when applying effective health promotion measures to the population [10].

There are limited studies on the population at risk of developing CVDs in SA, and the difference in onset between the Saudi population and the expatriates [5]. Cardiovascular diseases (CVDs) are the main cause of morbidity and mortality in individuals with diabetes [22], reduced awareness is the reason for the unavailability of early detection and apply preventive measures [22]. For example, a study in Makkah, SA revealed that only 40% of diabetic patients are aware of their higher risk to develop a CVD [23].

A study in Qassim, SA showed that CAD has high prevalence and more than 50% of studied population had more than three risk factors for developing CAD [23]. 50% were obese and had hypertension, and 75% had dyslipidemia [23]. Most of participants had one or more uncontrolled risk factor that demonstrate low level of awareness about the disease, risk factors, and measures to prevent them [23].

MI and acute coronary syndrome can lead to a CVD [1]. MI is due to a sudden stop of blood supply to the heart and can be due to blockage in the blood vessels that supply the heart [1]. MI kills a person every 40 seconds in the US, while the incidence in Saudi is not as high [1]. Nevertheless, the incidence of MI in SA is increasing with multiple risk factors including obesity, consumption of fatty food, physical inactivity and smoking [1]. Only 42% of the population are aware about MI risk factors, and interventions to reduce its risk [1]. Increasing awareness of risk factors like diet and PA significantly reduces the onset, and recurrence of MI [1].

SA initiated various registries to determine patient with different CVD including, the Saudi Project for Assessment of Coronary Events (SPACE) [24] [25], and Saudi Acute Myocardial Infarction Registry Program (STARS-1 Program) [25]. SPACE provides a comprehensive overview of current diagnostic and treatment strategies for acute coronary syndrome (ACS) patients in SA [24] [25].

The Prospective Urban Rural Epidemiology (PURE) cohort study accumulates information on social, environmental, and individual CVD risk factors [26]. Saudi as a high-income country, reveals many reports containing the effect of demographics (rural vs. urban) areas, and daily lifestyle of the occurrence of CVD [26].

There are a set of tools to assess the risk of Common CVDs, of which is the Framingham Risk Score (FRS) [27]. The study in Abha revealed that the population is at risk of almost 9% developing coronary artery disease (CAT) [27]. Another study on military individuals with supposedly high physical activity demonstrated that 10% of the studied group had a mean risk of almost 5% to develop CVD in ten years [27]. There are no available studies on the general Saudi population and the association of physical inactivity to the risk of developing CVD in ten years [27].

Physical inactivity leads to premature mortality and is a risk factor for various chronic NCD [4]. Physical inactivity is a worldwide issue and according to the WHO, people become less physically active with age [4]. A study in Eastern Saudi described the factors that increase modifiable risk of CVD in which physical inactivity was an identifiable factor [10]. PA boosts the immune system, safeguarding people from infectious diseases, and increases metabolism, which directly affects the risk of chronic diseases [10]. Exercise is a structured, planned, and systematic form of PA [6] [9] [10]. Do not confuse work or home-related activity with the structured movement of a physically active exercise [28]. WHO identified barriers to outdoor exercise like anxiety about traffic & violence, bad climate conditions, and lack of parking, and sidewalks [10]. Research review in Saudi also identified factors like cultural reasons, lack of social support, and proper gyms [10]. Females in Saudi had extra barriers in PA because of the absence of proper facilities, cultural pressure, and lack of time [10]. In addition, despite that, females are more aware than males of the importance of PA, Saudi women are less active than Saudi men [10]. PA is one vital determinant of healthy life [28]. PA maintains a proper weight and reduces the risk of many comorbidities [28]. Less than 20% of young adults are physically active worldwide [28]. In Saudi, only 40% of the whole population is physically active [28]. PA has beneficial results at the individual and community level [4]. There has been rapid modification in the lifestyle In SA with the changes in economy, people are becoming less physically active [4]. People in Saudi do not participate in physical activity that provides them a healthy standard and protects them from illnesses [4]. One study by Al-Nozha et al. concluded that physical inactivity accounts for more than 95% of the population [4]. Another study by Al-Hazzaa concluded that physical inactivity in Saudis ranges from 43.4% to 99.5% between children and adults [4]. PA level had not changed much notwithstanding the many reports that support various benefits of PA [4].

