Evaluation of a short food frequency

questionnaire used among Norwegian

children
Inger Therese L. Lillegaard
1
*, Nina Cecilie verby
2
and
Lene Frost Andersen
3
1
Norwegian Scientic Committee for Food Safety, Oslo, Norway;
2
Faculty for Health and Sport, Department of Public
Health, Sports and Nutrition, University of Agder, Oslo, Norway;
3
Department of Nutrition, IMB, University of Oslo,
Oslo, Norway
Abstract
Objective: The aim of this study was to evaluate a short food frequency questionnaire (FFQ) against
a four-day precoded food diary (PFD) with regard to frequency of food intake among Norwegian 9- and
13-year-olds.
Subjects and design: A total of 733 9-year-olds and 904 13-year-olds completed first a short FFQ and one to
two weeks later a four-day PFD. The short FFQ included questions about 23 food items, including different
drinks, fruits, vegetables, bread, fish, pizza, sweets, chocolate and savoury snacks. The PFD covered the whole
diet.
Results: When comparing mean intake from the PFD with comparable food items in the FFQ, all food items
showed that increasing intake measuredwith the PFDcorrespondedwith increasing intake with the short FFQ.
However, participants reported a significantly higher frequency of intake for most foods with the short FFQ
comparedwith PFD, except for soft drinks with sugar and sweets. The median Spearman correlation coefficient
between the two methods was 0.36 among the 9-year-olds and 0.32 among the 13-year-olds. Often eaten foods
such as fruits and vegetables had higher correlations than seldom eaten foods such as pizza and potato chips.
The median correlation coefficients for drinks alone were higher (r0.47) for both age groups.
Conclusions: Results indicate that the short FFQ was able to identify high and low consumers of food intake
and had a moderate capability to rank individuals according to food intake. Drinks, fruits and vegetables had
better correlations with the PFD than infrequently eaten food items.
Keywords: short food frequency questionnaire; evaluation; relative validation; children; adolescents
Received: 17 February 2011; Revised: 8 December 2011; Accepted: 9 December 2011; Published: 16 January 2012
F
ood frequency questionnaires (FFQs) have been
used as an epidemiological tool for several decades
(1). Many FFQs of variable lengths with primary
aims to measure the whole diet have been developed and
validated (26). However, when a single nutrient or food
group is of interest, short FFQs may be enough to assess
the intake. Several studies among adults have evaluated
short FFQs at the food intake level (79), and short FFQs
have also been evaluated among children and adolescents
(1018). The advantages of a short questionnaire are
the ability to collect data more frequently because it is
less expensive than more traditional dietary assess-
ment methods; it is less burdensome for participants to
complete; and data processing time is less than what
is needed for more extensive dietary assessment methods.
Measuring dietary intakes in children and adolescents
is challenging. For example, children may have difficulty
remembering quantities, and they are not always able to
describe in detail the food they eat (19). Also, the concept
of time and estimation of mean frequency of food intake
can be problematic for children. The main nutritional
challenges among Norwegian children and adolescents
are high intakes of sugar and low intakes of fruits and
vegetables (20, 21). Our intentions in developing a short
FFQ were to monitor foods high in fat and sugar, along
with fruit and vegetable intake. Both traditionally eaten
food items such as wholegrain bread, potatoes and fish
for dinner, use of butter on bread, and more modern
foods such as pizza and sugar- and non sugar-containing
beverages, along with intake of chocolate and sweets,
(page number not for citation purpose)

Original Article
Food & Nutrition Research 2012 # 2012 Inger Therese L. Lillegaard et al. This is an Open Access article distributed under the terms of the Creative Commons
Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial use, distribution, and reproduction in
any medium, provided the original work is properly cited.
1
Citation: Food & Nutrition Research 2012. 56 6399 - DOI: 10.3402/fnr.v56i0.6399
fruits and vegetables were included in the questionnaire.
Moreover, the FFQ had to be inexpensive, undemanding,
able to detect changes on group level and to rank children
and adolescents according to food intake.
This article presents the evaluation of a short FFQ
developed for use among children and adolescents. The
objective of this study was to examine how well the short
FFQ corresponded to a four-day precoded food diary
(PFD) with regard to frequencies of food intake and
mean food intake.
Subjects and methods
Subjects
A total of 1,018 9-year-olds (4
th
grade) and 1,181 13-year-
olds (8
th
grade) were invited to take part in a nationally
representative dietary survey, UNGKOST-2000. There
were 733 9-year-olds and 904 13-year-olds who com-
pleted both a short FFQ and a four-day PFD. This
corresponds to a participation rate of 74%.
The study protocols were approved by the National
Committee for Research Ethics in Norway and the
Norwegian Social Science Data Services.
Design
The data collection was carried out during September
December 2000. Students received an invitation letter
along with a short FFQ at school approximately two
weeks before food recording started. Students and
parents who wanted to participate returned informed
consent and the short FFQ by mail to the University of
Oslo. A nutritionist visited each class and gave oral and
written instructions on how the diet should be recorded.
Participants received four PFDs and a photographic
booklet depicting portion sizes. All participants were
phoned on the second day of their recording period to
encourage participation and provide answers to ques-
tions. Participants were instructed to call the study
nutritionist any time if they had questions.
