“To eat and to know what you eat”: Exploring perceptions on diet and diet recording among people in a Sri Lankan locality

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This study was a preliminary step in designing a culturally-apt dietary data collection tool that reflects local food culture and eating habits, based on public perceptions of diet and diet recording in Sri Lanka. Three focus group discussions were conducted among a heterogeneous, purposively selected sample of 30 adults to identify perceptions on diet and diet recording, following completion of a standard food diary. Content analysis identified six key themes: i.e. definition of a meal, knowledge on calories, determinants of diet, benefits / difficulties in diet recording and expected improvements of the diet diary. The understanding of a meal, calories and determinants of diet were major components in the perceptions of diet. Individual, family, occasion and time-related and economic factors were identified as determinants of daily diet. Participants stated that documenting diet is useful to define health, nutritional components of a meal and diet control, while time factor was a limitation. A user-friendly diet diary was expected to include information on balanced diet and diet-related diseases, appearance, instructions and food lists to choose from. These findings are important in designing culturally appropriate tools for the dietary assessment in the management of non-communicable diseases. Diet Diet recording tools. Perception of diet Experience of diet recording Introduction The diet is recognized as an important determinant of the quality of life as well as the progression of diseases ( 1 ). Healthy diet is considered as a basic human right and it is essential to maintain a healthy life ensuring the prevention of malnutrition and to reduce the risk of non-communicable diseases such as heart diseases, diabetes mellitus and diet related cancers ( 2 ). Having a healthy diet is vital to maintain a healthy weight by achieving energy balance. The dietary recommendations for a healthy diet include limiting energy intake from total fats, replacing saturated fats with unsaturated fats and eliminating trans fatty acids, increasing consumption of fruits, vegetables, legumes, whole grains and nuts, reducing the intake of sugars and limiting salt consumption ( 3 ). The key properties of a healthy diet also requires ensuring sufficient intake of micronutrients, macronutrients and energy to meet the requirement without excess, maintaining appropriate balance of macronutrients (carbohydrates, proteins and fats), maintaining the diversity of diet by consuming a wide variety of food groups and limiting the food groups that are associated with the development of non-communicable diseases( 2 )( 4 ). A proper definition of “healthy diet” will be beneficial to deliver appropriate health education on nutrition on an individual basis as well as population basis and to deliver specific guidelines for the management of patients with diet-related diseases ( 1 ). In a healthy diet, to maintain a healthy energy balance the daily uptake of total calories without affecting the nutritional balance is important ( 5 ), however, when considering the public perception on a healthy diet based on calorie count many exhibit lack of knowledge, where in a study done among Italian consumers the statement “A healthy diet is based on calorie count” was neither agreed nor disagreed by a majority of the participants ( 6 ). With the global nutrition transition and the effects of colonisation in the in South Asian region, the population rapidly changed their diet from a diet rich in unrefined grains, legumes, vegetables and fruits to one that is rich in refined carbohydrates, sugar and fat ( 7 )( 8 )( 9 ). Similarly, their food habits changed from homemade food consumption to highly processed food consumption and out of home eating ( 8 ). Sri Lanka, too, has undergone similar changes with the effect of global and regional nutrition transition ( 10 ). Sri Lankan diet mainly consist of high amounts of starch and pulses with less amount of dairy products, fruits and vegetables ( 11 ). Analysis of the findings from the World Health Organization (WHO) STEPS data revealed insufficient consumption of fruits and vegetables among Sri Lankans ( 12 ). Recent research evidence shows that a considerable proportion of Sri Lankan population does not consume a diverse and a balanced diet leading to unhealthy eating habits ( 13 )( 14 ). Therefore, better measurements and the monitoring of dietary habits is much needed for the promotion of healthy diets among people and establishment of policies and programs by the governments to promote healthy eating in communities in any country ( 2 ). A meal from food science perspective is described with the components, size, nutrient composition and energy content, while in nutrition and health perspective it is described in relation to dietary or nutritional guidelines, specific health outcomes, specific nutrient components and related health outcomes. However, in cultural and communication perspectives a meal is viewed as a social linkage with family and a family meal is shown as a cultural icon ( 15 ). The motives influencing food choices such as health and nutrition perceptions, psychological factors, sociocultural influences, sensory appeal, social interactions, socio-demographics and ethical concerns. Food environment related factors that affect food choices are food affordability, convenience, food availability and promotional information. ( 16 ) Scientific literature also describes attention to health, food waste, food labels and economic and availability factors and dietary components such as palatability and alcohol, cognitive affective factors (stress, anxiety, depression) and familial and genetic influences as determinants of food choice ( 6 ) ( 17 ). Food choices are not determined only by stimulation from food or hunger, but also the food preferences and desires developed throughout the life through experience and attitude ( 18 ). While the nutrition knowledge correlates positively with healthy food choices, the knowledge on calories does not show any correlation with the choice of food ( 19 ). On the other hand, some individuals may have physiological and psychological influences such as being overweight or obese to develop a tendency towards a greater liking for energy dense food ( 18 ). Therefore, understanding the food choice behavior is also beneficial for dietary modification in the prevention and control of non-communicable diseases, lifestyle modification and establishing nutrition related policies ( 17 )( 18 ). Most widely used dietary assessment methods include 24 hour dietary recall, food frequency questionnaire, food record (food diary), brief dietary assessment instruments known as diet screeners and nutritional biomarkers ( 2 ). The diet record or the food diary is a comprehensive recording of all food items, beverages, dietary supplements for three to seven consecutive days including both weekdays and the weekend ( 20 ). The strength of the diet diary is the relatively accurate information on individual meals and eating frequency, while the decreasing completion rate over time is identified as a limitation ( 21 ). However, any method of diet recording is known to encounter difficulties in estimating the amount of food item consumed, documenting the method of preparation of a food item, description of food items consumed in restaurants, and comprehensive recall ( 22 ) ( 23 ). Sometimes, the respondents may tend to eat with less variety, limiting the food choices and avoiding healthier eating patterns to make it easier to log the food items, although the mindfulness created by journaling can lead to healthier choices or the difficulty in entering certain food items in current designs may negatively impact a person’s food choices ( 22 ). Moreover, people might avoid recording exactly what they had in their meal or completely stop diet recording due to the fear of stigma and judgment, if the food they consumed are considered unhealthy or of poor quality ( 22 ). Similarly, there is a tendency to log the socially desirable food items, limiting the accuracy of the data ( 23 ). Despite these shortcomings, diet recording can provide an understanding of the unhealthy food consumption patterns, helping to transform into more healthier food choices and eating patterns ( 22 ) ( 24 ). The widely used dietary data collection tools have been developed in high income countries and are not apt to measure the South Asian or the Sri Lankan diet. Hence, the development of a culturally grounded dietary data collection tool based on observations and in discussion with the local communities is an important step towards accurate study of the dietary patterns and eating behaviours in the local context. To obtain a detailed understanding of the dietary needs and practices, it is important to understand the perception of diet. Additionally, understanding the expectations of the public on dietary data collection tools are important for their cultural adaptation. A diet diary data collection tool that has been shaped by the public perceptions on diet and diet recording and designed to capture the local food choices and patterns, will provide a broader understanding to the healthcare workers in assessing the patients’ diet in relation to the control of diet-related diseases. Hence, there is a urgent need for a culturally appropriate dietary data collection tool to study dietary patterns in the Sri Lankan setting. This study was designed to explore the perception of the diet and diet recording among the adult Sri Lankan population as a preliminary step of fulfilling this need. Methods Study design and setting This qualitative study used three focus group discussions (FGDs), conducted in Warakapola health unit area, Kegalle District, Sri Lanka. Purposive sampling was carried out to include both males and female adults representing different ages, educational levels and occupations to ensure the diversity of the information collected. Following discussions with the Medical Officer of Health of the area, three settings in Warakapola; namely, Alpitiya Public Health Midwife area (n = 10), Tholangamuwa Central Collage (n = 9) and Warakapola Divisional Secretariat Office (n = 11) were selected to recruit the participants for the focus group discussions. Once the participants were recruited, a standard diet diary was distributed to record their dietary intake including the date, items of food or drinks consumed during the day and the amount of each food or drink consumed. The participants were asked to fill the diet diary for seven consecutive days and the instructions were provided on maintaining the diet diary. Data collection instrument The focus group discussions were conducted using a discussion guide that contained an introduction to the discussion and guidance questions. The discussion guide was developed by the research team specifically for the purpose of this research and the questions were based on the findings of a thorough literature review conducted under two domains: i.e. the perception of diet and dietary behaviors and the experience of using the diet diary including the benefits and difficulties identified during diet recording. The guidance questions were constructed to facilitate the discussion with a good flow of conversation throughout and to ensure uniformity in data collection (Supplementary file 01). It was pretested on five individuals with different socio-economic backgrounds to identify the appropriateness of the questions, clarity, wording and flow of ideas to ensure that the discussions will be likely to elicit rich descriptive responses. Data collection The focus group discussions were carried out in a comfortable room with no disturbances and written, informed consent was obtained from all participants prior to the discussion. The discussions started with a brief introduction of its purpose by the moderator. The participants were allowed to freely express their ideas, but were directed if necessary facilitating them to express their ideas on the topic. Each discussion lasted approximately 40–60 minutes. All discussions were conducted