Original Paper
Ann Nutr Metab 2010;56:233–240 Received: January 4, 2009
DOI: 10.1159/000288313
Nutritional Knowledge, Attitude and Practice of
Tehranian Adults and Their Relation to Serum Lipid
and Lipoproteins: Tehran Lipid and Glucose Study
Parvin Mirmiran a, b Fatemeh Mohammadi-Nasrabadi a Nasrin Omidvar b
Firoozeh Hosseini-Esfahani a Homeira Hamayeli-Mehrabani a Yadollah Mehrabi c
Fereidoun Azizi a   
a
Obesity Research Center, Research Institute for Endocrine Sciences, b Faculty of Nutrition Sciences and Food
Technology, National Nutrition and Food Technology Institute c Faculty of Public Health, Shahid Beheshti
University of Medical Sciences, Tehran, Iran
Key Words
Knowledge, nutritional ⴢ Non-communicable disease ⴢ
Risk factors ⴢ Tehran Lipid and Glucose Study
Abstract
Background/Aim: The high prevalence of non-communica-
ble diseases and their risk factors among the general urban
population of Tehran necessitates an urgent implementa-
tion of nutritional interventional programs to curtail these
risk factors. This study aimed to provide preliminary data on
the knowledge, attitude and practices of urban Tehranian
adults regarding nutrition and their relation to major non-
communicable disease risk factors and to assess the need for
educational interventions. Methods: This cross-sectional
study was performed within the framework of the second
phase of the Tehran Lipid and Glucose Study (TLGS). Subjects
were 826 individuals, 369 men and 457 women, aged 20–70
years old, selected randomly from among 15,005 partici-
pants in the TLGS. Knowledge, attitude and practices of sub-
jects were assessed by a ‘knowledge, attitude and practice’
questionnaire; height, weight, waist and hip circumferences
were measured, and BMI and waist to hip ratio were calcu-
lated. Biochemical data including fasting blood glucose,
cholesterol, triglycerides and HDL-cholesterol were mea-
© 2010 S. Karger AG, Basel
0250–6807/10/0563–0233$26.00/0
Fax +41 61 306 12 34
E-Mail karger@karger.ch Accessible online at:
www.karger.com www.karger.com/anm
Accepted after revision: February 10, 2010
Published online: March 30, 2010
sured, based on standard protocols, and LDL-cholesterol was
calculated. Associations between nutritional knowledge, at-
titude, practice, sex, age and educational level, and between
knowledge, attitude and practice and BMI, waist to hip ratio
and levels of lipid and lipoproteins, were determined. Re-
sults: For knowledge 26.5, 52.7 and 20.8%, for attitude, 27.6,
48.9 and 23.5% and for practice, 27.4, 51.7 and 20.9% of
individuals had desirable, moderate and weak knowledge
scores, respectively. With increases in educational levels,
knowledge scores increased (p ! 0.001). Attitudes of illiterate
and poorly literate groups were weaker than those of other
groups (p ! 0.001). However, illiterate and poorly literate
groups had higher practice scores as compared to middle
school and high school graduates (p ! 0.001). Mean practice
scores of university graduates were higher than high school
graduates (p ! 0.05). Those aged 30–50 years had higher
knowledge scores than older individuals (p ! 0.001). LDL-
and total cholesterol were correlated to practice scores (p !
0.001, r = 0.23). Subjects with borderline triglyceride levels
had better practice scores than normal individuals (p !
0.001). Conclusions: The findings revealed that age, educa-
tional level and gender are factors that can influence knowl-
edge, attitude and practices, regarding nutrition. It is vital to
develop approaches and implement programs to improve
the nutritional practices of the population.
Copyright © 2010 S. Karger AG, Basel
Parvin Mirmiran, PhD
Obesity Research Center, Research Institute for Endocrine Sciences
Shahid Beheshti University of Medical Sciences
PO Box 19395-4763, Tehran (Iran)
Tel. +98 21 2243 2484, Fax +98 21 2240 2463, E-Mail mirmiran @ endocrine.ac.ir
 Introduction
Non-communicable diseases (NCDs) are a major
health burden in industrialized countries, and are on the
rise in developing countries owing to demographic tran-
sitions and changing lifestyles among people. In the
Global Burden of Disease Study 1990 [1], which estimated
the distribution of deaths by region, non-communicable
diseases ranked first as cause of death in developed coun-
tries, in many developing countries and in the world as a
whole. In the developed countries, 3 out of 4 deaths are
due to cardio-vascular disease (CVDs), cancer, accidents
or other violent causes. In many developing countries,
NCDs, especially cardiovascular disease, are already a
more common cause of death than infectious diseases [2].
Thus, addressing the problems and issues connected with
non-communicable diseases will lead to major health
benefits.
Research has clearly shown that non-communicable
diseases have their roots in unhealthy lifestyles or adverse
