Knowledge of dietary guidelines and portion sizes in Saudi Arabian mothers; cross-sectional study


 Background: it is known that knowledge of dietary guideline is linked to healthy eating habit. This study aims to investigate Saudi Mother’s knowledge of current dietary guidelines regarding food groups and portion sizes and to investigate its relation to the sociodemographic factors.Methods: This cross-sectional study using Nutrition Education Program to recruit 101 mother and child. Instructed on site- online survey were collected to measure the mother’s knowledge of dietary guideline and portion sizes. quantitative analysis using Chi-square and Kruksan-Wallis tests.Results: 29.1 % of the participants were aware of the MyPlate guidelines and 51.5 % said that they affected by healthy plate choices. Being married was significantly associated with knowing about the MyPlate Image (P= 0.004). Correct identification of food groups on the MyPlate Image and correct identification of serving sizes of food group was less than 50% for most food groups. A significantly greater percentage of those with a postgraduate education were accurate about the correct servings of fruit, vegetables and grains (P=0.049).Conclusions: Nutrition knowledge of food groups and serving sizes was poor in the sample of Saudi women. This research provides evidence that nutrition education is needed in the Saudi Arabia and the finding are relevant for future health promotion strategies. The study has also identified sociodemographic groups that possibly may need to be targeted with more attention in future nutrition education programs such as those with low income, lower education level and unmarried women.


Background
Knowledge and awareness of dietary guidelines has been linked to having a healthier diet and better diet quality [1,2,3,4]. Nutrition knowledge is also an important factor in overall health literacy where low health literacy is linked to unhealthy outcomes [5]. Currently there is little research investigating awareness or use of dietary guidelines in Saudi Arabia. Although there are some basic dietary guidelines on the website of the Ministry of Health since 2012-these are not widely disseminated and there is no data showing implementation or results of implementation of these guidelines [6]. There is high quality research (a cohort study of 10 735 nationally representative participants) indicating that only a small percentage of the Saudi population meet the dietary recommendations (2% for fruit and 7.5% for vegetables for example) and thus there is an urgent need for programs to improve dietary behavior to reduce the burden of disease [7]. This study intends to design a nutrition education program for mothers as it has been shown that mothers can in uence children's food intakes through shopping, feeding practices and attitudes [8,9]. Before designing such a program, we wanted to characterize the current level of knowledge so that we could target where to focus our efforts in future educational interventions.
The American MyPlate guidelines developed by the United States Department of Agriculture ( USDA) developed in 2011 is well known and user friendly [10]. It is the image of a plate with food groups on it, as shown in Figure 1. The Saudi guidelines are a one-page written description of what people should eat, as they have not been disseminated, we chose to use the more accessible MyPlate image to investigate knowledge and awareness of dietary guidelines. This image has also been successfully used in nutrition education and therefore will be of use in any future nutrition education interventions that might be designed. The image represents dietary guidelines in a meal setting that is helpful to for meal composition that has been used by products manufacturers for food promotion, and by nutrition educators to improve eating habit of children and adults [2]. They are also used in research studies and clinicals setting as a teaching tool, and guidance for assessing diet quality [11,12,13,14]. In addition, many registered dietitians/nutritionists use this tool in delivering information to patients [15]. The main aim of the image when it was developed was for it to be a usable tool for consumers [16].
The novelty of the current research is measuring the nutritional knowledge of Saudi mothers and testing their background of MyPlate and serving sizes guidelines. In addition, we wanted to investigate if knowledge and awareness was linked to the socioeconomic factors of income, education, employment and marital status in the Saudi population. This information could help the community to target different population groups when implementing future educational programs. The aim of this study was to therefore assess how aware Saudi Mothers were of current dietary guidelines regarding food groups and portion sizes and to investigate if this awareness was related to sociodemographic factors.

Data Collection
All subjects were recruited from local social events targeted middle to high income families for Healthy Nutrition program to evaluate mother and children knowledge background on eating habit and to educate them on how to be healthy. Healthy activities and games have been designed for the children to enjoy and learn whereas mothers were interviewed by Clinical Nutrition students to answer eating habit (using dietary guideline and portion size) survey on data link using tablets. The educational program including activities were part of the volunteer service targeted mother and children to promote healthy eating pattern. All volunteering individuals were under the supervisions of the study's investigators where at least one supervisor was available during each session. Each session last 45 minutes including the Nutritional Educational and survey interview. Power sample have been calculated following the study of Farahat et. al., 2015 but were underpower since the current study involve Nutritional Educational sessions that require long period of interview [17]. Ethical approval from the University's ethical committee have been approved prior to the study conduction and consent forms have been signed by the mothers prior to the survey responses.