in Sinhala and were audio-recorded. In addition, contextual notes were taken and observations were recorded during the discussion. The discussions were focused on their ideas of what a meal or diet is, how many meals they usually consume per day, ideas and knowledge on calories and nutrients, factors affecting the preparation or consumption of a meal, the idea of connection between the meals and the health, their experience of filling the diet dairy including the difficulties they faced and the interesting aspects which they really enjoyed about filling it. At the end of the sessions, the key points discussed were summarized and the participants were given the opportunity to express any final thoughts or observations before concluding the discussion. The participants’ personal queries on diet were discussed and clarified accordingly. Data analysis Once the discussions were over, the conversations were transcribed verbatim and were translated to English by a bilingual expert. Participants were de-identified during transcribing. Findings of the interviews were coded and thematically analysed. The basic content analysis was done manually. The themes were developed inductively based on the different sections in the focus group discussion guide. Identification of themes, categorization and the development of final themes were carried out with the consensus of the research team. Ethical aspects Ethical clearance for the study was obtained from the Ethics Review Committee, Faculty of Medicine, University of Kelaniya, Sri Lanka (P/23/04/2022). Informed written consent was obtained, allowing the participants the freedom to withdraw from the study at any point during the study implementation without prejudice. All the discussions were conducted at the participants’ convenience in a separate room with privacy, without disturbing the official activities of the institutions. The administrative approval was taken from the Regional Director of Health Services, Kegalle and the Medical Officer of Health, Warakapola. Results Socio-demographic profile of the participants The participants were recruited in three settings and included both males and females of varying socio-economic backgrounds. The first setting, Alpitiya Public Health Midwife area, was a rural village. The participants (n = 10) were in their mid-thirties to late fifties with educational levels ranging from primary education to General Certificate of Education (GCE)-Ordinary Level and included drivers, housewives, farmers and a small village restaurant owner. The second setting was the Divisional Secretariat Office Warakapola and the participants (n = 11) were aged from mid-twenties to mid-fifties. Their educational levels ranged from GCE-Ordinary Level to degree level and the sample consisted of manual labourers, skilled labourers, clerical staff and administrative officers. The third setting was Tholangamuwa Central Collage and the participants (n = 9) were teachers in Science, Commerce and Arts subject streams, aged between mid-twenties to mid-fifties with educational levels ranging from diploma to degree level . Perceptions on diet and diet recording Basic content analysis was used to identify the presence, meanings and the relationships of certain words within the context of focus group discussions and the codes and the themes were derived (Table 01 ). Table 01 Themes and codes of perception on diet and diet data collection tool Themes Codes Conceptualization of a meal [What is a meal?] Nutritional components Balance of nutrients Effects on health Knowledge on calories Meaning of calories How calories affect my health Determinants of the daily diet Individual factors Family factors Availability of food items Special occasions Time factors Socioeconomic factors Benefits of diet record keeping Being conscious on meals Being conscious on effects of meals Intentional cut down on meals Difficulties in diet record keeping Time factor Fear of stigma Expectations of the improvements of the diet diary Information Appearance Guidance notes Convenience The themes were organized into two distinct domains; namely, the perception of diet and dietary behaviour and experience of using the diet diary. Domain 1: The perception of diet and dietary behavior Three themes emerged under the perceptions of diet and dietary behaviour, which included conceptualization of a meal, knowledge on calories and determinants of the daily diet. Theme 1: Conceptualization of a meal [what is a meal?] The codes “nutritional components”, “balance of nutrients” and “effects on health” were used to express the theme “What is a meal”. The simplest expression of a meal was that it was ‘something that satisfies our hunger’. Majority expressed the ideas on a meal as an essential thing for life. Different participants used different terms and words to express this complex idea. The better educated participants addressed the complex nature of a meal by discussing that it is a ‘balanced diet’ and that a meal is something that should have a ‘nutritional value’. Some participants with more sophisticated understanding elaborated that a meal consisted of ‘carbohydrate, starch, fat, protein, vitamin and mineral salts’. When discussing the nutritional value of a meal, a participant who is a house wife and part time worker in a small village restaurant expressed her view on bioavailability of the nutrients and the importance of preserving them, elaborating on the practice in relation to cooking green leaves. W hen completely cooked the nutritional components will be destroyed W hen we prepare mallum [green leaves] it should be taken lightly cooked not to destroy the nutritional components Overall, the participants had a clear idea of the categories of food which contain certain nutrients; e.g. fruits and vegetables as a source of vitamins. Other than nutritional components and the balance of nutrients, the participants discussed the effect of the meal as one aspect of their perceptions, particularly the effects of an unhealthy diet. They stated that food containing too much fat and oil will lead to illnesses and that they avoid such meals as much as possible, indicating that they understand the meal is related to their health. Theme 2: Knowledge on calories Two codes; namely “what calorie means to us” and “how calories affect my meal” emerged from the analysis and were used to develop the theme “knowledge on calories”. The code “what calories means to us” was based on the ideas of existence of ‘ something called a calorie ’, meaning it as ‘energy’ and the knowledge of food rich in calories. The participants stated that they have heard of it, while some better-educated participants expressed it as energy. The participants were able to identify the high calorie food categories as sweets, starchy food and foods containing oils and fat. Something stored in food we need for the energy It’s different in different foods Some participants reported that they have never heard of calories. Some of the participants shared their ideas on applying the knowledge on calories in purchasing food items from the market. They stated that if it is mentioned on the packaging, they will be able to identify the caloric content in a certain food. However, they also mentioned that sometimes even if it is printed on the packaging, they might not pay attention to it when purchasing foods. Some participants mentioned that they particularly check these when they purchase food for kids rather than for themselves. One participant who was a school teacher stated that he is much more attentive on side effects or any unhealthy additives of the food during purchasing than on calories. Theme 3: The determinants of the daily diet The participants discussed ‘what really determines their diet’ and expressed that the factors such as what they like to eat [individual food preferences], taste, whether having an illness or not, physical appearance of the body, what is easy for them to prepare, as a tradition will influence their decision on what to eat. These ideas were coded as “individual factors” that determine the daily meal, which depend on the person him or herself. There was a clinic here in December and when I measured my weight there, it was 78 kilograms. Waist was 100 centimetres. From that day onwards I thought I will reduce the amount of rice I eat. I eat only one spoon of rice now. When I bring the lunch to the office I bring more curries. Earlier I used to eat lot of jack curry when I return from work, if it was prepared at home. But now I don’t do that. Now my weight has reduced to 66.5 kilograms. Waist is also reduced One participant stated that the meal menu depends on children’s and husband’s preferences. Another participant mentioned that dinner will be more perfectly prepared since all the family members are available to eat together during the night. Therefore, “family factors” were also coded as a determinant of the daily diet. “Nutritional factors” was another main code identified under determinants of a meal. Participants mentioned adding green leaves and having at least two different curries for a meal to ensure the nutritional value of the meal. Some participants stated special preparation methods even to preserve the nutrients in the meal such as eating green leaves as half cooked or eating without cooking. Many stated “availability of the food item” as another determinant. M ost of the time it’s what kids like to eat …or maybe husband likes to eat. Sometimes it’s what’s available at home to prepare Sometimes family members prefer rice instead of other food prepared with flour “W hen we prepare “mallum” should be taking it as lightly cooked so as not to destroy the nutritional components. Trying to take things as minimally cooked because when it’s completely cooked, the nutritional components will be destroyed ”. The food intake also differed according to “special eating occasions”. As one participant who was a driver mentioned, “ When we drink alcohol, we take bites with alcohol and that’s all; will never take dinner after that ”. The “socio-economic status” and the “time” were the other two factors that influence the decision on what to eat. The participants mentioned that if there is less time for cooking they will select the things they can prepare fast. The participants also stated that their financial status will determine what they can afford as food in day-to-day life, when buying pre-cooked meals or buying raw material to prepare food at home. What can be prepared easily … with the available time Have to check for money with current situation Domain 2: The experience of using the diet diary, benefits and the difficulties identified of using the diet diary. The ideas and the experience of filling a standard diet diary were discussed under this domain. Prior to the discussions, the participants were provided with a standard diet diary and were advised to fill it for seven continuous days. Three themes emerged from the discussion; namely, benefits of the diet record keeping, difficulties in diet record keeping and their expectations for improvement of the diet diary. Theme 4: Benefits of diet record keeping Participants discussed the benefits of record keeping in a diet diary and three codes, “being conscious on meals”, “being conscious on effects of meals”, and “intentional cut down on meals” emerged from the discussion. The participants expressed that, by having records of diets, they could check what they eat, assessing “whether they really need to eat this much”. Also diet recording was said to help in assessing the nutritional components included in their meals and identifying the components that are lacking. One participant who was a teacher mentioned that since they have different dietary patterns, maintaining the diary motivates them to practice a healthier eating behavior. Participants also stated that when they started diet recording they were conscious about the amount of food consumed and then they could adjust their physical activity level according to the amount they eat. This explains that they were conscious on the quantity and type of food, as well as not to exceed the daily requirement of the food and healthy eating while filling the diet dairy. Sometimes when the doctor asked to write, even if we are