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1994
The development of a food frequency questionnaire to be used to identify the dietary intake of phytoestrogens in a sample study group of middle aged Italian women living in the Illawarra
Karen Elizabeth Christian UnivFollowersity this of and Wollongong additional works at: https://ro.uow.edu.au/theses
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Recommended Citation Christian, Karen Elizabeth, The development of a food frequency questionnaire to be used to identify the dietary intake of phytoestrogens in a sample study group of middle aged Italian women living in the Illawarra, Master of Science thesis, Department of Public Health and Nutrition, University of Wollongong, 1994. https://ro.uow.edu.au/theses/2685
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UNIVERSITY OF WOLLONGONG
COPYRIGHT WARNING
You may print or download ONE copy of this document for the purpose of your own research or study. The University does not authorise you to copy, communicate or otherwise make available electronically to any other person any copyright material contained on this site. You are reminded of the following:
Copyright owners are entitled to take legal action against persons who infringe their copyright. A reproduction of material that is protected by copyright may be a copyright infringement. A court may impose penalties and award damages in relation to offences and infringements relating to copyright material. Higher penalties may apply, and higher damages may be awarded, for offences and infringements involving the conversion of material into digital or electronic form. UNIVERSITY OF WOLLONGONG
Department of Public Health and Nutrition
Master of Science ( NUTRITION AND DIETETICS)
MAJOR PROJECT
UNIVERSITY OF WOLLONGONG LIBRARY
THE DEVELOPMENT OF A FOOD FREQUENCY QUESTIONNAIRE TO BE USED TO IDENTIFY THE DIETARY INTAKE OF PHYTOESTROGENS IN A SAMPLE STUDY GROUP OF MIDDLE AGED ITALIAN WOMEN LIVING IN THE ILLAWARRA
KAREN ELIZABETH CHRISTIAN
SUPERVISOR- LINDA TAPSELL
SUBMISSION DATE JULY 1994 TABLE OF CONTENTS
LIST OF FIGURES...... iii
LIST OF TABLES...... iii
APPENDICES...... iv
ACKNOWLEDGEMENTS...... v
ABSTRACT...... vi
CHAPTER 1
1.1 INTRODUCTION...... 1
1.2 AIM...... 2
1.3 OBJECTIVES...... 2
1.4 DEFINITIONS...... 3
CHAPTER 2 LITERATURE REVIEW
2.1 INTRODUCTION...... 4
2.2 THE ITALIAN WAY OF LIFE...... 8
2.3 FOOD SOURCES OF PHYTOESTROGENS...... 11
2.4 TYPES OF PHYTOESTROGENS...... 15
2.5 DIETARY INTAKE ASSESSMENT...... 26 2.6 DEVELOPMENT OF THE FOOD FREQUENCY QUESTIONNAIRE.30
2.7 CONCLUSION...... 33
CHAPTER 3 METHODOLOGY
3.1 METHODOLOGY...... 34
3.2 COMPILE FOOD LISTS...... 34
3.3 DETERMINATION OF FOOD PORTION SIZES-...... ,,.....36
(i) 3.4 FREQUENCY OF CONSUMPTION 36
CHAPTER 4 RESULTS
4.1 FOOD LIST OF 51 SUBJECTS...... 37
4.2 FOOD LIST...... 55
4.3 SERVING SIZES...... 60
4.4 THE FOOD FREQUENCY QUESTIONNAIRE...... 60
CHAPTER 5 DISCUSSION
5.1 DISCUSSION...... 64
5.2 PHYTOESTROGENS...... 65
5.3 COMPUTER ANALYSIS OF FOOD ITEMS...... 67
5.4 FFQ- DEVELOPMENT AND STRUCTURE...... 68
5.5 COMPARISONS WITH OTHER RELEVANT STUDIES...... 70
CHAPTER 6 LIMITATIONS OF STUDY
6.1 PHYTOESTROGENS...... 72
6.2 RAW DATA COLLECTION...... 73
6.3 NUTRIENT ANALYSIS OF SELECTED FOOD ITEMS...... 74
6.4 AREAS FOR FURTHER INVESTIGATIONS...... 75
CHAPTER 7 CONCLUSIONS...... 76
REFERENCES...... 77
APPENDICES...... 87
(ii) LIST OF FIGURES ------PAGE FIGURE 2.1 Plants known to possess oestrogenic
compounds...... * ... 13
FIGURE 2.2 Comparison of the potency of various
oestrogen sources...... 17
LIST OF TABLES
TABLE
4.1 25 most commonly consumed foods in the Italian
women's diet...... 38
4.2 Major dietary sources of Fibre...... 41
4.3 Major dietary sources of Energy...... 43
4.4 Major dietary sources of Protein...... 44
4.5 Major dietary sources of Carbohydrates...... 45
4.6 Major dietary sources of Fat...... 47
4.7 Major dietary sources of Polyunsaturated fat... 48
4.8 Major dietary sources of Saturated fat...... 50
4.9 Major dietary sources of Monounsaturated fat...51
4.10 Major dietary sources of Calcium...... 52
4.11 Major dietary sources of vitamin C ...... 53
(iii) PAGE TABLE
4.12 Major dietary sources of vitamin A 54
4.13 List of alternative names 58
4.14 Food list 56
Appendices
1 . 24 hour recall list and frequency...... 2 . Foods that contribute to 90% of Fibre intake...... 3. Foods that contribute to 90% of Energy intake......
4. Foods that contribute to 90% of Protein intake......
5. Foods that contribute to 90% of Carbohydrate intake...
6 . Foods that contribute to 90% of Fat intake......
7. Foods that contribute to 90% of Polyunsaturated
fat intake......
8 . Foods that contribute to 90% of Saturated fat
intake......
9. Foods that contribute to 90% of Monounsaturated fat
intake......
1 0 . Foods that contribute to 90% of Calcium intake ......
11. Foods that contribute to 90% of Vitamin C intake.....
12 . Foods that contribute to 90% of Vitamin A intake.....
13. Sample Food Frequency Questionnaire......
14. Appropriate recipes......
(iv) ACKNOWLEDGEMENTS
To my husband ADAM for his love and support, and to my 2 year old daughter, DEBRA and 9 month old son, DEAN for being such great kids.
To my parents PAT and BETH DEASY for their help and enthusiasm.
