1

1Article
2Knowledge, Consumption, and Attitude towards the
3Importance of Dietary Fibers in Health in Adult

4Saudi Population
5 Hanan Alfawaz1,2*, Nasiruddin Khan3, Haya Alhuthayli1, Kaiser Wani2, Muneerah Aljumah5,
6 Malak N.K. Khattak2, Saad A. Alghanim4, Nasser M. Al-Daghri2.
7
8 1College of Food Science & Agriculture, Department of Food Science & Nutrition, King Saud University,
9 Riyadh, Saudi Arabia
10 2Chair for Biomarkers of Chronic Diseases, Biochemistry Department, King Saud University, Riyadh, 11451
11 Saudi Arabia
12 3College of Applied and Health Sciences, Department of Food Science and Human Nutrition, A’ Sharqiyah
13 University, Ibra, 400 Sultanate of Oman
14 4Health and Hospital Administration Program, Dept. of Health Administration, College of Business
15 Administration, King Saud University, Riyadh, Saudi Arabia
16 5Almaarefa University, College of Medicine Medical Student, 11597 Riyadh, Saudi Arabia
17 * Correspondence: halfawaz@ksu.edu.sa; Tel: 009668055890; Fax: 0096614675931
18
19 Received: date; Accepted: date; Published: date

20 Abstract: The objective of this study was to study the awareness, knowledge, and
21 habits of dietary fiber intake among Saudi population. A survey-based study
22 using face to face interviews was designed and 1363 apparently healthy adult
23 Saudi males and females were recruited. Most of our respondents were females
24 (81.2%), aged 25 and above (87.2%), and were educated at least up to the
25 secondary level of education (80.8%). A fair proportion of our respondents were
26 aware of role of fiber rich foods in health conditions like obesity (70.5%),
27 cardiovascular diseases (68.9%), and regulation of blood sugar (68.9%) with
28 females significantly better in having this nutrition knowledge. A disconnect in
29 translating this nutrition knowledge was seen in the respondents especially in
30 food preferences while eating out like using white bread (84.4%), fried potatoes
31 (69.9%) and peeled fruits (60.6%) more in comparison to cooked vegetables
32 (29.6%) and brown bread (18.1). The most common reason for this disconnect was
33 noted as the perception of respondents related to foods rich in dietary fibers being
34 expensive (72.1%), having no beneficial health effect (56.5%) and not readily
35 available (51.6%); and their disliking of the taste (52.8%). Males showed
36 significantly high use of fiber supplements, white bread, peeled fruits (all p<0.01);
37 while females used more legumes (p<0.01), brown bread (p<0.01), and cooked
38 vegetables (p<0.01). A significantly higher number of males respondents exhibited
39 diabetes, hypertension, and high cholesterol (all p<0.01); and constipation
40 (p<0.04), and osteoporosis (p<0.01) was more common in for females. In
41 conclusion, a disparity between knowledge and attitude towards intake of dietary
42 fibers was seen in Saudi adults. Intervention studies should be conducted in the

2Nutrients 2019, 11, x; doi: FOR PEER REVIEW www.mdpi.com/journal/nutrients

 3Nutrients 2019, 11, x FOR PEER REVIEW 2 of 23

43 Saudi society to impart knowledge on the emotional, cognitive and sensory

44 factors related to food choices so that a gap between nutrition knowledge and
45 consumption of healthy high fiber diet is minimized.

46 Keywords: Dietary fiber, Nutrition knowledge, Fiber and health, Saudi Arabia.

47

48

49

501. Introduction

51Balanced dietary habits and healthy lifestyle may play an important role in every
52stage of human life. It may prove beneficial for the prevention and even treatment
53of some diseases. The young as well as adult generation must be aware of the basic
54pros and cons of the food they are eating. Dietary fiber is one such element in a
55balanced diet and refers to the edible portion of the plant foods which are resistant
56to absorption and digestion in the small intestine. They are analogous to
57carbohydrates and provide bulk in the diet and aids in proper gastrointestinal (GI)
58function [1]. The major food sources of dietary fiber includes wholegrain cereals,
59legumes, fruits and vegetables and their contribution to dietary fiber has been
60reported as 50%, 30-40%, and 16% respectively for cereals, vegetables and fruits
61[2]. The fiber content and composition differs based on different food sources and
62the amount of intake [3].

63Epidemiological studies have shown the preventive role of dietary fiber in several
64diseases such as cardiovascular, cancer, obesity and type 2 diabetes [4,5]. Intake of
65diets rich in fiber can lead to decreased blood pressure [6], increased rate of bile
66excretion thus reducing total and LDL cholesterol (LDL-C) [7], increased insulin
67sensitivity [8], stimulate optimal gastrointestinal function and prevents certain
68disorders [9]. However, a high dietary fiber intake than recommended can produce
69abnormal distension, intestinal gas, bloating and cramping [10,11]. It is
70recommended that a high fiber intake must always be accompanied with high fluid
71intake as it allows the absorption of water by the intestines and, therefore,
72produces a softer and bulkier bowel movement. Moreover, higher than
73recommended intake of dietary fiber can also limit the absorption of some
74nutrients and make them less available to the body. For instance, an inhibiting
75effect of fiber had been demonstrated on non-heme iron absorption [12] .

76The population from many European countries and the USA is reported to
77consume a low fiber intake as compared to recommended level [3]. This pattern of
78dietary fiber intake can have deleterious health effects. Recommendations of total
79fiber intake for an average population are differentiated in some countries and
80range from 20-45g/day [13]. However, according to the dietary reference intakes
 4Nutrients 2019, 11, x FOR PEER REVIEW 3 of 23

81(DRIs) developed by the Institute of Medicine of The National Academics, the

82Adequate Intake (AI) of dietary fibers for adult males and females aged 20+ years
83is 30-38 g/day and 21 to 25 g/day respectively [14]. The plausible causes for this
84unhealthy fiber intake pattern may include the reduced intake of whole meal
85products in daily diet and higher price along with un-availability of varied range
86of cereal products [15,16]. A study performed by Ahmed and colleagues in rural
87and urban areas of Bangladesh demonstrated the requirement of awareness, and
88consumer education in order to increase dietary fiber intake [17] . A recent survey
89from Croatia demonstrated the importance of nutritional knowledge about healthy
90foods. The study reported that the knowledge about fiber consumption varied
91depending on age, gender, education level, and location (rural versus urban) [18].
92Similar results from Romania demonstrated the vital role of knowledge,
93information and community intervention regarding fiber intake and its role in
94health status [19]. Thus, nutrition education and health awareness programs are
95preferred choices to educate today’s young generation to develop proper dietary
96habits.