used to a different food pattern we tend to get into healthy food habits and may avoid bad food behaviours… it’s really worth We can find what we are lacking in nutrition These ideas were coded as “Being conscious on meals”. The participants also noted the importance of “being conscious on effects of meals”. A participant who was a housewife stated that food and illness had a close association and perceived diet record keeping as a useful exercise to observe these effects. I filled it as I thought sometimes we will be able to check our illnesses with this, since our illnesses depend on what we eat When some of the participants started recording the meals they had started to control their diet. One participant who was a teacher reported that when she started to maintain the diet diary she remembered that her personal physician has advised her to control her diet since she is overweight. Hence, naturally she started controlling her diet. When inquired on the reason for filling the diet diary from the participants who completed it properly, and another participant claimed, I felt when I started writing there will be a control on what I eat, since I have to write what I eat These ideas were coded as “intentional cut down on meals”. Theme 5: Difficulties in diet record keeping Under this theme, two codes were identified as “time factor” and “fear of stigma”. The participants explained on the difficulty in record keeping due to demands on time. The participants who could not complete the given diet diary have expressed their ideas as, We didn’t have time. We have lot of work. Otherwise we could have filled it It is hard to write with the busy schedule One participant, who is working as a clerk expressed his idea as, People who have low economic status might not be having meals, but might not like to tell that they have not eaten. So they might not fill the diary Theme 6: Expectations of the improvements of the diary The codes “information needs”, “appearance”, “guidance notes” and “convenience” were combined to develop the theme “Expectations of the improvements of the diary”. With the experience of filling the diet diary, there were many suggestions on including the nutritional information such as the balanced diet, nutritional value of food and diseases that are related to the diet. One participant who was in officer category stated that, The importance of a meal, what is a balanced diet, people might not be knowing how to prepare a balanced diet easily. If we can provide suggestions on that including information on food it would be better A participant stated that it would be nice to include the information on adjusting diet according to activity level. If someone works hard (physical) they have to eat more. But if a person who doesn’t work hard need not to eat a lot….I think it would be nice if you have mentioned that in the booklet Another main concern was that diet recording tool should be more attractive in appearance. If you design it attractively just like baby’s clinic card printed in a nicer way The participants explained the importance of having guidance notes on how to fill the diet dairy and displaying the portion sizes of commonly consumed food including cultural food items. Some participants preferred to have a list of food items to tick, that would facilitate time management and also help people with low literacy. There are no instructions given Since we have a higher educational level we tend to do these kind of things. We think this is a must-do. But when doctors give this to general public [patient] they may miss this … since there is a lot to fill. If there was a list to tick would have been better and easy. If we eat rice we can mark it....something like that... In summary, participants expressed the idea that meals are essential for living and that food contain specific nutrients necessary for health. While most participants expressed their awareness of calories, only a few had a clear understanding of its meaning as a unit of energy. Various factors that determine a person’s diet were identified. The participants’ ideas and expectations on a user friendly, interesting diet diary recommended including information on a balanced diet, nutritional value of food, diseases related to diet, improving the appearance, including guidance notes and convenient food lists to choose from. The participants thought that the diet diary can be used to track one’s illnesses, assess the nutritional quality of a meal and control diet. When discussing the difficulties faced during filling the diet dairy, the time factor was stressed as the main limitation. Discussion This qualitative exploration of the perception of diet and diet recording was done among 30 males and females diverse in age, education and socio-econmic level using focus group discussions. Six themes were identified as perceptions on diet and diet recording, which included “what is a meal?”, “knowledge on calories”, “determinants of the daily diet”, “benefits of diet record keeping”, “difficulties in diet record keeping” and “expectations of the improvement of the diet diary”. The key findings include having the idea of diet as a collection of food with different nutritional values, which consists of carbohydrates, proteins, lipids, minerals and vitamins with a balance between these nutrients. The determinants of an individual’s diet was related to the individual person as well as the surrounding environment such as the family, economy and time. It was an alarming finding that people were not much knowledgeable or are concerned about calories, despite Sri Lanka being one of the countries with high literacy in South Asia ( 25 ). In recording diet, the time constraints and the economic status were reported as the barriers for accurate recording and participants identified being conscious and mindful of the meals, being conscious on effects of meals and intentional cut down of the meal as the beneficial aspects of recording their own diet. In literature, the concept of diet is related with nutrition and human health ( 1 ). A nutritionally well balanced diet or a collection of food with good nutritional value was identified as crucial for a healthy life ( 2 ). Therefore, the concept of healthy diet was defined in relation to diseases and was correlated to the negative health outcomes and lack of wellbeing. Similarly, in the current study the concept of a meal was described with nutrition related ideas and the notions related to the connection between health and diet. Further, the balanced diet was elaborated as consisting of carbohydrate, starch, fat, protein, vitamin and minerals, whereas in the literature it is defined that the key properties of healthy diet is ensuring sufficient intake of micronutrients, macronutrients and energy to meet the requirement without excess, maintaining appropriate balance of macronutrients carbohydrates, proteins and fats ( 2 )( 4 ). The ideas on calories were expressed merely as knowing the word and that it is related to energy, in keeping with the existing literature. A study done by Wongprawmas et al among Italian consumers revealed that the majority of the participants were uncertain about the statement ‘A healthy diet is based on calorie count’ ( 6 ). The knowledge on calorie was not correlated with the food choices ( 19 ). Similarly in this study, the participants stated that even if the calorie count is stated in packaging they might not consider it when purchasing the food. This proves that the idea of calories need to be emphasized more in nutrition education, in addition to the nutritional quality of the food items. The factors that determine the diet were similar to the factors reported in literature ( 16 ) ( 17 )( 18 )( 19 ), however, one participant remarkably stated how her body weight and the waist size altered her dietary behavior in a healthy manner, aiming to reduce weight and waist. In the literature, it is mentioned that the physiological and psychological influences such as being overweight or obese incline towards a greater liking for high energy density food ( 18 ). This shows that in this sample, the body image plays a major role as a dietary determinant than the physiological or psychological influence, shifting the dietary behavior towards the healthy behaviours related to weight management. Though the food waste and food labeling did not emerge as dietary determinants in this study as mentioned in previous literature ( 6 ), the family factors exerted more weightage on food choices, demonstrating the cultural value of the family as a unit which influences a person’s dietary choices. In this study special occasions were a determinant of the diet and the relationship between the diet and alcohol intake was discussed. Similarly, the existing literature shows a link between alcohol and food choices ( 17 ). However, the participant in this study stated that eating snacks with alcohol leads to avoiding the main meal, while in literature it was stated that alcohol and food are linked with palatability. Though it was mediated through different mechanisms, the present study confirms that alcohol also affects the dietary behavior of people. The benefits and barriers of diet recording elaborated in this study are similar to those mentioned in the literature ( 22 )( 23 ), however, the participants in this study had more positive ideas on the benefits of record keeping such as being mindful of what they eat and intentional cut down of the diet as needed according to their medical condition or to maintain a healthy lifestyle (e.g. healthy body weight). Both in literature and in the present study findings, the participants have expressed their fear of stigma of diet recording, while in the literature it was identified as the unwillingness to show others the diet records ( 22 ) and the present study participants indicated reluctance of recording the things they eat, revealing the poor diet quality due to low socio-economic status. Though the reluctance of reporting was highlighted as a barrier, the participants did not attempt to change their food choices or including false information in the diet diary to provide ‘socially desirable’ responses. Conversely, according to literature, measures such as limiting the food choices, eating less and selecting instant or packed food have been adopted to ease the recording procedure ( 23 ). This is a negative impact on the data quality of diet recording, though the participants of the present study had no intention of changing their dietary behavior, indicating a positive mindset. The strengths of this study in assessing the perception on diet and diet recording include the sampling procedure which allowed the inclusion of a diverse group of male and female adults representing different ages, educational and socio-economic levels to ensure the richness of the information elicited. However, cultural diversity of the sample could not be achieved since the sample was limited only to the Sinhalese, which was a major limitation of the study. In future studies, it would be beneficial to assess the perception on diet and diet recording in Tamil and Muslim communities to elicit more comprehensive and culturally-specific information. Conclusion The present study revealed public perceptions on diet and diet recording under six main themes. The findings reveal a sound general awareness of diet and positive ideas on diet recording with an inadequate understanding of calories. The public should be empowered with the knowledge on calories and how to use the knowledge on calories and nutritive values for the selection of healthier food items and preparation of healthy meals. It would be much beneficial to incorporate this knowledge to the school curriculum, both in theory and practice, with the activities of the school health program. The findings of this study can be used to design culturally appropriate dietary data collection tools, addressing the public expectations. Further research in multicultural settings would be beneficial to evaluate the cultural influences on the perceptions of diet. Declarations Ethics approval and consent to participate The authors declare that Ethical approval for the study was obtained from the Ethics Review Committee, Faculty of Medicine, University of Kelaniya (Registration No. P/23/04/2022). Administrative approval was obtained from all relevant authorities (District Secretariat Kegalle District, Regional Director of Health Services-Kegalle District, Medical Officer of Health, warakapola). Informed written consent was obtained from all participants before data collection. Study was conducted while adhering to the World Medical Association Declaration of Helsinki on ethical principles for medical research involving human subjects. Consent for publication In the current study consent for publication is not applicable as no individual-level data with identification was included in the manuscript. Funding The study was self-funded by the corresponding author. Author Contribution Rajakaruna VPC did the planning the research project, data collection, content analysis and manuscript writing. Chandana GJ and Athuda LK provided the technical guidance. Wijesinghe CJ and Kasturiratne supervised the research project. All authors read and approved the manuscript. Acknowledgement Regional Director of Health and the staff, RDHS Office, KegalleMedical officer of Health and the staff, Warakapola MOH Divisional secretary and the staff, Divisional Secretariat Office, WarakapolaThe Principal and the staff, Tholagamuwa Central Collage, Warakapola Data Availability The recordings of focus group discussions, the transcriptions and the translations used for the manual content analysis during the current study are available in the following link.https://drive.google.com/drive/folders/1eJS3g-ahE7u_cWl5qNTadaIJNdrzxnF6?usp=sharing References Cicero AFG, Fogacci F, Borghi C. An Evolving Definition of a “Healthy Diet”. Nutrients. 