Improper diet high in trans fats [29] that lacks fruits and vegetables, physical inactivity, and obesity are main risk factors to develop NCDs [18]. Obesity prevalence is between 35% - 63.5% in various areas in the kingdom [28]. A study in the US showed that having regular breakfast meal reduced obesity onset in 30% of adolescent [18]. Healthy eating habits have been shown to reduce CVDs, a main subset of NCD [18] [30]. Conversely, low consumption of fruits and vegetables can increase hypertension, and hypercholesterolemia, which are risks to developing CVDs [18].

Vitamins, minerals, and fiber components of fruits, vegetables, and multi-grain products have scientifically proven rolls to reduce oxidative stress, inflammation, high blood pressure, and enhance insulin sensitivity [8]. On the other hand, a diet with high saturated fat and processed carbohydrates increases the risk of CVDs [8]. However, studies in Saudi about the relationship between diet and CVD are lacking, unlike in the US [8]. Moreover, there are no studies in Saudi examining the impact of dietary guidelines on the risk of CVD [8].

The Glycemic index estimates the quality of carbohydrates in a diet [30]. The Glycemic index measures how much 59 g of carbs in a diet will increase blood glucose level [30]. The high glycemic index is caused by a high percentage of the refined diet, while a low glycemic index is demonstrated in healthier, whole food grains [30]. A healthy diet includes high fiber constituents, a low percentage of refined grains, and a low glycemic index [30]. High fiber food low in glycemic index can lower the risk of developing many chronic diseases and hence mortality rate [30].

Trans fatty acids (TFA) are synthetic fat produced by heating liquid oil and catalyzing the oil with hydrogen to convert the oil to solid fat [29]. The heating step involved in the process will transform the carbon double bond to the transform [29]. TFA has worse health consequences than saturated fatty acids and is linked to increasing CAD [29]. In addition, TFA increases total plasma cholesterol level and the bad cholesterol low-density lipoprotein (LDL) [29]. Mean percentage of TFA in margarine and butter is 4.25% with SD of 2.025, and 10.75% with SD of 4.925 respectively [29]. Acknowledging the presence of TRA is mandatory in the US by the FDA [29]. In Saudi, the government recently mandated labeling food with TRF content [29]. Labeling is essential to inform the public about the content of their diet that could have a risk of CVD [29].

Proper nourishing diet greatly influences one’s health and protection from illness [16]. A balanced diet offers vital nutrients and the addition of dietary supplement deliver a vital source of micronutrients not provided in the diet and that can protect from birth defects [31]. Pregnant and lactating women, the elderly, and adolescents with bad eating habits can benefit from dietary supplements [17] [31]. Some dietary supplements have active ingredients that have to be monitored properly for safe uptake [31]. There are reported cases of side effects to clinically unapproved dietary supplement that are sold illegitimately or using over the recommended dose [31]. Evidence of dietary supplements in reducing or increasing the risk of chronic diseases is not clear [31]. Supplements of vitamin B lower the incidence of stork, but have no effect on CVD [31]. Omega-3 fatty acids also showed no effect on CVD [31]. Studies on dietary supplements are limited in Saudi and not much is known about their effect [31].

Attention to mind and body medicine has changed over the past 30 years [32]. The effect of religious practices has great effect in healing exercises of physiological and psychological diseases [32]. Mediation has direct effect on reducing stress, depression and anxiety among Saudi students [15]. Mayo Clinic has up to 850 studies demonstrating the effect of religious practices on physical and mental health respectively [32]. The majority of these studies showed the positive effect of spirituality in religious practices on the length and quality of life [32]. Religious practices are related to decreasing mortality and morbidity [32]. Religious practices were associated with lower level of smoking, drinking alcohol and depression; consume healthier diet, and a better immune system [32]. Mediation has effects to reduce the risk of CVD as part of guideline-directed cardiovascular risk reduction [32].

