Development & Validation of Knowledge regarding diet & nutrition scale- Kuwaiti version

Objective This study aims to report the developmental processes and validation of Knowledge regarding diet & nutrition scale (Kuwaiti version). Results A total of 173 (response rate= 86.93%) participants responded to the survey. There was a total of 92 (53.2%) nutritionists and 81(46.8%) doctors/surgeons. The Kuwaiti Diet and Nutrition Scale was found to have an acceptable validity and reliability. The first subscale named “Factual knowledge about nutrition” comprised of nine items. It yielded a Cronbach’s alpha value of 0.78. The second subscale “knowledge about nutrition in morbidities” comprised of seven items and yielded a Cronbach’s alpha value of 0.71. The third subscale “counselling of patients” comprised of 11 items and yielded a Cronbach’s alpha of 0.68. The fourth subscale comprising nine items yielded a Cronbach’s alpha value of 0.64 and was named, “Dietary programs and supplementation”.


Introduction
Nutrition is an essential component of medical care, bearing an association with prognosis, management and outcomes of chronological diseases such as coronary and metabolic diseases [1][2][3]. Therefore, it is crucial for medical professionals to have an adequate level of nutrition in order to improve patient outcomes [4]. Unfortunately, several investigations have shown poor knowledge of nutrition among medical professionals, partly owing to their deficient education during preclinical and clinical training [5][6][7]. It is, therefore, imperative that nutrition knowledge of practicing medical professionals be assessed to overcome gaps in knowledge and improve patient care [8].
It is very important to develop tools and assessment questionnaires pertaining to attitude, knowledge and practices regarding nutrition. However, no such tool has been developed for the middle eastern population of Kuwait. Although an earlier study assessed nutrition knowledge of physicians in Kuwait, a psychometrically valid nutrition knowledge questionnaire has not yet been developed [8]. The present study, therefore, addresses this paucity of data. This study aims to report the developmental processes and validation of Knowledge regarding diet & nutrition scale (Kuwaiti version).

Methods
The development of the questionnaire was done in a multiphasic process. In the first phase, a thorough review of the literature was conducted to identify the questionnaires and modalities that have been used in the Middle East [9][10][11][12][13][14][15][16]. The items in these questionnaires were then checked for their suitability and adaption by an experienced dietician and a public health researcher (

NS & AW) inclusion in the Kuwaiti Diet & Nutrition
Scale. In addition, several more items were developed, based upon the Ajzen's theory of Planned Behaviour, which states that an action requires three pre-meditated components; attitudes, knowledge and practice [17]. Overall, these items assessed the participants on attitudes, knowledge and practices related to nutrition and diet in their clinical practice.
Responses on these items were assessed using a five-point Likert Scale ranging from strongly agree to strongly disagree.

Pilot survey
In the next phase, we recruited 18 dieticians and nutritionists (n = 6), medical students (n = 3) and medical doctors (n = 9). The participants were requested to respond to the KDNS and then comments on its suitability, strengths and weaknesses. Using open ended questions, they were also requested to comment on the items to be excluded or point out sentences to rephrase for an improved comprehension. They were also requested to point out more items that could be added in the questionnaire. Typical comments raised were to mention measurement units as mmol/l instead of mg/dl; less suitability for medical students and a high number of items. While it was suggested that questions pertaining to physical activity, renal-nutrition, bariatric surgery, physical activity and knowledge acquisition behaviors be added in the questionnaire. After the pilot study, we made necessary changes in the questionnaire, yielding a total of 52 items in the finalized questionnaire (Table 1). It is important to note that the data collected from the pilot survey was not included in the final dataset.

