Consumer attitudes and misperceptions associated with trends in self-reported cereal foods consumption: cross-sectional study of Western Australian adults, 1995 to 2012

Consuming diets high in cereal foods, particularly whole-grains, has been shown to be protective against cardiovascular disease, cancer, Type 2 diabetes, and excess body weight [1‐4]. Countries are encouraged to develop, promote and monitor culturally specific food-based dietary guidelines to promote health and prevent or control non-communicable diseases [5]. Australian Dietary Guidelines (ADG) recommend that adults eat plenty of cereal foods, preferably whole-grain [6‐8]. The Australian Guide to Healthy Eating, the food selection guide, recommended adults eat at least four standard servings, equivalent to about 500 kJ, of cereal foods per day, particularly whole-grains and/or high cereal fibre varieties [8]. Most adults do not adhere to the cereal ADG and there is emerging evidence from national survey data that intake is declining. Only 7 % of 18,226 women from the Australian Longitudinal Study on Women’s Health met the recommendation [9]. The 2011–2012 Australian Health Survey found in adults aged 19 years and older, the mean intake of cereals foods was less than in the 1995 National Nutrition Survey (164 g (g) compared to 215 g) [10, 11].

Although dietary guidelines of most countries recommend whole-grain foods there is no universally accepted definition [12] making country comparisons challenging. Cereals, also known as grain foods [13], include breads, breakfast cereals, grains, and other products. Since 1981, ADGs direct consumers to choose brown or wholegrain varieties over the ‘regular’ or refined versions (for example cereal germ and bran, either as a whole product such as brown rice, or wholemeal products where the whole-grain has been ground into flour such as that in wholemeal pasta), while excluding energy dense refined cereal foods with added sugars, saturated fats or salt [8, 14].

Australian adults consumed on average 83 g of whole-grain foods and 188 g of refined grains in 2011–2012 and need to eat 160% more whole-grains and 30% less refined grains to meet the cereal recommendation [8].

Previous research shows that people consuming whole-grains tend to have healthier lifestyles overall, and eat more fruit and vegetables [(15, 16], less fat [17, 18], and a more nutrient dense diet [16]. They are also more likely to be physically active [17, 19], non-smokers [15, 17, 19], and have a lower body mass index (BMI) [15, 20]. Those who consume whole-grains are more likely to be older [19, 21], from high socio-economic groups [19, 21], more educated [22], and live in cities [22].

Barriers to eating enough cereal foods, particularly whole-grains, include difficulty identifying them, high prices, perceptions of inferior taste compared to refined grains, poor food preparation skills, and lack of awareness of dietary recommendations [23] and their importance [24]. Monitoring the population’s response to dietary recommendations, including the barriers and promoters to consumption including their beliefs and intentions to change [25, 26] is important to inform the development of policy and interventions to encourage healthful eating.

In Australia however, population surveillance of dietary intake is limited and sporadic with the two most recent national dietary surveys conducted seventeen years apart, in 1995 and 2011–2012. The Western Australian (WA) Department of Health conducts state-wide triennial surveys to monitor changes in self-reported knowledge, attitudes, beliefs and behaviours relating to the ADG. The aim of this paper is to explore trends in consumption of cereal foods intention to change and factors associated with intake among Western Australian adults 18 to 64 years.

Sample characteristics of the 7044 adults presented in Table 1 shows the sample characteristics and Table 2 shows consumption patterns. Across all survey years, 78% of respondents said they ate bread and 50% ate breakfast cereal the day prior to the survey. In 2012, 37.2% of respondents ate no whole-grain cereal foods compared with 51.1% in 1995 (p < .001).

The proportion of Western Australian adults consuming cereal foods has decreased over the past two decades. The amount eaten has also decreased, yet most adults were unaware of the recommended intake and believed they were eating enough. In 2012, only 6% were able to identify the correct number of servings for cereals.

