The Cardio-Med survey tool: development and pilot validation of a FFQ in a multicultural cardiology cohort

OBJECTIVE

(i) Describe the development of a multipurpose Cardio-Med survey tool (CMST) comprising a semi-quantitative FFQ designed to measure dietary intake in multicultural patients with or at high risk of CVD and (ii) report pilot evaluation of test-retest reliability and validity of the FFQ in measuring energy and nutrient intakes.

DESIGN

The CMST was developed to identify CVD risk factors and assess diet quality over 1 year using an FFQ. Design of the ninety-three-item FFQ involved developing food portion photographs, and a list of foods appropriate for the Australian multicultural population allowing the capture of adherence to a Mediterranean diet pattern. The FFQ was administered twice, 2 weeks apart to assess test-retest reliability, whilst validity was assessed by comparison of the FFQ with a 3-d food record (3DFR).

SETTING

The Northern Hospital and St Vincent's Hospital, Melbourne, Australia.

PARTICIPANTS

Thirty-eight participants aged 34-81 years with CVD or at high risk.

RESULTS

Test-retest reliability of the FFQ was good: intraclass correlation coefficient (ICC) ranged from 0·52 (Na) to 0·88 (alcohol) (mean 0·79), with energy and 70 % of measured nutrients being above 0·75. Validity was moderate: ICC ranged from 0·08 (Na) to 0·94 (alcohol) (mean 0·59), with energy and 85 % of measured nutrients being above 0·5. Bland-Altman plots demonstrated good levels of agreement between the FFQ and 3DFR for carbohydrates, protein, alcohol, vitamin D and Na.

CONCLUSIONS

The CMST FFQ demonstrated good test-retest reliability and moderate validity for measuring dietary energy and nutrients in a multicultural Australian cardiology population.

Invited Commentary: The Contribution to the Field of Nutritional Epidemiology of the Landmark 1985 Publication by Willett et al

The semiquantitative food frequency questionnaire (FFQ) has been the primary source of dietary exposure data in epidemiology for decades. Although frequency instruments had been evaluated before the 1985 publication "Reproducibility and Validity of a Semiquantitative Food Frequency Questionnaire" by Willett et al. (Am J Epidemiol. 1985;122(1):51-65), that paper was the prototype for the development and validation of what was then a highly innovative method for collecting dietary data. This approach was adopted in nearly all subsequent cohort studies of diet and disease. The paper also catalyzed an extended scientific discourse regarding methods for validation, energy adjustment, and measurement error. It is now well established that data from FFQs and other self-reported dietary assessment instruments have both value and error and that this error should be considered in the analysis and interpretation of findings, including sensitivity analyses in which adjustment for measurement error is explored. Advances in technology make it feasible to consider collecting multiple granular short-term instruments such as recalls or records over time in addition to FFQs among all participants in large cohort studies; both provide valuable information. Without a doubt, the 1985 publication by Willett et al. provided the foundation that propelled the field of nutritional epidemiology forward, and it continues to be relevant today.

Nutritional intake of Korean population before and after adjusting for within-individual variations: 2001 Korean National Health and Nutrition Survey Data

Accurate assessment of nutrient adequacy of a population should be based on usual intake distribution of that population. This study was conducted to adjust usual nutrient intake distributions of a single 24-hour recall in 2001 Korean National Health and Nutrition Surveys (KNHNS) in order to determine the magnitude of limitations inherent to a single 24-hour recall in assessing nutrient intakes of a population. Of 9,960 individuals who provided one 24-hour recall in 2001 KNHNS, 3,976 subjects provided an additional one-day 24-hour recall in 2002 Korean National Nutrition Survey by Season (KNNSS). To adjust for usual intake distribution, we estimated within-individual variations derived from 2001 KNHNS and 2002 KNNSS using the Iowa State University method. Nutritionally at risk population was assessed in reference to the Dietary Reference Intakes for Koreans (KDRIs). The Korean Estimated Average Requirement (Korean EAR) cut-point was applied to estimate the prevalence of inadequate nutrient intakes except for iron intakes, which were assessed using the probability approach. The estimated proportions below Korean EAR for calcium, riboflavin, and iron were 73%, 41%, and 24% from usual intake distribution and 70%, 51%, and 39% from one-day intake distribution, respectively. The estimated proportion of sodium intakes over the Intake Goal of 2,000 mg/day was 100% of the population after adjustment. The energy proportion from protein was within Korean Acceptable Macronutrient Distribution Ranges (Korean AMDR), whereas that of carbohydrate was higher than the upper limit and that of fat was below the lower limit in the subjects aged 30 years or older. According to these results, the prevalence of nutritional inadequacy and excess intake is over-estimated in Korea unless usual intake distributions are adjusted for one-day intakes of most nutrients.

