Original Article

Perceived benefits and barriers of increased dietary fiber consumption: Validation of a decisional balance scale


Background: This study was conducted to develop and validate a scale in order to assess perceived benefits and barriers (decisional balance) to improving dietary fiber consumption in patients with type 2 diabetes (T2D).
Methods: In order to develop the questionnaire, focus-group discussions, in-depth interviews and literature review were carried out. Validity of the questionnaire was assessed using content validity, face validity and construct validity. The factor structure of the questionnaire was also extracted by performing both principle component analysis (PCA) and confirmatory factor analyses. Reliability was then estimated using internal consistency and test-retest analysis. Two groups of T2D patients participated in the study. 146 T2D patients participated in the content validity and the other 265 T2D patients were those whose data were used for the confirmatory factor analysis
Results: The mean age of the participants was 52.3±7.6 years. PCA indicated two components representing benefits (Cronbach’s α=0.75) and barriers (Cronbach’s α=0.71). Confirmatory factor analysis supported the two-component structure [Goodness of Fit Index = 0.94, χ 2/df=1.56 (χ 2 =118.28, df=76, p <0.001), RMSEA=0.046]. The Test–retest results, measured by interclass correlation (ICC), for all the items were between 0.62 and 0.78.
Conclusion: The designed questionnaire is valid and reliable to assess perceived benefits and barriers of dietary fiber intake in patients with T2D.

Anderson JW, Baird P, Davis RH, Ferreri S,Knudtson M, Koraym A, et al. Health benefits ofdietary fiber. Nut Rev. 2009;67 :188-205.

Chandalia M, Garg A, Lutjohann D, von BergmannK, Grundy SM, Brinkley LJ. Beneficial effects ofhigh dietary fiber intake in patients with type 2diabetes mellitus. N Engl J Med. 2000;342 :1392-8.

Weickert MO, Mohlig M, Schofl C, Arafat AM,Otto B, Viehoff H, et al. Cereal fiber improveswhole-body insulin sensitivity in overweight andobese women. Diabetes Care. 2006;29 :775-80.

Brennan CS. Dietary fibre, glycaemic response,and diabetes. Mol Nutr Food Res. 2005;49:560-70.

Institute of Medicine, Food and Nutrition Board2015; Dietary Reference Intakes: EstimatedAverage Requirements and RecommendedIntakes; Available from:http://www.nal.usda.gov/fnic/DRI/DRI_Tables/recommended_intakes_individuals.pdf

Anderson JW, Smith BM, Gustafson NJ. Healthbenefits and practical aspects of high-fiber diets.Am J Clin Nutr. 1994;59:1242S-7S.

Shirinzadeh M, Shakerhosseini R, Hoshiyar rad A.Nutritional value assessment and adequacy ofdietary intake in type 2 diabetic patients. IranianJournal of Endocrinology and Metabolism.2009;11: 25-32.

Hosseinpour Niazi S, Mirmiran P, Sohrab G,Hosseini Esfahani F, Azizi F. Associationbetween Dietary Fiber Intake and MetabolicSyndrome: Tehran Lipid and Glucose Study.Iranian Journal of Epidemiology. 2012;7:19-28.

Esmaillzadeh A, Azadbakht L. Food intakepatterns may explain the high prevalence ofcardiovascular risk factors among Iranian women.J Nutr. 2008;138: 1469-75.

Smith AM, Owen N. Associations of social statusand health-related beliefs with dietary fat andfiber densities. Prev Med. 1992;21: 735-45.

Kavookjian J. The Relationship Between Stagesof Change and Glycemic Control in Patients withDiabetes [dissertation]. Alabama, AuburnUniversity; 2001.

Kavookjian J, Berger BA, Grimley DM, VillaumeWA, Anderson HM, Barker KN. Patient decisionmaking: strategies for diabetes diet adherenceintervention. Res Social Adm Pharm. 2005;1:389-407.

Ma J, Betts N, Horacek T, Georgiou C, White A,Nitzke S. The importance of decisional balanceand self-efficacy in relation to stages of changefor fruit and vegetable intakes by young adults.Am J Health Promot. 2002;16: 157-66.

Havas S, Treiman K, Langenberg P, BallesterosM, Anliker J, Damron D, et al. Factors associatedwith fruit and vegetable consumption amongwomen participating in WIC. J Am Diet Assoc.1998;98: 1141-8.