2023;15(9):2–4. World Health Organization (WHO). Guidance for monitoring healthy diets globally [Internet]. Available from: https://www.who.int/publications/i/item/9789240094383 Hatherall D. Global strategy on Diet, Physical Activity and Health. WHO. 2004;2002(May):314–23. Cena H, Calder PC. Defining a healthy diet: Evidence for the role of contemporary dietary patterns in health and disease. Nutrients. 2020;12(2):1–15. Rattan SIS, Kaur G. Nutrition, Food and Diet in Health and Longevity: We Eat What We Are. Nutrients. 2022;14(24):1–7. Wongprawmas R, Mora C, Pellegrini N, Guiné RPF, Carini E, Sogari G, et al. Food choice determinants and perceptions of a healthy diet among Italian consumers. Foods. 2021;10(2). Ministry of Women and Child Development G of I. Nutrition transition in India 1947-2007. 2007;5:131–46. Available from: http://wcd.nic.in/research/nti1947/NTI1947CONTENT.htm World Health Organization (WHO). https://www.who.int/southeastasia/health-topics/nutrition. Bishwajit G. Nutrition transition in South Asia: The emergence of non-communicable chronic diseases. F1000Research. 2015;4(0). Weerasekara PC, Withanachchi CR, Ginigaddara GAS, Ploeger A. Nutrition transition and traditional food cultural changes in Sri Lanka during colonization and post-colonization. Foods. 2018;7(7):1–18. Jayawardena R, Thennakoon S, Byrne N, Soares M, Katulanda P, Hills A. Energy and nutrient intakes among Sri Lankan adults. Int Arch Med. 2014;7(1):1–11. Biswas T, Townsend N, Gupta R Das, Ghosh A, Rawal LB, Mørkrid K, et al. Clustering of metabolic and behavioural risk factors for cardiovascular diseases among the adult population in South and Southeast Asia: findings from WHO STEPS data. Lancet Reg Heal - Southeast Asia [Internet]. 2023;12:100164. Available from: https://doi.org/10.1016/j.lansea.2023.100164 Jayawardena R, Byrne NM, Soares MJ, Katulanda P, Hills AP. Validity of a food frequency questionnaire to assess nutritional intake among Sri Lankan adults. Springerplus. 2016;5(1):1–6. Jayawardena R, Byrne NM, Soares MJ, Katulanda P, Hills AP. Food consumption of Sri Lankan adults: An appraisal of serving characteristics. Public Health Nutr. 2013;16(4):653–8. Life E. Exploring the meal concept – an interdisciplinary literature overview. 2015;(12). Karanja A, Ickowitz A, Stadlmayr B, McMullin S. Understanding drivers of food choice in low- and middle-income countries: A systematic mapping study. Glob Food Sec [Internet]. 2022;32:100615. Available from: https://doi.org/10.1016/j.gfs.2022.100615 Leng G, Adan RAH, Belot M, Brunstrom JM, De Graaf K, Dickson SL, et al. The determinants of food choice. Proc Nutr Soc. 2017;76(3):316–27. Mela DJ. Determinants of food choice: relationships with obesity and weight control. Obes Res. 2001;9 Suppl 4(November). Koch F, Hoffmann I, Claupein E. Types of Nutrition Knowledge, Their Socio-Demographic Determinants and Their Association With Food Consumption: Results of the NEMONIT Study. Front Nutr. 2021;8(February):1–11. Bailey RL. HHS Public Access. PMC. 2021;91–6. Illner AK, Freisling H, Boeing H, Huybrechts I, Crispim SP, Slimani N. Review and evaluation of innovative technologies for measuring diet in nutritional epidemiology. Int J Epidemiol. 2012;41(4):1187–203. Daniel E Shumer, Natalie J Nokoff NPS, Erin C. Dowd, M.D.a, Michael J. Frank, Ph.D.b, Anne Collins, Ph.D.c, James M. Goldd, and Deanna M. Barch PD. Barriers and Negative Nudges: Exploring Challenges in Food Journaling HHS Public Access. Physiol Behav. 2017;176(12):139–48. Ortega RM, Perez-Rodrigo C, Lopez-Sobaler AM. Métodos de evaluación de la ingesta actual: Registro o diario dietético. Nutr Hosp. 2015;31:38–45. Bailey RL. Overview of dietary assessment methods for measuring intakes of foods, beverages, and dietary supplements in research studies. Curr Opin Biotechnol [Internet]. 2021;70:91–6. Available from: https://doi.org/10.1016/j.copbio.2021.02.007 south-asia-highest-literacy-rate @ gospelforasia.org [Internet]. Available from: https://gospelforasia.org/functional-illiteracy/south-asia-highest-literacy-rate Additional Declarations No competing interests reported. Supplementary Files Supplimentaryfile01Focusgroupdiscussionguide.pdf Cite Share Download PDF Status: Published Journal Publication published 26 Nov, 2025 Read the published version in BMC Public Health → Version 1 posted Editorial decision: Revision requested 29 Jul, 2025 Reviews received at journal 28 Jul, 2025 Reviewers agreed at journal 20 Jul, 2025 Reviews received at journal 19 Jul, 2025 Reviews received at journal 30 Jun, 2025 Reviewers agreed at journal 27 Jun, 2025 Reviewers agreed at journal 23 Jun, 2025 Reviewers invited by journal 12 Jun, 2025 Editor assigned by journal 12 Jun, 2025 Editor invited by journal 30 May, 2025 Submission checks completed at journal 29 May, 2025 First submitted to journal 29 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Healthy diet is considered as a basic human right and it is essential to maintain a healthy life ensuring the prevention of malnutrition and to reduce the risk of non-communicable diseases such as heart diseases, diabetes mellitus and diet related cancers (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Having a healthy diet is vital to maintain a healthy weight by achieving energy balance.\u003c/p\u003e \u003cp\u003eThe dietary recommendations for a healthy diet include limiting energy intake from total fats, replacing saturated fats with unsaturated fats and eliminating trans fatty acids, increasing consumption of fruits, vegetables, legumes, whole grains and nuts, reducing the intake of sugars and limiting salt consumption (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). The key properties of a healthy diet also requires ensuring sufficient intake of micronutrients, macronutrients and energy to meet the requirement without excess, maintaining appropriate balance of macronutrients (carbohydrates, proteins and fats), maintaining the diversity of diet by consuming a wide variety of food groups and limiting the food groups that are associated with the development of non-communicable diseases(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eA proper definition of \u0026ldquo;healthy diet\u0026rdquo; will be beneficial to deliver appropriate health education on nutrition on an individual basis as well as population basis and to deliver specific guidelines for the management of patients with diet-related diseases (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). In a healthy diet, to maintain a healthy energy balance the daily uptake of total calories without affecting the nutritional balance is important (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e), however, when considering the public perception on a healthy diet based on calorie count many exhibit lack of knowledge, where in a study done among Italian consumers the statement \u0026ldquo;A healthy diet is based on calorie count\u0026rdquo; was neither agreed nor disagreed by a majority of the participants (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eWith the global nutrition transition and the effects of colonisation in the in South Asian region, the population rapidly changed their diet from a diet rich in unrefined grains, legumes, vegetables and fruits to one that is rich in refined carbohydrates, sugar and fat (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e)(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Similarly, their food habits changed from homemade food consumption to highly processed food consumption and out of home eating (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Sri Lanka, too, has undergone similar changes with the effect of global and regional nutrition transition (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eSri Lankan diet mainly consist of high amounts of starch and pulses with less amount of dairy products, fruits and vegetables (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Analysis of the findings from the World Health Organization (WHO) STEPS data revealed insufficient consumption of fruits and vegetables among Sri Lankans (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Recent research evidence shows that a considerable proportion of Sri Lankan population does not consume a diverse and a balanced diet leading to unhealthy eating habits (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e)(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Therefore, better measurements and the monitoring of dietary habits is much needed for the promotion of healthy diets among people and establishment of policies and programs by the governments to promote healthy eating in communities in any country (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e A meal from food science perspective is described with the components, size, nutrient composition and energy content, while in nutrition and health perspective it is described in relation to dietary or nutritional guidelines, specific health outcomes, specific nutrient components and related health outcomes. However, in cultural and communication perspectives a meal is viewed as a social linkage with family and a family meal is shown as a cultural icon (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). The motives influencing food choices such as health and nutrition perceptions, psychological factors, sociocultural influences, sensory appeal, social interactions, socio-demographics and ethical concerns. Food environment related factors that affect food choices are food affordability, convenience, food availability and promotional information. (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) Scientific literature also describes attention to health, food waste, food labels and economic and availability factors and dietary components such as palatability and alcohol, cognitive affective factors (stress, anxiety, depression) and familial and genetic influences as determinants of food choice (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Food choices are not determined only by stimulation from food or hunger, but also the food preferences and desires developed throughout the life through experience and attitude (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). While the nutrition knowledge correlates positively with healthy food choices, the knowledge on calories does not show any correlation with the choice of food (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). On the other hand, some individuals may have physiological and psychological influences such as being overweight or obese to develop a tendency towards