Short food frequency questionnaire
In the short FFQ, frequency of intake of 23 food items
was recorded. Nine questions pertained to drinks: milk
(four different fat contents), orange juice, fruit drinks
and soft drinks with and without sugar. Furthermore,
the FFQ contained questions about each of the following
food items or food groups: potatoes, vegetables, fruit/
berries, potato chips, whole meal bread, fish for dinner
(not including bread spread), pizza, hamburger/hot dog/
kebab, sweets, chocolate, savoury snacks, peanuts, cod liver
oil and vitamin supplements. In addition, one question
pertained to the use of butter/margarine on bread. The
participants were asked to have in mind their food habits
during the last year when filling in the questionnaire.
The short FFQs were filled in at home, and the
participants could get help from their parents to complete
the questionnaire.
The frequency scale used for drinks were neverseldom,
13 glasses per month, 13 glasses per week, 46 glasses
per week, 13 glasses per day, 46 glasses per day and
7 glasses or more per day. Half a litre was set equal to
3 glasses. For other foods the frequency scales were never
seldom, 13 times per month, 13 times per week, 46
times per week, 1 time per day, 2 times per day, 3 times per
day and 4 or more times per day. The question about use of
buttermargarine on bread was answered with yes or no.
In the short FFQ, the highest frequencies were rarely
reported; therefore, for drinks the frequencies 46 glasses
per day and 7 glasses or more per day were combined for
analyses. For other foods, the frequencies 3 times per day
and 4 or more times per day were combined. The
questions from the short FFQ about hamburger/hot
dog/kebab and peanuts were not included in the analyses
because these food items were not possible to match with
categories from the PFD, and only a few participants
reported in the short FFQ that they ate peanuts more
often than three times per month.
Besides the food frequency questions the participants
were also asked about age, self-reported height and
weight, along with parents education and questions
about physical activity and meal patterns.
Precoded food diary
The participants received one PFD for each day they
were to record their food intakes. The 18-page PFD
had lists of 277 food items (28 drinks, 24 dishes and 255
food items) grouped together according to the typical
Norwegian meal pattern (an example of the PFD can
be found at the following web site: http://www.med.uio.
no/imb/english/research/groups/dietary-research/methods).
Each food group was supplemented with open space for
food items/dishes not on the list.
Portion size estimations in the PFD were made by
household units (e.g. glasses, pieces or tablespoons) or as
portions estimated from photographs. Each participant
received an evaluated photographic booklet that con-
tained 13 colour photograph series, each with four
different photographs ranging from small to large por-
tion sizes (22). The design of the PFD may be viewed as a
cross-table, with food listed on the left and time span
across the top. Participants indicated an eating event by
filling in how many units they had eaten of each food
item in the correct time span. Four time spans covered
4 hours each (e.g. 6 a.m.10 a.m., 10 a.m.2 p.m.) and one
covered 8 hours (10 p.m.6 a.m.). Participants were
instructed to either fill in the PFD immediately after
finishing each meal or to record foods eaten on an
attached memory note-paper and complete the PFD in
the evening. The 13-year-old participants recorded their
Inger Therese L. Lillegaard et al.
2
(page number not for citation purpose)
Citation: Food & Nutrition Research 2012, 56: 6399 - DOI: 10.3402/fnr.v56i0.6399
diets themselves, while parents helped the 9-year-olds to
fill in the PFDs.
Data were scanned using the Teleform programme
(6.0) (Datascan). Daily intake of foods food groups
from the PFD (amounts in grams per day) were
computed using the food database and software system
(KBS, version 4.7, 2004) at the Department of Nutrition,
University of Oslo. The food items from the PFD were
also recoded into glasses per day and times per day to
allow for a more direct comparison to the frequencies
obtained from the short FFQ. For drinks, the amount in
grams per day from the PFD was divided by 167 (half a
litre equals 3 glasses) to get glasses per day. For foods, the
PFD was divided into five time spans during one day, and
when a participant indicated to have eaten a food in one
time span it was counted as one time per day, indepen-
dent of the portion size.
BMR, BMR-factor and energy under-reporters
Estimates of basal metabolic rate (BMR) were calculated
from standard equations based on height, weight, age and
sex (23). The equations for girls and boys aged 410 years
and 1118 years were used. The ratio between energy
intake and estimates of BMR can be used to calculate the
number of participants in a dietary survey who under-
report their energy intakes (24). Based on estimates of
BMRwith 95% confidence limits, a diet record period of
4 days, and a physical activity level for girls and boys of
1.70 and 1.75, respectively (23), participants were classi-
fied as energy under-reporters when having a ratio
between measured energy intake and BMR (EI/BMR)
below 1.12 for girls and 1.16 for boys.
Statistics
Data were analysed using SPSS version 13.0 for Win-
dows. Data from the short FFQ and the PFD were
generally skewed; hence, nonparametric statistical meth-
ods were mostly chosen. The medians, means, 25
th
and
75
th
percentiles are presented. Participant characteristics
are presented as means and standard deviation (SD). The
food intake reported with the PFD was calculated both in
gram per day and frequencies (glasses per day or times
per day), and Spearman correlation coefficients were
calculated between frequencies from the short FFQ and
the PFD for both grams per day and frequencies. The
confidence intervals of Spearman correlation coefficients
were used to detect differences between girls vs. boys and
all participants vs. energy under-reporters. The differ-
ences between the two methods were tested using
Wilcoxons signed-rank test. A nonparametric test for
ordered groups (25) was used to test whether the short
FFQ categories ranked daily intake from the PFD in a
specific order. MannWhitney test was used to compare
intake between participants and non-participants.
To evaluate the butter on bread, cod liver oil and
vitamin supplement questions, we calculated the short
FFQs specificity and sensitivity compared with the PFD.