To ALAN and BELINDA MICHIE, for the loan of their computer, and their assistance with the installation of a suitable program.
and,
A special thanks to LINDA TAPSELL for her time, guidance, and assistance with this project, and to LISA FRANCO for those helpful tips she provided.
(V) ABSTRACT
Menopause is one of the major biological events to occur in a women's lifetime.
Although it is considered as a normal physiological change, its effects often have social and psychological implications. (Morse et al 1993). At present there is minimal information regarding the experience women face during the menopause, particularly in multicultural societies.
Currently, Morse et al (1993) from the University of Wollongong are investigating the health experiences of middle aged Italian women in the Illawarra area of N.S.W.
The aims of their research are;
• To identify the groups menopausal experiences and attitudes, and compare the findings with those of the dominant culture (Anglo- Australians);
• To examine the nutrition of these groups and to relate dietary factors to the type and severity of reported menopausal changes;
• Further to consider the role if any, of acculturation of this group within a different dominant host culture that may influence the incidence and character of menopause related morbidity. (Morse et al 1993)
At present evidence is mounting that nutritional intake may effect menopausal symptoms. This evidence is focused on phvtoestrogens and the oestrogenic activity of certain foods ( Wilcox et al 1990).
(VI) The purpose of this research project was to prepare a food frequency questionnaire that may be utilised to assess and rank the dietary intake of middle aged Italian women in the
Illawarra. The questionnaire is based on data provided by 24 hour recall dietary interviews. A research assistant at the university of Wollongong conducted a series of
24 hour recalls with approximately 10% of the study group population. The data from these recalls was analysed and the dietary information attained was used to develop a winter food frequency questionnaire specific to the middle aged Italian female population of the Illawarra. !
(VII) CHAPTER 1 INTRODUCTION
The purpose of this research project was to develop a food frequency questionnaire aimed at identifying the major food sources of phytoestrogens and their precursors, in a sample study group of middle aged Italian women living in the Illawarra. The questionnaire devised is to be used in the assessment and ranking of this subgroups dietary intake. The frequency questionnaire developed is culturally specific for middle aged Italian women living in the Illawarra.
T The completed questionnaire is to be used in a larger research study which investigates menopausal symptoms and the migrant woman.
The developed questionnaire focuses on assessing the women's food intake, and in particular focuses on outlining food sources of phvtoestrogens. Phvtoestrogens are targeted because they have been linked to possible reductions in pre-menopausal symptoms by Wilcox et al (1990).
The development of the questionnaire relied on food consumption data provided by a subgroup of the population of middle aged Italian women in the Illawarra. This data was collected as four 24hour dietary recalls taken from 51 subjects randomly selected from the Italian community.
In order to produce a valid and reproducible questionnaire, a literature review on the development of food frequency questionnaires, sources of phvtoestrogens, diet intake methodology, and Italian eating habits was performed.
1 AIM AND OBJECTIVES.
1.2 AIM:
To develop a food frequency questionnaire from 24 hour dietary recall data of middle
aged Italian women residing in the Illawarra area of N.S.W.
1.3 OBJECTIVES:
1. To review current literature on diet intake methodology, development of food
frequency questionnaires, and phytoestrogens.
2. To attain an average food consumption pattern from the study group
3. To group foods from the 24 hour dietary recalls with similar nutrient composition together.
4. To identify the consumption rate of these foods, i.e. amount and ffequencv.
5. To devise a food frequency questionnaire, that is specific to the population of middle aged Italian women living in the Illawarra, and which enables ranking of these women according to their dietary phytoestrogen consumption.
2 1.4 DEFINITIONS
1. PHYTOESTROGEN
Phytoestrogens are the chemical compounds found in many plants that have been shown to possess biological oestrogenic activity. (Rose 1992)
2. 24 HOUR RECALL
Lee-Han et al (1987), describes the 24 hour recall as a method of data collection that requires the subject to recall all foods and beverages consumed over the previous 24 hours.
3. FOOD FREQUENCY QUESTIONNAIRE
The food frequency questionnaire is a method of dietary data collection It directly estimate the frequency of food consumption over a specified time period, and it consists of a food list and frequency response section. (Willet 1990).
3 CHAPTER 2
LITERATURE REVIEW
2.1 INTRODUCTION
Menopause is a significant mid life event for nearly all women. Although it is traditionally considered a physiological event, it also has significant socio-cultural consequences. During the past ten years there has been increasing amounts of research done on the menopause. An interesting aspect of this research has been the idea that nutritional factors may affect a women's lifestyle and the experience of menopause. It is believed that the traditional diets of women from non-westernized societies may provide vegetable food sources that exhibit oestrogenic activity and act as precursors that attenuate the usual oestrogen depletion of menopause. They may therefore decrease the most common menopausal symptoms of hot flushes, night sweats, and vaginal atrophy. (Morse et al 1992)
At present there is a growing amount of evidence about the influential roles of diet and nutritional status on the production and excretion of oestrogens in women.(Goldin et al
1992) The results of research performed in this area appears to indicate that the findings have implications on women with breast cancer, decreased fertility, and menstrual cycle irregularities. (Setchell et al 1984)
4 In 1990 Wilcox et al conducted a preliminary study on 25 post-menopausal women in
Melbourne Australia. These women received measured amounts of supplements of foods considered to contain high amounts of oestrogenic compounds (phytoestrogens), and consequently after six to eight weeks on the diet the women were found to have evidence of oestrogenized vaginal cells.
The issue of whether nutrition influences menopausal symptoms is an interesting and intriguing area of research which deserves further investigation. There is published literature on the types and functions of oestrogenic properties of foodstuffs.(Price and
Fenwick 1985^ Adlercreutz et al 1982 and Setchell 1984). This literature focuses mainly on the effect plant oestrogens (phytoestrogens) have on hormone dependent diseases such as breast cancer, prostate cancer, colon cancers, decreased fertility, and menstrual cycle irregularities.
The compounds identified in these reviews most commonly regarded as having oestrogenic activity, are the plant lignans found in fibre rich foods. Lignans of various structures have been found in some plants, and lignans with unusual structures have been found in animals including man.(Price and Fenwick 1985). The principle compounds found in man are enterolactone, and enterodiol. These two compounds are formed from dietary precursors by intestinal tract bacteria. The biological functions of these compounds in man are still unclear, however some plant lignans have been shown to have anti-cancer, anti-viral, anti-bacterial, anti-fungal, anti-insecticidal, anti-oestrogenic, and weak oestrogenic effects. (Adlercreutz et al 1982).
