The body of evidence supporting whole grains continues to grow and highlights the significant health benefits of regular consumption and protective effects [1
]. These effects include decreased risk of a range of chronic illnesses such as type 2 diabetes mellitus [2
], cardiovascular disease [2
], certain cancers including colorectal [3
], along with their potential risk factors including obesity [2
], hypertension and elevated fasting glucose, insulin and low-density lipoprotein (LDL) cholesterol levels [5
]. It has been suggested that the health benefits of whole grain consumption may be attributed to the synergistic effects of the bran and germ component of whole grains, as they are rich in micronutrients, dietary fibre and phytochemicals [6
]. However, the complete mechanisms as to how these constituents have such health benefits remains unclear. Results from the National Nutrition and Physical Activity Survey 2011–2012 (NNPAS) indicated that approximately 30% of Australians met recommended grain intake, with one-third (34%) of total grains consumed as whole grains. Whole grains made up 55% of all grains consumed by individuals over 71 years, which was double of those aged 14–18 years (22%) [8
]. Consumption of whole grains was calculated at 21 g/d for adults (19–85 years) [9
], indicating inadequate whole grain consumption. However, this was similar to the level of consumption recorded in the United Kingdom [10
], the United States [11
], Ireland [12
] and Singapore [13
], while other countries, such as France [14
], Italy [15
] and Malaysia [16
] have far lower intakes. Scandinavian countries have recently increased intakes, in particular Denmark, where successful promotion of whole grains, via a public-private partnership, increased consumption from 33 g/day (from 2000 to 2004) to 55 g/day (in 2011–2014) [17
Food Standards Australia New Zealand (FSANZ) define whole grain as the intact grain or the dehulled, ground, milled, cracked or flaked grain, where the constituents—endosperm, germ and bran—are present in such proportions that represent the typical ratio of those fractions occurring in the whole cereal, and includes wholemeal [18
]. With the aim of proposing an international definition, the Whole Grain Initiative has suggested that whole grains shall consist of the intact, ground, cracked, flaked or otherwise processed kernel after the removal of inedible parts such as the hull and husk. All anatomical components, including the endosperm, germ, and bran must be present in the same relative proportions as in the intact kernel [19
]. This definition closely aligns with the Australian definition. Defining whole grain foods is far more problematic and has been described as foods containing ≥51% whole grain by weight per reference amount customarily consumed by the United States Food and Drug Administration [20
], and The Health Grain Forum has proposed that whole grain foods are ≥30% whole grain ingredients on a dry weight basis and contain more whole grain than refined grain ingredients [21
]. Since FSANZ do not regulate claims describing the amount of whole grain in foods, a voluntary Code of Practice for Whole Grain Ingredient Content Claims designed to complement existing food standards and to assist consumers in meeting the 48 g Daily Target Intake (DTI) has been established by the Grains & Legumes Nutrition Council (GLNC). In order to gain an understanding of whole grain, GLNC had conducted attitude and behaviour surveys over a number of years and in 2017 results indicated that fifty percent of Australians were unaware of the definition of whole grain food [22
]. Whole grain foods are commonly identified through the use of food labels, as well as by their appearance and colour. Research conducted outside of Australia has indicated that potential barriers to adequate whole grain consumption relate to taste, lack of understanding of health benefits, family influence, price and availability of whole grains [23
]. Without sufficient knowledge of how to read a label and identify whole grains, consumers may become confused [25
], or incorrectly mistake refined products for whole grain sources (e.g., multigrain bread), thereby unintentionally reducing whole grain intake. Therefore, understanding of consumers’ knowledge of whole grains may provide insight into strategies to increase whole grain consumption. The aim of this study was to conduct an online semi-structured questionnaire to investigate consumers’ knowledge, attitudes and identification of whole grains, incorporating an exploration of factors influencing consumption, promotion and provision.
2. Materials and Methods
A cross-sectional approach used an online survey (SurveyMonkey [26
]) with both open and closed questions. Ethical approval for this study was provided by the University of Wollongong and Illawarra and Shoalhaven Local Health District Health and Medical HREC (Ethics number: 2019/049, Approval date: 26 February 2019). Consumer perspectives were sought from Australians over the age of 18 years, as adults are more likely to be responsible for their own food choices and parental consent was not possible for children. Individuals with formal nutrition qualifications or who were currently involved in nutrition education were excluded through the promotional materials for the survey due to the likelihood that this cohort would have greater knowledge associated with whole grains compared to the general population. Participants were alerted to this study through a combination of convenience, snowballing and purposive recruitment, via word of mouth, as well as advertisement on social media platforms such as Facebook, Twitter and Instagram via a nationwide promotion of the survey link. This study was also advertised in the GLNC newsletter to over 5000 subscribers. An incentive of a $
50 grain food prize pack was offered to encourage participation.
