Development And Testing of an Expanded Global Diet Quality Score Incorporating Lifestyle Factors for Cardiovascular Disease Risk Assessment Among Lebanese Adults

Abstract

Background: Non-communicable diseases (NCDs) impose a substantial and growing burden in Lebanon, where poor diet quality co-occurs with high rates of tobacco use, physical inactivity, alcohol consumption, and insufficient sleep. While the Global Diet Quality Score (GDQS) is a validated and globally applicable tool for assessing diet-related chronic disease risk, its exclusive focus on dietary intake limits its capacity to capture the full spectrum of behavioral exposures that drive cardiometabolic risk in populations where multiple lifestyle risk factors are highly prevalent.

Objective: This study aimed to develop an Expanded Global Diet Quality Score (EGDQS) by incorporating four lifestyle behaviors, namely tobacco use, physical activity, sleep duration, and alcohol consumption, into the validated GDQS framework, and to compare both scores in terms of risk classification profiles and associations with cardiometabolic risk factors among Lebanese adults.

Methods: Data were drawn from a community-based survey of Lebanese adults residing in Greater Beirut conducted in 2014 (n = 501). A total of 150 participants aged 35 to 64 years with complete dietary, lifestyle, anthropometric, and biochemical data were included after excluding individuals with prior diagnoses of diabetes, dyslipidemia, or hypertension. The GDQS was derived from single 24-hour dietary recalls. Cardiometabolic outcomes included metabolic syndrome and its five individual components, and obesity defined as BMI of 30 kg/m² or above. Binary logistic regression was used to examine associations between score categories and cardiometabolic outcomes, with multivariable adjustment for sociodemographic covariates.

Results: The EGDQS was developed by expanding the GDQS by assigning additional points to four lifestyle components using a proportional weighting approach grounded in evidence-based estimates, yielding a maximum total score of 98 points. The mean total GDQS score was 17.15 ± 4.33, with 33.3% of participants classified as high dietary risk. The mean total EGDQS score was 35.16 ± 15.86, with 56.0% classified as high combined diet-lifestyle risk, representing a 22.7 percentage point increase in high-risk classification compared to the GDQS. The dietary profile was characterized by widespread low intake of protective food groups alongside high consumption of refined grains and baked goods. Adverse lifestyle behaviors were highly prevalent, with 70.0% of participants being current smokers, 68.0% reporting insufficient sleep, 31.3% physically inactive, and 79.3% current alcohol drinkers. MetS was present in 38.3% of participants, and 76.7% exceeded sex-specific WC thresholds. In multivariable logistic regression, the GDQS showed significant inverse associations with elevated WC in the unadjusted and partially adjusted models, but lost significance upon full sociodemographic adjustment. In contrast, the EGDQS retained significant inverse associations across all three models for elevated WC and additionally demonstrated significant inverse associations with hypertension and obesity in the fully adjusted model, corresponding to 76%, 65%, and 64% lower odds respectively.

Conclusion: The EGDQS demonstrated superior and more robust associations with cardiometabolic outcomes compared to the GDQS under full covariate adjustment, supporting the incremental value of integrating lifestyle behaviors into a composite dietary risk scoring framework. These findings highlight the limitations of diet-only assessment in populations with high co-occurring lifestyle risk exposures and underscore the potential of the EGDQS as a more comprehensive tool for NCD risk profiling in Lebanese adults. Longitudinal validation in larger and more diverse samples is warranted.