STUDY ON DIET, LIFESTYLE AND HEALTH
Use a black or blue ball-point pen. If you want to change your answer, fill in the wrong box completely and mark the correct box.
Personal number –
PHYSICAL ACTIVITY AND EXERCISE SUN HABITS 1. Your level of physical activity during the past year: 4. Do you travel to sunny resorts during winter time? Walking/cycling No Yes, sometimes Yes, every year Hardly ever 40-60 min/day 5. How does your skin react when you are in the sun? Less than 20 min/day 1-1,5 hours/day Always red/never tanned Sometimes red/always tanned 20-40 min/day More than 1-1,5 hours/day Always red/sometimes tanned Never red/always tanned Daily occupation/work 6. When it is sunny, you prefer: Mostly sitting down Mostly walking, min. lifting/carrying The sun at all the time Sitting down half the time Mostly walking, sig. lifting/carrying Both the sun and the shade Mostly standing up Heavy manual labour Seeking shade at all the time Home/household work 7. Do you use sunblock? Less than 1 hour/day 5-6 hours/day Yes, always Most of the time Sometimes Never 1-2 hours/day 7-8 hours/day 3-4 hours/day More than 8 hours/day EATING HABITS Watching TV/reading 8. Which meals do you usually eat? Less than 1 hour/day 5-6 hours/day Breakfast Lunch Dinner 1-2 hours/day 7-8 hours/day Mid-morning snack Afternoon snack Evening snack 3-4 hours/day More than 6 hours/day 9. On average, how often do you eat the following? Exercise (examples: gym and calisthenics) Times per month Per week Per day Almost never 2-3 hours/week 0 1-3 1-2 3-4 5-6 1 2 3+ Less than 1 hour/week 4-5 hours/week Cooked meal 1 hour/week More than 5 hours/week Meals outside home 2. How far can you walk outdoors? Frozen meals Cannot walk outdoors Almost as far as I want Canned food Only short distances Unlimited distances Ready-made food 3. Do you usually perform any physical activity (that (retirement home, home makes you short of breath) for more than two hours help, relative) per week? E.g.: gardening, brisk walks or similar Fish Yes No Meat
10. How big are your portion sizes? Even Even Mark the image that best describes smaller larger your portion size (volume). portions portions
11. What is your main type of diet? Mixed Vegetarian Vegan
12. Do you exclude/avoid anything in your diet? Gluten Lactose Milk protein Nuts Other:______Nothing 13. During childhood, did you eat more sweets (such as cakes, cookies, sweets, puddings, fruit fool or soup) compared to your peers? Yes, much more Yes, some more No, same No, some less No, ate none at all
14. How often did you eat these sweets? times/week or times/month Do not know
DIETARY HABITS IND THE LAST YEAR
15. How much did you usually drink/eat of the following? 17. On average, how often you eat each of the If you do not eat/drink the specific food item, mark ”0”. following. Mark only one mark on each row 1 glass, 1 cup= 2 dl (enter only whole numbers). If you seldom or never eat that specific item, mark “0”. Per day or Per week Times per month per week per day Milk, skimmed (<0,5% fat) glass/d glass/w CEREALS 0 1-3 1-2 3-4 5-6 1 2 3+ Oatmeal/rye porridge Milk, semi-skimmed (1,5% fat) glass/d glass/w Other porridge/gruel
Milk, whole (3% fat) glass/d glass/w Müesli
Fruit yoghurt/sour milk glass/d glass/w Breakfast cereals
Bran of wheat or oats Yoghurt/sour milk, low-fat glass/d glass/w (<0,5% fat) Linseed
glass/d glass/w Sour milk, reduced fat (1,5% fat) Sesame seeds