Specificity for the three items was defined as the number of
subjects having answered neither to eat the item in the
short FFQ nor recorded the item in the PFD as a
percentage of those not having recorded the item accord-
ing to the PFD. Sensitivity was calculated as the number of
those having answered that they ate the food item, with
both the short FFQ and the PFD as a percentage of those
who had recorded the food item with the PFD.
Results
Characteristics of the participants are shown in Table 1.
The mean intake of food items from the PFD increased
with increasing frequency categories from the short FFQ
(Tables 2 and 3). Spearman correlation coefficients
between the frequency reported from the short FFQ
and the amount (grams per day) from the PFD ranged
from 0.11 for pizza to 0.67 for low-fat milk among the
9-year-olds, with a median correlation coefficient of 0.36
(Table 2). Among the 13-year-olds, the range was from
0.14 for pizza to 0.63 for low-fat milk, the median
correlation coefficient was 0.32 (Table 3). The median
correlation coefficients for drinks were higher with 0.47
for both age groups. Similar results were found when the
data were analysed for gender separately (see additional
data Tables 5 and 6).
The short FFQ was also compared with food intake
from the PFD recoded into frequencies per day (Tables
56), as opposed to grams per day (Tables 23). There
were no differences in the Spearman correlations,
whether food intake with the PFD was coded as
frequencies per day or grams per day. However, partici-
pants reported a significantly higher frequency of intake
for most foods with the short FFQ compared with PFD,
except for soft drinks with sugar and sweets, which were
reported at levels significantly higher with the PFD for
both age groups (Tables 56). There were no significant
differences between the short FFQ and PFD for soft
drinks without sugar, pizza and savoury snacks among
both age groups, and for skimmed milk among the
13-year-olds.
Forty-nine 9-year-olds (7%) and 200 13-year-olds
(24%) had EIBMR ratios below the lower cut-off points
of 1.12 for girls and 1.16 for boys; these participants are
likely to have under-reported their energy intakes during
the PFD recording period. The association between
frequency of intake reported by the short FFQ and the
amount eaten by the PFD was similar whether the under-
reporters were included or not.
Sensitivity and specificity for intake of butter on bread,
cod liver oil and vitamin supplements are presented in
Table 4. The sensitivity was high for the three questions in
both age groups, while the specificity varied more, with
Evaluation of a short FFQ among Norwegian children
Citation: Food & Nutrition Research 2012, 56: 6399 - DOI: 10.3402/fnr.v56i0.6399 3
(page number not for citation purpose)
the lowest value at 66% for vitamin supplements among
the 13-year-olds.
Discussion
Several studies have developed and evaluated short FFQs
with the aim of collecting data on fat intake, calcium
intake or, more often, fruit and vegetable intake among
children and adolescents (1018 years). We are not aware,
however, of studies that have evaluated short FFQs with a
broader aim of monitoring diet changes in sugar- and fat-
containing foods, fruits, vegetables and more tradition-
ally eaten food items among children and adolescents.
In a validation study, the reference method should be
as accurate as possible. The energy intake estimated
from the PFD, used as the reference method in the
present study, has been validated among 46 9-year-olds
(26) and 31 13-year-olds (27) against energy expenditure
estimated from a position and activity monitor. It was
found that the energy intake was underestimated by
around 1520% (26, 27). In the present study, 7% of the
9-year-olds and 24% of the 13-year-olds under-reported
their energy intakes in the PFD recording period
according to the calculated cut-off points. Under-
reporting may have been caused by omitting some foods
or food groups or a general under-reporting of amounts
eaten. There are indications among adults that those
who grossly under-report their energy intakes tend to
underestimate intake of foods believed to be unhealthy
(28, 29). Sjo berg et al. (30) did not find systematic
misreporting of foods among older adolescents,
and neither did Lillegaard and Andersen (26) among
9-year-olds. In the present study, the association be-
tween frequency of intake reported by the short FFQ
and the amount eaten by the PFD was similar whether
under-reporters were included or not.
FFQs cannot be considered to have a global validity.
Each item within a questionnaire and any combination of
these into complex estimates can be described in terms of
their specific validity. This becomes pronounced when
looking at Tables 2 and 3. Within the same questionnaire
the Spearman correlation coefficient varies from 0.11 for
pizza to 0.67 for low-fat milk, among the 9-year-olds.
We found that the mean intake of food items reported
by the PFD was increased with increasing quantities
reported by short FFQ (Tables 2 and 3). The trend was
significant for every food item for both age groups. This
indicates that the FFQ can be used to distinguish between
low and high consumers.
The present study showed better correlations for drinks
than for other food items. It might be that the preferred
kinds of milk, soft drinks and fruit drinks are part of a
more regular eating practise and are easier for children
and adolescents to remember than the other food items
asked about in the short FFQ. The number of days
required to rank dietary intakes with desired precision
varies between different study groups (31) and food items.
Several studies have shown that day-to-day variability is
high for foods, and usual intake of foods eaten rarely
would be very difficult to capture (31, 32). Correlation
coefficients between the short FFQ and the PFD were
mostly in the moderate range. However, the lowest
correlations were observed for food items eaten at the
lowest frequencies. This could be due to the relatively
short recording period of four days.
