Development of a food frequency instrument: ethnic differences in food sources

Evaluation of a Planned Behavior Theory-Based Intervention Programme to Promote Healthy Eating

The objective of the study was to test the effectiveness of an intervention program based on the theoretical framework of the Theory of Planned Behavior, with the addition of attitude strength and role identity. The aim was to alter adolescents' healthy eating attitudes and behaviour. In the sample were 335 high school students, who were divided into intervention and control groups. The intervention lasted 12 weeks and included posters and lectures promoting healthy eating. The measures included a questionnaire assessing the hypothesis and a food frequency questionnaire which measured eating habits. Analysis showed the intervention was effective in improving attitudes toward healthy eating and attitude strength, intention, perceived behavioral control, and healthy eating behaviour, but not effective in predicting subjective norms and role identity. Results provide evidence that intervention changed attitudes toward a behavior in a school setting.

A prospective assessment of dietary patterns in Muslim subjects with type 2 diabetes who undertake fasting during Ramadan

AIMS

The aim was to assess the dietary pattern during Ramadan season among type 2 diabetic Muslim subjects who underwent fasting and intensive dietary counseling.

MATERIALS AND METHODS

The study was conducted among 70 Muslim subjects with type 2 diabetes mellitus who undertook fasting during Ramadan and was part of a randomized control trial using pioglitazone published previously. All subjects were subjected to a dietary assessment and counseling at three stages, i.e., initiation of the study, mid-Ramadan and post-Ramadan, by a trained dietician. Dietary assessment was done by the 24-hour dietary recall method and the food frequency questionnaire. Diabetic diet sheets were dispensed to subjects based on their body mass index (BMI), daily activity, and needs.

RESULTS

The mean caloric intake between pre-Ramadan (before fasting) and mid-Ramadan (15 days after fasting) were 1506.80 kcal and 1614.29 (P = 0.001) respectively. The distribution of active components pre and during Ramadan were: carbohydrates (g) 260.76 and 265.35 g (P = 0.001), proteins (g) 43.64 and 46.19 (P = 0.001) and fat (g) was 32.88 and 44.16 (P = 0.0001) respectively. The percentage of energy from dietary carbohydrate prior to fasting (64.11 ± 6.73) and during fasting (68.41 ± 4.41) remained almost unchanged but statistically significant when compared at different intervals before and during fasting. Fat intake increased significantly during fasting (P = < 0.001).

CONCLUSIONS

The dietary composition in a type 2 diabetic Muslim population who undertook fasting during Ramadan showed a mean increase in consumption of all components of diet during the period of fasting. Nutritional compliance during such a time seems to be difficult and warrants repeated counseling and regular follow-up to achieve targets.

Food-frequency questionnaires: a review of their design, validation and utilisation

A review of the literature concerning the design, utilisation and validation of food-frequency questionnaires (FFQ) has been carried out using a semi-systematic approach to obtaining, reviewing and extracting data from articles. Databases were searched from 1980 to 1999. The present review identified 227 validation (from 1980 to September 1999) and 164 utilisation (for 1998 only) studies. A number of design issues have been evaluated through the present review. These include: the need to consider how portion sizes have been described, self-defined giving higher mean correlations; how an FFQ was administered, interviewer-administered giving higher mean correlations for some nutrients; how many items to include on an FFQ, those with the largest number of items having higher correlations. Validation techniques were described. Most validation studies involved comparing an FFQ against another dietary assessment method; only 19 % compared an FFQ to a biomarker. Measurement differences were most commonly assessed by correlation coefficients as opposed to other more appropriate methods. Mean correlation coefficients were highest for Ca and fat, and lowest for vitamin A and vegetables. The utilisation studies showed that FFQ were most commonly used in cross-sectional surveys, with ninety-three of the FFQ being designed to be disease-specific. The present review results were presented to a group of experts and a consensus arrived at concerning the development, validation and use of FFQ. Recommendations derived from the consensus arising from the literature review are presented as an appendix to the present paper.

