Georgescu Ion Mihai  ( Department of Community Nutrition and Food Hygiene, University of Medicine and Pharmacy Tirgu Mures, Romania )
Rus Victoria Ancuta  ( Department of Community Nutrition and Food Hygiene, University of Medicine and Pharmacy Tirgu Mures, Romania )
Tarcea Monica  ( Department of Community Nutrition and Food Hygiene, University of Medicine and Pharmacy Tirgu Mures, Romania )
Ruta Florina  ( Department of Community Nutrition and Food Hygiene, University of Medicine and Pharmacy Tirgu Mures, Romania )
Fazakas Zita  ( Department of Biochemistry, University of Medicine and Pharmacy Tirgu Mures, Romania )
Guine Raquel  ( Department of Food Industry, Agrarian School, Polytechnic Institute of Viseu, Portugal )
Serban Costela  ( Department of Informatics and Biostatistics, University of Medicine and Pharmacy, Victor Babes, Timisoara, Romania )
Iacob Oana  ( Department of Molecular Biology, University of Medicine and Pharmacy Tirgu Mures, Romania )
Frigy Atilla  ( Cardiology Clinic, Mures County Hospital, Romania )

Objective: To investigate the perceived importance of information about dietary fibre with regard top opulation socio - demographic characteristics and consumption patterns .
Methods: The cross-sectional study was conducted from September to November, 2016, in six different counties and 57 cities across Romania, and was part of a larger project that had nine other countries as well. Data of the Romanian subjects was collected using a validated questionnaire that was disseminated across the 10 countries at the same time. Knowledge about dietary fibre was explored through 10 questions, and the respondents were asked to answer on a 5-point Likert scale varying from 1 (totally disagree) to 5 (totally agree). SPSS 22 was used for data anaylsis.
Results: Of the 670 subjects, 358 (53.4%) were females, and the overall mean age was 35.81±15.61 years (range: 18-89 years). There were 298 (44.5%) subjects with a university degree, 314(46.9%) had completed high school and 57 (8.5%) had done primary school. Besides, 568 (84.8%) participants lived in an urban environment. Internet was the main source of getting information for 368(54.9%) subjects, while the lowest was hospitals 122 (18.2%). The percentage of correct answers regarding knowledge about health effects of dietary fibre was 23.12%. Most accurate answers were related to deficiency of vitamins and minerals 370 (55.5%), breast cancer 202(30.3%), vision problems 202(30.3%) and diabetes 168 (25.2%). The question with least accurate answer was the one about general preventive characteristics of dietary fibres 65 (9.7%).
Conclusions: A proper and friendly way to transmit information about the importance of dietary fibre consumption is critical in promoting healthy diet patterns and in preventing non-transmissible diseases.
Keywords: Dietary fibre, Sources of information, Chronic disease, Internet, Television. (JPMA 69: 985; 2019)

Introduction

For dietary fibre (DF), several standards have been developed depending on country, region or authority. According to the European Food Safety Authority (EFSA), the average fibre intake of 25g per day is adequate for adults.1 The Nordic Councils of Ministers recommends that DF intake should be at least 25-35g/day, or approximately 3g/MJ. 2 In Romania, an intake of 25-30g fibre per day is recommended as part of a healthy diet. 3 Against these recommended values, average intake for adult males in Europe has been 18-24 g/day and for females 16-20 g/day. 4 Chronic diseases, such as cardiovascular disease (CVD), diabetes mellitus (DM) and cancer, are major causes of morbidity and mortality worldwide. In 2013, in Romania, CVD accounted for 59.5% of all deaths; the highest in Europe. 5 The age- and gender-adjusted prevalence of DM is 11.6%.6 Breast cancer is the most common cancer in women. Large bowel cancer is the second most common cancer in men and third in women and the third most common cause of cancer death in Romania after lung and breast cancer. 7  The current study was planned to investigate the perceived importance of information about DF from various sources with regard to socio-demographic characteristics of the population, and the interest and level of knowledge about health effec ts of DF consumption.