As mentioned above, several studies have validated
short fruit and vegetable questionnaires among children
and adolescents (10, 12, 14, 15). In the present study, the
short FFQ overestimated the intake of fruit and vegetable
compared to PFD. This has also been observed by others
(10, 12, 16). The correlation coefficients found between
the short FFQ and the PFD in our study were in the mid-
range. Andersen et al. (10), also using the PFD as
reference method, found correlation coefficients from
0.21 to 0.32 among 11-year-old Norwegians when
validating a short FFQ concerning fruits and vegetables.
Others (12, 15, 16) have also found lower correlation
coefficients than in the present study. A study by Eriksen
(14) showed high correlation for vegetables (0.65) but
lower correlation for fruits (0.27).
Results showed a tendency to over-report healthy foods
such as low-fat milk, orange juice, boiled potatoes,
Table 1. Participant characteristics
9-year-olds 13-year-olds
Girls, mean (SD) Boys, mean (SD) Girls, mean (SD) Boys, mean (SD)
Age (years) 8.9 (0.3)
a
8.9 (0.3)
e
12.9 (0.3)
i
12.9 (0.3)
m
Height (cm) 137 (7)
b
137 (6)
f
161 (7)
j
161 (9)
n
Weight (kg) 32 (6)
c
32 (6)
g
50 (9)
k
49 (10)
o
BMI (kg/m
2
) 17.1 (2.7)
d
17.1 (2.5)
h
19.1 (2.8)
l
18.9 (2.8)
p
Due to missing values, the number of participants vary between cells:
a
n365,
b
n334,
c
n346,
d
n333,
e
n368,
f
n331,
g
n344,
h
n327,
i
n467,
j
n439,
k
n444,
l
n426,
m
n437,
n
n409,
o
n413,
p
n398.
Inger Therese L. Lillegaard et al.
4
(page number not for citation purpose)
Citation: Food & Nutrition Research 2012, 56: 6399 - DOI: 10.3402/fnr.v56i0.6399
Table 2. (a) Mean intake (g/day) reported by the precoded food diary ranged by glasses per day reported by the FFQ, number of respondents for each FFQ category in parentheses, Spearman
correlation coefcients between the two measurements, 9-year-olds, (n733).
Glasses per month, week and day
Food item Never 13/month 13/week 46/week 13/day ]4 /day
a
Spearman
b
Full-fat milk 9 (446) 26 (37) 51 (36) 105 (27) 261 (94) 286 (22) 0.66 (0.620.70)
Low-fat milk (1.5% fat) 43 (161) 39 (38) 63 (45) 124 (84) 262 (296) 398 (71) 0.67 (0.630.71)
Semi-skim milk (0.7% fat) 7 (474) 18 (33) 42 (32) 64 (21) 166 (67) 256 (9) 0.59 (0.540.64)
Skimmed milk 7 (556) 22 (18) 43 (13) 88 (10) 237 (27) 0.46 (0.400.52)
Orange juice 7 (125) 24 (174) 41 (199) 95 (95) 131 (90) 94 (6) 0.45 (0.390.51)
Fruit drink with sugar 58 (78) 70 (71) 110 (159) 128 (157) 243 (217) 342 (26) 0.48 (0.420.53)
Fruit drink without sugar 5 (420) 17 (71) 28 (52) 70 (41) 162 (58) 176 (7) 0.47 (0.410.52)
Soft drinks with sugar 106 (23) 81 (80) 153 (401) 212 (185) 333 (21) 0 (2) 0.30 (0.230.36)
Soft drinks without sugar 9 (445) 9 (96) 39 (73) 88 (28) 172 (5) 0.32 (0.250.38)
(b) Mean intake (g/day) reported by the precoded food diary ranged by times per day reported by the FFQ, number of respondents for each FFQ category in parentheses, Spearman correlation coefficients
between the two measurements, 9-year-olds, (n733).
Times per month, week and day
Food item Never 13/month 13/week 46/week 1/day 2/day ]3/day
a
Spearman
b
Potatoes, boiled 6 (20) 14 (39) 29 (265) 49 (324) 59 (78) 53 (6) 0.36 (0.300.42)
Potato chips 1 (161) 5 (477) 11 (80) 0 (3) 0.23 (0.160.30)
Vegetables 17 (48) 28 (68) 39 (224) 66 (224) 80 (128) 105 (27) 118 (8) 0.43 (0.370.49)
Fruit and berries 16 (19) 14 (36) 59 (158) 63 (199) 89 (189) 116 (94) 164 (28) 0.44 (0.380.50)
Wholemeal bread 18 (33) 9 (20) 21 (46) 30 (52) 28 (81) 39 (213) 50 (277) 0.24 (0.170.31)
Fish for dinner 8 (59) 17 (204) 27 (460) 37 (7) 50 (1) 0.25 (0.180.32)
Pizza 16 (26) 30 (518) 35 (186) 0.11 (0.040.18)
Sweets 4 (18) 7 (58) 16 (613) 21 (31) 15 (10) 5 (1) 4 (1) 0.21 (0.140.28)
Chocolate 6 (47) 8 (133) 14 (518) 31 (17) 0 (2) 12 (2) 39 (1) 0.19 (0.120.26)
Savoury snacks 3 (56) 6 (242) 9 (420) 2 (5) 6 (1) 0.16 (0.090.23)
a
A non-parametric method was used to test for trend across ordered groups (Altman 1991). There were significant trends for all food items shown in Table 2 (p B0.01).
b
Spearman correlation coefficients (95% confidence interval)
E
v
a
l
u
a
t
i
o
n
o
f
a
s
h
o
r
t
F
F
Q
a
m
o
n
g
N
o
r
w
e
g
i
a
n
c
h
i
l
d
r
e
n
C
i
t
a
t
i
o
n
:
F
o
o
d
&
N
u
t
r
i
t
i
o
n
R
e
s
e
a
r
c
h
2
0
1
2
,
5
6
:
6
3
9
9
-
D
O
I
:
1
0
.