Western Australians were more likely to eat bread than any other type of cereal food although the proportion of adults eating bread declined from 88.4% in 1995 to 70.4% in 2012. A similar decline in bread consumption is evident from Australian dietary surveys using 24-h dietary recall methods, from 81% of adults consuming bread in 1995 to 65% in 2011–12 [10, 11]. The amount of bread consumed also decreased from 4.1 slices in 1995 to 2.6 slices in 2012 in the current study, compared to a decline in the national surveys from 2.7 slices (109 g) of regular bread and rolls in 1995 to 2.2 slices (88 g) in 2011/12 [10, 11]. While the proportion consuming bread alternatives (e.g. bread muffins, pita bread, or rice crackers) in the current study remained unchanged, the amount of these types of bread alternatives consumed increased over the two decades.

Cultural similarities and differences in bread consumption are seen when the current study findings are compared to intakes in other countries. Adult bread consumption in the UK declined in the decade preceding 2011 by around 12% [30] to an average of 186 g / day [31], whereas in 2011 98% of the Swedish population ate bread and intake had not changed since 1989 [32]. Despite this, in 1992–1998 the average Swedish bread consumption of 56 g / day was less than the intake from surrounding countries Norway and Denmark (127 g / day and 142 g / day respectively) [33]. Wheat bread intake in the United States (US) in 2003–6 NHANES accounted for 7.2% of energy intake [18], similar to Australian dietary surveys.

The current study found the proportion consuming breakfast cereals remained constant at about 50% with no change in the amount consumed (around two cups among those consuming) over the survey years. Australian dietary surveys also show breakfast cereal consumption has remained constant [10, 11], however, in contrast to the current study, they report increasing prevalence of ready-to-eat cereals (from 26.4% in 1995 to 34.5% in 2012) [10, 11]. The difference in prevalence may be due to different survey methodology including the categorisation of breakfast cereals or seasonality differences. In general, UK and Scandinavian national surveys show a lower mean intake of breakfast cereals compared with Australia, an average of 26 g of breakfast cereals per day among UK adults in 2008–11 [31], and Norway, Sweden and Denmark averaged 21 g per day, while Swedish adults consumed 51 g per day [33].

The findings on cereal food consumption are policy relevant, as the Australian Government uses food consumption information to inform food fortification and regulation policy to address public health nutrition deficiencies and prevent neural-tube defects. This has occurred through mandatory fortification of bread flour with thiamin since the 1970s, and folic acid and iodised salt since 2009 [34]. The current study findings suggest that further research is required to explore the impact of declining bread intake on the effectiveness of these regulatory policies.

The proportion of WA adults consuming whole-grain cereal foods increased in 2009 with health conscious eaters and those with higher educational attainment more likely to eat whole-grain foods. The diet of regular whole-grain consumer is likely to be more nutrient dense diet compared with non-consumers [16, 18]. Given the importance of dietary whole-grains to reducing the population risk of non-communicable diseases [5], it is concerning that there has been little change in intake over twenty years. Although a larger proportion of bread consumers selected whole-grain or wholemeal breads, the decline in prevalence and amount of bread eaten suggest there has been no change in the overall population intake of whole-grain bread. This finding is consistent with Australian manufacturing industry reports of a shift toward whole-grain and seeded varieties of bread [35], despite the ongoing popularity of traditional white bread [36]. Bread and breakfast cereals are the main contributors of whole-grains in the current study and in the US and UK [37]. In the UK bread provides almost half and breakfast cereals about one-third of dietary whole-grains [38]. Population surveys reveal cultural differences in whole-grain food consumption which is typically higher in Scandinavian countries than in many European countries, the US [33] and Australia. Only 7% of adults from Denmark, Sweden and Norway [15] did not consume any foods containing whole-grains compared to 46% in this study, 18% of UK adults [16], 42% of US adults [39] and 68% of French adults [22].

