ARTICLE INFO		ABSTRACT
ORIGINAL ARTICLE		Background: Use of additives in food industry is of specific importance. Currently, more than 2,500 additives are added to foods to achieve the desired goals or to extend the product’s shelf life. However, application of these substances has raised concerns about the consumers’ health. Since public information on these substances is inadequate, promoting people’s knowledge can play a key role in this regard. Therefore, knowledge, attitude, and practices of the personnel of Isfahan University of Medical Sciences toward food additives were evaluated. Methods: This cross-sectional descriptive study included 800 participants selected randomly among the personnel of Isfahan University of Medical Sciences in Iran. The participants’ demographic information, knowledge, attitudes, and practices were measured via a self-administered questionnaire. The relationship of participants’ educational level, age, and gender with their knowledge, attitudes, and practices were determined. Results: The participants’ knowledge, attitudes, and practices average scores were calculated as 30.6±1.3, 32±0.9, and 15±1.5 for food additives, respectively. Conclusion: The participants’ knowledge, attitude, and practices were at a poor level. So, people should receive the necessary education and training in terms of food additives as well as food labels in order to prevent misinterpretations regarding food additives.   Keywords: Knowledge; Attitudes; Practices; Food additives
Article history: Received: 29 Jun 2020 Revised: 20 Jul 2020 Accepted: 20 Jul 2020
*Corresponding author z.esfandiari@nutr.mui.ac.ir Department of Food Science and Technology, School of Nutrition and Food Science, Food Security Research Center, Isfahan University of Medical Sciences, Isfahan, Iran.   Postal code: 81746-73461 Tel: +98- 3137923155

owadays, numerous processed foods are manufactured and consumed as a result of developments in food technology and alteration in dietary patterns. In Iran, remarkable changes have occurred in food consumption patterns in recent decades, so that most consumers are demanding healthful, safe, suitable, and cheap foods. 
Food additives play a crucial role in food industry. More than 2,500 food additives are used to achieve the intended goals or increase the food product’s shelf life. However, many additives were excluded globally or in some countries over the past years (Carocho et al., 2014). Food additives are not generally consumed as food alone.
They are used for technological purposes in production, preparation, refinement, packaging, transportation, and maintenance of food products (Esfandiari et al., 2017). According to the European classification, additives are categorized based on their usage to: sweetening, coloring, preservative, antioxidant, carrier, acid regulating, acidic, anti-caking, anti-foaming, voluming, emulsifier, emulsifying salt, stiffening, flavor enhancing, foaming, gelling, glazing, humectant, modified starch, packaging gas, propellant, rising, sequestrant, stabilizer, thickening, and flour improving agents (Carocho et al., 2014). These chemicals has positive effects on the food quality, but their application above the standard and acceptable daily intake values can have adverse effects on human health (Esfandiari et al., 2013, Esfandiari et al., 2016).
Some additives have negative influence on children since they may cause insulin resistance, decrease immune, lead to hyper active practices, and change thyroid hormone function (McCann et al., 2007, Trasande et al., 2018). Therefore, laws and standards focus on controlled consumption of food additives (Council Regulation (EC), 2008).
According to the regulations of Iranian National Standard Organization, permitted additives used in food products must be indicated on the food labeling (Institute of Standards and Industrial Research of Iran (ISIRI), 2009). Consumers all around the world are worried about food safety (Shim et al., 2011). Several studies investigated the consumers’ knowledge, attitudes, and practices toward food additives (Bearth et al., 2014, Choe et al., 2005, Shim et al., 2011). However, no studies have ever investigated the knowledge, attitudes, and practices of people toward food additives in Iran. In fact, increased level of knowledge toward food additives can decrease the consumers’ fear in choosing the processed food (Shim et al., 2011). To this end, the knowledge, attitudes, and practices of the personnel of Isfahan University of Medical Sciences were studied toward food additives.
Materials and Methods
Design and participants: In this cross sectional study, the participants’ knowledge, attitudes, and practices were evaluated toward food additives using a self-administered questionnaire. The participants included 800 volunteers selected randomly from Isfahan University of Medical Sciences, Iran.
Measurements: The questionnaire was designed based on the classification of food additives by the European :union: and Iranian national standard (Carocho et al., 2014, Council Regulation (EC), 2008, Institute of Standards and Industrial Research of Iran (ISIRI), 2009). The validity and reliability of the questionnaire were assessed by the faculty members of School of Nutrition and Food Science, Statistics and Epidemiology, as well as the food experts in Iran-Food and Drug Administration: IFDA in Isfahan University of Medical Sciences.