Subjects and Methods

The cross-sec tional study was conduc ted from September to November, 2016, in six different counties and 57 cities across Romania, and was part of a larger project that had nine other European countries as well. The timeframe coincided with the season when fruit and vegetable consumption is on the national average compared to the year-long consumption pattern. The study was approved by the ethics committee of the Centro de Estudos em Educação, Tecnologias e Saúde (CI&DETS) Research Centre, Portugal, under whose umbrella the multi-nation study was conducted. Other than Romania, the countries were, in alphabetical order were Argentina, Croatia, Egypt, Hungary, Italy, Latvia, Macedonia, Portugal, and Turkey. The sample for the current study in Romania was raised using convenient sampling technique, and data was collected using a validated questionnaire which was disseminated online. 8,9The questionnaire was designed to access the socio-demographic characteristics of participants, such as age, gender, level of education, their preferences on information sources about DF intake, and the correctness about DF knowledge. Sources of information were evaluated with a 6-point Likert scale. The respondents were asked to classify the different options on a scale from 1 (least important) to 6 (most important), about the questions: "From where do you usually find information about dietary fibre?". The  answering options were: health centres/hospitals, radio, television, school, magazines/books, and internet. For further analysis, options 5 and 6 were classified as important, while the rest were re-coded as not-soimportant. Knowledge of DF effects was measured through 10 questions that needed answers on a 5-point Likert scale varying from 1 (totally disagree) to 5 (totally agree) to indicate their extent of agreement regarding the following statements: "Eating dietary fibres in appropriate amounts can prevent and/or treat diseases", "Fibres can prevent and/or treat cancer", or the same about cardiovascular diseases, obesity, constipation, diabetes, and deficiency of vitamins and minerals. Eight questions were correct with 'agree' options and two questions were considered correct if participants had chosen the 'disagree' option. Participants choosing the 'neither agree nor disagree' option were considered undecided and their answers were counted separately. For each participant, the proportion of correct, incorrect and undecided answers were calculated, and fur ther analysed. For this purpose, a new variable was created, classifying the participants in two categories: those with 50% or more of correct answers regarding DF knowledge, and those with less than 50% correc t answers. Data was analysed using SPSS 22. The level of significance considered was 5%, except in situations where Bonferroni correction was applied and the level of significance was set at 0.016. For comparisons of ordinal variables, Mann- Whitney and Kruskal-Wallis tests were applied. Chisquared tests were used in tables with nominal/ordinal variables. Direct logistic regression was applied for testing relations between individual sources of information considered important and the knowledge level greater than or equal to 50%.

Results

Of the 6010 subjects in the larger project, there were 847(14%) in Argentina, 2530(42%) in Croatia, 281(4.6%) in Egypt, 296(5%) in Hungary, 312(5.2%) in Italy, 180(3%) in Latvia, 312(5.2%) in Macedonia, 382(6.3%) in Portugal, 200(3.3%) in Turkey and 670(11.2%) in Romania. Of the 670 subjects in the current study, 358(53.4%) were females, and the overall mean age was 35.81±15.61 years (range: 18-89 years). There were 298(44.5%) subjects with a university degree, 314(46.9%) had completed high school and 57(8.5%) had done primary school. Besides, 568(84.8%) participants lived in an urban environment. The most frequent knowledge source was internet 368 (54.9%), followed by television 258 (38.5%), magazines 252 (37. 6%) and radio 204 (30.4%) ( Table 1 ).



The proportion of correct answers for the sample was 23.12% (range: 0-80%). Most accurate answers were related to deficiency of vitamins and minerals 370 (55.5%), breast cancer 202 (30.3%), vision problems 202(30.3%) and DM 168 (25.2%). The question with least accurate answer was the one about general preventive characteristics of DF 65 (9.7%) (Table 2).



Higher knowledge was a predictor for television as an important information source on DF's health effects (odds ratio [OR]: 31.94; 95% confidence interval [CI]: 14.238 - 71.650). For participants choosing internet as an important source, the knowledge level was not significantly different from those not depending on the (Table 3).