Knowledge of the amount of cereal food recommended for good health was low, only 6% of WA adults knew the recommendation in 2012, with most giving an incorrect amount of less than four servings. Consumer misperceptions, typically perpetuated by the media and celebrity diets, that carbohydrates and cereal foods are fattening [30] or bloating or gastrointestinal discomfort indicative of allergy or food intolerances [30, 40] may contribute to declining intakes. About one in ten Australian adults avoided wheat containing foods due to perceived gastrointestinal discomfort without any formal diagnosis in 2011 [40]. Although coeliac disease affects approximately 1 % of the Australian [40], US [41], and European populations [42] and about 13% of Australian [40] and US [43] adults report self-diagnosed gluten sensitivity, there has been a rapid proliferation of wheat-free and gluten-free food products on supermarket shelves in the last decade or so [44]. Some consumers mistakenly believe that gluten free eating assists with weight loss [41]. Combined with low awareness of health benefits of eating whole-grains, these food avoidance perceptions may be contributing to the declining cereal food intake [24]. Further research is needed to understand the impact of popular or fad food and diet trends on perceptions of and adherence to ADG.

Although dietary cereal intake is less than recommended, in 2012, most WA adults were not thinking about increasing the amount they ate and many believed they already ate enough. The low awareness of the recommended cereal intake and misperceptions of dietary adequacy are barriers to adhering to dietary guidelines.

Cost has also been identified as a barrier to consuming whole-grain foods [24] and whole-grain food consumption is lower among Australian low income households [45]. However, whole-grain cereal foods, for example, rice, pasta and bread are priced equivalent to their refined versions, suggesting an opportunity for practical education to encourage consumption. Other barriers to increasing whole-grain consumption include taste [24, 30], particularly for bread [46], lack of understanding of the health benefits, inability to identify whole-grain foods, poor preparation skills, and the influence of family members, particularly young children [24].

All of these barriers could be addressed through a public education program such as the Danish health promotion campaign to increase whole-grain consumption which increased the average whole-grain intake from 36 g to 63 g per day per 10 MJ between 2008 and 2014 [47]. The multi-strategy Danish campaign included: increasing whole-grain content of commercial food products; mass communication to improve consumers’ knowledge about whole-grain foods and their health benefits; and a certification logo on foods with a high whole-grain content (which also met strict criteria for total sugar, fat, and sodium) [47]. Similarly, following the widespread media attention regarding the 2005 US Dietary Guidelines which included a recommended amount of whole-grains for the first time, sales of whole-grain pasta, bread, rice and flour increased and new and reformulated products increased the availability and sales of all whole-grain foods [48]. Food industry action to improve the availability, accessibility, and affordability of whole-grain cereal foods can work in tandem with public education to increase awareness of the need to eat more and the benefits of eating more cereal foods.

ADG promotion has been very limited in Australia with the exception of the government-led comprehensive multi-strategy Gofor2&5© fruit and vegetable social marketing campaign. Triggered by similar consumer misperceptions regarding adequacy of consumption, Gofor2&5© successfully increased awareness of the need to eat more fruit and vegetables with population increases in consumption [49]. Current findings suggest that a similar strategy for cereal foods, particularly for wholegrains, is warranted. The newly formed Australian Government’s Healthy Food Partnership has the potential to put such a strategy in place as it brings together the public health sector, food industry and government to improve the dietary habits of Australians [50].

A potential limitation of the current study is the cross-sectional self-report dietary intake methodology which restricts assessment of percentage contribution to total energy intake and the potential for social desirability bias. However, the similarity between the current study findings and the 24 food recall national dietary survey results suggest otherwise. A strength is that surveys have been repeated over time so the population prevalence of consumption, mean intake and consumer beliefs and attitudes have been monitored, particularly in the absence of a routine Australian dietary monitoring system. The cultural difference in dietary intakes described previously, suggest that the study findings are likely to be generalizable only in the Australian context, however, the attitudes and barriers may be similar in other countries.

Cereal food consumption by Western Australian adults continues to decrease and whole-grain consumption has not improved, yet there is a common misconception of dietary adequacy and low awareness of the amount that should be eaten for good health. The decline in bread consumption is particularly concerning as bread is the primary vehicle for folate, thiamine and iodine fortification. The WA population would benefit from a health promotion intervention to increase awareness of the importance of cereal foods, in particular breads and whole-grains, and assistance with overcoming practical barriers to incorporating these foods into their diet.