Dietary patterns, insulin sensitivity and adiposity in the multi-ethnic Insulin Resistance Atherosclerosis Study population

Epidemiological investigations increasingly employ dietary-pattern techniques to fully integrate dietary data. The present study evaluated the relationship of dietary patterns identified by cluster analysis with measures of insulin sensitivity (SI) and adiposity in the multi-ethnic, multi-centre Insulin Resistance Atherosclerosis Study (IRAS, 1992–94). Cross-sectional data from 980 middle-aged adults, of whom 67% had normal and 33% had impaired glucose tolerance, were analysed. Usual dietary intake was obtained by an interviewer-administered, validated food-frequency questionnaire. Outcomes included SI, fasting insulin (FI), BMI and waist circumference. The relationship of dietary patterns to log(SI+1), log(FI), BMI and waist circumference was modelled with multivariable linear regressions. Cluster analysis identified six distinct diet patterns – ‘dark bread’, ‘wine’, ‘fruits’, ‘low-frequency eaters’, ‘fries’ and ‘white bread’. The ‘white bread’ and the ‘fries’ patterns over-represented the Hispanic IRAS population predominantly from two centres, while the ‘wine’ and ‘dark bread’ groups were dominated by non-Hispanic whites. The dietary patterns were associated significantly with each of the outcomes first at the crude, clinical level (P<0·001). Furthermore, they were significantly associated with FI, BMI and waist circumference independent of age, sex, race or ethnicity, clinic, family history of diabetes, smoking and activity (P<0.004), whereas significance was lost for SI. Studying the total dietary behaviour via a pattern approach allowed us to focus both on the qualitative and quantitative dimensions of diet. The present study identified highly consistent associations of distinct dietary patterns with measures of insulin resistance and adiposity, which are risk factors for diabetes and heart disease.

Review of evaluation tools used to assess the impact of nutrition education on dietary intake and quality, weight management practices, and physical activity of low-income audiences

Nutrition education programs and social marketing campaigns frequently focus on low-income audiences with the goal of improving dietary intake and quality, weight management practices, and physical activity. The impact of nutrition education can be assessed by measuring change in relation to any or all of these broad variables. Unfortunately, little information is available concerning the reliability, validity, and sensitivity to change of measures used to assess these constructs with low-income audiences of adults and adolescents. This article reviews the literature and discusses the types of available measures that have been used and evaluated for the above audiences. It describes specific measures used to assess total diet, consumption of food groups from the Food Guide Pyramid, and behaviors related to weight management and physical activity. Overall, this review suggests that there is a critical need for additional development and evaluation of dietary quality measurement tools for low-income and minority audiences.

Assessing the diet of the British African-Caribbean population: frequency of consumption of foods and food portion sizes

There is a very high prevalence of diet related disorders in the British African-Caribbean population but very few studies have determined associations between diet and disease within this community. There are virtually no published data on the frequency of foods consumed by this population or on the usual portion sizes which are necessary not only for nutritional epidemiological studies but also for treating diet related conditions such as diabetes. Here we present the frequency of foods consumed, assessed by a quantitative FFQ specifically developed for this sample, and the usual portion size reported by 210 randomly selected adult men and women. Frequency of consumption of foods and food portion sizes reported differed greatly from those consumed by the majority White population. This paper highlights the need to collect valid food consumption data for specific ethnic groups rather than using data available from another population, which is inappropriate. Such data will enable more precise dietary assessment and will further our understanding of the role of diet in the aetiology and prevention of diet-related diseases.

A motivational interviewing intervention to increase fruit and vegetable intake through Black churches: results of the Eat for Life trial

OBJECTIVES

This study reports on Eat for Life, a multicomponent intervention to increase fruit and vegetable consumption among African Americans that was delivered through Black churches.