Measurements
The study survey was designed for the purpose of the study although some items were adapted from previous study [18]. The survey questionnaire consists of two sections: demographics which include educational background, marital status and income level and dietary guidelines & portion size questions.
The survey contains questions asking about subject's knowledge of the recommended serving amount of each food group based on US recommendation for healthy adults which is supposed to be grain 6-11, vegetables 3-5 serving, fruit 2-4, meat and milk groups 2-3 serving per day based on 2000 calories need per day. Subjects also have been asked if they know "MyPlate" and if they follow it for their diet intake, colorful picture of the plate have been provided in the survey and nally subjects have been tested their knowledge to recognize "MyPlate" with appropriate food group. The idea of this question has been adapted form USDA choose my plate quiz to test the knowledge how much of the person's plate should be each food group [16].

Statistical analysis
Analyses were conducted using IBM SPSS Statistics 21.0 (Armonk, NY, USA). Associations between sociodemographic variables and correct identi cation of the food groups on My Plate and correct knowledge of recommended of food servings of food groups and whether or not the MyPlate image affected eating choices were examined using the Chi-square statistic. The association between socioeconomic factors and the response to "Do you know about MyPlate" was tested using the Kruksan-Wallis test as there were three possible responses (yes, No or Maybe). For all analyses, signi cance level was set at alpha level ≤ 0.05.

Results
Sample characteristics are shown in table 1. The mean age of participants was 33 years old. 70% of the mothers had a college education or higher but only 32% were employed. 41.4% had an income of 10 000 SAR and 58.5 had an income of 10 000 or more. 72.3 % of the women were married. Only 29.1 % of people were aware of the MyPlate guidelines with 41.7 % responding "maybe" they were aware of the guidelines. 51.5 % said the healthy plate always or mostly affected their eating choices. Table 2 shows the amount of people that correctly identi ed food groups on the MyPlate image.
Vegetables and milk were food groups that were identi ed well (58.4 and 61.8 respectively). The other 3 groups were poorly identi ed (33% or less). The number of people correctly identifying serving sizes was also low. Fruit was the food group that had the highest percentage of people responding correctly (59.8%) and grains was the food group the most poorly identi ed (8.5 %).    Table 5. Association between socioeconomic factors and correct identification of the food groups on My Plate Table 6. Association between socioeconomic factors and correct knowledge of recommended of food servings of food groups (n=101) Married women were much more likely to know what MyPlate was (P=0.004) and for it to affect their eating choices compared with unmarried women (P=0.000). There was a signi cant association between being married and correctly identifying the food group vegetables on the MyPlate image and a signi cantly greater number of married women also had correct knowledge of the serving size for fruit and milk compared to unmarried women. Having a high income was signi cantly associated with MyPlate in uencing food choices (P=0.053) but otherwise was not associated with any other of the knowledge questions.
A signi cantly higher percentage of employed people said that healthy plate affected their eating choices compared to unemployed people (P=0.039). Employment did not make a difference to correctly identifying food groups on the MyPlate image or to correctly identifying the serving sizes for food groups apart from the food group protein/meat where a higher percentage of employed people correctly identi ed serving sizes compared to unemployed people (P=0.059).