a greater liking for energy dense food (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Therefore, understanding the food choice behavior is also beneficial for dietary modification in the prevention and control of non-communicable diseases, lifestyle modification and establishing nutrition related policies (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMost widely used dietary assessment methods include 24 hour dietary recall, food frequency questionnaire, food record (food diary), brief dietary assessment instruments known as diet screeners and nutritional biomarkers (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). The diet record or the food diary is a comprehensive recording of all food items, beverages, dietary supplements for three to seven consecutive days including both weekdays and the weekend (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e). The strength of the diet diary is the relatively accurate information on individual meals and eating frequency, while the decreasing completion rate over time is identified as a limitation (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). However, any method of diet recording is known to encounter difficulties in estimating the amount of food item consumed, documenting the method of preparation of a food item, description of food items consumed in restaurants, and comprehensive recall (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Sometimes, the respondents may tend to eat with less variety, limiting the food choices and avoiding healthier eating patterns to make it easier to log the food items, although the mindfulness created by journaling can lead to healthier choices or the difficulty in entering certain food items in current designs may negatively impact a person\u0026rsquo;s food choices (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Moreover, people might avoid recording exactly what they had in their meal or completely stop diet recording due to the fear of stigma and judgment, if the food they consumed are considered unhealthy or of poor quality (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e). Similarly, there is a tendency to log the socially desirable food items, limiting the accuracy of the data (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). Despite these shortcomings, diet recording can provide an understanding of the unhealthy food consumption patterns, helping to transform into more healthier food choices and eating patterns (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe widely used dietary data collection tools have been developed in high income countries and are not apt to measure the South Asian or the Sri Lankan diet. Hence, the development of a culturally grounded dietary data collection tool based on observations and in discussion with the local communities is an important step towards accurate study of the dietary patterns and eating behaviours in the local context. To obtain a detailed understanding of the dietary needs and practices, it is important to understand the perception of diet. Additionally, understanding the expectations of the public on dietary data collection tools are important for their cultural adaptation.\u003c/p\u003e \u003cp\u003eA diet diary data collection tool that has been shaped by the public perceptions on diet and diet recording and designed to capture the local food choices and patterns, will provide a broader understanding to the healthcare workers in assessing the patients\u0026rsquo; diet in relation to the control of diet-related diseases. Hence, there is a urgent need for a culturally appropriate dietary data collection tool to study dietary patterns in the Sri Lankan setting. This study was designed to explore the perception of the diet and diet recording among the adult Sri Lankan population as a preliminary step of fulfilling this need.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design and setting\u003c/h2\u003e \u003cp\u003eThis qualitative study used three focus group discussions (FGDs), conducted in Warakapola health unit area, Kegalle District, Sri Lanka. Purposive sampling was carried out to include both males and female adults representing different ages, educational levels and occupations to ensure the diversity of the information collected. Following discussions with the Medical Officer of Health of the area, three settings in Warakapola; namely, Alpitiya Public Health Midwife area (n\u0026thinsp;=\u0026thinsp;10), Tholangamuwa Central Collage (n\u0026thinsp;=\u0026thinsp;9) and Warakapola Divisional Secretariat Office (n\u0026thinsp;=\u0026thinsp;11) were selected to recruit the participants for the focus group discussions.\u003c/p\u003e \u003cp\u003eOnce the participants were recruited, a standard diet diary was distributed to record their dietary intake including the date, items of food or drinks consumed during the day and the amount of each food or drink consumed. The participants were asked to fill the diet diary for seven consecutive days and the instructions were provided on maintaining the diet diary.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eData collection instrument\u003c/h3\u003e\n\u003cp\u003e The focus group discussions were conducted using a discussion guide that contained an introduction to the discussion and guidance questions. The discussion guide was developed by the research team specifically for the purpose of this research and the questions were based on the findings of a thorough literature review conducted under two domains: i.e. the perception of diet and dietary behaviors and the experience of using the diet diary including the benefits and difficulties identified during diet recording. The guidance questions were constructed to facilitate the discussion with a good flow of conversation throughout and to ensure uniformity in data collection (Supplementary file 01). It was pretested on five individuals with different socio-economic backgrounds to identify the appropriateness of the questions, clarity, wording and flow of ideas to ensure that the discussions will be likely to elicit rich descriptive responses.\u003c/p\u003e\n\u003ch3\u003eData collection\u003c/h3\u003e\n\u003cp\u003e The focus group discussions were carried out in a comfortable room with no disturbances and written, informed consent was obtained from all participants prior to the discussion. The discussions started with a brief introduction of its purpose by the moderator. The participants were allowed to freely express their ideas, but were directed if necessary facilitating them to express their ideas on the topic. Each discussion lasted approximately 40\u0026ndash;60 minutes. All discussions were conducted in Sinhala and were audio-recorded. In addition, contextual notes were taken and observations were recorded during the discussion.\u003c/p\u003e \u003cp\u003eThe discussions were focused on their ideas of what a meal or diet is, how many meals they usually consume per day, ideas and knowledge on calories and nutrients, factors affecting the preparation or consumption of a meal, the idea of connection between the meals and the health, their experience of filling the diet dairy including the difficulties they faced and the interesting aspects which they really enjoyed about filling it. At the end of the sessions, the key points discussed were summarized and the participants were given the opportunity to express any final thoughts or observations before concluding the discussion. The participants\u0026rsquo; personal queries on diet were discussed and clarified accordingly.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eOnce the discussions were over, the conversations were transcribed verbatim and were translated to English by a bilingual expert. Participants were de-identified during transcribing. Findings of the interviews were coded and thematically analysed. The basic content analysis was done manually. The themes were developed inductively based on the different sections in the focus group discussion guide. Identification of themes, categorization and the development of final themes were carried out with the consensus of the research team.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical aspects\u003c/h3\u003e\n\u003cp\u003e Ethical clearance for the study was obtained from the Ethics Review Committee, Faculty of Medicine, University of Kelaniya, Sri Lanka (P/23/04/2022). Informed written consent was obtained, allowing the participants the freedom to withdraw from the study at any point during the study implementation without prejudice. All the discussions were conducted at the participants\u0026rsquo; convenience in a separate room with privacy, without disturbing the official activities of the institutions. The administrative approval was taken from the Regional Director of Health Services, Kegalle and the Medical Officer of Health, Warakapola.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eSocio-demographic profile of the participants\u003c/h2\u003e \u003cp\u003eThe participants were recruited in three settings and included both males and females of varying socio-economic backgrounds. The first setting, Alpitiya Public Health Midwife area, was a rural village. The participants (n\u0026thinsp;=\u0026thinsp;10) were in their mid-thirties to late fifties with educational levels ranging from primary education to General Certificate of Education (GCE)-Ordinary Level and included drivers, housewives, farmers and a small village restaurant owner. The second setting was the Divisional Secretariat Office Warakapola and the participants (n\u0026thinsp;=\u0026thinsp;11) were aged from mid-twenties to mid-fifties. Their educational levels ranged from GCE-Ordinary Level to degree level and the sample consisted of manual labourers, skilled labourers, clerical staff and administrative officers. The third setting was Tholangamuwa Central Collage and the participants (n\u0026thinsp;=\u0026thinsp;9) were teachers in Science, Commerce and Arts subject streams, aged between mid-twenties to mid-fifties with educational levels ranging from diploma to degree level .\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003ePerceptions on diet and diet recording\u003c/h3\u003e\n\u003cp\u003eBasic content analysis was used to identify the presence, meanings and the relationships of certain words within the context of focus group discussions and the codes and the themes were derived (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e01\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 01\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThemes and codes of perception on diet and diet data collection tool\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThemes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCodes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConceptualization of a meal [What is a meal?]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNutritional components\u003c/p\u003e \u003cp\u003eBalance of nutrients\u003c/p\u003e \u003cp\u003eEffects on health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge on calories\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMeaning of calories\u003c/p\u003e \u003cp\u003eHow calories affect my health\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDeterminants of the daily diet\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndividual factors\u003c/p\u003e \u003cp\u003eFamily factors\u003c/p\u003e \u003cp\u003eAvailability of food items\u003c/p\u003e \u003cp\u003eSpecial occasions\u003c/p\u003e \u003cp\u003eTime factors\u003c/p\u003e \u003cp\u003eSocioeconomic factors\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenefits of diet record keeping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBeing conscious on meals\u003c/p\u003e \u003cp\u003eBeing conscious on effects of meals\u003c/p\u003e \u003cp\u003eIntentional cut down on meals\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDifficulties in diet record keeping\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime factor\u003c/p\u003e \u003cp\u003eFear of stigma\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExpectations of the improvements of the diet diary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInformation\u003c/p\u003e \u003cp\u003eAppearance\u003c/p\u003e \u003cp\u003eGuidance notes\u003c/p\u003e \u003cp\u003eConvenience\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe themes were organized into two distinct domains; namely, the perception of diet and dietary behaviour and experience of using the diet diary.