METHODS

Fourteen churches were randomly assigned to 3 treatment conditions: (1) comparison, (2) self-help intervention with 1 telephone cue call, and (3) self-help with 1 cue call and 3 counseling calls. The telephone counseling in group 3 was based on motivational interviewing. The primary outcome, assessed at baseline and 1-year follow-up, was fruit and vegetable intake as assessed by 3 food frequency questionnaires.

RESULTS

Change in fruit and vegetable intake was significantly greater in the motivational interviewing group than in the comparison and self-help groups. The net difference between the motivational interviewing and comparison groups was 1.38, 1.03, and 1.21 servings of fruits and vegetables per day for the 2-item, 7-item, and 36-item food frequency questionnaires, respectively. The net difference between the motivational interviewing and self-help groups was 1.14, 1.10, and 0.97 servings for the 2-item, 7-item, and 36-item food frequency questionnaires, respectively.

CONCLUSIONS

Motivational interviewing appears to be a promising strategy for modifying dietary behavior, and Black churches are an excellent setting to implement and evaluate health promotion programs.

GO GIRLS!: results from a nutrition and physical activity program for low-income, overweight African American adolescent females

This article describes the development, implementation, and results of an intervention designed for inner-city, overweight African American adolescent women. Fifty-seven participants were recruited from four public housing developments. Participants were administered physiologic, dietary, and cognitive assessments at baseline and immediately postintervention. Each session comprised three elements: (1) an educational/behavioral activity, (2) 30 to 60 minutes of physical activity, and (3) preparation and tasting of low-fat meals. In the absence of a control group, results were compared for high and low attenders, the former defined as attending at least 50% of the sessions. High attenders (n = 26) showed more favorable 6-month posttest values for most outcomes compared with low attenders (n = 31). These effects achieved statistical significance for nutrition knowledge, low-fat practices, perceived changes in low-fat practices, and social support.

A qualitative study of participants' experiences with dietary assessment

OBJECTIVE

This article reports on the use of focus groups and an experimental participatory activity to investigate factors influencing participants' decisions about what to eat and what to report on food records and food frequency questionnaires.

DESIGN

Four focus groups examined participants' experience with diet records and 3 focus groups explored the topic of food portions using a group consensus activity. Twenty-two women participated in the diet record focus groups, and 15 participated in portion estimation groups.

SUBJECTS

Focus group participants were equally distributed by age and body mass index values. Each woman completed a 10-day doubly labeled water protocol to measure total energy expenditure, 7 days of diet records (before and during total energy expenditure), and a food frequency questionnaire after the total energy expenditure.

ANALYSIS

Transcripts of the focus groups were coded to index categories of responses and to identify themes within and across those responses. Themes discussed in this article are those that were discussed most often and at greatest length by all groups.

RESULTS

The diet record focus groups revealed that 2 major factors influenced reporting on diet records: honesty vs social acceptability, and simplifying food intake. The portion estimation focus groups revealed 5 factors that influenced perceptions of portion size: the role of food in the meal, the type of food, personal preferences, product serving sizes, and comparison of personal servings with those of others.

APPLICATIONS

The validity and reliability of self-reported food consumption is greatly influenced by the ways people interpret and respond to dietary assessment instruments. These findings indicate that dietetics professionals need to take extra steps to address issues of accurately recording "bad" foods when training patients to complete diet records. Extra probing is needed when dietary records do not include snacks and include simple meals and a large amount of prepared and packaged food because this may indicate that changes in normal dietary patterns were made in order to more easily complete a dietary record.

Assessing the cultural relevance of an education program for urban African Americans with diabetes

PURPOSE

This study was conducted to assess the cultural relevance of an education program for urban African Americans with diabetes.

METHODS

A set of 12 videotape vignettes were developed for use in diabetes education for urban African Americans with diabetes. Focus groups and questionnaires were used to determine if patients and diabetes educators would find the materials stimulating, culturally appropriate, and useful.