Data were collected from March to May 2019. The survey (Appendix A
) comprised 39 questions and was designed to gain information on general dietary information, consumption of grains, perceived whole grain definition, and, understanding and identification of ‘whole grains’. In addition to this, participants were asked whether they believed whole grains were important in their diet, if they were aware of the recommended daily intake of grains and whole grains, and any health benefits associated with their consumption. Questions associated with food labels and claims, including claims such as high in protein, contains whole grains, high in fibre and low glycaemic index (GI) were also included. The survey utilised multiple choice, check multiple choice box selection, rank and scale, a 3-point scale ranging from ‘never to frequently’, a 5-point scale ranging from ‘strongly agree to strongly disagree’, and free-text responses. Recorded demographic characteristics were age, gender, employment status, highest level of education, and residential area.
Questions in this study were modelled on a study conducted by McMackin et al. (2011) which utilised focus groups to gain in-depth information regarding consumer attitudes and awareness of whole grain as well as barriers and facilitators to their consumption [27
]. Questions were refined in consultation with relevant stakeholders, and surveys piloted by five dietitians and three non-dietitians to assist with construct and content validity, as well as the general understanding of questions and flow of the survey tool.
Data were exported from SurveyMonkey to Microsoft Excel™ (Version 16.22, 2019, Washington, DC, USA), where data collation and cleaning occurred. Descriptive statistics were used to provide frequency counts and percentages for demographic information, multiple choice questions, check multiple choice box selection, rank and scale and Likert scale-related questions. Content analysis and themes were identified utilising data visualisation methods, including content or word clouds. These were used to identify, analyse and report patterns from the open-ended questions [28
]. Content analysis of responses was used to explore topics and themes as they emerged in the data, representing a conventional approach to this analysis with no preconceived ideas as to the relevant themes derived from responses [29
This study provides some understanding of Australians’ views of whole grains, their attitudes, knowledge and health literacy and provides insights into factors that may affect choice of grain foods. Whole grain intake within Australia is below current recommendations [9
] and one of the first steps in developing modes of action to increase intake is understanding Australians current knowledge related to whole grains, as this may impact food choices and the likelihood of making dietary changes.
While it must be noted that the sample was not representative of the Australian population, results from this study are consistent with other work suggesting that the participants consume less than the recommend amount of grain food serves per day for their age and gender. Data from the NNPAS 2011–2012 reported that 70% of Australians did not consume sufficient quantities of grains [8
]. If individuals consume insufficient grains, then not only will they be likely to consume insufficient whole grains, but they may also be at risk of inadequate consumption of other key elements derived from grain foods such as dietary fibre, B group vitamins and iodine.
In order for individual adherence to dietary guidelines, an appropriate level of nutrition knowledge is required for success [30
]. This study found that less than one in ten participants were able to correctly identify both the recommended number of grain serves per day and also recommended whole grain serves a day for their age and gender. Over half of all participants were unable to identify any recommended quantities of grain serves (62%) or whole grain serves (61%). This was an important finding, as without sufficient knowledge on whole grain recommendations, the success of positive health behaviours related to adequate intake is limited. In a study aimed at increasing fruit and vegetable intake, a nutrition intervention provided participants with information on nutrients in fruit and vegetables, the role these nutrients played in the body and current intake recommendations. At the end of this, 91% of participants within the intervention increased fruit and vegetable intake compared to only 22% in the control group [31
]. This highlights the value in improved understanding of dietary guidelines and recommendations as a possible strategy to increasing knowledge, compliance and consumption.
