Effect of changes in an FFQ: comparing data from two national dietary survey instruments among 2-year-olds.

In the interpretation of dietary trends, it is important to consider the potential effect of modifications in the dietary assessment method. Therefore, our objective was to explore the comparability of data obtained at two time points by a semi-quantitative FFQ (SFFQ) which has had slight modifications over time. In the national dietary surveys among Norwegian 2-year-olds, diet was assessed by an SFFQ which underwent modifications between the 1999 survey and the 2007 survey. In the present study, fifty-nine families with a 2-year-old child participated by completing both the SFFQ in a crossover design within a month's time. With regard to the reported intake of energy and nutrients, the largest significant differences observed between the two questionnaires were for carbohydrates and added sugar. According to intake of food groups, significant differences were observed for five out of sixteen food groups. Spearman's correlation coefficients for energy, nutrients and food groups ranged from 0.43 (Ca) to 0.85 (soft drinks). Most Bland-Altman plots indicated broad limits of agreement. The differences between the two questionnaires can be explained by changes in the questionnaires, changes in the food composition databases used and random variation. Comparing differences between the questionnaires by maternal educational level, number of children and type of day care revealed minor differences. In conclusion, this study showed that at the group level there was reasonable comparability between the two questionnaires, except for carbohydrates, added sugar and some food groups. Moreover, there were moderate to high correlations for energy, nutrients and food groups.

Rationale and methods of the European Food Consumption Validation (EFCOVAL) Project.

BACKGROUND/OBJECTIVES: The overall objective of the European Food Consumption Validation (EFCOVAL) Project was to further develop and validate a trans-European food consumption method to be used for the evaluation of the intake of foods, nutrients and potentially hazardous chemicals within the European population. SUBJECTS/METHODS: The EFCOVAL Project was carried out by 13 institutes from 11 European countries. The main activities were centered on the three main objectives of the project organized in different sub-projects. RESULTS: In EFCOVAL, EPIC-Soft (the software developed to conduct 24-h dietary recalls (24-HDRs) in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study) was reprogrammed and adapted according to prioritized specifications, resulting in a software program working under the Windows operating system. In parallel of the EPIC-Soft development, the repeated 24-HDR method using EPIC-Soft and a food propensity questionnaire was evaluated against biomarkers in 24-h urine collections and in blood samples among adults from Belgium, the Czech Republic, (the South of) France, the Netherlands and Norway. As a result from an expert workshop on a proposed dietary assessment method for children (4-12 years), the suggested method was tested in a feasibility study in Denmark and Spain among children of 4-5, 7-8 and 12-13 years. To ensure that collected data had sufficient detail in food description for the assessment of additives and contaminants to foods the EPIC-Soft databases were adapted. Finally, the EFCOVAL Consortium developed a statistical tool (Multiple Source Method) for estimating the usual intake and distribution, which has been tested using real food consumption data and compared with three other statistical methods through a simulation study. In addition, a methodology was developed to quantify uncertainty due to portion-size estimation in usual intake distributions. CONCLUSION: The findings of EFCOVAL provide sufficient evidence to conclude that the repeated 24-HDR using EPIC-Soft for standardization in combination with a food propensity questionnaire and modeling of usual intake is a suitable method for pan-European surveillance of nutritional adequacy and food safety among healthy adults and maybe in children aged 7 years and older.

The European Food Consumption Validation Project: conclusions and recommendations.