RESULTS

The videotape and discussion guide were perceived as valuable by both healthcare professionals and patients.

CONCLUSIONS

This education program could be a valuable resource for diabetes educators who want to provide culturally sensitive and relevant diabetes education for urban African Americans with diabetes.

Trends in dietary sources of nutrients among middle-aged men in southern Germany. Results of the MONICA Project Augsburg: dietary surveys 1984/1985 and 1994/1995. MONItoring trends and determinants in CArdiovascular disease

The study analyses 10-year trends (1984/1985-1994/1995) in southern Germany in the food sources of nutrients. In two phases of the MONICA Project in Augsburg, dietary surveys were conducted in subsamples of 45 to 64 year-old men. Responses in 1984/1985 and 1994/1995 were 69.8% and 70.8% with eligible samples of 603 and 607, respectively. Seven-day records were collected and coded with the German food composition database. Percentage contribution of food groups to selected nutrient intakes were calculated. Meat and meat products and eggs decreased in importance as contributors to the intake of energy and several nutrients, whereas fish and fish products, milk and milk products and various food groups of plant origin became more important. In 1984/1985, for instance, meat and meat products delivered 23.4% of energy, 47.5% of protein and 38.1% of fat, whereas in 1994/1995 the respective contributions declined to 21.4%, 44.0% and 34.5%. The new product group of supplements has already become an important contributor to the intake of vitamin C. Both static intakes and changes in intake of certain nutrients can be explained by corresponding fluctuations in patterns of intake of the underlying food sources. Therefore it is recommended that dietary assessments use food source lists derived from the most recent dietary surveys.

Validity and reproducibility of a food frequency interview in a Multi-Cultural Epidemiology Study

PURPOSE

There is limited support for the validity and reproducibility of dietary assessment in culturally diverse populations. The goal of this study was to evaluate the comparative validity and reproducibility of a Food Frequency Questionnaire (FFQ) used in the observational, multi-cultural Insulin Resistance Atherosclerosis Study (IRAS).

METHODS

Women (n = 186) were approximately equally distributed by ethnicity from one urban center (African Americans and non-Hispanic whites) and one rural center (Hispanics and non-Hispanic whites). The IRAS FFQ was modified from the National Cancer Institute Health Habits and History Questionnaire to include ethnic and regional foods. Validity was assessed by comparing dietary values, including supplements, obtained from the FFQ to the average intake estimated from a series of 8 24-hour dietary recalls collected by telephone over the same 1-year period. Reproducibility was assessed among women who reported no change in their usual diet (n = 133) by comparing data from the original IRAS FFQ (in-person) with the FFQ administered for the validity study (two to four years later, by telephone).

RESULTS

Correlation coefficients for validity were statistically significant for most nutrients (mean r = 0.62 urban non-Hispanic white, 0.61 rural non-Hispanic whites, 0.50 African American, 0.41 Hispanic) and did not differ among subgroups of obesity or diabetes status. The median correlation coefficient for the total sample was 0.49. Correlations were lower for women with less than 12 years of education (mean r = 0.30; median r = 0.25). The lower correlations among Hispanics was largely explained by the lower educational attainment in that sample. For reproducibility, the mean correlation for nutrients evaluated was r = 0.62 (median r = 0.63) and did not differ for subgroups.

CONCLUSIONS

Although educational attainment must be considered, the IRAS FFQ appears to be reasonably valid and reliable in a diverse cohort.

The reliability of the Diabetes Care Profile for African Americans

The Diabetes Care Profile (DCP) is an instrument used to assess social and psychological factors related to diabetes and its treatment. The reliability of the DCP was established in populations consisting primarily of Caucasians with type 2 diabetes. This study tests whether the DCP is a reliable instrument for African Americans with type 2 diabetes. Both African American (n = 511) and Caucasian (n = 235) patients with type 2 diabetes were recruited at six sites located in the metropolitan Detroit area. Scale reliability was calculated by Cronbach's coefficient alpha. The scale reliabilities ranged from .70 to .97 for African Americans. These reliabilities were similar to those of Caucasians, whose scale reliabilities ranged from .68 to .96. The Feldt test was used to determine differences between the reliabilities of the two patient populations. No significant differences were found. The DCP is a reliable survey instrument for African American and Caucasian patients with type 2 diabetes.