Data collection
Thereafter, we initiated the cross-sectional survey where a total of 200 dieticians, nutritionists and medical doctors were invited to participant in the survey, using convenient sampling method. Participants were recruited using an electronic survey developed using Survey Monkey platform. Professionals from several institutes and hospitals were contacted to participate in the survey during face to face meetings conducted at the Ministry of Health of Kuwait, Kuwait. Before participating in the survey, all the participants signed informed consent forms. Participation in the survey was voluntary, anonymous and the participants could leave the study at any time. Average time for completion of the questionnaire was around 20 minutes. Ethical approval for this study was provided by Ethical Review Board of Ministry of Health of Kuwait, Kuwait.
All data were analyzed using the SPSS v.25. Firstly, the data was subjected to dimension reduction using the Principal Component Analysis (PCA) and orthogonal rotation [18]. This process ascertained the dimensionality of the questionnaire by guiding the number of factors to retain and redundant items to be excluded. Before running the PCA, its suitability was assessed using the KMO sampling adequacy statistic (> 0.60) and Bartlett's test of sphericity. Number of factors to retain was based on three criteria; variance explained by each factor, Eigen value > 1 and the Cattell's Scree Plot. Naming of each factor retained was done subjectively by analyzing the theme of most items included in the questionnaire. Suitability of each item was assessed using several criteria. For each item to be suitable for inclusion in the final scale, it was ensured that the KMO sampling adequacy value was > 0.6 for each item in the anti-image of the covariance matrix; communality value was > 0.2 and the factor loading was > 0.32.
Reliability analysis was done to evaluate the internal consistency of the overall scale, where a value > 0.60 as considered to be acceptable [19]. Convergent validity was assessed using the Pearson's correlation indices obtained using the inter-item correlations. Moreover, contribution to the overall Cronbach's alpha value yielded by the scale was also assessed.   (Table 2) validity period a few items were reworded. For instance, units for several metabolic parameters were changed from mg/dl to mmol/l that is more prevalent in medical practice.

Results
A few of the physicians also noted difficulty in understanding US dietary guidelines, however, these questions were kept in the questionnaire because no alternative guidelines were available for the Kuwaiti population.

Limitations
This study has several strengths. An appropriate sample size was used for this study that comprised healthcare professionals across several specialties. It showed excellent internal consistency and validity among both the nutritionists and physicians and surgeons. This scale has several practical implications. It can be used to assess knowledge and attitudes of nutrition among doctors and assess areas/topics where training is required. It can thus, help to develop or tailor and tweak educational intervention packages for doctors. It can also be used to conduct pre and post assessment studies after delivery of an educational intervention regarding nutrition.

Declarations
Ethics approval and consent to participate: Ethical approval was granted by the Ministry of Public Health, Kuwait. All members provided with written informed consent and voluntarily participated in the study.
Availability of data and material: The data associated with this study can be provided on request to the authors.

Consent for publication: Not Applicable
Competing interests: The authors report that they have no conflict of interests to declare.
Dr. Ahmed Waqas serves BMC Research Notes as an associate editor.
Funding: This study has not received any funding.
Authors' contributions: NS and AA conceived the idea of the study, collected the data and wrote initial draft of the manuscript. AW analyzed the data, interpreted it and critically reviewed and edited the manuscript. HM revised the manuscript. All authors approved the final manuscript for submission. Unsaturated fatty acids are healthier than saturated fatty acids.

10
A BMI value > 18.5 is considered to be overweight among young adults.

11
US dietary guidelines recommend more than 7 servings of fruits per day for an adult.

12
A high caffeine intake can lead to increased heart rate and anxiety.

13
Zinc is a dietary trace element that plays a role in cell division, and maturation.
14 Folic acid supplements should be started in third trimester of pregnancy.

15
Calcium supplementation is not important for patients with osteoporosis. 16 US dietary guidelines recommend less than 2 servings of dairy products per day for an adult.

17
US dietary guidelines recommend between 6 to 11 servings of grain based products per day for an adult.

18
Statin drugs are important prescription medicines for prevention of cardiovascular diseases such as stroke and heart attack.

19
Diet with lower pro-inflammatory scores lead to lower risk of cancers.

20
Patients with diabetes should be prescribed a diet with a low glycemic index to improve their blood sugar levels.

21
Meat products have the highest vitamin B-12 levels.

22
Vegetable oil has higher trans-fats than hydrogenated oils.

23
Proteins contain higher number of calories than carbohydrates and fats.

24
Women should have adequate exposure to sunlight to aid in vitamin D synthesis in their bodies.

25
Lower hemoglobin levels in blood may be due to poor levels of potassium in diet.

26
There are around 20 essential amino acids that are synthesized in human body and do not have to be taken from outside source.

27
Bariatric surgery is a good treatment option for patients with extremely high BMI (> 40).

28
It is important to counsel patients regarding proper nutrition.

29
It is important to refer most of my patients with obesity to nutritionists for expert advice.

30
I believe that a balanced nutrition is important for prevention of diseases including cardiovascular (atherosclerosis) and metabolic (diabetes mellitus) diseases.

31
Taking CME courses in nutrition in dietetics enhance my clinical practice, and management of patients.

32
Nutritionists are an important part of inter-disciplinary healthcare teams in hospitals.

51
For guidance related to nutrition, I use authentic sources such as text books, Medscape and up-to-date.

52
I counsel patients with chronic kidney disease, on reducing salt and protein intake.