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eDomain 1: The perception of diet and dietary behavior\u003c/h2\u003e \u003cp\u003eThree themes emerged under the perceptions of diet and dietary behaviour, which included conceptualization of a meal, knowledge on calories and determinants of the daily diet.\u003c/p\u003e \u003cp\u003eTheme 1: Conceptualization of a meal [what is a meal?]\u003c/p\u003e \u003cp\u003eThe codes \u0026ldquo;nutritional components\u0026rdquo;, \u0026ldquo;balance of nutrients\u0026rdquo; and \u0026ldquo;effects on health\u0026rdquo; were used to express the theme \u0026ldquo;What is a meal\u0026rdquo;. The simplest expression of a meal was that it was \u0026lsquo;something that satisfies our hunger\u0026rsquo;. Majority expressed the ideas on a meal as an essential thing for life. Different participants used different terms and words to express this complex idea. The better educated participants addressed the complex nature of a meal by discussing that it is a \u0026lsquo;balanced diet\u0026rsquo; and that a meal is something that should have a \u0026lsquo;nutritional value\u0026rsquo;. Some participants with more sophisticated understanding elaborated that a meal consisted of \u0026lsquo;carbohydrate, starch, fat, protein, vitamin and mineral salts\u0026rsquo;.\u003c/p\u003e \u003cp\u003eWhen discussing the nutritional value of a meal, a participant who is a house wife and part time worker in a small village restaurant expressed her view on bioavailability of the nutrients and the importance of preserving them, elaborating on the practice in relation to cooking green leaves.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eW\u003cem\u003ehen completely cooked the nutritional components will be destroyed\u003c/em\u003e\u003c/p\u003e\u003cp\u003eW\u003cem\u003ehen we prepare mallum [green leaves] it should be taken lightly cooked not to destroy the nutritional components\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e Overall, the participants had a clear idea of the categories of food which contain certain nutrients; e.g. fruits and vegetables as a source of vitamins.\u003c/p\u003e \u003cp\u003eOther than nutritional components and the balance of nutrients, the participants discussed the effect of the meal as one aspect of their perceptions, particularly the effects of an unhealthy diet. They stated that food containing too much fat and oil will lead to illnesses and that they avoid such meals as much as possible, indicating that they understand the meal is related to their health.\u003c/p\u003e \u003cp\u003eTheme 2: Knowledge on calories\u003c/p\u003e \u003cp\u003eTwo codes; namely \u0026ldquo;what calorie means to us\u0026rdquo; and \u0026ldquo;how calories affect my meal\u0026rdquo; emerged from the analysis and were used to develop the theme \u0026ldquo;knowledge on calories\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe code \u0026ldquo;what calories means to us\u0026rdquo; was based on the ideas of existence of \u0026lsquo;\u003cem\u003esomething called a calorie\u003c/em\u003e\u0026rsquo;, meaning it as \u0026lsquo;energy\u0026rsquo; and the knowledge of food rich in calories. The participants stated that they have heard of it, while some better-educated participants expressed it as energy. The participants were able to identify the high calorie food categories as sweets, starchy food and foods containing oils and fat.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSomething stored in food we need for the energy\u003c/p\u003e\u003cp\u003eIt\u0026rsquo;s different in different foods\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSome participants reported that they have never heard of calories.\u003c/p\u003e \u003cp\u003eSome of the participants shared their ideas on applying the knowledge on calories in purchasing food items from the market. They stated that if it is mentioned on the packaging, they will be able to identify the caloric content in a certain food. However, they also mentioned that sometimes even if it is printed on the packaging, they might not pay attention to it when purchasing foods. Some participants mentioned that they particularly check these when they purchase food for kids rather than for themselves. One participant who was a school teacher stated that he is much more attentive on side effects or any unhealthy additives of the food during purchasing than on calories.\u003c/p\u003e \u003cp\u003eTheme 3: The determinants of the daily diet\u003c/p\u003e \u003cp\u003eThe participants discussed \u0026lsquo;what really determines their diet\u0026rsquo; and expressed that the factors such as what they like to eat [individual food preferences], taste, whether having an illness or not, physical appearance of the body, what is easy for them to prepare, as a tradition will influence their decision on what to eat. These ideas were coded as \u0026ldquo;individual factors\u0026rdquo; that determine the daily meal, which depend on the person him or herself.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eThere was a clinic here in December and when I measured my weight there, it was 78 kilograms. Waist was 100 centimetres. From that day onwards I thought I will reduce the amount of rice I eat. I eat only one spoon of rice now. When I bring the lunch to the office I bring more curries. Earlier I used to eat lot of jack curry when I return from work, if it was prepared at home. But now I don\u0026rsquo;t do that. Now my weight has reduced to 66.5 kilograms. Waist is also reduced\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant stated that the meal menu depends on children\u0026rsquo;s and husband\u0026rsquo;s preferences. Another participant mentioned that dinner will be more perfectly prepared since all the family members are available to eat together during the night. Therefore, \u0026ldquo;family factors\u0026rdquo; were also coded as a determinant of the daily diet.\u003c/p\u003e \u003cp\u003e\u0026ldquo;Nutritional factors\u0026rdquo; was another main code identified under determinants of a meal. Participants mentioned adding green leaves and having at least two different curries for a meal to ensure the nutritional value of the meal. Some participants stated special preparation methods even to preserve the nutrients in the meal such as eating green leaves as half cooked or eating without cooking. Many stated \u0026ldquo;availability of the food item\u0026rdquo; as another determinant.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eM\u003cem\u003eost of the time it\u0026rsquo;s what kids like to eat \u0026hellip;or maybe husband likes to eat. Sometimes it\u0026rsquo;s what\u0026rsquo;s available at home to prepare\u003c/em\u003e\u003c/p\u003e\u003cp\u003e \u003cem\u003eSometimes family members prefer rice instead of other food prepared with flour\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e\u0026ldquo;W\u003cem\u003ehen we prepare \u0026ldquo;mallum\u0026rdquo; should be taking it as lightly cooked so as not to destroy the nutritional components. Trying to take things as minimally cooked because when it\u0026rsquo;s completely cooked, the nutritional components will be destroyed\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe food intake also differed according to \u0026ldquo;special eating occasions\u0026rdquo;. As one participant who was a driver mentioned,\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eWhen we drink alcohol, we take bites with alcohol and that\u0026rsquo;s all; will never take dinner after that\u003c/em\u003e\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe \u0026ldquo;socio-economic status\u0026rdquo; and the \u0026ldquo;time\u0026rdquo; were the other two factors that influence the decision on what to eat. The participants mentioned that if there is less time for cooking they will select the things they can prepare fast. The participants also stated that their financial status will determine what they can afford as food in day-to-day life, when buying pre-cooked meals or buying raw material to prepare food at home.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWhat can be prepared easily \u0026hellip; with the available time\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eHave to check for money with current situation\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eDomain 2: The experience of using the diet diary, benefits and the difficulties identified of using the diet diary.\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThe ideas and the experience of filling a standard diet diary were discussed under this domain. Prior to the discussions, the participants were provided with a standard diet diary and were advised to fill it for seven continuous days. Three themes emerged from the discussion; namely, benefits of the diet record keeping, difficulties in diet record keeping and their expectations for improvement of the diet diary.\u003c/p\u003e \u003cp\u003eTheme 4: Benefits of diet record keeping\u003c/p\u003e \u003cp\u003e Participants discussed the benefits of record keeping in a diet diary and three codes, \u0026ldquo;being conscious on meals\u0026rdquo;, \u0026ldquo;being conscious on effects of meals\u0026rdquo;, and \u0026ldquo;intentional cut down on meals\u0026rdquo; emerged from the discussion.\u003c/p\u003e \u003cp\u003eThe participants expressed that, by having records of diets, they could check what they eat, assessing \u0026ldquo;whether they really need to eat this much\u0026rdquo;. Also diet recording was said to help in assessing the nutritional components included in their meals and identifying the components that are lacking. One participant who was a teacher mentioned that since they have different dietary patterns, maintaining the diary motivates them to practice a healthier eating behavior. Participants also stated that when they started diet recording they were conscious about the amount of food consumed and then they could adjust their physical activity level according to the amount they eat. This explains that they were conscious on the quantity and type of food, as well as not to exceed the daily requirement of the food and healthy eating while filling the diet dairy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eSometimes when the doctor asked to write, even if we are used to a different food pattern we tend to get into healthy food habits and may avoid bad food behaviours\u0026hellip; it\u0026rsquo;s really worth\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eWe can find what we are lacking in nutrition\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese ideas were coded as \u0026ldquo;Being conscious on meals\u0026rdquo;.\u003c/p\u003e \u003cp\u003e The participants also noted the importance of \u0026ldquo;being conscious on effects of meals\u0026rdquo;. A participant who was a housewife stated that food and illness had a close association and perceived diet record keeping as a useful exercise to observe these effects.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eI filled it as I thought sometimes we will be able to check our illnesses with this, since our illnesses depend on what we eat\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eWhen some of the participants started recording the meals they had started to control their diet. One participant who was a teacher reported that when she started to maintain the diet diary she remembered that her personal physician has advised her to control her diet since she is overweight. Hence, naturally she started controlling her diet. When inquired on the reason for filling the diet diary from the participants who completed it properly, and another participant claimed,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eI felt when I started writing there will be a control on what I eat, since I have to write what I eat\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThese ideas were coded as \u0026ldquo;intentional cut down on meals\u0026rdquo;.