Case-control assessment of diet and lung cancer risk in African Americans and Mexican Americans

In this case-control study we determined whether dietary differences underlie some of the ethnic and sex differences in US lung cancer rates. We examined the relationship between diet and lung cancer development in 137 lung cancer cases (93 African Americans and 44 Mexican Americans) and 187 controls (78 African Americans and 109 Mexican Americans). Cases reported a higher daily mean total fat intake (p < 0.001), whereas controls had a higher daily mean intake of dietary fiber (p < 0.001) and fruits (p = 0.02). Ethnic differences in diet were also observed: Mexican Americans consumed less total fat (p < 0.02) and more fiber (p < 0.001) and vegetables (p = 0.08) than African Americans. Additionally, men consumed more total fat (p = 0.08) and less fiber (p = 0.001), fruits (p < 0.001), and vegetables (p = 0.002) than women. Multivariable analysis, after adjustment for the effects of pack-years of smoking, age, total energy intake, sex, and ethnicity, demonstrated a positive association between high total fat consumption and lung cancer risk (p < 0.01) and an inverse association between high fruit consumption and lung cancer risk (p = 0.05). In conclusion, our findings support the hypothesis that diet, particularly high fat consumption and low fruit and vegetable consumption, contributes (independent of cigarette smoking) to the excess lung cancer risk in African-American men, who have the highest lung cancer rates in the United States.

Picture-sort method for administering a food frequency questionnaire to older adults

OBJECTIVE

To assess the validity of a picture-sort approach to administering the National Cancer Institute food frequency questionnaire to older adults.

DESIGN

A picture-sort interview was conducted in each respondent's home. After the picture sort, a 24-hour recall interview was administered on the same occasion. Five additional in-home recall interviews were subsequently conducted at approximately 1-month intervals.

SUBJECTS/SETTING

Forty-seven female and 49 male volunteers aged 66 to 100 years were recruited from among Cardiovascular Health Study participants from Maryland and North Carolina.

MAIN OUTCOME MEASURES

Estimates from the picture sort and the recall for intakes of macronutrients, cholesterol, fiber, and selected vitamins and minerals exclusive of supplements.

STATISTICAL ANALYSES

Comparison of means estimated by the two methods and correlation analyses were used. Correlations were adjusted under varied assumptions about the nature of the information contained in the six 24-hour recalls relative to respondents' usual intakes.

RESULTS

After correction for attenuation, Pearson correlation coefficients for macronutrients ranged from .41 for protein to .74 for saturated fat and cholesterol. For vitamins and minerals, correlations ranged from .26 for beta carotene to .62 for calcium.

APPLICATIONS

Picture-sort estimates of mean nutrient intakes were comparable with estimates based on 24-hour recalls, and correlations with reference data were similar to those reported in the literature for conventionally administered food frequency questionnaires. This dietary assessment method may, therefore, offer a way to simplify or structure responses to improve ease of administration and increase respondents' liking for the interview without loss of data quality.

Food-frequency questionnaire validation among Mexican-Americans: Starr County, Texas

A food-frequency questionnaire (FFQ) for low-income Mexican-Americans in Starr County, Texas, was developed as part of an epidemiologic study of gallbladder disease during 1985 and 1986. The FFQ was developed from 7-day food records collected from the first sample. In the validity study, using the second sample, correlations between nutrients calculated from 3-day food records and the FFQ were 0.77, 0.76, and 0.61 for energy, total fat, and saturated fat, respectively. In the reliability study, using the third sample, for the 1-month interval between baseline and a repeat FFQ measurement correlations ranged from 0.90 for energy to 0.85 for total fat and for the 2-month interval they were 0.84 for energy and 0.70 for total fat. The high correlations are largely explained by the lack of diversity in the diets of Starr County individuals which facilitated the high agreement between the FFQ and the food records for estimates of energy, fats, and cholesterol.