Participants within this study primarily understood whole grains as a less processed grain, higher in dietary fibre. Only half of participants identified whole grains as a food containing all components of a grain when provided with multiple options, and even fewer participants noted this within open responses. Results were comparable to a previous attitude and behaviour survey, with 50% of participants not knowing precisely what constitutes a whole grain, but the majority acknowledging level of processing as a feature of these grain foods [22
]. Findings from this study suggest that individuals may have difficulty in identifying whole grains and whole grain foods, particularly those described as wholemeal or those categorised as snacks or breakfast cereals, for example, wholemeal flour, popcorn and Weet-Bix™ or other cereal products. The possible basis for this misconception could be related to individuals believing whole grains are unprocessed or less processed grains [25
]. Consequently, if they are transformed from their original “intact” form, they may no longer be perceived as whole grain by many consumers who assume a literal meaning for this food label. Correct identification of these manufactured whole grain foods could potentially encourage intake and therefore impact total daily whole grain consumption. The inability to differentiate whole grain and refined grain varieties is widely acknowledged as a barrier to consumption of grain foods [27
]. Previous research on whole grains has identified barriers to whole grain consumption including texture and taste with a number of studies assessing the general acceptability of whole grain foods including muffins, bread, rolls, breakfast cereals, oats, muesli, pasta, brown rice, cookies, granola bars, cereal bars and other snacks [15
]. Perhaps if individuals are informed that whole grain-containing foods come in a variety forms and they are able to identify these, preconceived taste and texture expectations may be overcome and consumption may increase.
The majority of participants (92%) believed that whole grains were important for their diet, as they provided dietary fibre and nutrients, they are less processed and more natural. However, almost all participants who stated the reverse, that whole grains were not important, explained that the reason for this belief was due to a lack of knowledge of the specific health benefits of whole grains. Overall, there were general perceptions of “healthfulness”, but thirty percent of participants were unaware of any specific health benefits associated with whole grains. The most frequent health benefits that participants associated with whole grains related to dietary fibre, digestion, bowel and gut health improvements and, that they are low GI. Digestive benefits are tangible for consumers. Recent work has noted that dietary fibre and whole grain content are better measures of carbohydrate quality than GI, so it is perhaps positive that fibre and broad health measures are most commonly recognised [33
]. Few participants identified whole grains as important in reducing chronic illnesses such as cardiovascular disease, certain cancers and their potential risk factors—obesity, hypertension and elevated fasting glucose levels [2
]. This indicates that individuals only have a basic understanding and awareness of whole grain health benefits, which is to be expected. It is unlikely that discussion of serious disease would take place in advertising or on social media, the key sources of information for participants in this study. Furthermore, making connections with serious disease via high-level health claims is not permitted on food product labelling.
Interestingly, three-quarters of participants stated that if they were informed of benefits associated with whole grain intake, it would encourage them to switch to whole grain options, which also corresponds with previous research [32
]. Participants stated that being educated on identification of whole grains along with information on how to cook them would also act as facilitators to further consumption. A recently published paper increasing exposure to whole grain food choices among low whole grain consumers over six weeks was shown to improve ratings of liking, flavor, texture and willingness to include more whole grains in the diet [34
]. This study emphasised that increasing exposure was key, with simple swaps rather than changes to the dietary pattern, leading to greater whole grain intake. A previous study utilised nutritional lectures to educate college students on physiological benefits of whole grains in relation to disease prevention, along with enabling them to identify whole grain foods on food labels and become involved with tasting activities. The study aimed to reduce taste and texture biases, and resulted in an increase in whole grain intake from 10% to 38% of total grain intake [35
]. Generally, multi-pronged approaches, with education and tasting, produce the outcomes required to impact dietary change.
Individuals in this study reported using on-pack messages to identify whole grain foods. While FSANZ do not regulate the use of on-pack whole grain claims, as they do with other nutrients, such as dietary fibre, protein, carbohydrate, and fat, the voluntary Code of Practice for Whole Grain Ingredient Content Claims in Australia, or overseas, labelling using whole grain “stamps” is used to guide consumers [36
]. According to research that aimed to assess the impact of the GLNC Code, the use of the on-pack claims was more prevalent in certain food product categories, with 75% of breakfast cereals and breads using the specified claims compared to just 40% of crispbreads/crackers/rice and corn cakes and rice, pasta, noodles or other grains [36
]. Although there was a high prevalence of whole grain claims on pack labels, it was estimated that only 43% of all eligible Australian grain food manufacturers and 65% of eligible grain food products in Australia are registered with the Code [36
]. Here, less than one-quarter of participants reported looking for whole grain foods specifically and almost half never looked for the term ‘whole grains’ on packaging. In research focused on multi-attribute choice modelling using bread as the example, Burke et al. [38
] found that whole grain was rated highly for both healthful and value for money by consumers. If more manufacturers routinely declared the percentage of whole grain content on packs, there would be a wider range of whole grain products for consumers to easily identify, providing the greatest opportunity to improve consumption patterns of whole grain foods across the population.