The questionnaire comprised of demographic information questions as well as some items that evaluated the participants’ knowledge (n = 18), attitudes (n = 20), and practices (n = 13), respectively. In the knowledge section, food additives were introduced. Correct answers received one score, while incorrect answers were scored zero (Tables 1). The next part of the questionnaire was designed to assess the respondents’ attitudes using a Likert scale ranging from zero (strongly disagree) to 4 (strongly agree) (Tables 2). The final part of the questionnaire included the participants’ practices with regard to food additives that should be answered in a 5-point Lickert scale containing “always”, “often”, “sometimes”, “seldom”, and “never” options scored from 0 to 4, respectively (Tables 3). The total attainable score of the questionnaire was 100.
Ethical considerations: The inclusion criterion was voluntary participation in the study. Also, the informed consent was obtained from all respondents. This study was approved by the Ethics Committee of Isfahan University of Medical Sciences (IR.MUI. RESEARCH. REC. 1398.269).
Data analysis: Statistical analyses were performed based on mean ± standard for the participants’ knowledge, attitudes, and practices via SPSS 22 (IBM, Armonk, NY, USA) considering the significant level of less than 0.05. Later, the Mann-Whitney test was run to determine the relationship of educational level, age, and gender with knowledge, attitudes, and practices of the participants.
Results
Of the 800 personnel participating in the study, 460 were female and 340 were male within the age range of 30 to 50 years. About 69.6%, 20.2%, and 10.2% of the respondents had BSc, MSc, and PhD degrees, respectively. The participants’ scores of knowledge, attitudes, and practices had no significant difference in terms of their demographic specifications (P > 0.05).
Knowledge, attitude, and practice scores of the personnel toward food additives were 30.6 ± 1.3, 32.0 ± 0.9, and 15.0 ± 1.5, respectively (Tables 1–3). Analysis of the differences between the three main variables did not show any significant difference between the study groups. Overall, no significant difference was found between the mean scores for knowledge (P = 0.65), attitude (P = 0.41), and practice (P = 0.48) with respect to food additives.

Discussion
The existing data show conflicting information about the advantages and disadvantages of food additives as well as the consumers’ information is inadequate in this regard. Therefore, the consumers’ awareness, attitude, and practice should be evaluated. According to our findings, the personnel’s awareness, attitudes, and practices about the food additives were weak.
Less than half of the participants answered the items correctly for the questions of knowledge (Table 1). The total knowledge score was 30.6 ± 1.3 that was poor. Most respondents were unaware of the functions and benefits of food additives.  According to Table 1, the most correctly answered question (46.9%) was associated with general information about additives in food (K1), while the most incorrectly answered question (31.25%) was related to application of preservatives as additives for increasing the product’s shelf life (K5). Given the importance of using preservatives in food industry, four questions were designed with regard to food preservative knowledge (K4, K5, K6 and K18) (Akbari-Adergani et al., 2018, Esfandiari et al., 2013, Esfandiari et al., 2016) Additives are used for a variety of reasons: improving the food quality, increasing shelf life, and controlling microbial growth in foods. Regarding the responses, most respondents believed that food preservatives were the most disadvantageous additives in terms of food safety. This finding was also reported in other countries showing the low level of awareness in terms of preservatives in different communities.  In South Kore, although the participants’ information was at a good level about preservatives, they were worried about to  preservatives among the studied additives such as colorants, flavor enhancers, and sweeteners (Shim et al., 2011). In another study, colorants and preservatives were found to cause the greatest anxiety among the participants (Choe et al., 2005). The discrepancy in findings of the present study and the aforementioned research can be attributed to the lack of information among the public about preservatives in Iranian society. However, the most correctly answered question was about the introduction of additive agents in food products, which could be due to the self-expressing etymology of this term (Shim et al., 2011). A study carried out in Switzerland over food additives revealed that awareness about reliance on rules, consumption of natural products, and awareness about the hazards and benefits were among the important variables for accepting food additives in the community. The study researchers also recommended enhancement of the public awareness  about the hazards of food additives (Bearth et al., 2014).