97Saudi Arabia witnessed a rapid inclination from its traditional diet towards
98western diet and lifestyles [20]. Studies from several parts of Saudi Arabia showed
99low levels of healthy diet awareness, sedentary behaviour, imbalanced nutrient
100intake and unhealthy dietary pattern including increased use of high levels of
101carbohydrates, fat, free sugars, sodium, cholesterol and low level of dietary fiber
102[21,22]. This sudden change in dietary behaviour had been reported as a major
103rationale for several diseases in this part of the world including obesity, diabetes,
104dyslipidaemia and coronary heart disease [23,24]. However, to the best of our
105knowledge, there is no study done in Saudi Arabia that reports the frequency of
106dietary fiber in a daily diet and also the awareness of basic knowledge and health
107impacts regarding the role of dietary fiber in a balanced diet. The present study
108thus aimed to demonstrate the dietary pattern of fiber intake in general population
109and its relationship with socioeconomic and demographic factors. It also focuses
110on the level of knowledge and awareness of fiber use in this population.

1112. Materials and Methods

1122.1. Study Design and Participants

113 This cross-sectional study was performed at Riyadh, the capital of Saudi
114Arabia. Total subjects included 1363 apparently healthy adults [N=256 males,
11518.8%; N=1107 females, 81.2%] aged between 20 and 70 years old, who responded
116to the announcement of the study from the general population in Riyadh City from
117January-May 2018. Areas of recruitment included schools, colleges, shopping malls
118and public parks. Inclusion criteria included apparently healthy Saudi adult males
119and females aged between 20-70 years. We divided Riyadh city to 4 parts: north,
120south, east and west for proper representation. Exclusion criteria included serious
 5Nutrients 2019, 11, x FOR PEER REVIEW 4 of 23

121disease such as cancer, renal, cardiac or gastrointestinal (GI) disease and any
122chronic diseases.
123 All the participants in this study gave their informed consent before inclusion.
124The study was conducted in accordance with the Declaration of Helsinki, and the
125protocol was approved by the Ethics Committee for Scientific Research and Post
126Graduate Studies at the College of Science, King Saud University, Saudi Arabia
127(reference# 4/67/175981).

1282.2. Data Collection and measurements

129 A pilot study including 50 participants was performed to confirm the
130reliability and validity of the questionnaire. Content and face validity were done to
131clarify all the questions. The questionnaire was then reviewed by experts in the
132related fields. Moreover, external reviewers provided their feedback and opinion
133in developing/improving the questionnaire to ensure reliability of the test. Expert
134feedback and suggestions were incorporated in the final questionnaire.
135Furthermore, Cronbach’s α, an estimate of coefficient of reliability (84%), was
136measured for the questionnaire.
137 A face to face questionnaire was filled. The questionnaire was divided into
138various parts including:
139 (1) Socio-demographic characteristics including sex, age, marital status,
140educational qualification etc.
141 (2) Consumption of food sources rich in fiber where the participants had to
142answer whether they consume a selected list of fiber rich foods as regularly (more
143than thrice a week) , rarely or do not consume at all.
144 (3) Knowledge about dietary fiber and their health impacts, and the preference
145of food choices while eating out/ having fast foods.
146 (4) Reasons for the lack of dietary fiber in their diet
147 (5) Health condition of the study participants.
 6Nutrients 2019, 11, x FOR PEER REVIEW 5 of 23

1482.3. Statistical Analysis

149Data were analysed using the SPSS 22.0 (SPSS Inc., Chicago, IL, USA). Data was
150presented as frequencies (%). Pearson Chi-square test was used to examine
151differences between use of dietary supplements during pregnancy and body
152mass index (BMI), educational level, family income, occupation, number of
153children and neonatal health. All p-values were two-tailed, and p-values <0.05
154were considered significant.

1553. Results

1563.1. Socio-demographic characteristics of the study participants:

157 Table 1 represents the demographic characteristic of the participants and
158their frequencies. Most of the study participants were in the age-group of 26-55
159(75.4% in for males and 82.8% in for females) and married (78.9% in for males
160and 74.7% in for females). The family income was more or less evenly
161distributed between low and high income families in both males and females.
162Most of the participants were educated at least up to the secondary level of
163education (98.4% in for males and 96.1% in for females). About 3.7% of the
164respondents were characterized as having low level of education, 12.2% had
165secondary education, and 63.1% graduated from university. The percentage of
166post graduate was higher in for males (11.3%) than females (8.4%).
167 Table 1. Socio-demographic characteristics of the study subjects
Parameters All Male Female

N 1363 256 1107

Age Group (years)

20-24 176 (12.9) 25 (9.8) 151 (13.6)
25-35 411 (30.2) 70 (27.3) 341 (30.8)
36-45 457 (33.5) 72 (28.1) 385 (34.8)
46-55 242 (17.8) 51 (19.9) 191 (17.3)
56-65 76 (5.6) 37 (14.5) 39 (3.5)
66-70 1 (0.1) 1 (0.4) 0 (0.0)
Marital Status
Married 1029 (75.5) 202 (78.9) 827 (74.7)
Unmarried 262 (19.2) 50 (19.5) 212 (19.2)
Widow 47 (3.4) 1 (0.4) 46 (4.2)
Divorce 25 (1.8) 3 (1.2) 22 (2.0)
Family Income (SAR/month)
Low (<5000) 262 (19.2) 62 (24.2) 200 (18.1)
Average (5000-10000) 444 (32.6) 51 (19.9) 393 (35.5)
Moderate (10001-16000) 384 (28.2) 55 (21.5) 329 (29.7)
High (>16000) 273 (20.0) 88 (34.4) 185 (16.7)
Education Level
Read & Write 4 (0.3) 1 (0.4) 3 (0.3)
Primary 1 (0.1) 0 (0.0) 1 (0.1)
 7Nutrients 2019, 11, x FOR PEER REVIEW 6 of 23

Intermediate 42 (3.1) 3 (1.2) 39 (3.5)