Discussion

To our knowledge, factors associated with consumption of DF have never been investigated in Romanian population. Using the same questionnaire, Guine at al., showed that regarding the general knowledge about fibres importance for health Romania had the lowest score, after Macedonia, Turkey and Latvia. 8,9 Szucs et al. found in Hungarians profound knowledge on DF health effects, with participants reporting using internet as a trusted information source. ¹⁰ Unlike other studies that were investigating health information-seeking behaviours, which found health professionals, pharmacists and the internet as the most used and trusted sources, 11 in our study, obtaining DF knowledge from health professionals and hospitals and schools was not considered important by most participants. Also, participants who considered internet as the most important source did not have higher knowledge content when compared to those who did not consider it as important. Characteristics of the website, such as design, layout and interactive features, have a positive effect on trust or credibility, whereas advertising has a negative effect. 12 Others have considered the internet communications channel YouTube as containing misleading information and primarily anecdotal, which contradicts the reference standards. The probability of a lay user finding such content is relatively high, but trustworthy and high-quality information can be accessed with the right search terms. 13 Although internet is valuable for those with limited access to health information, individuals vary in approach and search patterns by socioeconomic status. 14 In the current study, the profile of internet users included females, young age, middle-level education, and rural environment. Similar profile was presented in an Italian sample. 15 A study in Germany found that due to social reasons and entertainment, women were more engaged in using the internet as information source compared to men. 16 In our sample, those considering hospitals and schools as important information sources represented 83.7% of the population. Sbaffi et al have also discussed that for seeking health information, older individuals relay mostly on interpersonal relations with physicians, pharmacists, friends, and family compared to web-based information. 12 A meta-analysis that investigated the effects of source. Using radio and magazines as important sources had a negative impact on knowledge quality. In our sample, television was considered an important source of information by less than 40% respondents, but the quality of their knowledge was the highest. The profile of individuals considering television as an important information source was urban males of higher age with middle school education. Reliability on television programmes for healthcare information is associated with good health-related lifestyle. 19 Health-care providers and television have laos been cited as effective tools for health education. 20 Individuals with higher diet knowledge index score, had increased intake of dietary fibre. 21 In a recent review, higher nutrition knowledge was positively but weakly associated with higher intake of fruits and vegetables. 22 A study showed that the average share of animal-source calories have increased from 530 kcal in the early 2000 to over 600 kcal lately, indicating that fruit and vegetable consumption has decreased per capita. 23 There are several interrelated barriers why DF consumption is much lower than recommended. These include lack of knowledge on health benefits of DF, little interest on media compared to other nutrients, and perceived high costs of fruits and vegetables. 24 Although the culture,climate and traditional diets in Asia are different from Europe, there is a shift in eating and disease patterns towards diet-related non-communicable diseases, and this shift is accompanied by changes in behaviour, lifestyle, food sources and physical inactivity. Several studies have  showed a rising of prevalence of diabetes and obesity in the general population and there is a need to highlight the importance of education, proper information and efficient interventions to be made in order to reduce this public health burden. 25-27

Conclusion

Creating awareness regarding the benefits of DF consumption is critical to promoting healthy diet patterns. Health professionals, mass media, including the internet, are key sources of information for the public at large.

Disclaimer: None.