\u003c/p\u003e \u003cp\u003eTheme 5: Difficulties in diet record keeping\u003c/p\u003e \u003cp\u003eUnder this theme, two codes were identified as \u0026ldquo;time factor\u0026rdquo; and \u0026ldquo;fear of stigma\u0026rdquo;. The participants explained on the difficulty in record keeping due to demands on time. The participants who could not complete the given diet diary have expressed their ideas as,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eWe didn\u0026rsquo;t have time. We have lot of work. Otherwise we could have filled it\u003c/em\u003e \u003c/p\u003e\u003cp\u003e \u003cem\u003eIt is hard to write with the busy schedule\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eOne participant, who is working as a clerk expressed his idea as,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003ePeople who have low economic status might not be having meals, but might not like to tell that they have not eaten. So they might not fill the diary\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eTheme 6: Expectations of the improvements of the diary\u003c/p\u003e \u003cp\u003eThe codes \u0026ldquo;information needs\u0026rdquo;, \u0026ldquo;appearance\u0026rdquo;, \u0026ldquo;guidance notes\u0026rdquo; and \u0026ldquo;convenience\u0026rdquo; were combined to develop the theme \u0026ldquo;Expectations of the improvements of the diary\u0026rdquo;.\u003c/p\u003e \u003cp\u003eWith the experience of filling the diet diary, there were many suggestions on including the nutritional information such as the balanced diet, nutritional value of food and diseases that are related to the diet. One participant who was in officer category stated that,\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThe importance of a meal, what is a balanced diet, people might not be knowing how to prepare a balanced diet easily. If we can provide suggestions on that including information on food it would be better\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eA participant stated that it would be nice to include the information on adjusting diet according to activity level.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIf someone works hard (physical) they have to eat more. But if a person who doesn\u0026rsquo;t work hard need not to eat a lot\u0026hellip;.I think it would be nice if you have mentioned that in the booklet\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eAnother main concern was that diet recording tool should be more attractive in appearance.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e \u003cem\u003eIf you design it attractively just like baby\u0026rsquo;s clinic card printed in a nicer way\u003c/em\u003e \u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003e The participants explained the importance of having guidance notes on how to fill the diet dairy and displaying the portion sizes of commonly consumed food including cultural food items. Some participants preferred to have a list of food items to tick, that would facilitate time management and also help people with low literacy.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003e\u003cem\u003eThere are no instructions given\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eSince we have a higher educational level we tend to do these kind of things. We think this is a must-do. But when doctors give this to general public [patient] they may miss this \u0026hellip; since there is a lot to fill. If there was a list to tick would have been better and easy. If we eat rice we can mark it....something like that...\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn summary, participants expressed the idea that meals are essential for living and that food contain specific nutrients necessary for health. While most participants expressed their awareness of calories, only a few had a clear understanding of its meaning as a unit of energy. Various factors that determine a person\u0026rsquo;s diet were identified. The participants\u0026rsquo; ideas and expectations on a user friendly, interesting diet diary recommended including information on a balanced diet, nutritional value of food, diseases related to diet, improving the appearance, including guidance notes and convenient food lists to choose from. The participants thought that the diet diary can be used to track one\u0026rsquo;s illnesses, assess the nutritional quality of a meal and control diet. When discussing the difficulties faced during filling the diet dairy, the time factor was stressed as the main limitation.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis qualitative exploration of the perception of diet and diet recording was done among 30 males and females diverse in age, education and socio-econmic level using focus group discussions. Six themes were identified as perceptions on diet and diet recording, which included \u0026ldquo;what is a meal?\u0026rdquo;, \u0026ldquo;knowledge on calories\u0026rdquo;, \u0026ldquo;determinants of the daily diet\u0026rdquo;, \u0026ldquo;benefits of diet record keeping\u0026rdquo;, \u0026ldquo;difficulties in diet record keeping\u0026rdquo; and \u0026ldquo;expectations of the improvement of the diet diary\u0026rdquo;.\u003c/p\u003e \u003cp\u003eThe key findings include having the idea of diet as a collection of food with different nutritional values, which consists of carbohydrates, proteins, lipids, minerals and vitamins with a balance between these nutrients. The determinants of an individual\u0026rsquo;s diet was related to the individual person as well as the surrounding environment such as the family, economy and time. It was an alarming finding that people were not much knowledgeable or are concerned about calories, despite Sri Lanka being one of the countries with high literacy in South Asia (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn recording diet, the time constraints and the economic status were reported as the barriers for accurate recording and participants identified being conscious and mindful of the meals, being conscious on effects of meals and intentional cut down of the meal as the beneficial aspects of recording their own diet.\u003c/p\u003e \u003cp\u003eIn literature, the concept of diet is related with nutrition and human health (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A nutritionally well balanced diet or a collection of food with good nutritional value was identified as crucial for a healthy life (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). Therefore, the concept of healthy diet was defined in relation to diseases and was correlated to the negative health outcomes and lack of wellbeing. Similarly, in the current study the concept of a meal was described with nutrition related ideas and the notions related to the connection between health and diet. Further, the balanced diet was elaborated as consisting of carbohydrate, starch, fat, protein, vitamin and minerals, whereas in the literature it is defined that the key properties of healthy diet is ensuring sufficient intake of micronutrients, macronutrients and energy to meet the requirement without excess, maintaining appropriate balance of macronutrients carbohydrates, proteins and fats (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe ideas on calories were expressed merely as knowing the word and that it is related to energy, in keeping with the existing literature. A study done by Wongprawmas et al among Italian consumers revealed that the majority of the participants were uncertain about the statement \u0026lsquo;A healthy diet is based on calorie count\u0026rsquo; (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). The knowledge on calorie was not correlated with the food choices (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Similarly in this study, the participants stated that even if the calorie count is stated in packaging they might not consider it when purchasing the food. This proves that the idea of calories need to be emphasized more in nutrition education, in addition to the nutritional quality of the food items.\u003c/p\u003e \u003cp\u003eThe factors that determine the diet were similar to the factors reported in literature (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e) (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e)(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), however, one participant remarkably stated how her body weight and the waist size altered her dietary behavior in a healthy manner, aiming to reduce weight and waist. In the literature, it is mentioned that the physiological and psychological influences such as being overweight or obese incline towards a greater liking for high energy density food (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This shows that in this sample, the body image plays a major role as a dietary determinant than the physiological or psychological influence, shifting the dietary behavior towards the healthy behaviours related to weight management.\u003c/p\u003e \u003cp\u003eThough the food waste and food labeling did not emerge as dietary determinants in this study as mentioned in previous literature (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e), the family factors exerted more weightage on food choices, demonstrating the cultural value of the family as a unit which influences a person\u0026rsquo;s dietary choices.\u003c/p\u003e \u003cp\u003eIn this study special occasions were a determinant of the diet and the relationship between the diet and alcohol intake was discussed. Similarly, the existing literature shows a link between alcohol and food choices (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). However, the participant in this study stated that eating snacks with alcohol leads to avoiding the main meal, while in literature it was stated that alcohol and food are linked with palatability. Though it was mediated through different mechanisms, the present study confirms that alcohol also affects the dietary behavior of people.\u003c/p\u003e \u003cp\u003eThe benefits and barriers of diet recording elaborated in this study are similar to those mentioned in the literature (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)(\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e), however, the participants in this study had more positive ideas on the benefits of record keeping such as being mindful of what they eat and intentional cut down of the diet as needed according to their medical condition or to maintain a healthy lifestyle (e.g. healthy body weight). Both in literature and in the present study findings, the participants have expressed their fear of stigma of diet recording, while in the literature it was identified as the unwillingness to show others the diet records (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e) and the present study participants indicated reluctance of recording the things they eat, revealing the poor diet quality due to low socio-economic status. Though the reluctance of reporting was highlighted as a barrier, the participants did not attempt to change their food choices or including false information in the diet diary to provide \u0026lsquo;socially desirable\u0026rsquo; responses. Conversely, according to literature, measures such as limiting the food choices, eating less and selecting instant or packed food have been adopted to ease the recording procedure (\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). This is a negative impact on the data quality of diet recording, though the participants of the present study had no intention of changing their dietary behavior, indicating a positive mindset.\u003c/p\u003e \u003cp\u003eThe strengths of this study in assessing the perception on diet and diet recording include the sampling procedure which allowed the inclusion of a diverse group of male and female adults representing different ages, educational and socio-economic levels to ensure the richness of the information elicited. However, cultural diversity of the sample could not be achieved since the sample was limited only to the Sinhalese, which was a major limitation of the study. In future studies, it would be beneficial to assess the perception on diet and diet recording in Tamil and Muslim communities to elicit more comprehensive and culturally-specific information.