5 Another dietary compound known to posses oestrogenic activity is equol found in large amounts in soya products. Equol is formed and excreted in large amounts from a phytoestrogen of isoflavanoid structure. Equol is a weak oestrogen that has been shown to bind to sheep and rat uterine receptors. Therefore it is considered to have potential anti oestrogenic effects in animals and humans (Setchell et al 1984).These three compounds are the most widely researched potential oestrogen influencing food components. The most commonly identified foods with oestrogenic activity are therefore foods containing these compounds. These foods include soya products (with an abundance of equol), and fibrefrch foods that contain varying amounts of enterolactone and enterodiol.
• In order to identify the most predominant sources of phytoestrogenic activity in a sub group’s diet, such as the pre-menopausal Italian women in this study, a suitable diet intake methodology is required. Studies to investigate dietary status and determine the relationship between diet and health require accurate information on the foods being consumed by the study group. This information includes types of foods, and the quantity and frequency of their consumption.
No matter what approach to intake assessment is taken there are accepted shortcomings: different methods yield different results, disparity within methods varies from nutrient to nutrient, and the selection of the most suitable method depends on the question being addressed. (Pelto et al 1989)
6 Food consumption of both the individual and groups can be performed in two ways;
1. QUANTITATIVELY- Where the quantity' of food eaten is measured over a specified time period, eg 3 day food record.
2. QUALITATIVELY- Where a retrospective method is used to obtain a usual food intake
.e.g. food frequency questionnaire (Rohan et al 1987).
The type of approach to data collection used is determined by several factors. These include; time, money, material, resources, motivation, and intelligence of the group or individual, and the amount of detail required for the study.
This research aims to utilise a quantitative method of food consumption data collection, the 24 hour, recall to produce a qualitative tool, the food frequency questionnaire. The resulting food frequency questionnaire will be used to perform dietary intake studies on the pre menopausal Italian women in the Illawarra. The questionnaire will be specific in its ability to identify the Italian women's dietary consumption of the specified nutrients, and enable ranking of their phytoestrogen intake according to their dietary fibre intake.
7 THE ITALIAN WAY OF LIFE.
Australia today is a multicultural society, and although there is a vast array of different cultures apparent, little work has been performed to study the individual eating habits of each culture. Studies that pinpoint particular lifestyle stages in conjunction with specific target groups are rare (Powles et al 1990)). This study is therefore somewhat unique, with its focus on the dietary intakes of middle aged Italian women living in the Illawarra.
There have been some studies performed on the foreign bom Australian Italian population as a whole (Margetts et al 1980 and Trevisan et al 1990).
These studies have shown that the majority of Australian immigrants bom in Italy have altered their eating habits since immigration. These changes have reflected the Australian population's eating habits. The immigrants diet leaned towards the more traditional
Australian diet of more meat and less cereals and vegetables, hence their diet became substantially higher in animal fats and lower in fibre ( Margetts et al 1980).
The Italian bom however still consume more traditional Italian foods than the Australian
no bom Italians. They consume more re d wine, spaghetti, salami, and fish, while con sum i“ 5 considerably less" Australian foods", such as beef, potatoes, and beer (Margetts et al
1980)
Margetts et al (1980) found on comparing the nutrient intake of Italian bom and
Australian bom women, that the Italian bom appear to consume less variety of nutrients than the Australian bom, but the Italian bom consume more energy. This energy' is
8 primarily contributed by their higher fat consumption due to their use of oil in cooking and fatty meat consumption (salami etc. )(Margetts et al 1980).
In Italy food consumption also varies between regions, therefore a review of Italian regional eating habits could be of value.
ITALIAN REGIONAL EATING HABITS
It is very difficult to generalise about Italian eating habits because they vary so widely from region to region. Conran (1981) describes life in Italy according to its regional variations. She outlines how in the south where durum (hard grain) grows best, pasta forms the basis of most meals, while in the north maize and rice grow in the rich fertile plains, where polenta and risotto are common staples. In the North people often cook with butter while in the south olive oil is frequently used, because an olive tree costs less to uphold than a cow and can live on poorer soil. She also explains that the people of the south eat less meat than their more prosperous northern cousins, as most of the southern cattle is kept for farm work or milk rather than meat (Conran 1981).
Fulton (1992) writes that Italy is virtually surrounded by sea, and that locally caught fish are a feature of most region's meals. She describes Italy's north as having abundant seafish supplies which are supplemented with excellent freshwater fish from the lakes.
She describes the southern coast and the islands of Sicily and Sardinia as being dotted with fishing villages, where tuna, sardines, and a variety of shellfish are caught and used locally in pasta dishes, sauces, soups, and salads.
She characterizes the southern region's cooking as having an abundance of tomatoes,
9 garlic, herbs and anchovies which gives their traditional dishes their unique flavour (Fulton 1992).
Italy is the world's largest wine producer, and almost all regions have their own specialities. Wine is characteristically consumed at each meal.
It is obvious that difficulty could arise in determining the dietary intake of Italian immigrants, as Italy itself contains of vast regional variations. The Southern Italians consume a diet higher in fibre and low in saturated fat, while the Northern Italians consume more meat and animal produce hence increasing their total saturated fat intake.
Trevisan et al (1990) indicated that the saturated fat consumption between the two regions could vary by as much as 60% when expressed as a percentage of total energy consumption.
This project aims to devise a questionnaire, based on 24 hour recall data collected, that will take into account traditional Italian foods and classify them according to their nutritional value. In particular the phytoestrogen content of the Italian study groups diet will be analysed. This will be performed by consideration of their fibre intake and intake of phytoestrogen rich foods.
10 2.3 FOOD SOURCES OF PHYTOESTROGENS AND THEIR PRECURSORS.
For over 500 years scientists have been aware of the presence of oestrus-producing substances in plants. The use of these plant sources of oestrogens to regulate fertility in both animals and humans has been recognised for hundreds of years. The pomegranate for example, has been utilised by Orientals for its associations with fertility for
2000 years ( Price and Fenwick 1985). More recently certain strains of clover used as fodder crops have been recognised as potential birth control methods for sheep and cattle and possibly man (Rose 1992).