physical and social environments. Over a prolonged pe-
riod, risk factors such as unhealthy nutrition, smoking,
physical inactivity, excessive use of alcohol, and psycho-
social stress are among the major lifestyle issues. How-
ever, the incidence of these factors and CVD on a longi-
tudinal basis has not been determined in most developing
countries [3]. The most systematic finding throughout
the limited number of countries studied was the rapid
increase of overweight and obesity, probably as a result of
shifts toward energy-dense diets, sedentary lifestyles and
increased risk factors for NCDs [4].
Identification of the presence and magnitude of CVD
risk factors is vital for the development of proper ap-
proaches to the prevention of NCDs. In response to this
necessity, the Tehran Lipid and Glucose Study (TLGS)
has been designed to study the trend of NCDs and their
risk factors in an urban population in Tehran, and also to
consider changing lifestyles to prevent and decrease the
risk of major NCDs and their outcomes [5].
For promotion of effective healthy eating, it is neces-
sary to understand the attitudes towards and beliefs
about nutrition among the general public [6]. The pres-
ent study was conducted to provide baseline data about
nutritional knowledge, attitude and practices of urban
Tehranians, and to identify the obstacles that prevent
implementation of healthy changes and to assess the
need for educational intervention within the framework
of the TLGS.
234 Ann Nutr Metab 2010;56:233–240
Method
The TLGS, initiated in 1999, is a large-scale, prospective study
of non-communicable diseases and their risk factors among Teh-
ran’s urban population. Its aim is to develop population-based
measures to change the lifestyle of the population and to prevent
the rising trend of diabetes mellitus and dyslipidemia. The ethical
committee of the National Research Council of the Islamic Re-
public of Iran has approved this research. The sampling frame was
chosen from urban district 13 of Tehran, the capital city of the
Islamic Republic of Iran. The age distribution of the population
of district 13 is representative of the urban population of Tehran
[5, 7]. The TLGS was conducted on 15,005 individuals, both males
and females, between the ages of 3 and 69 years, who were ran-
domly sampled from Tehran’s urban district 13 and assessed for
the presence of the following non-communicable risk factors: di-
abetes, hyperlipidemia, smoking, hypertension, glucose intoler-
ance, obesity, physical inactivity and dietary habits, as well as cor-
onary artery disease. A sub-sample consisting of 826 individuals
(369 males and 457 females) aged 20 years and over, was random-
ly selected from the TLGS population for knowledge, attitude and
practice study. Subjects were divided into 4 groups (illiterate and
poorly literate, middle school, diploma and university graduates),
based on their educational levels and, again into 2 groups, based
on marital status (single and married).
Anthropometrical Assessment
Weight was recorded without shoes and socks using the Seca
707 weighing machine (range 0.1–150 kg) with an accuracy of up
to 100 g. The weighing machine was repeatedly checked by a stan-
dard weight for accuracy after every 10th weighing. Height was
measured without shoes with a tape meter stadiometer with a least
count of 1 mm. BMI was calculated by dividing weight (kg) to
height squared (m2). Underweight, overweight and obesity were
defined according to recommended BMI cut-off values for adults
[8]. Waist and hip circumferences were measured according to
standard protocols to the nearest 0.5 cm. Waist to hip ratios 61.0
in males, and 60.8 in females, were considered as abdominal obe-
sity [7].
Biochemical Assessment
After 12–14 h fasting, a venous blood sample was taken from
each subject for measurement of fasting blood glucose, total cho-
lesterol and HDL-cholesterol, and triglycerides. FBG was mea-
sured by enzymatic glucose oxidase. The auto analyzer Selectra 2
performed all serum lipid and lipoprotein measurements on the
same day. Total cholesterol was measured by the enzymatic meth-
od, using cholesterol esterase and cholesterol oxidase. HDL-cho-
lesterol was measured using the same method after precipitation
of apolipoprotein B by phosphotungstic acid. Serum triglyceride
concentration was measured by the enzymatic method, using
glycerol phosphate oxidase. LDL-cholesterol was calculated in se-
rum samples with TG !400 mg/dl using the Friedwald formula
[9]. The classification criteria for serum lipid and lipoprotein lev-
els in adults as recommended by the National Cholesterol Educa-
tion Program were used [10, 11].
Knowledge, Attitude, Practice Assessment
Knowledge, attitude and practice of subjects, regarding nutri-