Secondary 166 (12.2) 36 (14.1) 130 (11.7)
Diploma 168 (12.3) 34 (13.3) 134 (12.1)
Graduate 860 (63.1) 153 (59.8) 707 (63.9)
Post-Graduate 122 (9.0) 29 (11.3) 93 (8.4)
168Note: Data represented as N (%).
 8Nutrients 2019, 11, x FOR PEER REVIEW 9 of 23

1693.2. Consumption of fiber rich foods by the study participants:

170 Table 2 shows the consumption of fiber rich foods among the study
171participants. Fruits and vegetables were mostly consumed regularly in the form of
172salad (86.9%) and cooked vegetables (81.5%) while fruits with peels are least
173consumed (61.1%). While in cereals, whole wheat and refined wheat were
174consumed regularly by 64.9% and 63.2% of the participants while only 15.6% of the
175participants consumed Quinoa regularly. Peanuts (74.5%) and pistachios (72.0%);
176and fava beans (68.7%), and oats (66.4%) were the choice of dry fruits and legumes
177respectively among the study participants. The consumption of cooked vegetables
178and oats in for females wasere significantly higher (p<0.001, 0.001, respectively) as
179compared to males (82.6 vs 77 %) while fresh peeled vegetable consumption was
180significantly higher (p<0.037) in for males as compared to females (64.8% vs 60.7%).
181The consumption of fruit juice, barley, millet, apricot, dried figs, raisin, white
182beans, chick peas and Libya beans was significantly higher in for males as
183compared to females.
 9Nutrients 2019, 11, x FOR PEER REVIEW 9 of 23

184 Table 2. Consumption of fiber rich foods in study participants

All Males Females p
Yes No Rarely Yes No Rarely Yes No Rarely
Fruits and Vegetables
Salad 1184 (86.9) 23 (1.7) 156 (11.4) 222 (86.7) 8 (3.1) 26 (10.2) 962 (86.9) 15 (1.4) 130 (11.7) 0.115
Cooked Vegetables 1111 (81.5) 30 (2.2) 222 (16.3) 197 (77.0) 13 (5.1) 46 (18.0) 914 (82.6) 17 (1.5) 176 (15.9) 0.001
Fruit juice 863 (63.3) 79 (5.8) 421 (30.9) 182 (71.1) 16 (6.3) 58 (22.7) 681 (61.5) 63 (5.7) 363 (32.8) 0.007
Fresh Peeled Vegetables 838 (61.5) 205 (15.0) 320 (23.5) 166 (64.8) 45 (17.6) 45 (17.6) 672 (60.7) 160 (14.5) 275 (24.8) 0.037
Fruits with peel 833 (61.1) 232 (17.0) 298 (21.9) 162 (63.3) 43 (16.8) 51 (19.9) 671 (60.6) 189 (17.1) 247 (22.3) 0.672
Cereals
Whole Wheat 884 (64.9) 157 (11.5) 322 (23.6) 168 (65.6) 33 (12.9) 55 (21.5) 716 (64.7) 124 (11.2) 267 (24.1) 0.536
Refined wheat 861 (63.2) 157 (11.5) 345 (25.3) 165 (64.5) 32 (12.5) 59 (23.0) 696 (62.9) 125 (11.3) 286 (25.8) 0.684
Maize 572 (42.0) 246 (18.0) 545 (40.0) 97 (37.9) 57 (22.3) 102 (39.8) 475 (42.9) 189 (17.1) 443 (40.0) 0.113
Burghul 377 (27.7) 368 (27.0) 618 (45.3) 59 (23.0) 83 (32.4) 114 (44.5) 318 (28.7) 285 (25.7) 504 (45.5) 0.052
barley 275 (20.2) 572 (42.0) 516 (37.9) 74 (28.9) 94 (36.7) 88 (34.4) 201 (18.2) 478 (43.2) 428 (38.7) 0.001
millet 241 (17.7) 572 (42.0) 550 (40.4) 62 (24.2) 94 (36.7) 100 (39.1) 179 (16.2) 478 (43.2) 450 (40.7) 0.007
Quinoa 213 (15.6) 698 (51.2) 452 (33.2) 39 (15.2) 144 (56.3) 73 (28.5) 174 (15.7) 554 (50.0) 379 (34.2) 0.151
Dried fruits
Peanuts 1015 (74.5) 61 (4.5) 287 (21.1) 198 (77.3) 11 (4.3) 47 (18.4) 817 (73.8) 50 (4.5) 240 (21.7) 0.525
Pistachios 982 (72.0) 89 (6.5) 292 (21.4) 191 (74.6) 19 (7.4) 46 (18.0) 791 (71.5) 70 (6.3) 246 (22.2) 0.257
almonds 854 (62.7) 147 (10.8) 362 (26.6) 160 (62.5) 31 (12.1) 65 (25.4) 694 (62.7) 116 (10.5) 297 (26.8) 0.729
Walnuts 678 (49.7) 246 (18.0) 439 (32.2) 123 (48.0) 42 (16.4) 91 (35.5) 555 (50.1) 204 (18.4) 348 (31.4) 0.503
Dried Pineapple 627 (46.0) 237 (17.4) 499 (36.6) 125 (48.8) 38 (14.8) 93 (36.3) 502 (45.3) 199 (18.0) 406 (36.7) 0.459
Dried Dates 595 (43.7) 450 (33.0) 318 (23.3) 124 (48.4) 71 (27.7) 61 (23.8) 471 (42.5) 379 (34.2) 257 (23.2) 0.096
Hazelnut 581 (42.6) 288 (21.1) 494 (36.2) 125 (48.8) 49 (19.1) 82 (32.0) 456 (41.2) 239 (21.6) 412 (37.2) 0.069
Raisin 573 (42.0) 313 (23.0) 477 (35.0) 129 (50.4) 42 (16.4) 85 (33.2) 444 (40.1) 271 (24.5) 392 (35.4) 0.005
 10Nutrients 2019, 11, x FOR PEER REVIEW 10 of 23