Although over the years an extensive array of plant oestrogens (phytoestrogens) have been identified, rarely are they found to be structurally identical with oestrogens of animal origin such as 17(3 oestrodiol and oestrone(I) (Hewitt 1980 cited in Price and
Fenwick 1985)
Fifty-three plants were listed as potential sources of phvtoestrogens by Bradbury and
White in 1954 (cited in Price and Fenwick 1985). Only two decades later in 1975
Farnsworth et al (cited in Price and Fenwick 1985) were able to derive a list of over 300 plants. In many cases however, the active oestrogenic compound of these plants have not been isolated, and of those that were isolated, the isoflavones, coumestans and lignans appear to be most dominant. In most cases these compounds are found in high fibre
11
3 0009 03132059 6 plants, hence their content in the human diet can be associated with the individuals dietary fibre intake (Mousavi and Adlercreutz 1992).
By correlating the findings of Bradbury and White, and Farnsworth et al, a list of 29 known plant oestrogens was drawn. Of these 29 phytoestrogens less than half have been significantly identified in plants commonly consumed by man ( refer to figure 1, Plants shown to posses oestrogenic activity) (Price and Fenwick 1985) Several of the listed plants have the potential to be consumed in large quantities. For this reason their potential contribution to biological hormones is of importance. In human vegetarians for example, the potential for a high consumption of phytoestrogens is apparent particularly if they rely on soya products to provide them with their daily protein requirements (Rose
1992). Similarly clover is consumed in large quantities by grazing animals such as sheep.
The increased incidence of infertility in sheep grazing on phytoestrogen rich clover has led to much of the published literature on the effects of phytoestrogens on animal fertility (Rose 1992).
Further interests in food sources of phvtoestrogens and their precursors has been sparked by the increased incidence of breast cancer and other hormone related cancers in western civilizations. The link has been attributed to the dietary differences between the western and non westernized world ( Adlercreutz et al 1990).
12 FIGURE 2.1 29 PLANTS KNOWN TO POSSESS OESTROGENIC COMPOUNDS
(Price and Fenwick 1985 p 74)
PLANT COMMON NAME PART ACTIVE PRINCIPLE
Aves sativum oats seed, meal zearalenone* sprouts zearalenol* Clcer arietinum chick pea seed, seedling isoflavones Bengal gram isoflavones Daucus carota carrot coumestans Foeniculum vugare fennel oil anethole Glycyrrihiza liquorice root oestriol glabrata Humulus lupulus hops colupulon lupulon Hordeum vulgare barley embryo zearalenone* Malus sylvestris apple fruit oestrone Medicago hispida toothed medic isoflavones Medicado barrel litteralis medic coumestrol Medicado sativa alfalfa 4 methoxy coumestrol Oryza sativa rice seed embrvo zearalenone* oestrone. oestradiol Phaseolus french seedling oestradioi vulgaris bean Phoenix date palm seed oestrone dactylifera Pimpineila anise oii anetnoie anisum Poa pratensis bluegrass isoflavones Prunus avium cherry fruit prunetin Punita granatum pomegranate seed oestrone Secale cereale rye zearalenone* Sesamum indicum sesame meal zearalenone* Soja max soya seed isoflavones sprout coumestrol Sorghum vulgare sorghum zearalenone* Triticum vulgare wheat flour, seed zearalenone* Trifolium spp. clovers leaves coumestrol stem isoflavones Vigna sinensis cowpea coumestrol Zea mays com zearalenone* zearalenol* hay zearalenone*
13 The western diet is characteristically high fat and low fibre, while the non western civilisations consume a high fibre low fat vegetarian or semi- vegetarian diet. Several studies were performed in this area by Adlercreutz et al.( 1990 and 1991). They showed that there was a positive correlation between fibre consumption and incidence of cancer, in particular breast cancer. Non westernized countries such as Japan consuming the higher fibre diet appeared to have lower breast cancer rates (Rose 1992).
Foods consumed by these non-westemized civilizations are high in fibre and also high in lignans. Lignans are a group of compounds with a dibenzylbutane skeleton. They were previously thought to be present in higher plants only, but in more recent studies they have been isolated from body fluids of animals and man (Adlercreutz et al 1982 ). The mammalian lignans enterolactone and enterodiol are believed to be derivatives from plant lignans and other dietary precursors such as daizden.the phytoestrogen precursor in soya products (Mousavi and Adlercreutz 1992). Studies have indicated that these lignans have beneficial values which include anti-tumour, anti-mitotic, anti-oxidative, weak oestrogenic and anti-oestrogenic effects.(Adlercreutz et al 1982)
Recently Wilcox et al (1990) performed a preliminary study which correlated phytoestrogen consumption with a reduction in menopausal symptoms in 25 Caucasian women residing in Melbourne Australia. These women received measured supplements of foods known to contain a high amount of oestrogenic compounds. Consequently after six to eight weeks on this diet the subjects were found to have evidence of oestrogenized vaginal cytology. This area of research is exciting particularly for women, Although
14 further investigation is required
The following review will focus on the types of phytoestrogens, where they are found, their biological effects and metabolism.
2.4 WHERE DO WE FIND PHYTOESTROGENS , AND WHAT TYPES ARE THERE?
The main compounds known to produce oestrus in immature animals or interfere with their reproductivity are the isoflavones and coumestans, both of which are considered to be true phytoestrogens and the fungal oestrogens, the resorcyclic acid lactones. The lignans are also known to effect hormone metabolism in man. Lignans are derived from phytoestrogens found in plants. The two most commonly referred to mammalian lignans are enterodiol and enterolactone. These are derived from precursors in soya products (Adlercreutz et al 1982).
The phytoestrogens or plant compounds responsible for producing oestrogenic activity' can be classified into three main groups and one subgroup the lignans. They are classified according to their chemical structure.
The three groups are; l. ISOFLAVONES 2. COUMESTANS 3. RESORCYCLIC ACID LACTONES and the LIGNANS formed from isoflavone precursors.
ISOFLAVONES AND ISOFLAVONE GLUCOSIDES.
There are eight known naturally occurring isoflavone phvtoestrogens which have been shown to produce oestrogenic activity. These are diadzein(rV) its glucoside daidzin (VI), its 4 methyl ether formontonetin(VT1I), genistein(V), its glucoside genistin(VII) it’s 4
15 methyl ether biochanin A (IX) protesein(X) and prumetin(XI). The last two however occur in minute quantities in the human diet (Ohta et al 1980, cited in Price and Fenwick
1985). These eight isoflavones usually occur in their bound form as glucosides in the intact plant.(Price and Fenwick 1985). When the intact plant is interfered with during analysis, processing and isolation these isoflavones are readily degraded chemically or enzymically to the aglycone. The crushing of clover and other related pastures leads to hydrolysis by endogenous glycosidases (Beck 1954 cited in Price and Fenwick 1985). It is also possible for this process to occur in animals and perhaps man if An enzyme is absent.