3
4
0
2
/
f
n
r
.
v
5
6
i
0
.
6
3
9
9
5
(
p
a
g
e
n
u
m
b
e
r
n
o
t
f
o
r
c
i
t
a
t
i
o
n
p
u
r
p
o
s
e
)
Table 3. (a) Mean intake (g/day) reported by the precoded food diary ranged by glasses per day reported by the FFQ, number of respondents for each FFQ category in parentheses, Spearman
correlation coefcients between the two measurements, 13-year-olds, (n904).
Glasses per month, week and day
Food item Never 13/month 13/week 46/week 1-3/day ]4/day
a
Spearman
b
Full-fat milk 8 (646) 33 (49) 73 (41) 55 (21) 194 (70) 243 (15) 0.57 (0.520.61)
Low-fat milk (1.5% fat) 18 (232) 40 (77) 48 (96) 96 (132) 191 (248) 377 (77) 0.63 (0.590.67)
Semi-skim milk (0.7% fat) 7 (548) 22 (79) 40 (59) 55 (46) 139 (84) 251 (26) 0.53 (0.480.58)
Skimmed milk 7 (686) 14 (45) 24 (38) 48 (20) 194 (23) 287 (16) 0.41 (0.350.46)
Orange juice 6 (139) 20 (192) 45 (232) 66 (157) 136 (123) 217 (31) 0.49 (0.440.54)
Fruit drink with sugar 55 (131) 38 (115) 90 (188) 135 (183) 255 (187) 308 (66) 0.47 (0.420.52)
Fruit drink without sugar 10 (506) 16 (116) 19 (91) 31 (56) 169 (50) 198 (13) 0.33 (0.270.39)
Soft drinks with sugar 127 (33) 160 (70) 234 (300) 300 (350) 483 (101) 725 (24) 0.35 (0.290.41)
Soft drinks without sugar 15 (557) 34 (124) 71 (85) 47 (45) 134 (23) 211 (8) 0.30 (0.240.36)
(b) Mean intake (g/day) reported by the precoded food diary ranged by times per day reported by the FFQ, number of respondents for each FFQ category in parentheses, Spearman correlation coefficients
between the two measurements, 13-year-olds, (n904).
Times per month, week and day
Food item Never 13/month 13/week 46/week 1/day 2/day ]3/day
a
Spearman
b
Boiled potatoes 2 (15) 22 (56) 33 (297) 49 (366) 56 (144) 91 (7) 52 (12) 0.26 (0.200.32)
Potato chips 3 (208) 7 (536) 8 (136) 40 (11) 0 (1) 0 (1) 0.15 (0.090.21)
Vegetables 30 (85) 28 (95) 48 (297) 63 (222) 80 (151) 103 (24) 109 (22) 0.32 (0.260.38)
Fruit and berries 22 (47) 32 (90) 39 (258) 55 (204) 80 (163) 89 (78) 114 (55) 0.31 (0.250.37)
Wholemeal bread 8 (67) 12 (52) 15 (121) 23 (101) 37 (110) 41 (192) 60 (244) 0.33 (0.270.39)
Fish for dinner 8 (105) 16 (367) 29 (392) 40 (22) 47 (5) 0.26 (0.200.32)
Pizza 18 (32) 43 (552) 53 (287) 118 (17) 49 (2) 68 (1) 0.14 (0.080.20)
Sweets 4 (31) 10 (71) 18 (579) 28 (138) 29 (53) 28 (15) 44 (9) 0.26 (0.200.32)
Chocolate 8 (56) 12 (168) 19 (539) 29 (83) 34 (34) 26 (9) 65 (3) 0.24 (0.180.30)
Savoury snacks 7 (78) 12 (232) 16 (506) 27 (48) 21 (20) 95 (5) 0.21 (0.150.27)
a
A non-parametric method was used to test for trend across ordered groups (Altman 1991). There were significant trends for all food items shown in Table 3 (p B0.01).
b
Spearman correlation coefficients (95% confidence interval)
I
n
g
e
r
T
h
e
r
e
s
e
L
.
L
i
l
l
e
g
a
a
r
d
e
t
a
l
.
6 (
p
a
g
e
n
u
m
b
e
r
n
o
t
f
o
r
c
i
t
a
t
i
o
n
p
u
r
p
o
s
e
)
C
i
t
a
t
i
o
n
:
F
o
o
d
&
N
u
t
r
i
t
i
o
n
R
e
s
e
a
r
c
h
2
0
1
2
,
5
6
:
6
3
9
9
-
D
O
I
:
1
0
.
3
4
0
2
/
f
n
r
.
v
5
6
i
0
.
6
3
9
9
wholemeal bread, fruits and vegetables in the short FFQ
compared with the PFD, and this tendency was the same
for both age groups. Two food items regarded as
unhealthy, namely soft drinks with sugar and sweets,
were significantly under-reported with the short FFQ
compared to the PFD.
The sensitivity for the three questions, butter on
bread, cod liver oil and vitamin supplements, were
high. Those who normally consume these food items
also consumed them during the four-day recording
period. The butter on bread question was phrased: Do
you normally use butter on bread? In this case, over-
reporting could have occurred because those who did not
habitually use butter on bread may have used butter once
or twice during the four-day recording period, thereby
being coded in the wrong category.