Aligned with this, strengthening public policy and regulation through the government, health professionals, health organisations and the food industry, perhaps via successful public–private partnership models utilised elsewhere, will become increasingly important to encourage whole grain and whole grain food consumption [39
]. Key to this research and the promotion of whole grains is the concept of health, nutrition and food literacy. Health literacy, as defined by the World Health Organisation, is “the cognitive and social skills which determine motivation and ability of individuals to gain access to, understand and use information in ways which promote and maintain good health” [40
]. Food literacy can be defined as the everyday practicalities associated with navigating the food system and being able to use it to ensure a food intake that aligns with nutrition recommendations [41
]. While there may be some ambiguity in these definitions, they are important in nutrition research because they can assist in determining how a consumer’s knowledge may affect their health [42
]. This is relevant when choosing between refined and whole grain foods. In order to assist Australians in making healthier choices, the Health Star Rating (HSR), a voluntary front-of-pack (FOP) labelling system, was adopted in Australia and New Zealand in 2014. Like other systems used internationally, the HSR was introduced as a strategy to guide selection of healthier foods in an easily understood manner, ranking foods on a scale between 0.5 (1/2) and 5 stars, based on the premise that more stars equate to a healthier product [44
]. The HSR system was designed to reflect principles outlined in the Australian Dietary Guidelines, and provide consumers with a simple measure to compare foods within the same category [45
]. The current HSR does not include whole grain within the algorithm. Some whole grain foods achieve a higher HSR due to the positive points gained from dietary fibre. However, research demonstrates that there is less than one star difference across multiple grain food categories [46
]. Addition of whole grains to the algorithm may assist in promotion of their intake.
Diets with varying carbohydrate content and aversions to carbohydrate foods and grains have gained substantial popularity in recent years [47
]. This was evident within this study, with almost all reasons individuals provided for not consuming whole grains related to participants’ dietary beliefs and regimens, with gluten-free (not for medical purposes), ketogenic, paleo and low-carbohydrate diets mentioned. Though diets lower in carbohydrate have been shown to have short-term weight-loss benefits, the long-term effects and safety of these diets are not thoroughly studied or understood [49
]. These diets exclude major carbohydrate food sources such as whole grain breads, pasta, and starchy vegetables including potatoes and corn, resulting in a significant decrease in carbohydrate, dietary fibre and micronutrient intakes of non-haem iron, magnesium, folate, thiamin, and iodine, which are the key nutrients supplied predominantly by grain foods in the Australian diet [51
]. With the decreased intake of these nutrients due to elimination of their primary sources, potential gastrointestinal consequences such as constipation, increased risk of bowel cancer [52
] and altered gut microbiota composition [54
] may impact overall health. This provides further evidence of the importance of education on the benefits of whole grain foods to assist in removing the negative stigma that implies that all carbohydrate sources are ‘bad’.
Online surveys are beneficial to reach a large array of individuals in a relatively short period [55
]. However, there may be unintentional exclusion of individuals, particularly those in remote areas, or of lower socioeconomic status or those of an older age. Although an active attempt was undertaken to ensure that a representative population was achieved for this study through active promotion via social media, the use of convenience sampling resulted in a less generalisable population, and an especially high proportion of female participants (87%), who tend to have higher food literacy. Importantly, the survey targeted the age groups making up ~65% of the Australian population [57
]. Although there were a limited number of participants ≥65 years of age, NNPAS data suggest that those ≥71 years of age already consume more whole grain than any other age group within the population (33.7 g/d) [9
]. Furthermore, of the 735 participants who commenced the survey, only 448 completed it, potentially due to the length of time required for completion. It was also possible that participants completing the survey may have had a greater general interest in nutrition compared to the general population. It is important to note that there was some unintentional ambiguity in the question asking consumers to classify multigrain and grainy bread with respect to whole grain content. Multigrain breads tend to be made from refined flour with the addition of seeds and grains, and therefore not classified as a whole grain food. However there are exceptions and some multigrain breads may be made from wholemeal (whole grain) flours and as a result participants’ responses may have varied depending on the type of multigrain and grainy breads encountered. Furthermore, consumption data received from this study were self-reported and based on estimates by participants and the precise amounts of grain food intake were not quantified. Therefore, consumption estimates can only be use as an indication of grain intake and not as an exact measure.