Longitudinal changes in dietary intake in Scottish women around the menopause: changes in dietary pattern result in minor changes in nutrient intake

Objective

To examine dietary change that has occurred over 5 to 6 years.

Subjects

A cohort of Scottish women (n=898) with a mean age of 47.5 years (range 45–54 years) at baseline.

Design

Dietary intake was assessed by validated food-frequency questionnaire (FFQ) and analysed using the UK Composition of Foods database.

Results

Since the first dietary assessment, mean daily energy intake had decreased from 8.2±2.3 to 7.9±2.2 MJ. The degree of low energy reporting (defined as ratio of energy intake to basal metabolic rate >1.1) had increased from 18.7% at baseline to 25.6% at follow-up. Low energy reporters were significantly heavier than ‘normal’ energy reporters (mean weight at follow-up, 68.9±12.6 vs. 66.8±11.3 kg) and could be deliberately restricting intake rather than underreporting. Overall there were decreases in intakes of red meat, processed meat and cheese, but increases in poultry and non-oily fish consumption. Consumption of bread, biscuits and cakes had gone down and there was an increase in cereal and rice/pasta consumption. Intake of potatoes had decreased whereas fruit intake had increased. There were small but statistically significant differences in intakes for most nutrients (>8% change). Nutrient intakes at both visits were similar across menopausal status and usage groups of hormone replacement therapy. Modifications to the computer version of the McCance and Widdowson nutrient database, which differed from the published version, were noted. These changes altered the original baseline values for our study.

Conclusions

The menopause per se is not a period of marked change in nutrient intake. Caution is advised when using computer databases of food compositions for longitudinal studies.

Sources of variation in nutrient intakes among men in Shanghai, China

BACKGROUND AND OBJECTIVE

Random errors, from any source, will attenuate epidemiological risk estimates. Before we launched the Shanghai Men's Health Study (SMHS), a large population-based cohort study investigating the diet-cancer association among Chinese men, a dietary calibration study was conducted among 96 men aged 40-75 years (mean age 56.5 years), with biweekly 24-hour dietary recalls (24HDRs) implemented over a 1-year period. Data from this study were analysed to evaluate the nature and magnitude of variances for intake of 26 nutrients among SMHS participants, to compare variance ratios of 26 nutrients among Chinese men and women and individuals in other studies, and to estimate the number of 24HDRs required for future dietary calibration studies in similar populations.

DESIGN

Ninety-six healthy, free-living men in Shanghai were administered biweekly 24HDR interviews 24 times over a 1-year period. To assess between-individual and within-individual contributions to variance, a mixed effects model was fitted and ratios of within-individual to between-individual (sigma(w)(2)/sigma(b)(2)) dietary intake variances were computed.

SETTING

Shanghai, China.

RESULTS

In agreement with reports from studies conducted in the USA and many other countries, we found that within-individual variances were usually larger than between-individual variances in dietary intake for all nutrients. The sum of all other variation (e.g. weekday and weekend, seasonal, interviewer) accounted for less than 5% of total variation. Ratios of within- to between-individual variances (for log-transformed data) ranged from 1.25 for carbohydrate intake to near 8 for delta-tocopherol intake.