Conflict of Interest: None.
Source of Funding: None.
References

1. European Food Safety Authority. Dietary Reference Values for carbohydrates, dietary fibre, and fat. [Online] 2010 [cited 2017 October 10]. Available from: URL: https://www.efsa.europa.eu/en/press/news/nda090805 
2. Nordic Nutrition Recommendations- Integrating nutrition and physical activity. 5th ed. The Nordic Councils of Ministers; Narayana Press, 2012.
3. Romanian Society of Diabetes, Nutrition and Metabolic Diseases. Reguli pentru o alimenta?ies?n?toas? (Guide for a healthy diet). [Online] 2015 [cited 2017 September 10]. Available from: URL: http://www.fao.org/3/a-as693o.pdf.
4. Stephen AM, Champ MM, Cloran SJ, Fleith M, Lieshout L, Mejborn H, et al. Dietary fibre in Europe: current state of knowledge on definitions, sources, recommendations, intakes and relationships to health. Nutr Res Rev 2017; 5: 1-42.
5. Eurostat. Cardiovascular diseases statistics. [online] [cited 2017 September 2]. Available from: URL: http://ec.europa.eu/eurostat/statisticsexplained/index.php/Cardiovascular_diseases_statistics
6. Mota M, Popa SG, Mota E, Mitrea A, Catrinoiu D, Cheta DM, et al. Prevalence of diabetes mellitus and prediabetes in the adult Romanian population: PREDATORR study. J Diabetes 2016; 8: 336-44.
7. International Agency for Research on Cancer. [Online] [Cited 2017 September 2]. Available from: URL: http://eco.iarc.fr/eucan/Country.aspx?ISOCountryCd=642
8. Guine R, Ferreira M, Correia P, Duarte J, Leal M, Rumbak I, et al. Knowledge about dietary fibre: a fibre study framework. Int J Food Sci Nutr 2016; 67: 707-14.
9. Guine R, Duarte J, Ferreira M, Correia P, Leal M, Rumbak I, et al. Attitudes towards dietary fibre on a multicultural basis: a fibre study framework. Curr Nutr Food Sci 2016; 12: 14-20.
10. Szucs V, Harangozó J, Guiné RP. [Consumer knowledge about dietary fibre: Results of a national questionnaire survey]. Orv Hetil 2016; 157: 302-9.
11. Medlock S, Eslami S, Askari M, Arts DL, Sent D, de Rooji SE, et al. Health Information-Seeking Behavior of Seniors Who Use the Internet: A Sur vey. J Med Internet Res 2015; 17: e10.
12. Sbaffi L, Rowley J. Trust and Credibility in Web-Based Health Information: A Review and Agenda for Future Research. J Med Internet Res 2017; 19: e218.
13. Madathil KC, Rivera-Rodriguez AJ, Greenstein JS, Gramopadhye AK. Healthcare information on YouTube: A systematic review. Health Informatics J 2015; 21: 173-94.
14. Perez SL, Kravitz RL, Bell RA, Chan MS, Paterniti DA. Characterizing internet health information seeking strategies by socioeconomic status: a mixed methods approach. BMC Med Inform Decis Mak 2016; 16: 107.
15. Bianco A, Zucco R, Nobile CG, Pileggi C, Pavia M. Parents Seeking Health-Related Information on the Internet: Cross-Sectional Study.J Med Internet Res 2013; 15: e204.
16. Bidmon S, Terlutter R. Gender Differences in Searching for Health Information on the Internet and the Virtual Patient-Physician Relationship in Germany: Exploratory Results on How Men and Women Differ and Why. J Med Internet Res 2015; 17: e156.
17. Shen F, Han J. Effectiveness of entertainment education in communicating health information: a systematic review. Asian J Commun 2014; 24: 605-16.
18. Quintero Johnson JM, Harrison K, Quick BL. Understanding the Effectiveness of the Entertainment-Education Strategy: An Investigation of How Audience Involvement, Message Processing, and Message Design Influence Health Information Recall. J Health Commun 2013; 18: 160-78.
19. Sejung K, Jeong YJ, Lee J, Jeon TH, Bang I. The Association between Reliability of the Television Programs for Healthcare Information and Health Related Lifestyle above 50 Years Old. Korean J Fam Pract 2016; 6: 489-96.
20. Akhu?Zaheya LM, Jagbir MT, Othman A, Ahram M. Media use for seeking health/cancer?related information: Findings from knowledge, attitudes and practices towards cancer prevention and care survey in Jordan. Int J Nurs Pract 2014; 20: 608-15.
21. Lee CJ, Godwin SL, Tsui J, Kumelachew M, McWhinney SL, Idris R, et al. Association between Diet Knowledge and Quality of Diets in Souther n Rural Elde rl y. J Nutr Elder ly 199 8; 1 7: 5 -7.
22. Spronk I, Kullen C, Burdon C, O'Connor H. Relationship between nutrition knowledge and dietary intake. Br J Nutr 2014; 111: 1-14.
23. Luca L. Changes in food consumption pattern of households in Romania in the period 2004-2011. Bulletin UASVM Horticulture 2013; 70: 344-9.
24. Lockyer S, Spiro A, Stanner S. Dietary fibre and the prevention of chronic disease - should health professionals be doing more to raise awareness? Nutr ition Bulletin 2016; 41: 214 -31.
25. Ulvi OS, Chaudhary RY, Ali T, Alvi R, Khan M, Khan M, et al. Investigating the awareness level about Diabetes Mellitus and associated factors in Tarlai (rural Islamabad). J Pak Med Assoc 2009; 59: 798-801.
26. Rehman R, Zafar A, Mohib A, Hussain M, Ali R. Self-reported academic performance in relation to health behaviours among Bahria University students. J Pak Med Assoc 2018; 68: 195-9.
27. Mehboob B, Safdar NF, Zaheer S. Socio-economic, environmental and demographic determinants of rise in obesity among Pakistani women: A Systematic Review. J Pak Med Assoc 2016; 66: 1165-72.