Islamic prayer is a form of meditation accompanying PA that is proven to activate the parasympathetic, reduce the sympathetic nervous system, and display slower alpha rhythm coherence on Electroencephalography (EEG) [32]. Prayer or (Salat) also reduces anxiety and influences balance in both adults and elderly [33]. Salat is also a form of physical exercise as many joints and muscles bend and flex during prayer [33]. More than 90% of people pray regularly five times a day and enjoy healthy knee movement [33]. Salat-altaraweeh is a longer form of the regular salat that is practiced during the month of Ramadan and is proven to have a preferable effect on mental health and physical strength [33].

In Summary, this paper is a systematic review investigating the effect of PA, diet and mindful medication on the risk of developing CVD and the severity of the CVD in patient with the disease. risk factors of CVD collaboratively combine and increase the risk of developing a cardiac illness; so, better interventions will attract multiple risks than those interventions that focus on only one risk factor at a time [12].

CVD is the main cause of mortality and morbidity worldwide and in SA. CVD is increasing dramatically in the Kingdome with urbanizations. Identifying risk factors is essential to set proper interventions that can prevent risk factors and slow progression of the disease.

After a thorough review of the literature, the researcher’s intention is to identify the impact of various practices on the risk of developing CVD, and on the severity of patients with the disease.

ACE African Middle East Cardiovascular Epidemiological

ACS Acute coronary syndrome

CAD Coronary Artery Disease

CHD Coronary heart Disease

CVD Cardiovascular Disease

EEG Electroencephalography

FRS Framingham Risk Score

GCC Gulf Council Countries

HDL high-density lipoprotein

IHC ischemic heart disease

LDL low-density lipoprotein

MBCT Mindfulness-Based Cognitive Therapy

MBSR Mindful Based Stress Reduction

MBI Mindfulness-Based Interventions

MI Myocardial Infarction

NCD Non-communicable Disease

NTP National Transformation Program

PA Physical Activity

PM Preksha Dhyãna meditation

PURE Prospective Urban Rural Epidemiology

SA Saudi Arabia

SPACE Saudi Project for Assessment of Coronary Events

STARS-1 Saudi Acute Myocardial Infarction Registry Program

TFA Trans fatty acids

TRS Trans fatty acids

WHO World Health Organization

This is a systematic review of published papers on the population of SA, about CVD risk factors and interventions like mindful meditation, physical activity, and diet effect on reducing the risk of developing CVDs and reducing severity in patients with CVDs.

This systematic review is a tertiary research that does not use human material or human data and does not require IRB approval. IRB approval is extracted only for publication and is submitted to the publishing Journal.

According to the Global Burden of Disease Study in 2013, the global mortality from CVD at all ages was estimated to be more than 17.2 million worldwide [9]. CVD is the leading cause of disability and death in SA [2], with the age group below 50 most affected [27]. In the Arab world, ischemic heart disease was the leading cause of mortality in 2010, contributing to 14.3% of all deaths [6]. Dyslipidemia, hypertension, metabolic disease, and obesity are risk factors for CVD [5] [21] [28] [29] [30]. Hypertension is a risk factor in almost 70% of patients with Acute Coronary syndrome (ACS) [34]. Depression is a risk factor for CHD but not anxiety [35].

Urbanization in SA dramatically changed the lifestyle of the Saudi population [5]. Females with medium educational levels showed the highest level of obesity, high blood pressure, and cholesterol, which can be attributed to the lower level of awareness about the importance of physical activity in reducing various chronic diseases [7]. Female in the eastern region was found to have the highest prevalence of diabetes, hypertension, and obesity than any other region [7].