tion, were assessed by questionnaires and face-to-face interviews
Mirmiran et al.
with regard to NCD risk factors and body weight, dietary lipids, Table 1. Structure and scores of knowledge, attitude and practice
sugar, fiber, fruits and vegetables and salt (table  1). Knowledge questionnaire
questions included yes/no and correct/false questions (46 ques-
tions, each scoring 1 point). Attitude was assessed based on the Questionnaire category Number of questions
Likert criteria from 1 point, as the weakest, to 5 points, as a desir-
able score (9 questions). For assessing practice, the food frequency knowledge attitude practice
questionnaire including dairy and meat products (low and high
fat), vegetables and fruits was used (35 questions, each scoring 1 Body weight 16 2 9
point). Dietary lipids 16 2 10
Focus groups and experts authenticated face and content va- Sugar 6 2 7
lidity of the questionnaires and their reliability was determined Fiber, fruits and vegetables 6 2 7
by pre- and post-tests. Following finalization of the question- Salt 2 1 2
naire, 4 interviewers were educated about completion of the ques- Total 46 9 35
tionnaires in a sample of 42 individuals as pre- and post-tests, Score range 0–46 9–45 0–35
with a 1-month interval, following which the association between
the scores of the 2 tests was determined (r = 0.75, p ! 0.001).
After calculating the scores of each of the 3 sections (knowl-
edge, attitude and practice), the quartiles were determined and
first quartile was coded as weak, the second and third quartiles
were coded as medium and the last quartile was coded as desir- Table 2. Characteristics of the study population
able. Minimum scores of knowledge, attitude and practice were
considered to be 0, 9 and 0, respectively and maximum scores Variable Men Women Total
were considered to be 46, 45 and 35, respectively. Respective (n = 369) (n = 457) (n = 826)
thresholds and ranges for weak, medium and desirable scores
were set as follows: knowledge ! 29, 29–39 and 139; attitude !30, Age group, years
30–35 and 135, practice ! 20, 20–26 and 126. 20–29 99 (26.8) 144 (31.5) 243 (29.4)
30–39 74 (20.1) 122 (26.7) 196 (23.7)
Statistical Analysis 40–49 86 (23.3) 113 (24.7) 199 (24.1)
Statistical analysis was performed using the Statistical Pack- 50–59 73 (19.8) 57 (12.5) 130 (15.7)
age for Social Sciences (SPSS) version 10.0, and data were present- ≥60 37 (10.0) 21 (4.6) 58 (7.0)
ed as mean 8 SD. To determine the association between nutri- Educational level
tional knowledge, attitude, practice, sex, age and educational lev- Illiterate or poorly literate 90 (24.4) 118 (25.8) 208 (25.2)
els of subjects, the ␹2 test was used after age and sex adjustment; Middle school 66 (17.8) 92 (20.1) 158 (19.1)
for associations between knowledge, attitude and practice and High school diploma 121 (32.9) 178 (38.9) 299 (36.2)
BMI, waist to hip ratio and levels of lipid and lipoproteins, the University graduate 92 (24.9) 69 (15.2) 161 (19.5)
Spearman correlation was used instead of Pearson, as the scores Marital statusa
lacked normal distribution. For detecting significant differences Single 82 (22.2) 100 (21.9) 182 (22.0)
between the key variables in age, sex, educational levels and BMI Married 286 (77.5) 333 (72.9) 619 (74.9)
groups and the normal, borderline and high concentrations of Divorced/widowed 1 (0.3) 24 (5.2) 25 (3.1)
total cholesterol, triglycerides, HDL- and LDL-cholesterol, the
Kruskal-Wallis test was used. Linear regression was performed Numbers in parentheses are percentages.
for testing different potential correlations. R 2 was 1 0.04 for dif-
ferent models with total cholesterol, BMI, triglycerides and LDL-
cholesterol as dependent variables and total practice score as in-
dependent variable. P values !0.05 were considered to be signifi-
cant.
Knowledge, Attitude and Practice Scores
In figure 1, the frequency of persons based on the score
Results of knowledge, attitude and practices is shown. Most had
medium scores of knowledge, attitude and practice, with
General Characteristics desirable scores of knowledge, attitude and practice being
Subjects of this study were 369 men and 457 women observed in less than 30% of subjects. Table  3 shows
with mean ages of 40.8 8 13.7 and 37.4 8 12.2 years, re- scores of various age, sex, educational level, marital status
spectively. Table 2 shows the general characteristics of the and weight groups. Younger people (30–50 years old) had
subjects studied. More than three fourths of the subjects significantly higher knowledge scores than those 150
were 20–49 years of age; almost half of the population years of age (p ! 0.01). Regarding attitudes, there was no
were high school and university graduates and three significant difference between age groups. Scores for
fourths were married. practice increased with increasing age (p ! 0.001), and