BACKGROUND/OBJECTIVES: To outline and discuss the main results and conclusions of the European Food Consumption Validation (EFCOVAL) Project. SUBJECTS/METHODS: The EFCOVAL Project was carried out within the EU Sixth Framework Program by researchers in 11 EU countries. The activities focused on (1) the further development of the EPIC-Soft software (the software developed to conduct 24-h dietary recalls (24-HDRs) in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study) and the validation of the 2-day non-consecutive 24-HDR method using EPIC-Soft, (2) defining and investigating the applicability of the most appropriate dietary assessment method to younger age groups and expanding the applicability of the software for use in exposure assessment of some potentially hazardous chemicals and (3) to improve the methodology and statistical methods that estimate usual intake distributions from short-term dietary intake information and develop a methodology to quantify uncertainty in usual intake distributions. RESULTS: The preexisting EPIC-Soft application was reprogrammed into a Windows environment and more than 60 new specifications were implemented in the software. A validation study showed that two non-consecutive EPIC-Soft 24-HDRs are suitable to estimate the usual intake distributions of protein and potassium of European adult populations. The 2-day non-consecutive 24-HDRs in combination with a food propensity questionnaire also appeared to be appropriate to rank individuals according to their fish and fruit and vegetable intake in a comparable way in five European centers. Dietary intake of (young) children can be assessed by the combination of EPIC-Soft 24-HDRs and food recording booklets. The EPIC-Soft-standardized method of describing foods is useful to estimate dietary exposure to potentially hazardous chemicals such as specific flavoring substances. With the developed Multiple Source Method, repeated non-consecutive 24-HDR data in combination with food propensity data can be used to estimate the population distribution of the usual intake by estimating the individual usual intakes. CONCLUSIONS: The findings provide sufficient evidence to conclude that the repeated 24-HDR using EPIC-Soft for standardization in combination with a food propensity questionnaire and modeling of usual intake is a suitable method for pan-European surveillance of nutritional adequacy and food safety among healthy adults and maybe in children aged 7 years and older. To facilitate this methodology in other European countries, the next step is to provide and standardize an implementation plan that accounts for maintenance and updates, sampling designs, national surveillance programs, tailored capacity building and training, and linkage to food composition and occurrence databases.

Respondents' evaluation of the 24-h dietary recall method (EPIC-Soft) in the EFCOVAL Project.

BACKGROUND: To improve participation rate, accuracy and respondents' compliance, it is important to know the respondents' viewpoint. OBJECTIVE: To evaluate respondents' preferences and perception about the EPIC-Soft (the software developed to conduct 24-h dietary recalls (24-HDRs) in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study) 24-HDR interviews and to compare these preferences and perception between population groups (for example, between genders). DESIGN: Data were collected in Belgium, Czech Republic, France, the Netherlands and Norway in 2007. Two 24-HDRs (face-to-face and telephone administered) were conducted using EPIC-Soft. An evaluation questionnaire on different study aspects was completed by the respondents. SETTING: Data were collected in the European Food Consumption Validation Study. SUBJECTS: A convenience sample of 600 apparently healthy men and women, 45-65 years old and including all educational levels, were recruited (120 subjects per country). Differences among population groups were compared by means of the χ (2)-test. RESULTS: A total of 585 respondents completed the evaluation questionnaire. In all, 88% experienced problems only to a low degree when answering face-to-face and telephone-administered 24-HDR using EPIC-Soft. A total of 15% would have preferred help of another person during the face-to-face interview in the study center (mainly men: P < 0.001). Significantly, more subjects in the Netherlands and in Norway preferred two telephone (instead of face-to-face) interviews compared with the other countries (P<0.001). CONCLUSION: Most subjects only experienced problems to a low degree during the EPIC-Soft interviews. Differences in preferences and capabilities to answer the EPIC-Soft interviews were identified between population groups (for example, gender differences). Therefore, the methods and the design to be used in a survey should be adapted according to the study population, so as to optimize response rate and compliance.

Biomarker-based evaluation of two 24-h recalls for comparing usual fish, fruit and vegetable intakes across European centers in the EFCOVAL Study.

BACKGROUND/OBJECTIVES: A standardized methodology is important to enable consistent monitoring of dietary intake across European countries. For this reason, we evaluated the comparability of the assessment of usual food intake collected with two non-consecutive computerized 24-h dietary recalls (24-HDRs) and a food propensity questionnaire (FPQ) among five European centers. SUBJECTS/METHODS: Two 24-HDRs using EPIC-Soft (the software developed to conduct 24-HDRs in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study) were performed to determine fish, fruit and vegetable (FV) consumed by 600 adults in Belgium (BE), the Czech Republic (CZ), France (FR), the Netherlands (NL) and Norway (NO) in a validation study. An FPQ was used to identify non-consumers. Information from the 24-HDRs and FPQ were used to estimate individual usual food intake by the Multiple Source Method (MSM). Blood samples were drawn to determine fatty acids in phospholipids and serum carotenoids as biomarkers of fish, and FV intake, respectively. RESULTS: The pooled correlation between usual fish intake and eicosapentaenoic acid plus docosahexaenoic acid in phospholipids was 0.19 in men and 0.31 in women (P for heterogeneity >0.50) and center-specific correlations ranged between 0.08 (CZ) and 0.28 (BE and NO) in men, and between 0.19 (BE) and 0.55 (FR) in women. For usual FV intake, the pooled correlation with serum carotenoids was 0.31 in men and 0.40 in women (P for heterogeneity >0.10); the center-specific correlations varied between 0.07 (NO) and 0.52 (FR) in men, and between 0.25 (NL) and 0.45 (NO) in women. CONCLUSION: Two standardized 24-HDRs using EPIC-Soft and an FPQ appeared to be appropriate to rank individuals according to their fish and FV intake in a comparable way among five European centers.