Questions have been raised whether FFQs asking
about usual intake are suitable for children (17, 19)
because they require abstract thinking, knowledge about
food names and food grouping, as well as basic reading
and arithmetic skills. This may be too advanced for 9-
year-olds, as well as young adolescents who may have
problems filling in a longer FFQ (33). In the present
study, the short FFQ had few questions and was
completed at home. There were only small differences
in correlations between the two age groups studied, where
the 9-year-olds showed slightly higher correlation coeffi-
cients compared to the 13-year-olds. Both age groups had
the opportunity to complete the short FFQ together with
their parents, but the 13-year-olds may have completed
more of the questionnaire themselves compared to the
9-year-olds.
Conclusion
Results indicate that the short FFQ was able to identify
low and high consumers of food intake and had a
moderate capability to rank individuals according to
food intake. Intake of drinks, fruits and vegetables
Table 4. Sensitivity and specicity of the short food frequency
questionnaire for use of butter on bread, cod liver oil and vitamin
supplements
Sensitivity (%) Specificity (%)
9-year-olds Butter on bread 89 72
Cod liver oil 87 83
Vitamin supplements 79 73
13-year-olds Butter on bread 82 69
Cod liver oil 76 83
Vitamin supplements 84 66
Table 5. Intake in glasses or times per day with the short food frequency questionnaire (FFQ) and with the precoded food diary (PFD)
among 9-year-olds, n733, median (P25, P75)
a
, mean
Food item Short FFQ PFD p
b
Spearman
c
Full fat milk 0 (0, 0.07) 0.46 0 (0, 0.22) 0.34 0.02 0.63 (0.580.67)
Low fat milk (1.5% fat) 2.00 (0, 2.00) 1.42 0.79 (0, 1.69) 1.07 B0.001 0.66 (0.620.70)
Semi-skim. milk (0.7% fat) 0 (0, 0) 0.28 0 (0, 0) 0.17 B0.001 0.57 (0.520.62)
Skimmed milk 0 (0, 0) 0.09 0 (0, 0) 0.12 0.001 0.42 (0.360.48)
Orange juice 0.29 (0.07, 0.71) 0.48 0 (0, 0.34) 0.29 B0.001 0.44 (0.380.50)
Fruit drink with sugar 0.71 (0.29, 2.00) 1.00 0.67 (0, 1.36) 0.89 0.03 0.50 (0.440.55)
Fruit drink without sugar 0 (0, 0.07) 0.28 0 (0, 0) 0.16 B0.001 0.44 (0.380.50)
Soft drinks with sugar 0.29 (0.29, 0.71) 0.42 0.75 (0.34, 1.40) 0.97 B0.001 0.30 (0.230.36)
Soft drinks without sugar 0 (0, 0.07) 0.08 0 (0, 0) 0.10 0.88 0.30 (0.230.36)
Boiled potatoes 0.71 (0.29, 0.71) 0.56 0.25 (0, 0.50) 0.30 B0.001 0.32 (0.250.38)
Potato chips 0.07 (0.07, 0.07) 0.08 0 (0, 0) 0.05 B0.001 0.22 (0.150.29)
Vegetables (fresh) 0.71 (0.29, 0.71) 0.60 0.25 (0, 0.75) 0.40 B0.001 0.50 (0.440.55)
Fruit (fresh) 0.71 (0.29, 1.00) 0.90 0.50 (0.25, 1.00) 0.72 B0.001 0.45 (0.390.51)
Wholemeal bread 2.00 (1.00, 3.00) 1.93 1.50 (1.00, 2.25) 1.60 B0.001 0.26 (0.190.33)
Fish for dinner 0.29 (0.07, 0.29) 0.21 0.25 (0, 0.25) 0.17 B0.001 0.24 (0.170.31)
Pizza 0.07 (0.07, 0.29) 0.12 0 (0, 0.25) 0.16 0.14 0.10 (0.030.17)
Sweets 0.29 (0.29, 0.29) 0.30 0.50 (0.25, 0.75) 0.56 B0.001 0.20 (0.130.27)
Chocolate 0.29 (0.07, 0.29) 0.25 0.25 (0, 0.25) 0.22 B0.001 0.17 (0.100.24)
Savoury snacks 0.29 (0.07, 0.29) 0.20 0.25 (0, 0.25) 0.23 0.59 0.15 (0.080.22)
a
P2525
th
percentile, P7575
th
percentile.
b
Wilcoxon signed rank test.
c
Spearman correlation coefficients (95% confidence interval).
Evaluation of a short FFQ among Norwegian children
Citation: Food & Nutrition Research 2012, 56: 6399 - DOI: 10.3402/fnr.v56i0.6399 7
(page number not for citation purpose)
reported in the short FFQ had better correlations with
intake recorded in the PFD than did food items eaten less
frequently.
Conflict of interest and funding
This study has partly been financially supported by the
Norwegian Extra Foundation for Health and Rehabilita-
tion through EXTRA funds. The authors declare no
conflict of interest.
References
1. Willett WC. Food-frequency methods. In: Willett W, ed.
Nutritional epidemiology. Oxford: Oxford University Press;
1998. p. 74100.
2. Andersen LF, Nes M, Lillegaard IT, Sandstad B, Bjorneboe GE,
Drevon CA. Evaluation of a quantitative food frequency
questionnaire used in a group of Norwegian adolescents. Eur
J Clin Nutr 1995; 49: 54354.