Dried Figs 539 (39.5) 381 (28.0) 443 (32.5) 122 (47.7) 52 (20.3) 82 (32.0) 417 (37.7) 329 (29.7) 361 (32.6) 0.001
apricot 433 (31.7) 434 (31.9) 496 (36.4) 97 (37.9) 66 (25.8) 93 (36.3) 336 (30.4) 368 (33.2) 403 (36.4) 0.031
Shea seeds 241 (17.7) 738 (54.1) 384 (28.2) 49 (19.1) 145 (56.6) 62 (24.2) 192 (17.3) 593 (53.6) 322 (29.1) 0.193
Legumes
Fava beans 936 (68.7) 122 (9.0) 305 (22.4) 187 (73.0) 24 (9.4) 45 (17.6) 749 (67.7) 98 (8.9) 260 (23.5) 0.110
Oats 905 (66.4) 121 (8.9) 337 (24.7) 150 (58.6) 37 (14.5) 69 (27.0) 755 (68.2) 84 (7.6) 268 (24.2) 0.001
Yellow lentils 868 (63.7) 147 (10.8) 348 (25.5) 157 (61.3) 32 (12.5) 67 (26.2) 711 (64.2) 115 (10.4) 281 (25.4) 0.495
chickpeas 867 (63.6) 130 (9.5) 366 (26.9) 185 (72.3) 19 (7.4) 52 (20.3) 682 (61.6) 111 (10.0) 314 (28.4) 0.009
Green Beans 690 (50.6) 261 (19.1) 412 (30.2) 131 (51.2) 37 (14.5) 88 (34.4) 559 (50.5) 224 (20.2) 324 (29.3) 0.074
White Beans 380 (27.9) 464 (34.0) 519 (38.1) 90 (35.2) 59 (23.0) 107 (41.8) 290 (26.2) 405 (36.6) 412 (37.2) <0.001
Libya beans 354 (26.0) 496 (36.4) 513 (37.6) 80 (31.3) 73 (28.5) 103 (40.2) 274 (24.8) 423 (38.2) 410 (37.0) 0.004
185Note: Data represented as N (%). p-value <0.05 is considered significant.
 11Nutrients 2019, 11, x FOR PEER REVIEW 9 of 23

1863.3. Knowledge about dietary fibers in study participants:

187 Table 3 presents the knowledge of the study participants about dietary fibers
188and their health effects, and preference of using foods high in dietary fibers while
189eating out. The study participants seems to be well aware of role of dietary fibers in
190prevention of obesity (84.3%) and cardiovascular diseases (70.5%), however, they
191seem to be less aware of the role of dietary fiber intake in flatulence (21%) and
192constipation (16.4%). 59.4% of the study participants were aware of the daily
193requirement of dietary fibers. 78.8% (N=1074) study participants said they don’t
194use any dietary fiber supplements. The females responded correctly as compared
195to males with a significantly higher frequency for questions like role of dietary
196fibers in prevention of obesity (86% vs 77%, p<0.01), in prevention of
197cardiovascular diseases (71.9% vs 64.5%, p<0.004), in regulation of blood sugar
198(70.9% vs 60.5%, p<0.002), in prevention of bowel cancer (65.4% vs 55.5%, p<0.01).
199 47.8% (N=652) of the study participants preferred eating out or consuming fast
200food which was comparable in both males and females. While eating out or having
201fast foods, they preferred to have white bread (84.4%), potato (69.9%) and peeled
202fruits (60.6%) as against brown bread (18.1%) and cooked vegetables (29.6%). There
203seems to be significant difference in the preference of having brown bread (30.5%
204vs 15.2%, p<0.001) in for males; and the preference of having white bread (85.4%
205vs. 80.5%, p=0.011) in for females while eating out/ having fast foods.
 12Nutrients 2019, 11, x FOR PEER REVIEW 9 of 23

206 Table 3. Knowledge about dietary fibers in study participants

All (N=1363) Males (N=256) Females (N=1107) p
Yes No Yes No Yes No
Knowledge about dietary fibers (DF)
DF and prevention of obesity 1148 (84.3) 214 (15.7) 197 (77.0) 59 (23.0) 951 (86.0) 155 (14.0) <0.001
DF and cardiovascular diseases 960 (70.5) 402 (29.5) 165 (64.5) 91 (35.5) 795 (71.9) 311 (28.1) 0.004
DF and regulation of blood sugar 939 (68.9) 423 (31.1) 155 (60.5) 101 (39.5) 784 (70.9) 322 (29.1) 0.002
DF and Reduction of blood cholesterol 895 (65.7) 467 (34.3) 159 (62.1) 97 (37.9) 736 (66.5) 370 (33.4) 0.293
DF and Prevention of bowel cancer 865 (63.5) 497 (36.5) 142 (55.5) 114 (44.5) 723 (65.4) 383 (34.6) <0.001
DF and Flatulence 286 (21.0) 1076 (78.9) 57 (22.3) 199 (77.7) 229 (20.7) 877 (79.2) 0.516
DF and Constipation 223 (16.4) 1139 (83.6) 52 (20.3) 204 (79.9) 171 (15.5) 935 (84.5) 0.020
Too much DF and health 183 (13.4) 1179 (86.5) 42 (16.4) 214 (83.6) 141 (12.7) 965 (87.2) 0.058
DF daily intake requirement
5-10 g/day 151 (11.0) 27 (10.7) 124 (11.2)
11-24 g/day 402 (29.6) - 59 (23.0) - 343 (31.0) - 0.060
25-38 g/day 810 (59.4) 170 (66.3) 640 (57.8)
Intake of fiber supplements 288 (21.1) 1074 (78.8) 61 (23.8) 195 (76.2) 227 (20.5) 879 (79.4) <0.001
Preference of dietary fiber intake in fast foods/eating out
Regularly taking fast foods/ eating out 652 (47.8) 711 (52.2) 115 (44.9) 141(55.1) 536 (48.5) 570 (51.5) 0.552
Use of white bread in fast foods / eating out 1150 (84.4) 212 (15.6) 206 (80.5) 50 (19.5) 944 (85.4) 162 (14.6) 0.011
Use of fried potato in fast foods / eating out 952 (69.9) 410 (30.1) 177 (69.1) 79 (30.9) 775 (70.1) 331 (29.9) 0.09
Use of peeled fruits in fast foods/ eating out 825 (60.6) 538 (39.4) 142 (55.5) 114 (44.5) 683 (61.7) 423 (38.2) 0.001
Use of legumes in fast foods / eating out 598 (43.8) 765 (56.1) 130 (50.8) 126 (49.2) 467 (42.2) 639 (57.8) 0.012
Use of cooked vegetables in fast foods/ eating out 404 (29.6) 959 (70.4) 92 (35.9) 164 (64.1) 311 (28.1) 795 (71.9) 0.005
13Nutrients 2019, 11, x FOR PEER REVIEW 10 of 23