Although there have been a considerable number of isoflavones isolated torn plants only a few have demonstrated an oestrogenic affect, and not all the isoflavones isolated from plants known to affect oestrus are active (Pierpont 1986). A good example of this is the soya bean. Soyabeans possess diadzen, genistein, and their glucosides, while also containing glycitein(XIV)) and glycitein 7 glucoside (XV) which are uterotropically inactive. This illustrates the potential difficulty that may occur when pinpointing the actual biological effect of foods such as the soyabean. The measure of total isoflavone concentration of a food is therefore not indicative of its potential oestrogenic activity, as a portion of the isoflavone content is biologically inactive.
The biological effects of these phytoestrogens vary in strength, however all are less potent than either synthetic or animal oestrogens (refer to figure 2). In figure 2, comparisons are drawn between the biological strengths of synthetic oestrogens and phytoestrogens. It is apparent that phytoestrogens are far less biologically significant than synthetic oestrogens, this does not however exclude their potential biological significance (Price and Fenwick 1985)
16 FIGURE 2.2 COMPARISON OF THE POTENCY OF VARIOUS OESTROGEN
SOURCES. (Price and Fenwick 1985 p97) Estimated daily dose
(ug Diethylstilboesterol equivalents.)
MORNING AFTER PILL 50000 BIRTH CONTROL PILL 2500 POST HYSTERECTOMY REPLACEMENT THERAPY 500-1000 POST MENOP AUS AT. THERAPY 500 lOOg BEEF LIVER (0.05ppb DIETHYLSTILBOESTEROn 0.05 lOOg WHEAT (2ppm ZEARALENONE) 0.2 20g dry weight SOYA BEAN SPROUTS (70ppm COUMESTEROL) 0.5 lOOg FRENCH BEANS (2-10ppb OESTRODIOL. 0.03-0.15
The most effective phytoestrogen is genistein which has only 10-5 the oestrogenic activity of diethystiboestrol. Variations in the biological activity of individual isoflavones can exist and these are affected by the strain of animal used in laboratory testing, the plant species, preparation of the plant for analysis, and the type of administration technique used for biological analysis (Price and Fenwick 1985).
In terms of the effect foods have , the most significant source of phytoestrogens would be the foods that posses the stronger activity when consumed orally.(Bickoff et ai 1962)
cited in Price and Fenwick 1985) found genistein to be the most active of the isoflavone aglucones tested by oral administration in mice.
Further studies in this area however have shown that the strain of mice used in laboratory diagnosis have led to differences in responses to other oestrogens. In 1984 Farmakalidis and Murphy (cited in Price andFenwick 1985) showed that a strain of mice referred to as cd-1 was relatively insensitive to diadzein, genistin and genistein. This emphasises that
17 the comparison of findings found using different animal species and cross comparisons of different studies results should be considered with caution or avoided.
Several studies including those performed by Martin et al (1978) (cited in Price and
Fenwick 1985) and Shutt (1976) have considered phytoestrogens to function as anti - oestrogens. This is because they exhibit an affinity for oestrogen receptor sites hence preventing the biosynthetic pathway linked to tissue growth (Rose 1992.) Studies into the effect of the metabolism of isoflavone oestrogens were sparked predominately by the decreased fertility of sheep grazing on clover, "CLOVER DISEASE"
This decreased fertility was originally associated with the high levels of isoflavones . present in subterranean and other clovers (Setchell et al 1984).
In 1964 however Millington et al were not abie to directly associate the level of hormone activity and levels of genistein and biochan A in sheep fed clover. There was however a positive correlation found between the formonetin, a weaker oestrogen, and oestrogenic activity in vivo. Tang and Adams (1980) (Price and Fenwick 1985) later realised that the reason for this lay in the metabolism of these isoflavones in the digestive tract. Both genistein and biochan A are converted into inactive products, but formonetin is converted to equol which produces oestrogenic activity in animals (Price and Fenwick 1985).
Studies performed to identify the isoflavone content of foods have mainly focused on the soya products. Most soya products appear to contain equol, daidzein, daidzin, genistein, genistin, and the two inactive isoflavones, glycitin and glycitein. (Eldridge and Kwolek
1983).Murphy et al (1982) ( cited in Price and Fenwick 1985) indicated that this isoflavone content is decreased substantially on germination, during protein isolation and
18 when calcium precipitated ofu was made.This outlines yet another area where the potential for vast variation in phvtoestrogen concentration exists.
In terms of food sources of isoflavones the soya products appear to be the most abundant sources according to most literature.
Finally in a Japan study performed by Setchell et al 1984, it was found that both
Japanese men and women excrete isoflavanoids in their urine in particular equol. This was found to be due to their high dietary intake of soya products. This may be seen as one of the reasons Japanese women have a lower incidence of breast cancer and menopausal symptoms than western women (Adlercreutz et al 1990).
LIGNANS.
Lignans are a group of compounds which contain a dibenzylbutane skeleton. They were previously thought to be native to higher plants only but more recently they have been found in the biological fluids of animals and man (Adlercreutz et al 1982).Many lignans have been considered to possess anti-tumour, anti-biotic, anti-fungal, anti-mitotic, anti - oxidative, weak oestrogenic, and anti-oestrogenic effects. (Setchell 1984).
Studies have revealed that the urinary excretion of lignans is found to be decreased in non-vegetarian and post-menopausal women with breast cancer (Mousavi and
Adlercreutz 1982). This area of interest is where most research into lignans has occurred ( Goldin et al 1982. Setchell et al 1984. and Adlercreutz et al 1990).
19 The mammalian lignans enterolactone and enterodiol are believed to be derived from
plant lignans and other dietary precursors. Studies by Thompson et al (1991) performed
on healthy humans who had not consumed antibiotics indicated that lignan production is dependent on bacteria in the digestive tract. In vitro studies by Setchell et al (1984) also demonstrated efficient production of mammalian lignans from dietary precursors by human faecal flora. These studies suggest that the primary site of lignan production is in the cecum and colon.