CONCLUSIONS

The results of this study suggest that among middle-aged and elderly Chinese men in Shanghai, within- and between-individual variation account for more than 95% of the total variation for 26 nutrients. Further dietary validation studies in the same population could be adequately carried out with only 12 days of dietary recalls, if 100 participants were enrolled.

Variation in nutrient intakes among women in Shanghai, China

BACKGROUND

In 1997, we launched a large population-based cohort study, the Shanghai Women Health Study (SWHS), to investigate diet in relation to cancer risk among 74 943 Chinese women. Simultaneously, a dietary calibration study was conducted among 200 SWHS participants with biweekly 24-h dietary recall (24HDR) over a 1-y period in order to evaluate the validity and reliability of the SWHS food frequency questionnaire (FFQ).

OBJECTIVE

The objectives of the current study were to evaluate the nature and magnitude of variances for intake of 26 nutrients among SWHS participants, and to estimate the number of 24HDR needed for estimate intake of the 26 nutrients examined in the study population.

DESIGN

In all, 1-y biweekly 24HDR collected from 200 healthy, free-living women aged between 40 and 70 y, who participated in the SWHS dietary calibration study, was analyzed by mixed effects model and ratios of within-individual and between-individual dietary intake variances (sigma(w)(2)/sigma(b)(2)) were estimated.

RESULTS

In agreement with reports from studies conducted in the US, we found that within-individual variances were larger than between-individual variances in dietary intake of most nutrients. The sum of all other variation (eg, weekday and weekend, seasonal, interviewer) accounted for less than 5% of total variation. Ratios of within- to between-individual variances (for log transformed data) ranged from 1.05 (carbohydrate) to 2.79 (fat) for macronutrient intake, 1.74 (niacin) to 8.48 (delta-tocopherol) for vitamin intake, and 1.35 (phosphorus) to 5.59 (sodium) for mineral intake.

CONCLUSIONS

The results of this study suggest that within- and between-individual differences in nutrient intake are the major sources of variation in this population of adult Chinese women. Cultural practices as well as seasonal supply and consumption patterns of vegetable intake are likely the major contributors to the variation. Implications of these results are discussed.

Differences between estimated caloric requirements and self-reported caloric intake in the women's health initiative

PURPOSE

To compare energy intake derived from a food frequency questionnaire (FFQ) with estimated energy expenditure in postmenopausal women participating in a large clinical study.

METHODS

A total of 161,856 women aged 50 to 79 years enrolled in the Women's Health Initiative (WHI) Observational Study (OS) or Clinical Trial (CT) [including the Diet Modification (DM) component] completed the WHI FFQ, from which energy intake (FFQEI) was derived. Population-adjusted total energy expenditure (PATEE) was calculated according to the Harris-Benedict equation weighted by caloric intakes derived from the National Health and Nutrition Examination Survey. Stepwise regression was used to examine the influence of independent variables (e.g., demographic, anthropometric) on FFQEI-PATEE. Race, region, and education were forced into the model; other variables were retained if they increased model explanatory ability by more than 1%.

RESULTS

On average, FFQEI was approximately 25% lower than PATEE. Regression results (intercept=-799 kcal/d) indicated that body mass index (b=-23 kcal/day/kg.m(-2)); age (b=15 kcal/day/year of age); and study arm (relative to women in the OS, for DM women b=169 kcal/d, indicating better agreement with PATEE) increased model partial R(2)>.01. Results for CT women not eligible for DM were similar to those of women in the OS (b=14 kcal/d). There also were apparent differences by race (b=-152 kcal/d in Blacks) and education (b=-67 kcal/d in women with<high school).

CONCLUSION

This large, carefully studied population confirms previous observations regarding underestimates in self-reported caloric intake relative to estimates of metabolic need in younger women, and those with higher weight, with less education, and in Blacks. These differences, along with effects related to intervention assignment, underline the need for additional research to enhance understanding of errors in dietary measurement.