Use of brown bread in fast foods/ eating out 246 (18.1) 1117 (81.9) 78 (30.5) 178 (69.5) 168 (15.2) 938 (84.8) <0.001
 14Nutrients 2019, 11, x FOR PEER REVIEW 9 of 23

2073.4. Reasons for the lack of dietary fibers in the diet:

208 Table 4 shows the reasons as reported by the study participants for the lack of
209dietary fiber in their diet. The four most important reasons that the study
210participants cited in order of highest to lowest prevalence was that they thought
211foods rich in dietary fibers were expensive (72.1%); that foods rich in dietary fibers
212have no beneficial health values (56.5%); that they do not like the taste of foods rich
213in dietary fibers (52.8%); and they thought foods rich in dietary fibers are not easily
214available (51.6%). Percentages of females are significantly high in not knowing the
215availability of foods rich in fiber (54.1% vs 40.5%, p<0.01) and if food rich in fiber is
216beneficial to their health (58.2% vs 49.2%, p=0.02) than males. The acceptance of
217taste of food rich in fiber is significantly high in for females as compared to males
218(38.8% vs 30.1%, p=0.04).
 15Nutrients 2019, 11, x FOR PEER REVIEW 10 of 23

219 Table 4: Reasons for the lack of dietary fibers in the diet
220
All (N=1363) Male (N=256) Female (N=1107) p

Yes No Don’t Know Yes No Don’t Know Yes No Don’t Know

Food rich in DF’s are
983 (72.1) 215 (15.8) 165 (12.1) 169 (66.1) 48 (18.6) 39 (15.3) 814 (73.5) 167 (15.1) 126 (11.4) 0.07
expensive
There is no beneficial effect in
consuming fiber rich food to 770 (56.5) 478 (35.1) 115 (8.4) 126 (49.2) 95 (37.2) 35 (13.6) 644 (58.2) 383 (34.6) 80 (7.2) 0.02
my health
I do not like fiber rich food
720 (52.8) 507 (37.2) 136 (10.0) 149 (58.1) 77 (30.1) 30 (11.9) 571 (51.6) 430 (38.8) 106 (9.6) 0.04
taste
Foods rich in DF’s are easily
703 (51.6) 478 (35.1) 180 (13.2) 104 (40.5) 104 (40.5) 48 (19.0) 601 (54.1) 374 (33.9) 132 (11.9) <0.01
not available

221Note: Data represented as N (%). DF is dietary fiber. p-value <0.05 is considered significant.
 16Nutrients 2019, 11, x FOR PEER REVIEW 9 of 23

2223.5. Health status of the study participants:

223 Table 5 provides an insight into the existing health status of the study
224participants. The most common of the diseases in the study participants (listed in
225the Questionnaire) were constipation (28.9%), high cholesterol (14.6%) and obesity
226(14.4); and the least common were cancer (1.2%), and cardiovascular disease
227(1.9%). A significantly higher percentage of males exhibited conditions such as
228diabetes (13.7% vs 8.5%, p<0.011), hypertension (15.2% vs 8.5%, p<0.001), and high
229cholesterol (21.5% vs 13%, p<0.001) as compared to females. On the other hand,
230females showed a higher frequency in diseases such as constipation (30.1% vs
23123.6%, p<0.04), and osteoporosis (14.1% vs 5.3%, p<0.001) as compared to their
232male counterparts.
233
234 Table 5: Health status of the study participants
Parameters All (N=1363) Male (N=256) Female (N=1107) p

394 (28.9) 60 (23.6) 334 (30.1) 0.040

Constipation
199 (14.6) 55 (21.5) 144 (13.0) 0.001
High Cholesterol
196 (14.4) 33 (12.9) 163 (14.8) 0.444
Obesity
169 (12.4) 13 (5.3) 156 (14.1) <0.001
Osteoporosis
134 (9.8) 39 (15.2) 95 (8.5) 0.001
Hypertension
130 (9.5) 35 (13.7) 95 (8.5) 0.011
Diabetes
38 (2.8) 7 (2.7) 31 (2.7) 0.938
Celiac diseases
26 (1.9) 7 (2.7) 19 (1.7) 0.291
Cardiovascular diseases
16 (1.2) 2 (0.08) 14 (1.3) 0.512
Cancer

235Note: Data represented as N (%).p-value <0.05 is considered significant.

2364. Discussion
237 The present survey-methodology based study highlighted the level of
238knowledge and awareness about the consumption and health importance; and
239frequency and preference of using foods rich in dietary fibers among Saudi
240population. This study reveals a discrepancy between the level of knowledge on
241the importance of dietary fibers in a balanced healthy diet and the food choices of
242the study participants especially while eating out. The study also enlists the
243reasons for shying away from adding dietary fibers in the regular diet in a Saudi
244population.
245 Health benefits like reduced risk of obesity, type 2 diabetes etc. could be
246derived by consuming recommended amount of dietary fibers in our diet [4,5]. A
247fiber intake of at least 25 g/day was recommended by World Health Organization
 17Nutrients 2019, 11, x FOR PEER REVIEW 10 of 23