Thompson et al (1991) performed a study to determine the lignan production from various food products. This was achieved by using an in vitro method which utilised fresh human faecal biota from healthy humans that had not consumed antibiotics in the previous six months. The results showed that human lignan production from different foods ranged from 21-65541ug/100g. Of the total lignans produced more enterolactone was produced than enterodiol in 44 of the foods and vice versa in 24 foods. The study concluded that most of the commonly eaten plant foods contain mammalian lignan precursors but in varying concentrations. The amount that an individual food contributes is therefore dependent on the significance of that food in the individuals diet.
Although flaxseed may produce a concentration of lignans 100 fold greater than most foods, its actual dietary contribution is relatively low as it is not a commonly consumed food. Foods such as fruits and vegetables, cereals and legumes, may have produced less lignans experimentally, they may however be more significant due to their greater consumption.
As both these studies were performed with faecal biota of healthy human subjects that had not consumed antibiotics six months prior to the analysis, the possibility may exist
20 that the mammalian lignan production of subjects that had consumed antibiotics may be substantially reduced despite a consumption of a diet high in lignan phytoestrogens. This could be due to the lack of essential intestinal tract bacteria.
At present there is still little known about the actual lignan precursors of plant foods, however two have been identified, seccoisclariresinol, and matairesinol. The first can be converted using a series of reactions involving bacterial enzymes to enterodiol. The second, matairesinol undergoes direct conversion to enterolactone by bacterial action.
In most foods there is a greater amount of enterolactone than enterodiol, this suggests that matairesinol a common plant lignan may be more abundant. Once digested the lignans undergo enteroheptatic circulation. First they are absorbed from the intestinal tract and then they are transported to the liver. In the liver they form conjugates which are excreted in the bile., and are then re absorbed as conjugates.(Price and Fenwick
1985). Some of the lignans then reach the kidneys and are excreted in urine. The more lignan precursors in the diet the higher the urine output. Therefore it can be assumed that the concentration of lignans in the urine is related to the lignan production from dietary sources I Adlercreutz et al 1982).
This hypothesis has been used in several studies to identify the relationships between the diets of vegetarians and non vegetarians. These studies have indicated that there is a correlation between diet and urinary excretion of lignans (Goldin et al 1982. Setchell et al 1984 and Adlercreutz et al 1991). These studies show that the urinary excretion of lignan phytoestrogens is higher in vegetarians than omnivores and breast cancer patients.
21 At present it appears that the types of diets that result in higher urinary excretion of
lignans are the diets that have a high fibre content, and Adlercreutz et al (1991) suggests
that there is a correlation between high fibre intake and increased lignan production. In
fact Thompson (1991) found that when they used flaxseed flour at a level of 10% in the
regular human diet the urinary lignan production increased 21 fold. The concept that a
high dietary fibre intake increases phytoestrogen intake will be the one used in the
development of the food frequency questionnaire for middle aged Italian women living in
the Illawarra.
COUMESTANS.
Structurally coumestans are similar to isoflavones. A significant number of coumestans
have been isolated from plant species, but of these only a few have been found to have
oestrogenic activity (Wong 1975). In 1979 Verdeal and Ryan (cited in Price and Fenwick
1985) listed 8 coumestals identified in alfalfa, and only two of these possessed
oestrogenic activity, coumestrol and 4 methoxy coumestrol. The presence of these two
active coumestans has been shown in clover and other fodder crops, and has been linked
to problems with animal fertility (Price and Fenwick 1985).
The coumestans act in a similar manner to the isoflavones, they bind competitively to the mammalian oestrogen receptor sites. Frederick et al (1981) related coumestols effect on
fertility to its ability to inhibit follicle stimulating hormone.
It appears that coumestols activity is related to its metabolism. Like the isoflavones coumestol is conjugated in vivo but to a lesser degree (Price and Fenwick 1985).
Man consumes several plant products that contain coumestrol. The highest reported levels occur in soyabeans and alfalfa sprouts. Over the past few decades these foods have
22 become increasingly popular, particularly in subgroups of the population such as the
vegetarians. Therefore this group of individuals are potentially more likely to consume
higher amounts of phytoestrogens.
The actual coumestrol content of foods is hard to define as several factors have been
reported to affect the concentration. Hansen et al (1965) (cited in Price and Fenwick
1985) showed that alfalfa coumestrol content could be affected by the species, presence
of disease, the stage of growth, geographic location, and mode of cutting.
The most common source of coumestrol in the diet are foods that have been subject to fungal damageJn particular attack by the fusarium species. This species has been identified in wheat, com,sorghum, alfalfa, and soyabeans (Blaney et al 1984).
Although the oestrogenic activity' of this group of compounds has been indicated, in this research study it would be inappropriate to consider their contribution to the Italian woman's diet. This is because actual coumestrol contents of foods already consumed could not be obtained, and the potential for vast variations in concentration exists..
RESORCYCLIC ACID LACTONES- Fungal Oestrogens.
The resorcyclic acid lactones are actually fungal oestrogens, they are secondary mould metabolites of fungal species (Price and Fenwick 1985). The majority of the available literature on these oestrogens is based on the effect these compounds produce on livestock fed mould-damaged crops. When considering human consumption the possibility that these compounds may be carried over into the food supply exists. This
23 would occur via consumption of animal products or cereal grains that had been contaminated.
Zearalenone is the most common fungal oestrogen recognised by man, its reduced derivative has been used as a growth promoter in cattle. Stob (1983) (cited in Price and
Fenwick 1985) suggested that mycoestrogen, fungal oestrogen, or oestrogenic metabolite were more appropriate names for zearalenol.
In 1984 Sheehan et al (cited in Price and Fenwick 1985) linked zearalenone's activity to its metabolism to zearalenol, which acts by binding to mammalian oestrogen receptors.
Hidy et al (1977) (cited in Price and Fenwick 1985) stated that an intake of as little as 50- F 75mg per day of zearalenol would be clinically effective in the treatment of post menopausal syndrome in women. This however still requires fiither investigation.
In comparison to other plant oestrogens, zearalenone has been shown to have a stronger binding capacity to rat uterine receptors than isoflavones, however not as strong as coumestrol. Hidy et al (1977) also stated that both zearalenone and zearalenol are effective contraceptive agents in humans.
In terms of human dietary intakes the major source is grain crops , in particular those affected by mould. Like the coumestans the zearalenone content of foods is affected by mould species, and hence for this research project it would be considered inappropriate to consider their contribution to the dietary phytoestrogen intake of the sample study group.