glass/d glass/w Sunflower/pumpkin seeds, etc. Sour milk/yoghurt (3% fat)
Wholemeal macaroni/spaghetti glass/d glass/w Water (including mineral) Spaghetti/macaroni/pasta
glass/d glass/w Coca Cola/Pepsi, light Pancakes/crepes
glass/d glass/w Couscous/bulgur Coca Cola/Pepsi
Wholegrain rice glass/d glass/w Other soft drinks/soda, light Other rice
glass/d glass/w Other soft drinks/soda Times per month per week per day
0 1-3 1-2 3-4 5-6 1 2 3+ cup/d cups/w MEAT Green tea Minced meat (meatballs, hamburger,
cup/d cups/w mincemeat sauce) Herbal tea/ red tea Pork (steak/casserole)
cup/d cups/w Tea (black) Beef/veal (steak/casserole)
cup/d cups/w Bacon Coffee (filtered)
Other meat cup/d cups/w Coffee (unfiltered) Lean sausage
Tsp/d Tsp/d Balogna sausage/Falukorv
Sugar Other sausage Tbsp/d Tbsp/w Honey Blood pudding/sausage
Tbsp/d Tbsp/w Liver/kidney Cottage cheese/quark
Meat toppings (e.g. ham/turkey) Tbsp/d Tbsp/w Cream cheese (low-fat) Sausage toppings (e.g. salami)
Tbsp/d Tbsp/w Cream cheese Times per month per week per day
Slices/d Slices/w FISH/ POULTRY/EGGS 0 1-3 1-2 3-4 5-6 1 2 3+ Hard cheese (low-fat) Smoked fish
Hard cheese Slices/d Slices/w Herring/mackerel
Tbsp/d Tbsp/w Salmon Dessert cheese
Sardines Tbsp/d Tbsp/w Liver paté (low-fat) Cod/saithe/plaice/grenadier
Tbsp/d Tbsp/w Tuna Liver paté
Pike/perch/bass Slices/d Slices/w Crispbread Fish fingers
Slices/d Slices/w White bread/loaf Other fish
Roe (e.g. Lump fish) Slices/d Slices/w Fibre enriched bread Caviar (e.g. Swedish Kalles)
Granary/wholemeal bread Slices/d Slices/w Shellfish (e.g. shrimp, crayfish etc.) Chicken/other poultry 16. Do you usually have milk in your coffee or tea? Eggs/omelette Yes, in coffee Yes, in tea No Times per month per week per day Times per month per week per day POTATOES ETC 0 1-3 1-2 3-4 5-6 1 2 3+ OT HER FOODS 0 1-3 1-2 3-4 5-6 1 2 3+
Boiled potatoes Salad dressing (reduced fat/fat free)
Fried potatoes Salad dressing Baked/mashed potatoes Mayonnaise (reduced fat/fat free) French fries Mayonnaise Carrots Crème fraîche (reduced fat/fat free) Beetroots Crème fraîche Times per month per week per day Double cream 0 1-3 1-2 3-4 5-6 1 2 3+ VEGETABLES/BEANS Single cream, sour cream, Lettuce/iceberg lettuce Yoghurt for cooking (8-10% fat) Cabbage (white, red, Chinese) Cauliflower Pizza Broccoli/brussels sprouts Ketchup Tomato/tomato juice Fresh herbs Peppers Dried herbs Spinach Cinnamon Green peas Pepper Onion Table salt Garlic Leek 18. Mark the type of fats you normally use Mixed frozen vegetables …in cooking Other vegetables Butter Bregott (butter/margarine) Pea soup Household margarine Liquid butter Liquid margarine Olive oil
Beans/lentils/chick peas Rapeseed/canola oil Corn or sunflower oil Avocado Other None Olives …in homemade dressing Sweetcorn Olive oil Rapeseed/canola oil Times per month per week per day Corn or sunflower oil Other oil None FRUIT/BERRIES 0 1-3 1-2 3-4 5-6 1 2 3+ …bread spreads Orange/citrus fruits Butter (80% fat) Bregott (butter/margarine) Orange/grapefruit juice Margarine (80% fat) Margarine (40% fat) Apple/Pears Becel (margarine) Oil Other Banana 19.How many slices of bread with butter/margarine do Other fruit you usually eat per day or per week? Berries (fresh or frozen) Slices/day Slices/week Lingonberry jam I do not use any butter/margarine on bread Other jam Fruit fool/soups 20. How much butter/margarine do you usually spread on your bread? Prunes (incl. juice) Fairly thick Thinly Very thin Raisins Apricots/other dried fruit 21. How often do you usually eat these fried foods? Times per month per week per day Times/Month Never/Seldom 0 1-3 1-2 3-4 5-6 1 2 3+ CAKES/SWEETS ETC Sausage/steak/pork chop (fried in a pan) Buns, cakes Biscuits/wafers/rusks Fish fried in a pan Gateau/confections Chicken/fillets/casserole (fried in a pan) Chocolate Grilled/oven-baked