Potential and requirements for a standardized pan-European food consumption survey using the EPIC-Soft software.

BACKGROUND/OBJECTIVES: To describe the strengths, limitations and requirements of using EPIC-Soft software (the software developed to conduct 24-h dietary recalls in the European Prospective Investigation into Cancer and Nutrition (EPIC) Study) in pan-European food consumption surveys, and to discuss potentials and barriers for a harmonized pan-European food consumption survey. SUBJECTS/METHODS: The paper is based on the experiences in the 'European Food Consumption and Validation' Project, which included updating six existing and preparing one new country-specific EPIC-Soft version, applying EPIC-Soft in validation and feasibility studies, and estimating the intake of nutrients and flavoring substances. The experiences were discussed in the September 2009 workshop 'Pan-European Food Consumption Surveys--for Standardized and Comparable Transnational Data Collection'. RESULTS: EPIC-Soft is suitable for detailed and standardized food consumption data collection in pan-European food consumption surveys. A thorough preparation of all aspects of the food consumption survey is important for the quality and efficiency during data collection and processing. The preparation and data-handling phase of working with EPIC-Soft is labor intensive and requires trained, motivated and qualified personnel. CONCLUSIONS: Given the suitability of EPIC-Soft as standardized dietary assessment tool in European dietary monitoring, the proposed strategy toward a pan-European food consumption survey is to prepare well, to allow flexibility in national extensions and to start with a limited number of countries that are interested.

Micronutrient recommendation stakeholders' beliefs on dietary guidelines: a qualitative study across six European countries/regions.

A range of stakeholders have been involved in the development and implementation of dietary guidelines (DG) across Europe. Seventy-seven semi-structured qualitative interviews explored stakeholders' beliefs of DG in six European countries/regions. A main theme, variation in the interpretation of the term dietary guideline, was identified using thematic analysis. Descriptions of DG varied across stakeholder groups and countries. Reference was made to both food-based and nutrient-based guidelines, including the terms food-based DG and food guides (for example, pyramids), nutrient recommendations, dietary recommendations, dietary reference values and guideline daily amounts. The terminology surrounding DG requires greater clarity. Until that time, stakeholders would benefit from increased awareness of potential misinterpretations and the implications of this on multi-stakeholder, multi-national policy development and implementation.

Relative validation of a pre-coded food diary among children, under-reporting varies with reporting day and time of the day.

OBJECTIVE: The aim of this study was to validate intake of energy, macro- and micronutrients assessed from pre-coded food diaries (PFDs) by using weighed records (WRs) as the reference method among a group of Norwegian 9-year-olds. We also examined how under-reporters (UR) differed from acceptable reporters (AR) according to the energy intake during the 4-day recording period and energy intake distribution during the day. SUBJECTS AND DESIGN: One hundred 9-year-olds, 45 girls and 55 boys, were recruited to complete a 4-day record with a PFD followed 3 days later with a 4-day WR. RESULTS: There were no differences between energy and nutrient intake from the two recording methods among boys, but girls reported significantly higher intakes with PFD compared with WR. The median Spearman correlation coefficient between PFD and WR for energy and nutrients was 0.43 for girls and 0.49 for boys. Twelve participants were classified as UR with the PDF method. Energy percentages from macronutrients were not significantly different between UR and AR with the PFD method. UR had significantly lower energy intake in the last two recording days and from 1000 to 2200 hours during the day compared to AR. CONCLUSIONS: The PFD method is promising as a tool for assessing food intake in large surveys among children. The present study indicates that the PFD gives more valid data for boys than girls according to the group intake and ranking of nutrient intake when WR is the reference method. However, UR seemed to develop a study fatigue during the day and during the recording period. Increased awareness about the tendency of study fatigue can lead to more specific instructions on how participants can handle the problem.