3. Rockett HR, Breitenbach M, Frazier AL, Witschi J, Wolf AM,
Field AE, et al. Validation of a youth/adolescent food frequency
questionnaire. Prev Med 1997; 26: 80816.
4. Subar AF, Thompson FE, Kipnis V, Midthune D, Hurwitz P,
McNutt S, et al. Comparative validation of the Block, Willett,
and National Cancer Institute food frequency questionnaires:
the Eating at Americas Table Study. Am J Epidemiol 2001; 154:
108999.
5. Schatzkin A, Kipnis V, Carroll RJ, Midthune D, Subar AF,
Bingham S, et al. A comparison of a food frequency ques-
tionnaire with a 24-hour recall for use in an epidemiological
cohort study: results from the biomarker-based Observing
Protein and Energy Nutrition (OPEN) study. Int J Epidemiol
2003; 32: 105462.
6. Ambrosini GL, de Klerk NH, OSullivan TA, Beilin LJ, Oddy
WH. The reliability of a food frequency questionnaire for use
among adolescents. Eur J Clin Nutr 2009; 63: 12519.
7. Osler M, Heitmann BL. The validity of a short food frequency
questionnaire and its ability to measure changes in food intake:
a longitudinal study. Int J Epidemiol 1996; 25: 10239.
8. Thompson FE, Subar AF, Smith AF, Midthune D, Radimer
KL, Kahle LL, et al. Fruit and vegetable assessment: perfor-
mance of 2 new short instruments and a food frequency
questionnaire. J Am Diet Assoc 2002; 102: 176472.
9. Andersen LF, Johansson L, Solvoll K. Usefulness of a short
food frequency questionnaire for screening of low intake of fruit
and vegetable and for intake of fat. Eur J Public Health 2002;
12: 20813.
10. Andersen LF, Bere E, Kolbjornsen N, Klepp KI. Validity and
reproducibility of self-reported intake of fruit and vegetable
among 6th graders. Eur J Clin Nutr 2004; 58: 7717.
11. Van Assema P, Brug J, Ronda G, Steenhuis I. The relative
validity of a short Dutch questionnaire as a means to categorize
adults and adolescents to total and saturated fat intake. J Hum
Nutr Diet 2001; 14: 37790.
12. Van Assema P, Brug J, Ronda G, Steenhuis I, Oenema A. A
short dutch questionnaire to measure fruit and vegetable intake:
relative validity among adults and adolescents. Nutr Health
2002; 16: 85106.
Table 6. Intake in glasses or times per day with the short food frequency questionnaire (FFQ) and with the precoded food diary (PFD)
among 13-year-olds, n904, median (P25, P75)
a
, mean
Food item Short FFQ PFD p
b
Spearman
c
Full fat milk 0 (0, 0) 0.28 0 (0, 0) 0.21 0.005 0.54 (0.490.58)
Low fat milk (1.5% fat) 0.71 (0, 2.00) 1.15 0.22 (0, 1.02) 0.69 B0.001 0.61 (0.570.65)
Semi-skim. milk (0.7% fat) 0 (0, 0.07) 0.41 0 (0, 0) 0.20 B0.001 0.52 (0.470.57)
Skimmed milk 0 (0, 0) 0.18 0 (0, 0) 0.11 0.09 0.38 (0.320.43)
Orange juice 0.29 (0.07, 0.71) 0.68 0 (0, 0.45) 0.33 B0.001 0.48 (0.430.53)
Fruit drink with sugar 0.29 (0.07, 2.00) 1.04 0.45 (0, 1.24) 0.83 0.003 0.46 (0.410.51)
Fruit drink without sugar 0 (0, 0.07) 0.27 0 (0, 0) 0.15 B0.001 0.32 (0.260.38)
Soft drinks with sugar 0.71 (0.29, 0.71) 0.75 1.38 (0.67, 2.46) 1.75 B0.001 0.33 (0.270.39)
Soft drinks without sugar 0 (0, 0.07) 0.17 0 (0, 0) 0.18 0.90 0.29 (0.230.35)
Boiled potatoes 0.71 (0.29, 0.71) 0.61 0.25 (0, 0.50) 0.25 B0.001 0.30 (0.240.36)
Potato chips 0.07 (0.07, 0.07) 0.10 0 (0, 0) 0.06 B0.001 0.15 (0.090.21)
Vegetables (fresh) 0.29 (0.29, 0.71) 0.58 0.25 (0, 0.50) 0.28 B0.001 0.33 (0.270.39)
Fruit (fresh) 0.71 (0.29, 1.00) 0.80 0.25 (0, 0.75) 0.49 B0.001 0.31 (0.250.37)
Wholemeal bread 1.00 (0.29, 3.00) 1.56 1.25 (0.75, 1.75) 1.25 B0.001 0.35 (0.290.41)
Fish for dinner 0.07 (0.07, 0.29) 0.18 0 (0, 0.25) 0.13 B0.001 0.24 (0.180.30)
Pizza 0.07 (0.07, 0.29) 0.15 0 (0, 0.25) 0.16 0.92 0.14 (0.080.20)
Sweets 0.29 (0.29, 0.29) 0.43 0.50 (0.25, 1.00) 0.73 B0.001 0.20 (0.140.26)
Chocolate 0.29 (0.07, 0.29) 0.32 0.25 (0, 0.50) 0.27 B0.001 0.22 (0.160.28)
Savoury snacks 0.29 (0.07, 0.29) 0.25 0.25 (0, 0.50) 0.29 0.90 0.21 (0.150.27)
a
P2525
th
percentile, P7575
th
percentile.
b
Wilcoxon signed rank test.
c
Spearman correlation coefficients (95% confidence interval).