24 Overall studies have indicated that there are several commonly eaten foods that have
been shown over the years to posses some type of oestrogenic activity These are;- soya
products, alfalfa, pomegranate, fibre rich foods, in particular vegetables and pulses (Price
and Fenwick 1985)
To date there is still however limited information about the actual phytoestrogen content
of individual foods. The amount of interest in this field of nutrition research is continuing
to grow. Of particular interest is the possible relationship between phytoestrogen intake
and cancer, hence sparking further investigations. In 1990 Wilcox et al investigated the
effect nutrient and phytoestrogen intake had on post-menopausal symptoms. They found
that when post menopausal women were supplemented with phvtoestrogen rich foods
they showed evidence of oestrogenized vaginal cytology. This particular finding is
related to this study. The aim of this study is to devise a tool, a food frequency
questionnaire that will be used to rank individuals according to their phytoestrogen
intake. To devise this tool the major phytoestrogen source considered will be the lignans
found in fibre'rich foods. The lignans are targeted because they are more likely to
produce reproducible results as their phytoestrogen content is not as variable as other phytoestrogen sources. The lignans are also more widely distributed among the
commonly eaten plant foods in the Italian diet.
25 2.5 DIETARY INTAKE ASSESSMENT- THE FOOD FREQUENCY QUESTIONNAIRE
The food frequency questionnaire is a popular tool used in the assessment of dietary
intake in specific target groups (Baghurst 1992).
The versatility of food frequency questionnaires centres on their ability to assess the
frequency of consumption of specific foods or food groups during a specified time period
(Willet 1990). In a food frequency questionnaire the subject is able to indicate how often
particular foods are eaten in a given time period. This is achievable because food
frequency questionnaires contain a list of commonly eaten foods and a participant response section.
The types of foods frequency questionnaires used vary and they may be classified into three main groups. These are;
1. THE CLASSIC FOOD FREQUENCY QUESTIONNAIRE
In this type of questionniare specific foods are focused .
2. SEMI-QUANTITATIVE FOOD FREQUENCY QUESTIONNAIRES.
In this type of questionnaire portion size is considered by a standard portion size for each food item being included on the questionnaire. The subjects response therefore indicates the frequency of consumption in relation to the standard size indicated.
3. THE QUANTITATIVE FOOD FREQUENCY QUESTIONNAIRE.
This type of food frequency allows the subject to supply information about the portion size of foods consumed. This is achieved by asking the subjects to supply information on their portion size ( Rohan et al 1987).
26 Over the past three decades the use of the food frequency questionnaire in
epidemiological studies has increased (Willet 1990). Since the 1960s the food frequency
questionnaire has been recognised as a useful tool particularly for its ease of use by the
non-nutritionist (Medlin and Skinner 1988).
Epidemiological studies are performed to allow researchers to make comparisons
between study subjects and populations. The food frequency questionnaire is therefore an
excellent tool as it allows the ranking of subjects according to the nutrient being studied
and if required find a relationship with another variable ( Bingham and Nelson 1991 ).
In order to rank individuals with regard to the concentration of particular nutrients,
quantitative studies are required. The need for food frequency questionnaire which
include information on portion sizes is therefore apparent ( Rohan et al 1987).
The use of food frequency questionnaires in dietary intake studies has been analysed over the years. Researchers have outlined the advantages and disadvantages of its various uses.
In favour of the food frequency questionnaire researchers found that the food frequency questionnaire was more widely accepted by study paricipants. They also indicate that they are easier to use as compared with diet records (Block et al 1991). The cost to researchers themselves was found to be lower than for example the time spent analysing multiple days diet records, and the comparison and ranking of results is quicker and less tedious. The food frequency questionnaire also decreases the threat of intraindividual variation among subjects that can occur in short term intake methods such as the 24 hour dietary recall ( Sempos et al 1992). The food frequency questionnaire is also useful in drawing out foods or food groups that are either staple items or avoided totally (Sempos et al 1992 ). Finally Rohan et al (1987) suggest that the food frequency questionnaire is
27 able to provide moderately repeatable estimates of nutrient and energy intakes after a one year period.
The disadvantages of food frequency questionnaire have also been addressed by numerous studies. Lui (1992) reported that the food frequency technique may tend to overestimate certain nutrient intakes. This was also indicated in a study by Bergman
1990, which showed that various nutrients, energy,carbohydrate, protein, vitamin A and
C, phosphorous, calcium, and magnesium were overestimated in comparison with a 3- day food record. Other studies have also reported overestimation in food frequency questionnaire results.
Another shortcoming of the food frequency questionnaire, and all recall methods of dietary assessment, is that recall methods usually suffer from omissions and estimates of intakes, hence actual intakes may vary from those reported..
The design of a food frequency questionnaire, and its grouping of foods ( eg cereal and cereal products) has also been criticised as the format of the questionnaire fails to provide information about cooking techniques, types of foods, consumption times and brand names etc.
Overall the food frequency questionnaire could be considered useful in monitoring trends in dietary patterns over time. The limitations outlined by various studies may be limited by careful composition of the food frequency questionnaire.
Baghurst (1992) stated that the food frequency questionnaire to be used needs to be specific for the population to be studied, and the purpose of the study. In order for this to occur research into the dietary habits of the study population needs to be performed. The staple foods, cooking techniques, geographic location, sociocultural habits,and overall
28 dietary behaviour must be identified. The questionnaire itself must also be targeted towards the study population. The food frequency questionnaire needs to be easy to interpret, the portion sizes need to be suitable, and the foods listed must be indicative of the population's cultural background.
The food frequency questionnaire to be devised in this study must therefore be based on the dietary information obtained from the study populations' four sets of 24-hour dietary recall data. The questionnaire will therefore be characteristic of the dietary habits of middle aged Italian women living in the Illawarra area of N.S.W.
29 2.6 FOOD FREQUENCY QUESTIONNAIRE: DEVELOPMENT AND STRUCTURE
As the winter food frequency questionnaire developed in this project is to be used as a tool in a larger study, the food frequency questionnaires structure must be comparable with food frequency questionnaires developed for other seasons. For this reason the method used by Lisa Franco (1993), based on the model set forward by Block et al
(1985), is to be used.