Trudeau E, Kristal AR, Li S, Patterson RE.Demographic and psychosocial predictors of fruitand vegetable intakes differ: implications fordietary interventions. J Am Diet Assoc. 1998;98:1412-7.

Van Duyn MA, Kristal AR, Dodd K, CampbellMK, Subar AF, Stables G, et al. Association ofawareness, intrapersonal and interpersonal factors,and stage of dietary change with fruit andvegetable consumption: a national survey. Am JHealth Promot. 2001;16: 69-78.

Chuan Ling AM, Horwath C. Perceived benefitsand barriers of increased fruit and vegetableconsumption: validation of a decisional balancescale. J Nutr Educ. 2001;33: 257-65.

Strauss A, Corbin J: Coding prosedures. Basics ofqualitative research: Grounded theory proceduresand techniques. 2nd ed. California: Sagepublications Newbury Park; 1998. p. 55-242.

Keshani P, Farvid MS. Perceived Benefits andBarriers Regarding High Fiber Food Intake inType 2 Diabetes Patients- A Qualitative study.Iranian Journal of Nutrition Sciences & FoodTechnology. 2012;7: 11-22.

Daskivich B A. Assessing readiness for behaviorchange associatd with type 2 diabetes in a nativeamerican population [dissertation]. Montana: Theuniversity of Montana; 1997.

Ounpuu S. Methodological considerations forapplications of the Transtheoretical Model todietary fat reduction [dissertation]. Guelph: Theunivesity of Guelph; 1996.

Ledermann Barbara A. Understanding dietarychange in non insulin dependent diabetes mellitus:an application of the transtheoretical model[dissertation]. Guelph: The University of Guelph;1997.

Cox DN, Anderson AS, Lean ME, Mela DJ. UKconsumer attitudes, beliefs and barriers toincreasing fruit and vegetable consumption.Public Health Nutr. 1998;1: 61-8.

Simmons D, Mesui J. Decisional balance andstage of change in relation to weight loss, exerciseand dietary fat reduction among Pacific Islandspeople. Asia Pac J Clin Nutr. 1999;8: 39-45.

Simmons D, Weblemoe T, Voyle J, Prichard A,Leakehe L, Gatland B. Personal barriers todiabetes care: lessons from a multiethniccommunity in New Zealand. Diabet med.1998;15: 958-64.

López-Azpiazu I, Martinez-González M, León-Mateos A, Kearney J, Gibney M, Martinez J.

Stages of dietary change and nutrition attitudes inthe Spanish population. Public Health. 2000;114:183-9.

Holgado B, de Irala-Estévez J, Martínez-GonzálezM, Gibney M, Kearney J, Martínez J. Barriers andbenefits of a healthy diet in Spain: comparisonwith other European member states. Eur J ClinNutr. 2000;54: 453-9.

Brown J, Harris S, Webster-Bogaert S, WetmoreS, Faulds C, Stewart M. The role of patient,physician and systemic factors in the managementof type 2 diabetes mellitus. Fam pract.2002;19:344.

Vijan S, Stuart N, Fitzgerald J, Ronis D, HaywardR, Slater S, et al. Barriers to following dietaryrecommendations in Type 2 diabetes. Diabet Med.2005;22: 32-8.

Moser R, Green V, Weber D, Doyle C.Psychosocial correlates of fruit and vegetableconsumption among African American men. JNutr Educ Behav. 2005;37: 306-14.

Nagelkerk J, Reick K, Meengs L. Perceivedbarriers and effective strategies to diabetes selfmanagement.J Adv Nurs. 2006,54: 151-8.

. 32. Chang MW, Nitzke S, Guilford E, Adair CH,Hazard DL. Motivators and barriers to healthfuleating and physical activity among low-incomeoverweight and obese mothers. J Am Diet Assoc.2008;108: 1023-8.

Pawlak R, Colby S. Benefits, barriers, selfefficacyand knowledge regarding healthy foods;perception of African Americans living in easternNorth Carolina. Nutr Res Pract. 2009;1(3): 56-63.

Mainvil LA, Lawson R, Horwath CC, McKenzieJE, Hart I. Validated scales to assess adultdecisional balance to eat more fruits andvegetables. Appetite. 2010;55(3): 454-65.