Inger Therese L. Lillegaard et al.
8
(page number not for citation purpose)
Citation: Food & Nutrition Research 2012, 56: 6399 - DOI: 10.3402/fnr.v56i0.6399
13. Cullen KW, Baranowski T, Baranowski J, Hebert D, de Moor C.
Pilot study of the validity and reliability of brief fruit, juice and
vegetable screeners among inner city African-American boys
and 17 to 20-year-old adults. J Am Coll Nutr 1999; 18: 44250.
14. Eriksen K. Developing and evaluation of a method for
measuring changes in intake of fruit and vegetable among
children aged 610 years. Copenhagen (in Danish): Institute for
human nutrition; 2010.
15. Domel SB, Baranowski T, Davis H, Leonard SB, Riley P,
Baranowski J. Fruit and vegetable food frequencies by fourth
and fth grade students: validity and reliability. J Am Coll Nutr
1994; 13: 339.
16. Baranowski T, Smith M, Baranowski J, Wang DT, Doyle C, Lin
LS, et al. Low validity of a seven-item fruit and vegetable food
frequency questionnaire among third-grade students. J Am Diet
Assoc 1997; 97: 668.
17. Field AE, Peterson KE, Gortmaker SL, Cheung L, Rockett H,
Fox MK, et al. Reproducibility and validity of a food frequency
questionnaire among fourth to seventh grade inner-city school
children: implications of age and day-to-day variation in dietary
intake. Public Health Nutr 1999; 2: 293300.
18. Harnack LJ, Lytle LA, Story M, Galuska DA, Schmitz L,
Jacobs DR Jr. et al. Reliability and validity of a brief
questionnaire to assess calcium intake of middle-school-aged
children. J Am Diet Assoc 2006; 106: 17905.
19. Livingstone MB, Robson PJ. Measurement of dietary intake in
children. Proc Nutr Soc 2000; 59: 27993.
20. Andersen LF, Overby N, Lillegaard IT. Intake of fruit and
vegetables among Norwegian children and adolescents. Tidsskr
Nor Laegeforen 2004; 124: 13968.
21. Overby NC, Lillegaard IT, Johansson L, Andersen LF. High
intake of added sugar among Norwegian children and adoles-
cents. Public Health Nutr 2004; 7: 28593.
22. Lillegaard IT, Overby NC, Andersen LF. Can children and
adolescents use photographs of food to estimate portion sizes?
Eur J Clin Nutr 2005; 59: 6117.
23. Nordic Nutriton Recommendations. Integrating nutrition and
physical activity. Norden: Nordic Council of Ministers; 2004.
24. Black AE. Critical evaluation of energy intake using the
Goldberg cut-off for energy intake:basal metabolic rate. A
practical guide to its calculation, use and limitations. Int J
Obes Relat Metab Disord 2000; 24: 111930.
25. Altman DG. Non-parametric test for ordered groups. In:
Practical statistics for medical research. London: Chapman
and Hall; 1991. p. 2157.
26. Lillegaard IT, Andersen LF. Validation of a pre-coded food
diary with energy expenditure, comparison of under-reporters v.
acceptable reporters. Br J Nutr 2005; 94: 9981003.
27. Andersen LF, Pollestad ML, Jacobs DR Jr, Lovo A, Hustvedt
BE. Validation of a pre-coded food diary used among 13-year-
olds: comparison of energy intake with energy expenditure.
Public Health Nutr 2005; 8: 131521.
28. Johansson L, Solvoll K, Bjorneboe GE, Drevon CA. Under- and
overreporting of energy intake related to weight status and
lifestyle in a nationwide sample. AmJ Clin Nutr 1998; 68: 26674.
29. Krebs-Smith SM, Graubard BI, Kahle LL, Subar AF,
Cleveland LE, Ballard-Barbash R. Low energy reporters vs
others: a comparison of reported food intakes. Eur J Clin Nutr
2000; 54: 2817.
30. Sjoberg A, Slinde F, Arvidsson D, Ellegard L, Gramatkovski E,
Hallberg L, et al. Energy intake in Swedish adolescents:
validation of diet history with doubly labelled water. Eur J
Clin Nutr 2003; 57: 164352.
31. Nelson M, Black AE, Morris JA, Cole TJ. Between- and within-
subject variation in nutrient intake from infancy to old age:
estimating the number of days required to rank dietary intakes
with desired precision. Am J Clin Nutr 1989; 50: 15567.
32. Palaniappan U, Cue RI, Payette H, Gray-Donald K. Implica-
tions of day-to-day variability on measurements of usual food
and nutrient intakes. J Nutr 2003; 133: 2325.
33. Andersen LF, Nes M, Bjorneboe GEAa, Drevon CA. Food
habits among 13-year-old Norwegian adolescents. Scand J Nutr
1997; 41: 1504.
*Inger Therese L. Lillegaard
Norwegian Scientific Committee for Food Safety
Postboks 4404 Nydalen, 0403 Oslo, Norway
Email: [email protected]
Evaluation of a short FFQ among Norwegian children
Citation: Food & Nutrition Research 2012, 56: 6399 - DOI: 10.3402/fnr.v56i0.6399 9
(page number not for citation purpose)
Copyright of Food & Nutrition Research is the property of Co-Action Publishing and its content may not be
copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written
permission. However, users may print, download, or email articles for individual use.