248(WHO) [3] which may vary slightly based on different populations. However, the
249average daily intake of less than 10 g/day of dietary fibers in a regular Saudi diet
250was reported by our recent study [22] and is very low as compared to the
251recommended levels which compromises the health benefits of a balanced high
252fiber diet. Dietary fiber amount and composition differs in different food types
253where cereals comprise major source of dietary fibers [25]. As per our study,
254among cereals wheat and maize are commonly consumed while millet and Quinoa
255were least consumed. Wheat is an important ingredient in the Saudi diet which is
256mostly consumed in the form of flat bread, local hamburger (Samoli), pizza etc. In
257our study, 47.8 % (N=652) of the study participants responded that they preferred
258eating out regularly, 84.4 % (N=1150) preferred having white bread instead of
259brown bread (18.1%, N=246) while eating out. Vegetables and fruits are the second
260important source of dietary fibers and in this study we revealed that respondents
261preferred fried potatoes and peeled fruits instead of cooked vegetables and fruits
262with peels.
263 A recent study exhibited gender difference regarding health and immune
264function based on dietary intake of fiber. The same study also showed a
265significantly high consumption of cereals and grain products in for males as
266compared to females [26]. These findings corroborate our present study showing
267the same consumption pattern. Our present study demonstrated a high frequency
268of consuming cooked vegetables in for females as compared to males. Natalie and
269colleagues also demonstrated that females are likely more consistent in consuming
270recommended amount of fruit and vegetables as compared to males [27].
271Moreover, this trend was strongly supported by studies showing the increased
272participation of females in family food and maintaining their self-image and
273appearance [28,29]. Also, in the present study, the consumption of fruit juice, fresh
274peeled fruits, and cereals were higher in for males as compared to females. Our
275result is supported by a study performed by Bagordo and colleagues, showing
276bread, fresh fruit and raw vegetables as the most frequently-consumed foods
277among males as compared to females [30].
278 Knowledge about nutrition and its effects is vital for healthy life behaviour and
279a great determinant for healthy food choices [31]. In our study, the respondents
280had a fair knowledge about the benefits of foods rich in dietary fibers on the
281prevention of metabolic diseases like obesity (84.3%), cardiovascular diseases
282(70.5%) and regulation of blood sugars (68.9%); however, there was a discrepancy
283in its translation to healthy food choices especially while eating out. N=1150
284(84.4%) of the respondents preferred having white bread instead of the whole
285bread (18.1%, N=246) while eating out. This is in contrast with some studies where
286nutrition knowledge was found to be correlated with the actual food choices
287[32,33] while it may in line with some other studies where the food choices was
288seen as not only dependant on the nutrition knowledge but also to some greater
289external factors like sensory evaluation, packaging, labelling, consumer
290perceptions etc. [34,35]. In this study also, the most common reasons for shying
 18Nutrients 2019, 11, x FOR PEER REVIEW 11 of 23

291away from the foods rich in dietary fibers that the respondents cited was their
292perception that they are expensive (72.1%), have no beneficial health effect (56.5%)
293and are not easily available (51.6%); and the reason that they don’t like the taste of
294foods rich in dietary fibers (52.8%). Unfortunately, even though there is a greater
295dissemination of knowledge on healthy food choices through advertisements, print
296media, internet etc.; there seems to be a great conflict of health and taste motives in
297the food choices [36]. Consumers often feel dilemma in their food choices within
298healthy and tasty options where on conscious cognitive level and based on their
299nutrition knowledge they demand healthy food but give up and chose less healthy
300option on a sensory level. A new methodical approach should be devised that
301combines both perspectives of imparting knowledge to overcome such consumer
302perceptions related to healthy=expensive=not easily available food choices; and at
303the same time working on the ways to replace low fibrous ingredients by high
304fibrous ones without compromising much into the sensory aspect.
305 In our research, statistically significant differences were reported on the level
306of nutrition knowledge related to dietary fibers and health in different sexes.
307Females seem to be more aware of the relation between dietary fiber consumption
308and prevention of metabolic diseases like obesity, type 2 diabetes and overall
309health status (table 3). This is in line with studies like one by Tarcea et al. [19]
310which demonstrated significantly more females than males responding correctly
311for favorable role of fiber in cardiovascular safety, regulating blood sugar,
312reducing risk for obesity etc. Although our present study showed slightly low
313frequency of higher education level in for females (post graduate) as compared to
314males, it supports the above mentioned studies showing a higher knowledge
315among females about fiber and its health effects which may mainly be attributed to
316greater involvement of females in food choice for their family [28] and a greater
317care to their own appearance [29]. Also, females in the present study though aware
318and had responded correctly about favorable role of dietary fibers in health, they
319report significant high rate of health conditions like constipation than do men. The
320reason behind this pattern encompasses many factors that may overcome the effect
321of knowledge. In USA, females are 2.2 times more likely to report constipation than
322males [37] due to hormonal factors, under the effect of progesterone, and damage
323to the pelvic floor muscles. Such studies corroborate our present finding that in
324spite of sufficient knowledge and education about role of dietary fibers in health,
325the females exhibits more constipation as compared to males.
326 The major significant health problems among our respondents were
327constipation, high cholesterol, obesity and osteoporosis which are linked to the low
328intake of dietary fibers in a regular diet. The majority of male respondents in our
329present study were uncertain about the favorable role of dietary fiber in obesity,
330reduction in blood sugar, hypertension, and high cholesterol level than the female
331counterparts. The lack of knowledge among male participants about these
332diabetes-specific risk factors may be associated with their significantly high
333unhealthy status as such as diabetes, hypertension, and high cholesterol as
 19Nutrients 2019, 11, x FOR PEER REVIEW 12 of 23

334compared to females. Recent studies in Arabian Gulf states have reported a rapid
335increase in type 2 diabetes mellitus and obesity in adults among the Saudi
336population. The prevalence of diabetes increased from 10.6% in 1989 to 32.1% in
3372009 with a faster rate among Saudi men than women [38] . The increasing trends
338of these diseases have been mainly attributed to unhealthy diet and lifestyle
339behaviour. Moreover, in our study, females reported a significantly higher rate of
340osteoporosis as compared to males which is in accordance with an epidemiological
341analysis on 24 studies, where 34% and 30.7% of healthy Saudi women and men
342respectively aged 50-79 years were osteoporotic [39].
343 The study has some limitations which the authors acknowledge here. This
344study was not designed to collect the dietary recall data and hence the actual
345average consumption of dietary fibers per day was not calculated. However, the
346reference of another of our published studies where less than10g/day of dietary
347fibers was reported was utilized to propose low intake of dietary fibers in a general
348Saudi diet. Also, the sociodemographic characteristics of the respondents should
349be looked at while interpreting the results of this study. Most of our respondents
350(87.2%) were aged more than 25 and hence could barely be a representative of the
351Saudi children and adolescents. A separate study on the dietary preferences and
352knowledge of dietary fibers in relation to health in Saudi children and adolescents
353may add more insight into the observations noted in this study. Also, a major
354representation of our respondents were educated at least up to the secondary level
355(96.6%) and were from families with at least average monthly income of 5000 Saudi
356Riyals (80.8%) and may not necessarily represent the illiterate Saudi population
357and ones who come from low income family.