Nutritional Knowledge, Attitude and Ann Nutr Metab 2010;56:233–240 235

Behavior of Tehranian Adults
 Table 3. Comparison of the scores of knowledge, attitude and
60 Desirable Medium Weak practice between various groups
*
50 * Variable Knowledge Attitude Practice

40 Age groups, years

20–29 33.786.4 32.284.1 20.983.9b
Percent

30
30–39 34.986.5a 32.484.4 22.283.9b
40–49 34.785.9a 31.984.0 23.483.9b
50–59 32.985.5 32.283.5 24.783.6b
20
≥60 32.382.5 31.583.9 26.383.3b
Educational level
10 Illiterate or poorly literate 30.385.4b 31.383.6 24.084.0
Middle school 32.985.9b 32.284.1 22.484.0
0 High school diploma 35.685.8b 32.584.3 22.384.3
Men Women Men Women Men Women University graduate 36.885.4b 32.584.2 22.284.0
Knowledge Attitude Practice Marital status
Single 33.786.4 32.284.1 20.483.7b
Married 32.286.1 32.184.1 23.484.0
Fig. 1. Relative frequency of people with desirable, medium and Sex
poor nutritional knowledge, attitude and practice. *  p ! 0.001, Male 33.586.1c 31.683.8b 21.684.2
men vs. women. Female 34.586.2 32.684.2 22.184.1
BMI status
Normal 34.486.4 31.584.5c 21.884.4
Overweight 34.985.8 32.984.0 23.983.5
with increasing educational levels knowledge of subjects Obese 33.886.1 32.383.7 23.683.7
increased significantly (p ! 0.001). a
p < 0.01 compared to 50–59 and ≥60 years age group.
In the middle school group, more than half of the peo- b
p < 0.001 compared to other groups.
ple had good knowledge and medium practice scores. In c
p < 0.05 compared to other groups.
the university graduate group, all individuals had good
scores of knowledge (data not shown in table 3). Females,
compared to males, had higher scores in their knowledge
and attitudes. Married individuals had higher scores in
practices than did singles (p ! 0.001). Overweight and is not an important source of cholesterol; 40.1% of these
obese people had higher practice scores than those with reported animal fat to be more delicious than vegetable
normal weight (23.9 8 3.5 and 23.6 8 3.7 vs. 21.8 8 4.4, oil, and most (76%) knew that non-hydrogenated oils are
respectively; p ! 0.01). Attitudes of overweight people better than hydrogenated ones. However, the consump-
were better than their normal weight peers. Knowledge tion of hydrogenated oils, was much higher than vegeta-
scores of normal weight, overweight and obese groups ble oils (75 vs. 25%). Only about 30% of subjects had a
were not significantly different. general idea of the meaning of ‘fiber’, whereas more than
There were significant positive, but weak associations 90% of them were conscious of the necessity of vegetable
between knowledge and attitudes (r = 0.26, p ! 0.001), and fruit consumption for healthy living. Fruits were pre-
knowledge and practice (r = 0.18, p ! 0.001) and between ferred as snacks by 87% of people and only 6% of the sub-
attitude and practice (r = 0.30, p ! 0.001) of the partici- jects preferred confectionery products as snacks.
pants. Women thought themselves to be overweight or obese
and had tried out low calorie diets more than men (67 vs.
Components of Knowledge, Attitude and Practice 39%; p ! 0.001); over 90% of them were aware of their
Fields weight and weighed themselves regularly. Overall regular
Table 4 demonstrates the results of responses to key physical activity (95.8%), lower fat intake (94.3%), lower
questions of the study in both genders. Of the studied sugar intake (88.4%), low calorie diets (86.2%), lower con-
population, 64.8% claimed to know the meaning of ‘cho- sumption of fried foods (81.6%) and higher consumption
lesterol’, but 43.6% of them could not identify its food of fruits and vegetables were seen to be the best ways to
sources correctly and believed that food items such as lose and maintain an appropriate weight, respectively.
bread, cereals and nuts have cholesterol or that egg yolk Most of the people reported inactivity as the most impor-

236 Ann Nutr Metab 2010;56:233–240 Mirmiran et al.

 Table 4. Correct answers to key components of knowledge, attitude and practice in study group