Validation of a pre-coded food diary with energy expenditure, comparison of under-reporters v. acceptable reporters.

The objective of the present study was to compare energy intake (EI) assessed from a pre-coded food diary (PFD) with energy expenditure (EE) measured by a validated position-and-movement monitor (ActiReg); PreMed AS, Oslo, Norway) in a group of Norwegian 9-year-olds. Moreover, we examined whether and how under-reporters (UR), identified with ActiReg), differed from acceptable reporters (AR) according to food intake and BMI. A total of fifty-one 9-year-olds completed PFD and ActiReg. The present study showed that on average EI was underestimated by 18 % compared with EE measured by ActiReg. The 95 % confidence limits of agreement in a Bland-Altman plot for EI and EE varied from 1.97 MJ to -4.23 MJ (sd 2) among the girls and from 0.74 MJ to -5.26 MJ (sd 2) among the boys. The Pearson correlation coefficient between EI and EE was 0.28 (P=0.05) for males and females combined. Fifty-seven per cent of the participants were classified as AR, 39 % as UR and 4 % as over-reporters with the PFD. Under-reporting of energy remains a problem with the PFD method used in a group of 9-year-olds, especially among boys. However, UR and AR did not show a systematic misreporting related to macronutrients, unhealthy foods or BMI.

Can children and adolescents use photographs of food to estimate portion sizes?

OBJECTIVE: The goals of this study were to investigate whether children and adolescents can accurately estimate portion sizes of preweighed food by viewing photographs of food, and whether age influences the ability to estimate food portion sizes. SUBJECTS: A total of 63 male and female volunteers aged 9-19 y participated in the study. DESIGN: Each participant received a photographic booklet with photograph series of 13 food items. Participants over 10 y of age were asked to estimate portion sizes of food on 34 plates placed in front of them by comparing the different portions to corresponding photographs of food. Younger participants were asked to estimate portion sizes of food on 17 plates by comparing the portions to photographs. RESULTS: Participants made 2019 comparisons between actual food portion sizes and photographs of food portion sizes. On average, 60% of the comparisons were made correctly. A photograph directly adjacent to the photograph depicting the correct portion size was chosen in 35% of the comparisons and 5% of the comparisons were made incorrectly. Portion sizes were estimated more accurately when the actual served portions of food had exactly the same appearance as the foods portrayed in the photographic booklet. No differences existed between children's and adolescents' abilities to estimate portion sizes using photographs. CONCLUSIONS: Large variability may exist in an individual's capability of choosing a photograph that correctly depicts food portion sizes, but the error at the group level is quite small. These data indicate that a photographic booklet of foods can be a useful tool for portion size estimates in these age groups. SPONSORSHIP: The Norwegian Foundation for Health and Rehabilitation through Norwegian Health Association.

Evaluation of a quantitative food frequency questionnaire used in a group of Norwegian adolescents.

OBJECTIVE: The study was conducted to assess the reproducibility and validity of a 190-item self-administered quantitative food frequency questionnaire, used in a nation-wide study of adolescents. DESIGN AND SUBJECTS: Reproducibility study; 103 11th grade students (18 years) completed the questionnaire twice, with a 6-week interval. Validation study; 49 11th grade students filled in the questionnaire and kept 7-day weighed food records. RESULTS: Spearman rank correlations between the nutrient intakes from the two questionnaires varied from 0.63 (sugar energy percentage) to 0.91 (alcohol). The median coefficient was 0.85. The first questionnaire produced generally higher nutrient intake estimates than the second. Correlations between nutrient intake values from the records and the questionnaire ranged from 0.14 (vitamin D, non-significant, cod liver oil not included) to 0.66 (monounsaturated fatty acids). The median coefficient was 0.52. Adjustment for energy intake did not materially affect the correlations. On average 41% of the subjects were classified in the same quartile in the questionnaire and the records, and 2% in the opposite quartiles. However, the percentage of subjects in the same/opposite quartiles for vitamin D and fibre were 33/12 and 22/6, respectively. CONCLUSIONS: It is concluded that the questionnaire is able to rank subjects according to the tested nutrients, except vitamin D and fibre.