3585. Conclusions
359 The present study observes a discrepancy between knowledge and
360consumption of dietary fiber in Saudi adultsThe participants exhibited low
361frequency of daily dietary fiber intake even though with a fair awareness and
362knowledge of role of dietary fibers in health. Nutritional education focusing on
363changing the perception towards foods rich in dietary fibers should be considered
364as a preferred choice to disseminate dietary fiber intake information to improve
365healthy lifestyle. Finally, more intervention studies in Saudi society should be
366devised to impart knowledge on the emotional, cognitive and sensory factors
367related to food choices so that a gap between nutrition knowledge and
368consumption of healthy high fiber diet is minimized.
369Author Contributions: HAA and NMA contributed to the study design. Subject selection and data collection
370were performed by HA .Manuscript draft preparation was done by NK, KW and HAA. Statistical analysis of
371the data was done by MK. Data interpretation was done by NK, KW and HAA. Manuscript was reviewed by
372HAA, MA, SAG and NMA. All authors (HAA, NK, KW, HA, MA, MK, SAG and NMA,) have read and
373approved the final manuscript.
374Acknowledgments: This work was supported by the Deanship of Scientific Research, Chair for Biomarkers of
375Chronic Diseases (CBCD), King Saud University (KSU), Riyadh, Saudi Arabia.
 20Nutrients 2019, 11, x FOR PEER REVIEW 13 of 23

376Conflicts of Interest: The authors declare that they have no competing interests.The funders had no role in the
377design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript, or in
378the decision to publish the results.
379
380
381References
382 1. Committee, A.A.o.C.C.F. The definition of dietary fiber: Report of the dietary fiber definition
383 committee to the board of directors of the american association of cereal chemists. Cereal Foods World
384 2001, 46, 112-126.
385 2. Dhingra, D.; Michael, M.; Rajput, H.; Patil, R. Dietary fibre in foods: A review. Journal of food
386 science and technology 2012, 49, 255-266.
387 3. Stephen, A.M.; Champ, M.M.-J.; Cloran, S.J.; Fleith, M.; Van Lieshout, L.; Mejborn, H.; Burley,
388 V.J. Dietary fibre in europe: Current state of knowledge on definitions, sources, recommendations,
389 intakes and relationships to health. Nutrition research reviews 2017, 30, 149-190.
390 4. Buttriss, J.; Stokes, C. Dietary fibre and health: An overview. Nutrition Bulletin 2008, 33, 186-
391 200.
392 5. Lie, L.; Brown, L.; Forrester, T.; Plange-Rhule, J.; Bovet, P.; Lambert, E.; Layden, B.; Luke, A.;
393 Dugas, L. The association of dietary fiber intake with cardiometabolic risk in four countries across the
394 epidemiologic transition. Nutrients 2018, 10, 628.
395 6. Whelton, S.P.; Hyre, A.D.; Pedersen, B.; Yi, Y.; Whelton, P.K.; He, J. Effect of dietary fiber intake
396 on blood pressure: A meta-analysis of randomized, controlled clinical trials. LWW: 2005.
397 7. Naumann, S.; Schweiggert-Weisz, U.; Eglmeier, J.; Haller, D.; Eisner, P. In vitro interactions of
398 dietary fibre enriched food ingredients with primary and secondary bile acids. Nutrients 2019, 11,
399 1424.
400 8. Weickert, M.O.; Möhlig, M.; Schöfl, C.; Arafat, A.M.; Otto, B.; Viehoff, H.; Koebnick, C.; Kohl,
401 A.; Spranger, J.; Pfeiffer, A.F. Cereal fiber improves whole-body insulin sensitivity in overweight and
402 obese women. Diabetes care 2006, 29, 775-780.
403 9. Tucker, L. Fiber intake and insulin resistance in 6374 adults: The role of abdominal obesity.
404 Nutrients 2018, 10, 237.
405 10. Petruzziello, L.; Iacopini, F.; Bulajic, M.; Shah, S.; Costamagna, G. Uncomplicated diverticular
406 disease of the colon. Alimentary pharmacology & therapeutics 2006, 23, 1379-1391.
407 11. Foley, A.; Burgell, R.; Barrett, J.S.; Gibson, P.R. Management strategies for abdominal bloating
408 and distension. Gastroenterology & hepatology 2014, 10, 561.
409 12. Fleming, D.J.; Tucker, K.L.; Jacques, P.F.; Dallal, G.E.; Wilson, P.W.; Wood, R.J. Dietary factors
410 associated with the risk of high iron stores in the elderly framingham heart study cohort. The
411 American journal of clinical nutrition 2002, 76, 1375-1384.
412 13. Murphy, N.; Norat, T.; Ferrari, P.; Jenab, M.; Bueno-de-Mesquita, B.; Skeie, G.; Dahm, C.C.;
413 Overvad, K.; Olsen, A.; Tjønneland, A. Dietary fibre intake and risks of cancers of the colon and
414 rectum in the european prospective investigation into cancer and nutrition (epic). PLoS One 2012, 7,
415 e39361.
416 14. Trumbo, P.; Schlicker, S.; Yates, A.A.; Poos, M. Dietary reference intakes for energy,
417 carbohdrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. Journal of the Academy of
418 Nutrition and Dietetics 2002, 102, 1621.
419 15. Adams, J.; Engstrom, A. Dietary intake of whole grain vs. Recommendations. Cereal Foods
420 World 2000.
421 16. Thane, C.; Jones, A.; Stephen, A.; Seal, C.; Jebb, S. Whole-grain intake of british young people
422 aged 4–18 years. British Journal of Nutrition 2005, 94, 825-831.
423 17. Ahmed, M.T.; Rahman, S.S.; Islam, M.S.; Rana, A.M.M.; Rahman, M.H. A comparative study of
424 dietary fiber awareness, diseases & drugs interaction in rural and urban areas of bangladesh. Science
425 2013, 1, 194-200.
426 18. Ljubicic, M.; Saric, M.M.; Rumbak, I.; Baric, I.C.; Komes, D.; Satalic, Z.; Guiné, R.P. Knowledge
427 about dietary fibre and its health benefits: A cross-sectional survey of 2536 residents from across
428 croatia. Medical hypotheses 2017, 105, 25-31.
 21Nutrients 2019, 11, x FOR PEER REVIEW 14 of 23