Questions Correct answers, n (%)

men women

Knowledge
Do you know the meaning of ‘cholesterol’? 231 (62.6) 304 (66.5)
Egg yolk is an important source of cholesterol 233 (63.1) 303 (66.3)
Fish is a source of cholesterol 87 (23.6) 95 (20.8)
Bread, cereals and pasta are not sources of cholesterol 95 (25.7) 109 (23.9)
Nuts and seeds are not sources of cholesterol 57 (15.4) 65 (14.2)
Non-hydrogenated oils are better for health than hydrogenated ones 292 (79.1) 386 (84.5)
Fiber is a substance in vegetables that cannot be digested and absorbed 120 (32.5) 158 (34.6)
For healthy nutrition, consumption of fruits and vegetables should be increased 348 (97.0) 444 (97.1)
The best ways to lose and maintain an appropriate weight
Lower fat intake 189 (93.1) 234 (93.2)
Lower sugar intake 170 (83.7) 225 (89.6)
Low calorie diets 170 (83.7) 223 (88.8)
Lower consumption of fried foods 157 (77.3) 217 (86.5)
Higher consumption of fruits and vegetables 44 (22.7) 46 (18.3)
Inactivity is the most important factor contributing overweight 195 (96.1) 231 (92.0)
People with normal weights run less risk of coronary heart disease 185 (91.1) 233 (92.8)
Overweight persons probably have higher blood pressure than do others 182 (89.7) 200 (79.7)

Answered ‘yes’, n (%)

men women

Attitudes
Animal fat is not more delicious than vegetable oil 124 (17.9) 66 (27.1)
I prefer fruits as snacks 312 (84.6) 415 (90.8)
I prefer sweets as snacks 28 (7.6) 23 (5.0)
I think myself to be overweight or obese and try out low calorie diets 144 (39.0) 306 (67.0)
Practice
I always use salt on my foods 155 (42.0) 284 (62.1)
I always use vegetable oil for cooking 109 (23.9) 108 (29.3)
I often weigh myself regularly 187 (92.1) 232 (92.4)

tant factor contributing to overweight and were aware
of the relation between overweight, hypertension and
CVDs.
Regarding fat and risk factors of CVD, the practices of
illiterate and poorly literate groups were better than mid-
dle school or diploma graduate groups (p ! 0.001). The
practices of university graduates in the field of fat and
confectionary consumption scored higher than diploma
graduates (p ! 0.05) as the university graduates reported
high consumption of low fat dairy products and low con-
sumption of sweets (data not shown).
In addition to significant differences in knowledge
and attitudes between men and women, knowledge of
women regarding disadvantages of sweet consumption
(4.6 8 1.2 vs. 4.8 8 1.0; p ! 0.05), their attitude regard-
ing the influence of fat consumption on the incidence of
non-communicable disease and its risk factors (6.0 8 1.5
vs. 6.8 8 1.7; p ! 0.001) and their practice in adding salt
to foods (1.1 8 0.8 vs. 1.5 8 0.7; p ! 0.001) were all better
than men.
Association of Lipids with Knowledge, Attitude,
Practice
Subjects with high serum total cholesterol and LDL-
cholesterol concentrations had better practices than oth-
ers (p ! 0.001). Also, subjects who had borderline serum
triglyceride levels had more desirable practices than those
with normal triglyceride levels (mean score of practice
24.3 8 3.7 vs. 22.6 8 4.2; p 1 0.01; fig. 2); however, no
significant difference between serum lipids and nutri-