Sources of energy and six nutrients in diets of low-income Hispanic-American women and their children: quantitative data from HHANES, 1982-1984

OBJECTIVE

Identification of important food sources of energy, protein, fat, vitamin A, vitamin C, calcium, and iron for low-income Hispanic women and their children.

DESIGN

A subset of 24-hour recalls from the Hispanic Health and Nutrition Examination Survey (HHANES), a sample representing 76% of the Hispanic-origin population, provides the most comprehensive examination of Hispanic food habits in the United States.

SUBJECTS/SAMPLES

The sample, which approximates the population of the Special Supplemental Food Program for Women, Infants, and Children (WIC), included 1,046 17- to 34-year-old women with household income less than 185% of poverty level and their 1- to 5-year-old children (n = 1,063).

MAIN OUTCOME MEASURES

Tables show the percentage that each food contributes to total intake of energy and six nutrients for women and for children and percentage of persons who reported consuming each food during a 24-hour period.

RESULTS

Cultural foods contributed less to the energy and nutrient intake of the population than expected, with few exceptions, notably beans, rice, tortillas, and salsa. Major sources of energy and nutrients were similar to those seen for blacks and whites in the second National Health and Nutrition Examination Survey (1976-1980).

APPLICATIONS

The data presented should be useful to researchers designing dietary assessment instruments and to nutrition educators designing or adapting educational materials. The data may be of particular interest to WIC staff who work with low-income Hispanic populations.

Diet measurement in Vietnamese youth: concurrent reliability of a self-administered food frequency questionnaire

Dietary patterns of Asian Americans change with increasing acculturation, leading to increased consumption of Western foods including those high in fat. Strategies to preserve the healthy aspects of traditional diets need to be developed and dietary assessment methods evaluated. Little is known about reliability of brief dietary measures in the general population or among minority youth. The concurrent reliability of a brief food frequency questionnaire (FFQ) was determined among Vietnamese youth using diet reports. Students in a bilingual high school program were given a FFQ. Students then completed daily diet reports one day each week over seven weeks. The data from the FFQ were compared to the daily food reports. The reliability of the FFQ was highest for frequently eaten food types like rice (r = 0.626, P < 0.01), fruit (r = 0.513, P < 0.01), meat (r = 0.525, P < 0.01) and vegetables (r = 0.474, P < 0.01) and was lower for less commonly eaten types including fish/shellfish (r = 0.227, P = 0.20) and fried foods (r = 0.310, P = 0.07). These results suggest that a few simple FFQ items, particularly for indicator foods such as rice, are reliable for dietary assessment in this population.

A comparison of diets of blacks and whites in three areas of the United States

Dietary factors may contribute to the increased cancer risk of blacks. As a first step to explore this hypothesis, we examined food frequency data obtained by interview with 1,976 adults (881 blacks and 1,095 whites) randomly selected from three areas of the United States. The a priori hypothesis was that blacks were more likely to consume diets low in fruits and vegetables and/or high in fat, particularly saturated fat. Contrary to expectation, blacks were more frequent consumers of fruits and vegetables considered to be protective against cancer (e.g., citrus fruits, cruciferous vegetables, and vegetables rich in vitamins A and C). Intake of both total and saturated fat was slightly lower among blacks than whites. This analysis does not rule out a role for these dietary factors in the etiology of cancer but indicates that ascribing the excess cancer risk among blacks to their frequency of fruit and vegetable consumption or intake of fat per se is inadequate. This suggests that alternative dietary explanations for the racial disparity in cancer risk should be pursued in future studies.