Table 2 provides a detailed explanation of the participants’ attitudes toward food additives. More than 90% of our respondents selected “no idea” when they were asked about their attitudes toward food additives. The total score for attitudes was 32.0 ± 0.9. A section of the administered questionnaires was devoted to different dimensions of food additives and their role in the development of some diseases such as cancer and allergies. Some of the questions were also devoted to government and health-care authority organizations for introducing and confirming the safety of these additives. According to the participants, food additives can cause such diseases because the study findings revealed that chemicals such as colorants, preservatives, and materials used in packaging may exert a detrimental effect on the community health, especially with respect to children. Recently, the American Academy of Pediatrics has urged serious changes and revisions in food additives in the legislation process (McBride, 2018, Trasande et al., 2018). Given the participants’ low level of awareness and information, the authorities are suggested to educate and inform the public via mass media. A study in China investigated the factors affecting public attitudes toward food additives. The researchers found that people’s attitudes played an important role in opting for safe foods. Moreover, raising the public awareness in respect to food additives is a major factor in reports on food safety hazards. In this regard, enhancing the public awareness plays an important role in the development and deployment of risk management policies regarding food safety. As a result, the government policy should be revised on food safety (Wu et al., 2013). A study in Spain evaluated the level of awareness and perception of participants regarding the use of food additives such as stiffeners. The results showed that most participants had limited awareness about this type of additive and informed participants had a negative attitude toward such substances. In addition, individuals had limited information about gum, starch, and wheat flour as additives. Due to the natural content of these additives, educational interventions should be carried out to introduce them (Varela and Fiszman, 2013). The discrepancy between our findings and the research conducted in Spain may be related to the application of words and language differences in the questionnaire. It seems that using the word “hydrocolloids” caused confusion for the Spanish respondents since they were not familiar with the expression. A review of 26 articles published in Canada on food safety indicated the necessity of increasing knowledge and awareness among vulnerable people (elderly and children) about food safety and high-risk foods containing additives. In addition, these studies suggested educational intervention (Nesbitt et al., 2014).
Considering the people’s awareness and attitude towards the packaged foods and effects of additives on health, 64.15% of the packaged foods consumers had a good level of awareness about the adverse health effects of these products. Interestingly, 70.96% of these respondents were still willing to consume these products. The results of this study revealed that consumers did not have enough information about the chemical properties of certain additives and their effects on health. As a result, we are faced with a serious need to promote the public awareness about health problems caused by food additives (Legesse et al., 2016).
More than 90% of the participants selected the phrase “never” for the practice section, suggesting that a majority of participants did not pay attention to the information provided on the food labels about food additives (Table 3). The practice section of the questionnaire received the score of 15.0 ± 1.5, which emphasizes that food labeling is a communication tool for consumers to opt food. According to the National Iranian Standard Organization, the labels of products must contain information including the product’s name and brand; date of production; expiration date; net weight; producer’s serial number; substances or ingredients (including various food additives); name and address of the producer, packer, or importer; nutritional value table; traffic light table, product storage conditions and warnings; instruction; and the term ‘Made in Iran’ if it applies (Esfandiari et al., 2019, Esfandiari et al., 2021, Institute of Standards and Industrial Research of Iran (ISIRI), 2009). With regard to this section, the most frequent response was ‘never” followed by “rarely” (Table 3).  In comparison to the scores obtained in the knowledge (30.6 ± 1.3) and attitude (32.0 ± 0.9) sections, the lowest score was associated with the practices section (15.0 ± 1.5), showing the poorest condition of respondents. The results of our study are consistent with other surveys conducted in other countries in this area. A review of the literature indicated that positive attitudes toward additives do not necessarily lead to behaviors enhancing selection of the safe food (Wilcock et al., 2004). A study over the knowledge and practices of people working in the take-out food stores in Turkey showed serious concern about food safety due to lack of awareness. The majority of the respondents had little information about additives and reported that these substances had adverse effects on health (Unusan, 2007). In another study conducted in India, awareness, attitude, and practice of adult girls were evaluated about food safety in four states. Based on the findings, participants did not have enough information about food safety labels used in India and consumers’ confidence in food was generally based on the popularity of the brand. The researchers of this study also recommended increasing the public knowledge about permitted additives used in foods (Gavaravarapu et al., 2009). The most interesting result of the practice section was related to the highest frequency of positive answers (always, often, and sometimes) concerning the application of natural additives such as thyme for flavoring and antimicrobial value (P10). This shows that respondents tend to use natural than artificial additives in food. 
Consequently, Iranian food producers are recommended to represent the information about food additives on the food labeling. Based on some previous studies conducted in Iran, the food consumers are not informed about the importance of data on food labeling (Esfandiari et al., 2019, Esfandiari et al., 2021). In fact, labelling can be a valid source of information about food additives for consumers in choosing the food products. Totally, the results of practice section showed the respondents’ lack of trust in processed foods due to their artificial food additives, which indicates the respondents’ lack of awareness about the benefits of additives in food industry.
Some limitations of the present study include the self-reporting nature of the applied questionnaire, especially in the practice section, which may have affected the result’s accuracy. Moreover, it was impossible to objectively examine the participants’ purchasing behaviors in real time
Conclusions
The study revealed that personnel of Isfahan University of Medical Sciences in Iran had poor knowledge, attitudes, and practices with regard to food additives. This can be attributed to the lack of information on food additives, inadequacy of related education and trainings, and public relations. In order to develop a healthy society, people need to make informed choices based on appropriate information about food contents. Therefore, it is recommended to educate Iranian society toward the necessary information about food safety regarding additives as well as food labelling. 