Nutritional Knowledge, Attitude and Ann Nutr Metab 2010;56:233–240 237

Behavior of Tehranian Adults

24.5 Normal Borderline
* *
24.0
23.5
Practice score
23.0
22.5
22.0
21.5
21.0
20.5
Total cholesterol LDL-cholesterol
Fig. 2. Comparison of practice scores of subjects with normal,
borderline and high concentrations of total cholesterol, LDL-cho-
lesterol and triglycerides. * p ! 0.001, vs. other groups.
tional knowledge and attitude was found. LDL- and total
cholesterol were correlated to practice scores (r = 0.23,
p  ! 0.001). BMI and triglyceride levels were also corre-
lated to practice scores (r = 0.27 and r = 0.14, p ! 0.01).
Discussion
In recent years, with increasing urbanization and in-
dustrialization, and with better access for populations to
public health care, the prevalence of communicable dis-
eases has reduced. In contrast, due to reduced physical
activity and changes in dietary patterns, more fat con-
sumption in particular, non-communicable diseases
have increased [12, 13]. This phenomenon, referred to as
‘nutritional transition’, has emphasized the vital need for
new strategies to improve the health and nutritional sta-
tus of the population. To reach this goal, it is imperative
to promptly identify the factors that influence dietary
practice and health, and educate the population regard-
ing these risk factors. This study showed that, regarding
NCD-nutritional risk factors, more than half of adults
had moderate knowledge, attitude and practices, whereas
desirable knowledge, attitude and practice were only ob-
served in a fourth of them.
A weak but significant association was found between
knowledge, attitude and practice, a finding that indicated
the sizeable gap that exists between what individuals
know and how much they put their knowledge into prac-
238 Ann Nutr Metab 2010;56:233–240
tice [14–16]. Some who can benefit from making dietary
High changes may not perceive a need to do so [14, 17], or some
individuals may know what changes to make but not
know how to make them [18, 19]. Broader social and cul-
tural factors also play an important role in shaping food
choices. Another explanation for the inconsistent asso-
ciations between knowledge and dietary behavior is that
* knowledge may be poorly assessed. Psychometrics, has
defined a set of criteria such as face and content validity,
internal reliability and test-retest reliability for a valid test
[20]. For example, whereas more than 60% of the popula-
tion studied claimed to know the meaning of ‘cholester-
Triglyceride ol’, less than 50% of them were able to identify its food
sources correctly (marked weakness of applied knowl-
edge). Also, whereas more than 80% of them knew that
vegetable oils are better than hydrogenated ones for
health, only one third of the people used the former for
cooking. These findings confirmed the Pirouznia opin-
ions that nutrition knowledge is not the only factor that
can influence eating behavior [21]. Lower consumption
of vegetable oil in the subjects studied can be due to the
higher price of this oil as compared to hydrogenated ones.
Other factors and variables include physiological needs,
body image, peer pressure, media social norms, and
availability of foods, personal experiences and food pref-
erences.
Literature available on eating behavior and its relation
to nutrition knowledge is often contradictory [22, 23].
Some researchers have shown that nutrition knowledge
was highly and positively related to behaviors toward nu-
trition, while others found little correlation between nu-
trition knowledge and actual choices of healthy food. In
the Saegert and Young [24] study, a strong positive rela-
tion between nutritional knowledge and practices of peo-
ple regarding dietary guidelines was found. Wardle et al.
[25] also found that general practitioners with higher
knowledge scores meet the fruit and vegetable recom-
mendations more than their peers with lower knowledge.
However, Story showed a weak association between nu-
tritional knowledge and food choices [26]. Other studies
also reported that despite most people being aware of the
relation between diet and health, their nutritional prac-
tices are not desirable; for example, their fat and sugar
consumption is high [27, 28].
In this study, knowledge and attitude scores of women
in some fields such as influence of consumption of fats,
sweets and salt on non-communicable diseases and their
risk factors were significantly higher than men; however,
there were no significant differences in their practices.
As a result, in spite of higher knowledge and attitude of
Mirmiran et al.
women, nutritional practices in the family followed men’s
preferences. Thus, there is a need to increase funding for
the education of men. Population-based food and nutri-
tion studies consistently demonstrate that women are sig-
nificantly more likely to comply with dietary guidelines
than men. At least 4 possible explanations for this finding
are suggested in the literature: (1) women are more knowl-