Sweets (not chocolate) chicken Ice-cream Gravy Chips/popcorn/cheese puffs 22. To what degree of browning do you usually fry these courses? Peanuts Lightly fried (light brown) Heavily fried (dark brown) Other nuts/almonds Moderately fried (brown) Very heavily fried (charred)
I don’t eat fried foods DIETARY SUPPLEMENTS AND MEDICINE 23. Do you eat vitamins, minerals or any other ALCOHOL supplements? 25. Mark how often you usually drink alcohol. Never Yes, sometimes Yes, regularly I have never had alcohol Never = None or very few Sometimes = 1-2 tablets/week or less than 100 tablets/year I stopped drinking alcohol when I was years old. Regularly= 3-7 tablets/week Times per month per week Mark: How often? For how many years? I usually drink Never 0-1 2-3 1-2 3-4 5-6 7
Beer, 2.25% alcohol
1
Beer, up to 3.5% alcohol
Beer, over 3.5% alcohol
19
or more or
-
4 9
- -
Sometimes Regularly than Less 1 5 10 20 DIETARY SUPPLEMENTS Never Red wine Multivitamins with minerals White wine Multivitamins without minerals Liqueur/sherry/fortified wines Vitamin B complex Spirits
Vitamin B12 26. On each occasion, how much do you usually drink of Vitamin B6 the following? Folic acid Beer cl Wine cl Liqueur cl Vitamin C Spirit cl
Vitamin E 1 can beer =33/50 cl, bottle wine/spirit=75 cl, 1 dl=10 cl Beta-carotene Magnesium TOBACCO
Calcium 27. Mark if you used to smoke cigarettes regularly. Vitamin D Regularly= more than 5 cigarettes/week Iron No, I have never smoked cigarettes regularly Zinc Yes, I smoke Selenium Yes, but I stopped smoking years ago Fish oil Number of cigarettes smoked per day at different ages: Linseed oil 51-60 yr 61-70 yr 71-80 yr 81- now This year Live bacterial culture: Verum,
Actimel, ProViva, Cultura 28. Mark if you have used snuff regularly MEDICINES How often? For how many years? Regularly = more than 5 servings snuff/week Cortisone in tablet form or
inhalation No, I have never used snuff regularly Alvedon, Panodil, Reliv, Yes, I use snuff Citodon, Panocod Ipren, Diklofenak, Voltaren, Yes, but I quit using snuff years ago
Ibumetin, Naproxen Magnecyl, Bambyl, Treo, Servings of snuff per day at different ages.
Aspirin, Albyl, Trombyl 51-60 yr 61-70 yr 71-80 yr 81 + This year Sleeping medication
24. Mark if you have taken any of the following. OUTDOOR ACTIVETIES Ginseng/Gerimax Yeast preparation Q10 29. How often are you outdoors… St. John’s wort Arctic root Chromium (e.g.,in nature, in the garden, in the park, on the balcony/patio, walks) Curbisin/Sabamin Ginkgo Biloba Tone Intestinal regulators Fiber supplement Cernitol ...spring and summer hours/week Very seldom
Valerina Night/Forte Remifemin Litozin …autumn and winter hours/week Very seldom Garlic tablets Echinacea/ Kan Jang/ Esberitox I have read the attached information letter and would like to continue taking part in the study. …………………………………………………………… Your signature
Please check that the questions are fully answered. Return the questionnaire in the enclosed freepost reply envelope. THANK YOU FOR YOUR PARTICIPATION