Hypertension increasingly affects women older than 40 years [10]. Diabetes also increased with age in men and women [3] [10] [36]. In contrast to hyperthyroidism, hypothyroidism showed a higher association with CVDs like heart failure and ischemic heart disease [19]. Therefore, it is crucial to identify the risk factors to manage the poorly controlled modifiable risk factors [5]. PA, mindful meditation, and diet have been identified to modify and lower those risk factors leading to CVD. Refer to Table 1 for the summary of studies in this systematic review.

CVD is increasing significantly among low- and middle-income individuals and their families [37] [38]. This increase accompanies the rapid economic change in the SA, leading individuals to be more sedentary, consume a poor diet, and smoke more [37]. The number of Prehypertension and obesity cases, which increase the risk of CVD, are also increasing among young adults in Saudi [21]. Working-age individuals with favorable risk profiles and low expenditure on healthcare are found to have a healthier and longer life span after age 65 [36]. Younger age patients are shown to improve better when enhancing the function of risk factors for CVD [12]. Ahmed et al. (2017) identified that almost half of the study’s population had more than three risk factors for CVD [5]. Less than one-fifth of the participants had only one risk factor [5]. Patients with CVD have higher cholesterol levels, hypertension, and diabetes and lower education than the control group [6] [10] [27]. Almost 61% of the participants in Alhabib et al. (2020) were aware of their hypertension, of which two-thirds had treatment and one-third had their blood pressure controlled [26]. There was no significant change in stage 1-hypertensive patients who did not take their medications [34]. Nearly 60% of ACS patients have ischemic heart disease (IHD), which makes them more susceptible to coronary death [34]. Dyslipidemia is a severe risk of ACS, especially in males [34]. However, the relationship between dyslipidemia and ACS differs in different studies, which may indicate the presence of another factor like demography [22] [23] [26] [34]. On the other hand, diabetes is the single most prominent risk of developing ACS, with increased death rates compared to ACS patients without diabetes [34]. On the other hand, hypertension, which increases with age, has a similar risk for men and women developing ACS [34].

CVD is the cause of premature death, and the mortality rate may rise to 25 million in 2030 due to heart disease and stroke [19]. Increased prevalence of risk factors like dyslipidemia, hypertension, and diabetes, especially in younger age groups, is overwhelming and is increasing CVDs [3] [34] [36]. Saudis have increased risk factors for developing atherosclerosis and more cases of atherosclerosis than their expatriate counterparts [24]. There is limited knowledge among some PHC physicians about CVD management and advanced treatment options [5]. Some physicians are not interested in identifying secondary risk factors of CVDs [40]. Public health stakeholders [5] must take it upon themselves to implement measures, increase awareness about modifiable risk factors, and implement systematic well-developed preventive plans [2] [5] [6] [34] [37]. Preventive measures include awareness programs about trans-fat in diet [29], the importance of PA, and the adoption of National Guidelines that support and inspire PA [5]. School kids consumed low amounts of fruits and vegetables [18]. In addition, older school kids spend more time with their friends than with their families, which may contribute to eating more fast food and staying home playing video games [18] instead of outdoor activities due to the harsh weather in Saudi [11] [18].

Dietary supplements and multivitamins are available on-the-counter drugs [17] [31]. Many are aware of the benefits of supplying the body with missing nutrients in the diet and their harmful effect from overuse [17]. Purchasing dietary supplements and multivitamins does not have a negative financial impact as most users pay less than 200 SR monthly [17]. The awareness is less among those with lower socioeconomic status [16] [17] [31]. Many supplement users do not have complete information about their supplements [31]. Educating the public through social media is essential as many use the internet for information [31]. Moreover, incorporating this health information into the curriculum can spread the knowledge to school kids and college students as this is the age they start taking supplements [31].

PA increases metabolism and brain function, enhancing losing weight, blood circulation, and hormonal functions [11]. In addition, PA reduces depression, diabetes, high blood pressure, CVDs, and cancers, including breast and colon [9]. PA was also shown to increase the family bond and create better relationships with family members [11].