edgeable regarding food, nutrition, health and related as-
sociations; (2) women exhibit more positive health and
food-related beliefs and attitudes; (3) women manifest a
more heightened concern about their personal and phys-
ical appearance than do men, and (4) women are more
likely than men to report that they prefer the taste of
healthy foods and meals [29].
In the present study, educational level, age and marital
status were considered as factors that can influence
knowledge, attitude and practice. More highly educated
people scored higher in knowledge than did those with
lower levels of education. Practices of illiterate or poorly
literate subjects regarding fat intake and risk factors of
non-communicable diseases scored significantly higher
than others. Since measurement of family income levels
is complicated, in some studies the educational level has
been used as an indicator of family income and socioeco-
nomic status [30]. It is concluded that more highly edu-
cated people with higher socio-economic status, in spite
of their higher levels of knowledge, consumed more fast
and fatty foods than others.
Nutritional knowledge of the 30–50 year group was
better than older age groups, but with increasing age,
practice scores increased. Higher knowledge scores of
younger groups are probably due to higher educational
levels, with a positive significant correlation being seen
between educational levels and knowledge [15, 17, 18].
However, better practice scores in older adults could be
due to more motivation in meeting the nutritional rec-
ommendations of their physician or other health care
personnel, since 30–50-year-old subjects usually have
one or more NCDs or at least one of their risk factors.
Another finding of the current study was the better
practices of persons with abnormal total cholesterol lev-
els, LDL-cholesterol and triglycerides compared with
those who had normal or borderline levels; this is similar
to the Dian et al. [31] study, which found that those with
heart disease and hypercholesterolemia had better knowl-
edge and better dietary practices about fat than those
without this condition. Compared with the total popula-
tion, these people benefit from lifestyle changes in the
best way and it appears that they are highly motivated to
comply with changes in lifestyle [32, 33]. Based on the
Nutritional Knowledge, Attitude and
Behavior of Tehranian Adults
‘stages of change’ theory [34], those individuals with a
health condition or disease may progress through the
stages to the action stage, where nutrition knowledge, be-
liefs and dietary practices would be more appropriate in
order to reduce risks. Overweight and obese people also
had better reported practices than their normal weight
peers [35].
The findings of the present paper revealed that age,
educational level, gender and marital status are factors
that can influence knowledge, attitude and practice, re-
garding nutrition. However, our previous data showed
that dietary behavior may not accord with the nutrition-
al knowledge of individuals [36]. Health education strate-
gies to encourage individuals to choose healthy diets
must be developed and enhanced to achieve health pro-
motion in Tehran. Programs designed to provide nu-
trition education can benefit from the present data on
lifestyle and nutrition behavior. The ability to look at
interrelationships among all these measures could
significantly improve our ability to appropriately design
and target interventions, such as nutrition education
programs [37].
Acknowledgments
This research project was supported by the combined support
of the National Research Council of the Islamic Republic of Iran
and Research Institute for Endocrine Sciences (grant No. 121).
We acknowledge and appreciate the efforts of the personnel of
the Glucose and Lipid Unit of the Research Institute for Endo-
crine Sciences and the participants of this study.
References 1 Nissinen A, Berrios X, Puska P: Community-
based noncommunicable disease interven-
tions: lessons from developed countries for
developing ones. Bull World Health Organ
2001;79:963–970.
2 Murray GYL, Lopez AD: Mortality by cause
for eight regions of the world: Global Burden
of Disease Study. Lancet 1997; 349: 1269–
1276.
3 Fuentes R: Hypertension in developing eco-
nomics: a review of population-based studies
carried out from 1980 to 1998. J Hyperten-
sion 2000;18:521–529.
4 WHO Multi-Country Study: The Nutrition
Transition Program. 2003. http://www.nu-
trans.org/index.html (accessed February 25,
2010).
5 Azizi F, Rahmani M, Emami H, Madjid M:
Tehran Lipid and Glucose Study: rationale
and design. CVD Prevention 2000; 3: 242–
247.
Ann Nutr Metab 2010;56:233–240 239
 6 Kearney JM, Gibney MJ, Livingstone BE,
Robson PJ, Kiely M, Tlarrington K: Attitudes
towards and beliefs about nutrition and
health among a random sample of adults in
the Republic of Ireland and Northern Ire-
land. Public Health Nutr 2001;4:1117–1126.
7 Azizi F, Ghanbarian A, Momenan AA, Ha-