Lawshe C. A quantitative approach to contentvalidity. Personnel Psychology. 1975;28:563-75.

Waltz C, Bausell R. Nursing research: Design,statistics, and computer analysis. 1st ed.Philadelphia: Davis Philadelphia; 1981

Gelaye B, Lohsoonthorn V, Lertmeharit S,Pensuksan WC, Sanchez SE, Lemma S, et al.Construct Validity and Factor Structure of thePittsburgh Sleep Quality Index and EpworthSleepiness Scale in a Multi- National Study ofAfrican, South East Asian and South AmericanCollege Students. PLOS ONE. 2014; 9(12):e116383

Kartal A, Özsoy SA. Validity and reliability studyof the Turkish version of Health Belief ModelScale in diabetic patients. Int J Nurs Stud.2007;44(8): 1447-58.

Marsh HW, Hau K, Wen Z: In search of goldenrules: comment on hypothesis testing approachesto setting cut-off values for fit indexes anddangers in over generalizing Huand Bentler’sfindings. Struct Equ Modeling 2004; 11:320–341.

Schermelleh-Engel K, Moosbrugger H, Müller H:Evaluating the fit of structural equation models:Tests of significance and descriptive goodness-offitmeasures. MPR-online. 2003; 8 (2): 23-74.

Schumacker RE, Lomax RG. A beginner's guideto structural equation modeling. 2nd ed. NewJersey: Lawrence Erlbaum Associates; 2004.

Bowman J, Lannin N, Cook C, McCluskey A.Development and psychometric testing of theClinician Readiness for Measuring OutcomesScale. J Eval Clin Pract. 2009;15(1): 76-84.

Ghazanfari Z, Niknami S, Ghofranipour F,Hajizadeh E, Montazeri A. Development andpsychometric properties of a belief-based PhysicalActivity Questionnaire for Diabetic Patients(PAQ-DP). BMC Med Res Methodol. 2010;10:104.

Prochaska JO. Decision making in thetranstheoretical model of behavior change. MedDecis Making. 2008;28(6): 845-9.

Prochaska JO, Redding CA, Evers K. Thetranstheoretical model and stages of change. InGlanz K, Rimer BK, Viswanath K (ed): Healthbehavior and health education. 4 ed. SanFrancisco: Jossey-Bass, 2004: 97-122.

Henry H, Reimer K, Smith C, Reicks M.Associations of decisional balance, processes ofchange, and self-efficacy with stages of changefor increased fruit and vegetable intake amonglow-income, African-American mothers. J AmDiet Assoc. 2006;106(6): 841-9.

Bawadi H A. Applying the transtheoretical modelto promote greater fruit and vegetableconsumption: A successful approach tomaintaning behavioral change [dissertation].Louisiana: Louisiana state University; 2004.

De Vet E, De Nooijer J, De Vries N, Brug J. TheTranstheoretical model for fruit, vegetable andfish consumption: associations between intakes,stages of change and stage transitiondeterminants. Int J Behav Nutr Phys Act. 2006;3:13.

Abdollahpour I, Nedjat S, Noroozian M,Majdzadeh R. Performing Content ValidationProcess in Development of Questionnaires.Iranian Journal of Epidemiology. 2011;6: 66-74.

Costello AB, Osborne JW. Best Practices inExploratory Factor Analysis: FourRecommendation for Getting the Most From YourAnalysis. Pract Assess Res Eval. 2005;10:1-9.

Newby P, Tucker KL. Empirically derived eatingpatterns using factor or cluster analysis: a review.Nutr Rev 2004;62(5): 177-203.

Steptoe A, Perkins-Porras L, McKay C, Rink E,Hilton S, Cappuccio FP. Psychological factorsassociated with fruit and vegetable intake andwith biomarkers in adults from a low-incomeneighborhood. Health Psychol. 2003;22(2):148-55.

IssueVol 2, No 1 (Winter 2016) QRcode
SectionOriginal Article(s)
Benefits Barriers Dietary fiber Diabetes type 2 Questionnaire validation

Rights and permissions
Creative Commons License This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
How to Cite
Keshani P, Tavousi M, Montazeri A, Farvid M-S. Perceived benefits and barriers of increased dietary fiber consumption: Validation of a decisional balance scale. J Nutr Sci & Diet. 2016;2(1):15-23.