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe present study revealed public perceptions on diet and diet recording under six main themes. The findings reveal a sound general awareness of diet and positive ideas on diet recording with an inadequate understanding of calories. The public should be empowered with the knowledge on calories and how to use the knowledge on calories and nutritive values for the selection of healthier food items and preparation of healthy meals. It would be much beneficial to incorporate this knowledge to the school curriculum, both in theory and practice, with the activities of the school health program.\u003c/p\u003e \u003cp\u003eThe findings of this study can be used to design culturally appropriate dietary data collection tools, addressing the public expectations. Further research in multicultural settings would be beneficial to evaluate the cultural influences on the perceptions of diet.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e \u003ch2\u003eEthics approval and consent to participate\u003c/h2\u003e \u003cp\u003e The authors declare that Ethical approval for the study was obtained from the Ethics Review Committee, Faculty of Medicine, University of Kelaniya (Registration No. P/23/04/2022). Administrative approval was obtained from all relevant authorities (District Secretariat Kegalle District, Regional Director of Health Services-Kegalle District, Medical Officer of Health, warakapola). Informed written consent was obtained from all participants before data collection. Study was conducted while adhering to the World Medical Association Declaration of Helsinki on ethical principles for medical research involving human subjects.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eIn the current study consent for publication is not applicable as no individual-level data with identification was included in the manuscript.\u003c/p\u003e \u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eThe study was self-funded by the corresponding author.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eRajakaruna VPC did the planning the research project, data collection, content analysis and manuscript writing. Chandana GJ and Athuda LK provided the technical guidance. Wijesinghe CJ and Kasturiratne supervised the research project. All authors read and approved the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eRegional Director of Health and the staff, RDHS Office, KegalleMedical officer of Health and the staff, Warakapola MOH Divisional secretary and the staff, Divisional Secretariat Office, WarakapolaThe Principal and the staff, Tholagamuwa Central Collage, Warakapola\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe recordings of focus group discussions, the transcriptions and the translations used for the manual content analysis during the current study are available in the following link.https://drive.google.com/drive/folders/1eJS3g-ahE7u_cWl5qNTadaIJNdrzxnF6?usp=sharing\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCicero AFG, Fogacci F, Borghi C. An Evolving Definition of a \u0026ldquo;Healthy Diet\u0026rdquo;. Nutrients. 2023;15(9):2\u0026ndash;4. \u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). Guidance for monitoring healthy diets globally [Internet]. Available from: https://www.who.int/publications/i/item/9789240094383\u003c/li\u003e\n\u003cli\u003eHatherall D. Global strategy on Diet, Physical Activity and Health. WHO. 2004;2002(May):314\u0026ndash;23. \u003c/li\u003e\n\u003cli\u003eCena H, Calder PC. Defining a healthy diet: Evidence for the role of contemporary dietary patterns in health and disease. Nutrients. 2020;12(2):1\u0026ndash;15. \u003c/li\u003e\n\u003cli\u003eRattan SIS, Kaur G. Nutrition, Food and Diet in Health and Longevity: We Eat What We Are. Nutrients. 2022;14(24):1\u0026ndash;7. \u003c/li\u003e\n\u003cli\u003eWongprawmas R, Mora C, Pellegrini N, Guin\u0026eacute; RPF, Carini E, Sogari G, et al. Food choice determinants and perceptions of a healthy diet among Italian consumers. Foods. 2021;10(2). \u003c/li\u003e\n\u003cli\u003eMinistry of Women and Child Development G of I. Nutrition transition in India 1947-2007. 2007;5:131\u0026ndash;46. Available from: http://wcd.nic.in/research/nti1947/NTI1947CONTENT.htm\u003c/li\u003e\n\u003cli\u003eWorld Health Organization (WHO). https://www.who.int/southeastasia/health-topics/nutrition. \u003c/li\u003e\n\u003cli\u003eBishwajit G. Nutrition transition in South Asia: The emergence of non-communicable chronic diseases. F1000Research. 2015;4(0). \u003c/li\u003e\n\u003cli\u003eWeerasekara PC, Withanachchi CR, Ginigaddara GAS, Ploeger A. Nutrition transition and traditional food cultural changes in Sri Lanka during colonization and post-colonization. Foods. 2018;7(7):1\u0026ndash;18. \u003c/li\u003e\n\u003cli\u003eJayawardena R, Thennakoon S, Byrne N, Soares M, Katulanda P, Hills A. Energy and nutrient intakes among Sri Lankan adults. Int Arch Med. 2014;7(1):1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eBiswas T, Townsend N, Gupta R Das, Ghosh A, Rawal LB, M\u0026oslash;rkrid K, et al. Clustering of metabolic and behavioural risk factors for cardiovascular diseases among the adult population in South and Southeast Asia: findings from WHO STEPS data. Lancet Reg Heal - Southeast Asia [Internet]. 2023;12:100164. Available from: https://doi.org/10.1016/j.lansea.2023.100164\u003c/li\u003e\n\u003cli\u003eJayawardena R, Byrne NM, Soares MJ, Katulanda P, Hills AP. Validity of a food frequency questionnaire to assess nutritional intake among Sri Lankan adults. Springerplus. 2016;5(1):1\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eJayawardena R, Byrne NM, Soares MJ, Katulanda P, Hills AP. Food consumption of Sri Lankan adults: An appraisal of serving characteristics. Public Health Nutr. 2013;16(4):653\u0026ndash;8. \u003c/li\u003e\n\u003cli\u003eLife E. Exploring the meal concept \u0026ndash; an interdisciplinary literature overview. 2015;(12). \u003c/li\u003e\n\u003cli\u003eKaranja A, Ickowitz A, Stadlmayr B, McMullin S. Understanding drivers of food choice in low- and middle-income countries: A systematic mapping study. Glob Food Sec [Internet]. 2022;32:100615. Available from: https://doi.org/10.1016/j.gfs.2022.100615\u003c/li\u003e\n\u003cli\u003eLeng G, Adan RAH, Belot M, Brunstrom JM, De Graaf K, Dickson SL, et al. The determinants of food choice. Proc Nutr Soc. 2017;76(3):316\u0026ndash;27. \u003c/li\u003e\n\u003cli\u003eMela DJ. Determinants of food choice: relationships with obesity and weight control. Obes Res. 2001;9 Suppl 4(November). \u003c/li\u003e\n\u003cli\u003eKoch F, Hoffmann I, Claupein E. Types of Nutrition Knowledge, Their Socio-Demographic Determinants and Their Association With Food Consumption: Results of the NEMONIT Study. Front Nutr. 2021;8(February):1\u0026ndash;11. \u003c/li\u003e\n\u003cli\u003eBailey RL. HHS Public Access. PMC. 2021;91\u0026ndash;6. \u003c/li\u003e\n\u003cli\u003eIllner AK, Freisling H, Boeing H, Huybrechts I, Crispim SP, Slimani N. Review and evaluation of innovative technologies for measuring diet in nutritional epidemiology. Int J Epidemiol. 2012;41(4):1187\u0026ndash;203. \u003c/li\u003e\n\u003cli\u003eDaniel E Shumer, Natalie J Nokoff NPS, Erin C. Dowd, M.D.a, Michael J. Frank, Ph.D.b, Anne Collins, Ph.D.c, James M. Goldd, and Deanna M. Barch PD. Barriers and Negative Nudges: Exploring Challenges in Food Journaling HHS Public Access. Physiol Behav. 2017;176(12):139\u0026ndash;48. \u003c/li\u003e\n\u003cli\u003eOrtega RM, Perez-Rodrigo C, Lopez-Sobaler AM. M\u0026eacute;todos de evaluaci\u0026oacute;n de la ingesta actual: Registro o diario diet\u0026eacute;tico. Nutr Hosp. 2015;31:38\u0026ndash;45. \u003c/li\u003e\n\u003cli\u003eBailey RL. Overview of dietary assessment methods for measuring intakes of foods, beverages, and dietary supplements in research studies. Curr Opin Biotechnol [Internet]. 2021;70:91\u0026ndash;6. Available from: https://doi.org/10.1016/j.copbio.2021.02.007\u003c/li\u003e\n\u003cli\u003esouth-asia-highest-literacy-rate @ gospelforasia.org [Internet]. Available from: https://gospelforasia.org/functional-illiteracy/south-asia-highest-literacy-rate\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Diet, Diet recording tools. Perception of diet, Experience of diet recording","lastPublishedDoi":"10.21203/rs.3.rs-6666274/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6666274/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eImproving nutrition through dietary modification is important for prevention of non-communicable diseases. This study was a preliminary step in designing a culturally-apt dietary data collection tool that reflects local food culture and eating habits, based on public perceptions of diet and diet recording in Sri Lanka. Three focus group discussions were conducted among a heterogeneous, purposively selected sample of 30 adults to identify perceptions on diet and diet recording, following completion of a standard food diary. Content analysis identified six key themes: i.e. definition of a meal, knowledge on calories, determinants of diet, benefits / difficulties in diet recording and expected improvements of the diet diary. The understanding of a meal, calories and determinants of diet were major components in the perceptions of diet. Individual, family, occasion and time-related and economic factors were identified as determinants of daily diet. Participants stated that documenting diet is useful to define health, nutritional components of a meal and diet control, while time factor was a limitation. A user-friendly diet diary was expected to include information on balanced diet and diet-related diseases, appearance, instructions and food lists to choose from. These findings are important in designing culturally appropriate tools for the dietary assessment in the management of non-communicable diseases.\u003c/p\u003e","manuscriptTitle":"“To eat and to know what you eat”: Exploring perceptions on diet and diet recording among people in a Sri Lankan locality","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-16 09:54:42","doi":"10.21203/rs.3.rs-6666274/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-29T06:53:35+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T04:10:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"145355003236402005366989165932014067323","date":"2025-07-21T00:33:09+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-19T15:10:18+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-06-30T11:08:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"316973682962735176847930916926046379440","date":"2025-06-27T07:30:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"202512910354088333912886127542837713999","date":"2025-06-23T08:25:47+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-12T09:04:34+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-12T08:59:28+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-30T04:30:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-29T15:26:32+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Public Health","date":"2025-05-29T15:23:32+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-public-health","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pubh","sideBox":"Learn more about [BMC Public Health](http://bmcpublichealth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pubh/default.aspx","title":"BMC Public Health","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"3557a83e-5657-475b-81c0-d43ebc21136d","owner":[],"postedDate":"June 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-12-01T16:05:03+00:00","versionOfRecord":{"articleIdentity":"rs-6666274","link":"https://doi.org/10.1186/s12889-025-25295-3","journal":{"identity":"bmc-public-health","isVorOnly":false,"title":"BMC Public Health"},"publishedOn":"2025-11-26 15:58:43","publishedOnDateReadable":"November 26th, 2025"},"versionCreatedAt":"2025-06-16 09:54:42","video":"","vorDoi":"10.1186/s12889-025-25295-3","vorDoiUrl":"https://doi.org/10.1186/s12889-025-25295-3","workflowStages":[]},"version":"v1","identity":"rs-6666274","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6666274","identity":"rs-6666274","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}