# Evaluation of Knowledge and Awareness of Dietary Nitrate Among Clinical Dietitians in Jeddah, Saudi Arabia: A Cross-Sectional Study

## TL;DR

This study found that dietitians in Jeddah, Saudi Arabia, have poor knowledge about dietary nitrate's health effects and sources, despite perceiving it as beneficial.

## Contribution

The study is the first to assess clinical dietitians' knowledge of dietary nitrate in Saudi Arabia, revealing significant gaps in understanding.

## Key findings

- Most dietitians incorrectly believed dietary nitrate is beneficial but lacked specific knowledge about its health effects like lowering blood pressure.
- Participants showed poor understanding of nitrate metabolism and dietary sources, despite good knowledge of factors affecting nitrate content in food.
- Educational background and experience did not significantly influence knowledge scores about dietary nitrate.

## Abstract

Background and objectives

Dietary nitrate (NO3) plays an important role in human physiological processes. In the past, inorganic NO3 was viewed negatively due to its link with carcinogenic effects, notably nitrosamine formation in the stomach; yet, current perspectives acknowledge NO3 as a potentially beneficial dietary element. Nutrition professionals (NPs) are crucial in promoting NO3 awareness in health and academic settings. The study aimed to evaluate the knowledge of NPs in Jeddah, Saudi Arabia, regarding the biological roles of dietary NO3, taking into consideration their qualifications and years of experience.

Methods

A cross-sectional study was conducted among NPs who had graduated from clinical nutrition programs or were employed in clinical or academic settings. A validated 12-item online questionnaire was used to assess dietary NO3 knowledge across five areas: health effects, dietary sources, recommendations, biomarkers of intake, and metabolism. The nitrate knowledge index (NKI) score was used to evaluate responses.

Results

Eighty-nine female NPs out of 144 completed the questionnaire. Most were ≤30 years old (75.4%) and had an undergraduate degree in clinical nutrition (70.8%), but 37 of them had ≤3 years of experience (62.7%). Overall, poor knowledge scores were observed among NPs, with a median (25th and 75th percentile) score of 10 (6, 13) out of 23. The majority (64%) perceived NO3 to be beneficial. However, most of the participants did not know its benefits in lowering blood pressure (BP) (68.5%) and were unsure about the effects of nitrate on cognitive function (60.7%) or kidney function (57.3%). Almost half of the NPs were unaware of NO3 sources and unsure about the mechanisms of the conversion of NO3 into nitrogen dioxide (NO2) in the mouth (48.3%). Overall, knowledge of factors that affect NO3 content in food was good. No significant differences were observed in the median NKI scores among the participants based on their level of education or years of experience.

Conclusion

This study suggests NPs lack knowledge about dietary NO3. To address this, educational programs should be developed and implemented in clinical and academic settings.