Acknowledgments
This study is deduced from thesis approved in School of Nutrition and Food Science and financial support of Vice Chancellery of Research and Technology in Isfahan University of Medical Sciences.
Conflict of interest
There is no conflict of interest.
Authors’ contributions
Bahreini Esfahani N, Ziaei H, and Esfandiari Z designed the study, administered and collected the questionnaires, analyzed the data, and wrote the manuscript. All authors read and approved the final manuscript.
 
References
Akbari-Adergani B, Poorasad M & Esfandiari Z 2018. Sunset yellow, tartrazine and sodium benzoate in orange juice distributed in Iranian market and subsequent exposure assessment. International food research journal. 25 (3).
Bearth A, Cousin M-E & Siegrist M 2014. The consumer’s perception of artificial food additives: Influences on acceptance, risk and benefit perceptions. Food quality and preference. 38: 14-23.
Carocho M, Barreiro MF, Morales P & Ferreira IC 2014. Adding molecules to food, pros and cons: A review on synthetic and natural food additives. Comprehensive reviews in food science and food safety. 13 (4): 377-399.
Choe J-S, Chun H-K, Hwang D-Y & Nam H-J 2005. Consumer perceptions of food-related hazards and correlates of degree of concerns about food. Journal of the Korean society of food science and nutrition. 34 (1): 66-74.
Council Regulation (EC) 2008. 1333/2008 of 16 December 2008 on food additives. (2008). OJ L354/16.
Esfandiari Z, et al. 2013. Simultaneous determination of sodium benzoate, potassium sorbate and natamycin content in Iranian yoghurt drink (Doogh) and the associated risk of their intake through Doogh consumption. Iranian journal of public health. 42 (8): 915.
Esfandiari Z, Ghassami N & Hosseini H 2017. Examination of the Antimicrobial Preservatives of Benzoic Acid and Sodium Benzoate in Different Food Products in Iran: A Review of the Current Evidence. Journal of health system research. 13 (1): 1-9 [In Pesian].
Esfandiari Z, et al. 2019. Influence of education on knowledge, attitude and practices of students of Isfahan University of Medical Sciences to traffic light inserted on food labeling. Tehran University medical journal 77 (1): 54-62.
Esfandiari Z, et al. 2021. Effect of Face-to-Face Education on Knowledge, Attitudes, and Practices Toward “Traffic Light” Food Labeling in Isfahan Society, Iran. International quarterly of community health education. 41 (3): 275-284.
Esfandiari Z, Saraji M, Madani RA & Jahanmard E 2016. Status of benzoic acid amount during processing from yoghurt to its by-product drink (Doogh). Italian journal of food science. 28 (3): 536.
Gavaravarapu SRM, Vemula SR, Rao P, Mendu VVR & Polasa K 2009. Focus group studies on food safety knowledge, perceptions, and practices of school-going adolescent girls in South India. Journal of nutrition education and behavior. 41 (5): 340-346.
Institute of Standards and Industrial Research of Iran (ISIRI) 2009. Prepackaged foods – General standard for the labelling. Retrieved on January 1, 2018 from ISIRI Website: www.isiri. org/ portal/files/std/4470.pdf.
Legesse A, Muluken A & Getasew A 2016. A survey on awareness of consumers about health problems of food additives in packaged foods and their attitude toward consumption of packaged foods: A case study at Jimma University. International food research journal. 23 (1): 375.
McBride DL 2018. Safety Concerns About Food Additives and Children's Health. Journal of pediatric nursing. 45: 76-77.
McCann D, et al. 2007. Food additives and hyperactive behaviour in 3-year-old and 8/9-year-old children in the community: a randomised, double-blinded, placebo-controlled trial. Lancet. 370 (9598): 1560-1567.
Nesbitt A, et al. 2014. Baseline for consumer food safety knowledge and behaviour in Canada. Food control. 38: 157-173.
Shim S-M, et al. 2011. Consumers’ knowledge and safety perceptions of food additives: Evaluation on the effectiveness of transmitting information on preservatives. Food control. 22 (7): 1054-1060.
Trasande L, Shaffer RM & Sathyanarayana S 2018. Food additives and child health. Pediatrics. 142 (2).
Unusan N 2007. Consumer food safety knowledge and practices in the home in Turkey. Food control. 18 (1): 45-51.
Varela P & Fiszman S 2013. Exploring consumers' knowledge and perceptions of hydrocolloids used as food additives and ingredients. Food hydrocolloids. 30 (1): 477-484.
Wilcock A, Pun M, Khanona J & Aung M 2004. Consumer attitudes, knowledge and behaviour: a review of food safety issues. Trends in food science & technology. 15 (2): 56-66.
Wu L, Zhong Y, Shan L & Qin W 2013. Public risk perception of food additives and food scares. The case in Suzhou, China. Appetite. 70: 90-98.