Discussion
This sample of Saudi mothers was young and highly educated with almost 60 % having a high household income and over 70 % were married. The knowledge and awareness of MyPlate was low with only 29.1 % saying they were de nitely aware of MyPlate and a further 41.7 responding that they were "maybe" aware of MyPlate. Only 11.2 and 39.8 % of the women said that MyPlate always or mostly affected their eating choices respectively. The number of women correctly identifying food groups on the plate and correctly identifying serving sizes was also low-under 50% for most of the food groups. These nding are in line with the literature [2,10] including the ndings of Scwartz et al who found only 29.6 % of the population in the US was using MyPlate [3]. These nding are also in line with the nding that only a very small percentage of Saudi people follow dietary guidelines [7].
Education was not associated with knowledge of Myplate, this may be because overall the Saudi population is not familiar with the MyPlate image. However, educated mothers were much more likely to say that dietary guidelines in uenced their choices and a signi cantly greater percentage of those with a postgraduate education were accurate about the correct servings of fruit, vegetables and grains compared to those without a postgraduate education. Our nding indicate that education is an important factor and merits further exploration. It is well known that education and other socio demographic factors affect health outcomes though less is known about speci c nutrition education versus general education level. One study has found that nutrition knowledge was important for healthy food intake independently of education level [19] and some studies have found educated people to have healthier dietary behaviors [20,21,22].
Married women were much more likely to know what MyPlate was and for it to affect their eating choices. There was a signi cant association between being married and correctly identifying the food group vegetables on the MyPlate image and a signi cantly greater number of married women also had correct knowledge of the serving size for fruit and milk compared to unmarried women. This is consistent with studies that show that being married is linked to eating more fruit and vegetables [22,23]. It has been shown that marriage positively affects health outcomes over the life course [24,25]. The protective effects of marriage include availability of partner's support; better regulation of health-related behaviors, which may be particularly important for men; and economic bene ts, such as partner's resources support, which may be particularly important for women or pooling of resource [26,27]. It is inconclusive how diet changes with marriage and what effect marriage and having children has on diet and how diet may mediate the protective effects of being married [28,29]. As a high proportion of this sample was married (72%) and the percentage of women married in in Saudi Arabia is not known our ndings cannot be generalized to the general population; however further research should include marital status, marital history and changes in marital status and investigate how this impact dietary intake and health so that educational programs can be designed effectively.
Having a high income was signi cantly associated with MyPlate in uencing food choices but otherwise was not associated with any other of the knowledge questions. Some studies have found higher income to be associated with healthier diets [30] and healthier diets cost more. Being able to afford a healthier diet has been shown to be an independent predictor of eating a healthier diet, [21] this may be one reason why those with a higher income were more likely to say MyPlate in uenced their food choices; they may have healthier diets and their dietary voices re ect the guidelines presented in MyPlate. It has also been shown that those on welfare in the US would nd it hard to afford the diet recommended by MyPlate [31].
Being employed was also signi cantly associated with Myplate in uencing their eating choices compared to unemployed people.; it was also signi cantly associated with correctly identifying the serving size for the food groups Protein Meat. This may be a chance nding and needs to be replicated in future studies. Employment is associated with income and also with socioeconomic class therefore our ndings regarding food choices is consistent with the literature. It has been shown that unemployed people, people on bene ts/welfare and those of a lower socioeconomic class have a lower intake of fruit and vegetables [23] and less healthy diets overall and worse health related behaviors [32,33,34]. Furthermore, it has been shown that maternal employments is linked to better infant and young child feeding [35].
One limitation of this study is the low sample size, future studies with a larger sample size can provide greater statistical power and reduce likelihood of type 2 error. Another weakness is the narrow age range and over 70 percent of the women were married so these ndings cannot be generalized to the whole Saudi population. Future studies should have a sample that is nationally representative and include different population groups, with diverse sociodemographic characteristics. Another limitation is the use of the American MyPlate logo which Saudi nationals may not be familiar with therefore the assessment of their knowledge of food groups may not be accurate; although using the Saudi written guidelines may have yielded the same results as these are not widely disseminated. A major strength of this study is that is the rst study investigating nutrition knowledge in the Saudi population and therefore is highly original research.

Conclusion
In summary, in this sample of Saudi women, nutrition knowledge of food groups and serving sizes was poor. Being educated and being married were associated with greater knowledge. Being married, highly educated, having a high income or being employed were all associated with women saying the MyPlate image in uenced food choices. This research provides evidence that nutrition education is needed in the Saudi Arabia and the nding are relevant for future health promotion strategies. The study has also identi ed sociodemographic groups that possibly may need to be targeted with more attention in future nutrition education programs such as those with low income, lower education level and unmarried women. This study needs to be replicated in a larger sample size in a more nationally representative sample. Future research needs to focus on implementation of nutrition education programs and measuring their effectiveness as well as investigating further the barriers to adopting healthy eating habits in Saudi Arabia. Figure 1 The MyPlate Image. Adapted from United States Department of Agriculture, C.f.P.a. and Promotion.,