daegh F, Mirmiran P, Hedayati M, et al: Pre-
vention of non-communicable disease in a
population in nutrition transition: Tehran
Lipid and Glucose Study phase II. Trials
2009;10:1–15.
8 NIH/NHLBI (National Institute of Health/
National Heart, Lung and Blood Institute):
Clinical guidelines on the identification,
evaluation and treatment of overweight and
obesity in adults: the evidence report. Obes
Res 6(suppl 2):1998;51S.
9 Friedwald WT, Levy RI, Fredrickson DS: Es-
timating of low-density lipoprotein choles-
terol in plasma, without use of preparative
ultracentrifuge. Clin Chem 1972; 18: 499–
502.
10 Mirmiran P, Ramezankhani A, Hekmat-
doost A, Azizi F: Effect of nutrition interven-
tion on non-communicable disease risk fac-
tors among Tehranian adults: Tehran Lipid
and Glucose Study. Ann Nutr Metab 2008;
52:91–95.
11 He J, Bazzano LA: Effects of lifestyle modifi-
cation on treatment and prevention of hy-
pertension. Curr Opin Nephrol Hypertens
2000;9:267–271.
12 Kimiagar SM, Ghaffarpour M, Houshiar-
Rad A, Hormozdyari H, Zellipour L: Food
consumption pattern in the Islamic Republic
of Iran and its relation to coronary heart dis-
ease. East Mediatr Health J 1998;4:539–547.
13 Ghassemi H, Harrison G, Mohammad K: An
accelerated nutrition transition in Iran. Pub-
lic Health Nutr 2002;5:149–155.
14 Poplein BM, Siega-Riz AM, Haines PS: A
comparison of dietary trends between racial
and socioeconomic groups in the United
States. N Engl J Med 1996;335:216–220.
240 Ann Nutr Metab 2010;56:233–240
15 Glanz K, Brug J, Van Assema P: Are aware-
ness of dietary fat intake and actual fat con-
sumption associated? A Dutch American
comparison. Eur J Clin Nutr 1997; 51: 542–
547.
16 Johansson L, Anderson LF: Who eats 5 a day?
Intake of fruits and vegetables among Nor-
wegians in relation to gender and lifestyle. J
Am Diet Assoc 1998;98:689–691.
17 DeGraaf C, Van der Gaag M, Kafatos A,
Lennernas M, Kearney J: Stages of dietary
change among nationally representative
samples of adults in the European Union.
Eur J Clin Nutr 1997;51(suppl 2):535–340.
18 Buttriss JL: Food and nutrition: attitudes, be-
liefs and knowledge in the United Kingdom:
Am J Clin Nutr 1997; 65(suppl 16):19855–
19955.
19 Harnack L, Block G, Subar A, Lane S: Cancer
prevention related nutrition knowledge, be-
liefs and attitudes of US adults: 1992 NHIS
cancer epidemiology supplement. J Nutr
Educ 1998;30:131–138.
20 Kline P: The Handbook of Psychological
Testing. London, Roultedge, 1993.
21 Pirouznia M: The correlation between nutri-
tion knowledge and eating behavior in an
American school: the role of ethnicity. Nutr
Health 2000;14:89–107.
22 Cotunga N, Subar AF, Heimendinger J, Kah-
le L: Nutrition and cancer prevention knowl-
edge, beliefs attitudes and practices: the 1987
National Health Interview Survey. J Am Diet
Assoc 1992;92:963–968.
23 Dallongeville J, Marecaux N, Cottle D, et al:
Association between nutrition knowledge
and nutritional intake in middle-age men
from Northern France. Public Health Nutr
2001;4:27–33.
24 Saegert J, Young EA: Nutrition Knowledge
and health food consumption. Nutr Behav
1983;1:103–113.
25 Wardle J, Parmenter K, Waller J: Nutrition
knowledge and food intake. Appetite 2000;
34:269–275.
26 Story M: Adolescents’ view of food and nutri-
tion. J Nutr Educ 1989;18:188–192.
27 Birgit R, Peter N, Jurgen B, et al: Eating hab-
its, health status, and concern about health:
a study among 1,641 employees in the Ger-
man metal industry. Prev Med 2000, 30;
295–301.
28 Luthy J: The development of a nutrition
policy in Switzerland. Nutr Rev 1997; 55
(suppl 1):S29–S31.
29 Turrell G: Determinants of gender differenc-
es in dietary behavior. Nutr Res 1997; 17:
1105–1120.
30 Kaplan GA, Keil JE: Socioeconomic factors
and cardiovascular disease: a review of the
literature. Circulation 1993;88:1973–1998.
31 Dian K, Sonja L, Gary S, et al: Knowledge of
and attitudes toward coronary heart disease
and nutrition in Oregon families. Prev Med
1984;13:390–395.
32 Adhikari P, Dhungel S, Shrestha R, Khanal
S: Knowledge attitude and practice (KAP)
study regarding facts for life. Nepal Med Coll
J 2006;8:93–96.
33 Pon LW, Noor-Aini MY, Ong FB, Adeeb N,
Seri SS, Shamsuddin K, Mohamed AL, Hap-
izah N, Mokhtar A, Wan HW: Diet, nutri-
tional knowledge and health status of urban
middle-aged Malaysian women. Asia Pac J
Clin Nutr 2006;5:388–399.
34 Prochaska JO, DiClemente CC: Transtheo-
retical therapy: towards a more integrative
model of change. Psychother Ther Pract
1982;19:276–288.
35 Carlton DJ, Kicklighter JR, Jonnalagadda SS,
Shoffner MB: Design, development, and for-
mative evaluation of ‘put nutrition into prac-
tice’, a multimedia nutrition education pro-
gram for adults. J Am Diet Assoc 2000; 100:
555–563.
36 Mirmiran P, Azadbakht L, Azizi F: Dietary
behaviour of Tehranian adolescents does not
accord with their nutritional knowledge.
Public Health Nutr 2007;10:897–901.
37 Murphy SP: Collection and analysis of intake
data from the integrated survey. J Nutr 2003;
133:585S–589S.
Mirmiran et al.