429 19. Tarcea, M.; Fazakas, Z.; Ruta, F.; Rus, V.; Zugravu, C.; Guiné, R. Romanian knowledge and
430 attitudes regarding dietary fibers. Bulletin of the University of Agricultural Sciences and Veterinary
431 Medicine Cluj-Napoca Food Science and Technology 2016, 73, 123-128.
432 20. DeNicola, E.; Aburizaiza, O.S.; Siddique, A.; Khwaja, H.; Carpenter, D.O. Obesity and public
433 health in the kingdom of saudi arabia. Reviews on environmental health 2015, 30, 191-205.
434 21. Al-Hazzaa, H.M. Physical inactivity in saudi arabia revisited: A systematic review of inactivity
435 prevalence and perceived barriers to active living. International journal of health sciences 2018, 12, 50.
436 22. Alfawaz, H.; Naeef, A.F.; Wani, K.; Khattak, M.N.K.; Sabico, S.; Alnaami, A.M.; Al-Daghri,
437 N.M. Improvements in glycemic, micronutrient, and mineral indices in arab adults with pre-diabetes
438 post-lifestyle modification program. Nutrients 2019, 11, 2775.
439 23. Al-Nuaim, A.A.; Al-Nakeeb, Y.; Lyons, M.; Al-Hazzaa, H.M.; Nevill, A.; Collins, P.; Duncan,
440 M.J. The prevalence of physical activity and sedentary behaviours relative to obesity among
441 adolescents from al-ahsa, saudi arabia: Rural versus urban variations. Journal of nutrition and
442 metabolism 2012, 2012.
443 24. Al-Daghri, N.; Khan, N.; Alkharfy, K.; Al-Attas, O.; Alokail, M.; Alfawaz, H.; Alothman, A.;
444 Vanhoutte, P. Selected dietary nutrients and the prevalence of metabolic syndrome in adult males and
445 females in saudi arabia: A pilot study. Nutrients 2013, 5, 4587-4604.
446 25. He, M.; van Dam, R.M.; Rimm, E.; Hu, F.B.; Qi, L. Whole grain, cereal fiber, bran, and germ
447 intake and the risks of all-cause and cvd-specific mortality among women with type 2 diabetes.
448 Circulation 2010, 121, 2162.
449 26. Fernstrand, A.M.; Bury, D.; Garssen, J.; Verster, J.C. Dietary intake of fibers: Differential effects
450 in men and women on perceived general health and immune functioning. Food & nutrition research
451 2017, 61, 1297053.
452 27. Riediger, N.D.; Moghadasian, M.H. Patterns of fruit and vegetable consumption and the
453 influence of sex, age and socio-demographic factors among canadian elderly. Journal of the American
454 College of Nutrition 2008, 27, 306-313.
455 28. Vereecken, C.A.; Keukelier, E.; Maes, L. Influence of mother's educational level on food
456 parenting practices and food habits of young children. Appetite 2004, 43, 93-103.
457 29. Wronka, I.; Suliga, E.; Pawlinska-Chmara, R. Perceived and desired body weight among
458 female university students in relation to bmi-based weight status and socio-economic factors. Annals
459 of agricultural and environmental medicine 2013, 20.
460 30. Bagordo, F.; Grassi, T.; Serio, F.; Idolo, A.; De Donno, A. Dietary habits and health among
461 university students living at or away from home in southern italy. Journal of Food & Nutrition Research
462 2013, 52.
463 31. Arvola, A.; Lähteenmäki, L.; Dean, M.; Vassallo, M.; Winkelmann, M.; Claupein, E.; Saba, A.;
464 Shepherd, R. Consumers’ beliefs about whole and refined grain products in the uk, italy and finland.
465 Journal of Cereal Science 2007, 46, 197-206.
466 32. Lin, W.; Yang, H.-C.; Hang, C.-M.; Pan, W.-H. Nutrition knowledge, attitude, and behavior of
467 taiwanese elementary school children. Asia Pacific journal of clinical nutrition 2007, 16, 534-546.
468 33. Barzegari, A.; Ebrahimi, M.; Azizi, M.; Ranjbar, K. A study of nutrition knowledge, attitudes
469 and food habits of college students. World Applied Sciences Journal 2011, 15, 1012-1017.
470 34. Dean, M.; Raats, M.; Shepherd, R.; Arvola, A.; Vassallo, M.; Winkelmann, M.; Saba, A.;
471 Claupein, E.; Lähteenmäki, L. Consumer perceptions and expectations for healthy cereal products. J.
472 Cereal Sci 2007, 46, 188-196.
473 35. Hoppert, K.; Mai, R.; Zahn, S.; Hoffmann, S.; Rohm, H. Integrating sensory evaluation in
474 adaptive conjoint analysis to elaborate the conflicting influence of intrinsic and extrinsic attributes on
475 food choice. Appetite 2012, 59, 949-955.
476 36. Raghunathan, R.; Naylor, R.W.; Hoyer, W.D. The unhealthy= tasty intuition and its effects on
477 taste inferences, enjoyment, and choice of food products. Journal of Marketing 2006, 70, 170-184.
478 37. Higgins, P.D.; Johanson, J.F. Epidemiology of constipation in north america: A systematic
479 review. The American journal of gastroenterology 2004, 99, 750.
480 38. Alharbi, N.S.; Almutari, R.; Jones, S.; Al-Daghri, N.; Khunti, K.; de Lusignan, S. Trends in the
481 prevalence of type 2 diabetes mellitus and obesity in the arabian gulf states: Systematic review and
482 meta-analysis. Diabetes research and clinical practice 2014, 106, e30-e33.
483 39. Sadat-Ali, M.; Al-Habdan, I.M.; Al-Turki, H.A.; Azam, M.Q. An epidemiological analysis of the
484 incidence of osteoporosis and osteoporosis-related fractures among the saudi arabian population.
485 Annals of Saudi medicine 2012, 32, 637-641.
 22Nutrients 2019, 11, x FOR PEER REVIEW 15 of 23

486
2. © 2019 by the authors. Submitted for possible open access
1. publication under the terms and conditions of the Creative
Commons Attribution (CC BY) license
(http://creativecommons.org/licenses/by/4.0/).
487