Meditating prayer increases the sense of security and boosts mental health [32]. The postures practice during prayer activates various body muscles and organs [33]. Stretching, bending, and contracting body muscles during prayer promote physical health [33]. Meditation as part of prayer reduces SHR & DHR, regulates heart rate, and promotes mental health [33].

Saudi Vision 2030 has primary healthcare transformation plans to reduce the rising number of CVD by incorporating preventive measures through PHC [26]. The public in SA is unaware of the risk factors for developing CVDs [2] [20] [23]. Mean age of 32 years; participants were aware of only 66.7% of the risk factors to develop a CVD [23]. More than 59% of participants had no acquaintances about risk factors for CVDs [23]. Saudi plans to reduce the mortality rate of CVDs by a quarter in 2025 by improving the population’s daily habits and increasing awareness [26]. Saudis have the highest prevalence of diabetes worldwide, according to the pure study [26], and at younger ages than the median worldwide [28]. According to the PURE study, poor lifestyle contributes to the rising number of CVDs in SA [26]. Poor lifestyle includes consuming unhealthy diet including junk food that is full of trans fats and unneeded calories, and sugary drinks, and long hours of sedentary behavior with no PA [26]. Many people are unaware of the dietary guidelines and how to differentiate between healthy and junky food [16]. Poor awareness about healthy dietary guidelines was associated with increased susceptibility to asymptomatic atherosclerosis [16]. However, individuals with and without asymptomatic atherosclerosis have similar diet habits [16]. Therefore, more efforts are needed to refine the Saudi dietary guidelines [8] [16]. It is also vital to set educational material in schools and as public awareness programs through social media and target the lower social level [12] [23]. Though diet is a significant risk factor for CVDs, caloric intake could be a confounder [16]. Further research is needed to identify the association between following the Saudi dietary guidelines and the risks of CVD [8]. Recommendations are needed to establish a pricing strategy to decrease the prices of participating in gyms [11]. Educate the public through social media about the importance of PA including time needed to spend practicing daily and the type of exercises according to the age and health status [11].

Moreover, Salat, a combined form of PA and meditation if practiced properly with mindful concentration and stillness has tremendous effects to lower risk factors of CVDs [26]. Awareness about the importance of Mindful concentration during prayer or mindful meditation in general will have promising effects [26]. Yet, not much research is performed on the mindful meditation field in SA [26]. Many studies on mindful meditation are done elsewhere and show encouraging results [26]. So, more research is needed to be implemented in SA regarding mindful meditation to see the effect on the Saudi population and spread the knowledge to increase awareness, because meditation as a practice other than daily prayer is considered new to the culture of SA [26].

This work is a testimony of my postgraduate journey that I have been undertaking for two years. I would like to pass my sincere gratitude to my parents and family, to Dr. Mai Alnbaheen at SEU, and to Dr. Saad Al-Daama, MD, Dr. Afra Al-Dayel, Dr. Heba Raslan, Dr. Reem Al-Rabeh, and Mrs. Najla Al-Mahbashi at KFSH-D for their continued guidance and support.

I declare that the research project entitled “Effect of Mindful Meditation, Physical Activity, and Diet to Reduce the Risk to Develop or Reduce Severity of Cardiovascular Diseases in Saudi Arabia: A Systematic Review “submitted to the Saudi Electronic University is my own original work. I declare that the research project does not contain material previously published or written by a third party, except where this is appropriately cited through full and accurate referencing.

The authors declare no conflicts of interest regarding the publication of this paper.

Al-Saber, A. and May, A.-N. (2023) Effect of Mindful Meditation, Physical Activity, and Diet to Reduce the Risk to Develop or Reduce Severity of Cardiovascular Diseases in Saudi Arabia: A Systematic Review. World Journal of Cardiovascular Diseases, 13, 46-72. https://doi.org/10.4236/wjcd.2023.131005