Block et al (1985), Stryker (1987), and Howe et al (1986), all used a similar food frequency development technique. They used the open ended method of data collection from prior studies performed on sample groups of the population. This information was either in the form of the lengthy diet history or shorter 24hour dietary recalls.
As the data obtained from the 24hour recalls is open ended the results obtained include the types of foods consumed as well as the relative frequency of consumption. This type of data is useful in identifying staple food items while also pinpointing foods that are avoided in an ethnic minority group's diet, such as the pre-menopausal Italian women in this study.
Block et al (1985) used the data they obtained to prepare food groups consisting of similar food items. These groups were then used to compose a food list. The resulting food list contained foods that were made an important contribution to the study groups overall nutritional intake. The food list contained foods that contributed to 90 percent of the dietary intake of energy or the specific nutrients being studied. The top 90 percent of
30 contribution was calculated by dividing the amount of nutrient present in individual food items and then dividing it by the total amount of that nutrient in the overall diet. This was then expressed as a percentage and the top food items that added up to 90 percent appeared in the food list.
This type of food list aims to optimise the ability of the study to account for a diverse range of nutrients (Block et al 1985), it enables the food list to be used in further studies if required. This approach to food list development ensures that the foods that contribute significantly to the study group's diet, i.e. those consumed frequently or in significant amounts are represented in the food frequency questionnaire (Willet 1990).
2.7 FORMAT OF THE FOOD FREQUENCY QUESTIONNAIRE
When developing a food frequency questionnaire consideration of the actual format of the questionnaire is vitally important. The questionnaire must be valid, reliable, easy to use, and be targeted towards the aims of the study.
The method used in the development of the food frequency questionnaire in this study is similar to that used by Block et al (1985). These techniques have been validated on several occasions and were shown by Block and Subar (1992 ) to produce reliable ranking of individuals, as well as accurate estimates of average daily intakes. (Block and
Suber 1992).
In order for a questionnaire to be user-friendly it needs to be easily understood with a short respondent burden time. The respondent burden time, or length of the questionnaire developed is dependent on the type and quality of information it aims at obtaining
(Howarth 1990).
31 In this project the food frequency questionnaire's respondent burden time is dependent on the length of its food list, as each food item listed requires a response by the study participants. Although there have been arguments about whether a long food list results in the attainment of more accurate information, several studies have concluded that there is actually only a small increase in accuracy of a long food list when compared with a short food list (Block et ai 1990, Pietinen et ai 1988). In this study a food list containing
137 food items was considered adequate.
As well as the food list the food frequency questionnaire contains a response section that requires the respondent to supply information on the , and frequency of consumption of foods contained in the food list. The food portion size section contains specific sizes, e.g. small, medium, or large. This approach is used in the questionnaire developed in this project as Block et al (1990) indicate that the three portion sizes gives results that are more valid in comparison with one standard portion size. The frequency section is a vital part of the questionnaire as information on the frequency of food consumption is more difficult to determine that the actual quantity of food consumed. When inaccurate estimates of consumption frequencies occur there is a potential for large errors in the results (Flegal, et al 1988).
In this study the respondents are asked to specify the number of times a particular portion size of food item is consumed under a column that specifies a certain time period, e.g. day, week, month or year.
32 2.8 CONCLUSION.
In this project a food frequency questionnaire is developed. This questionnaire aims to enable ranking of pre-menopausal Italian women living in the Illawarra, according to their dietary intake of phytoestrogens. The study group's dietary fibre intake will be used to quantify their phytoestrogen intake to enable ranking to occur. The developed questionnaire based on the method used by Block et al (1985) will also account for other nutrients so the questionnaire may be utilised in future studies on the same population.
m
33 CHAPTER 3 METHODOLOGY
3.1 METHODOLOGY
To begin this research project an extensive literature review was first performed. The literature review included information on phytoestrogens, diet intake methodology,
Italian eating habits , and preparation of food frequency questionnaires.
In order to attain information about the actual food intake of the sample study group, the
24 hour dietary recall method was used. Four 24 hour dietary recalls were collected from
51 middle aged Italian women residing in the Illawarra. Of these four dietary recalls collected, 3 days dietary recalls were of mid week days, and one was of a weekend day.
Overall a total of 204 dietary recalls were available for the development of a suitable food frequency questionnaire.
To enable the food frequency questionnaire developed to be as valuable as possible both now, and in the future, the questionnaire developed assesses the sample groups entire diet instead of concentrating on a few specific nutrients. The information provided by the 204 dietary recalls was used to compile a food list.
3.2. COMPILING THE FOOD LIST
Intake data from the recalls were cumulated to identify the types and frequencies of the foods consumed by the study sample. Firstly all 204 dietary recalls were analysed. This was performed by listing all the foods in each individual's four dietary recalls and
34 dividing the total food items consumed by four. This approach resulted in the 51 individual average daily food intakes. By totalling the 51 average daily intakes a food list was obtained (refer to appendix 1).
Foods with similar nutrient composition were then grouped. Foods that contribute negligible fibre, nutrients, or phytoestrogens , and are therefore unlikely to be included in the questionnaire were eliminated. Those foods found to be good sources of fibre, specific nutrients, or phytoestrogens were also grouped .
This approach aims to allow an easy estimate of the groups likely dietary intake of phytoestrogens and other specified nutrients. When compiling the food lists several grouping techniques were used. These were;
1. Bread rolls were included as 2 slices of bread.
2. Hamburgers, rissoles and meatballs were classified as cooked mince.
3. Pasta, shapes,spirals,spaghetti, were classified as white pasta.
4. Milk coffee, and milk arrowroot biscuits etc., were classified as plain sweet biscuits
5. Coca Cola, Chinotto, and other cola drinks were classified as soft drinks cola based.
6. Cheese not listed as a specific type was classified as cheddar cheese.
7. Minestrone soup was classified as either with beans or without beans, to enable differences in fibre consumption to be shown.
To identify the major dietary sources of the nutrients to be analysed, i.e. protein, energy, carbohydrates, fat, vitamin C, fibre, calcium, polyunsaturated, monounsaturated, and saturated fats computer analysis was required. This analysis was worked out using the
DIET 1 program available on NUTTAB. Each food item consumed by the group was
35 entered into the DIET 1 program. If profiles were not available for food items they were
classified as foods that resembled them nutritionally. In most cases where information on
the nutrient composition of mixed dishes was not available they were listed under their
individual ingredients. The foods found to be contributors to 90 percent of any of the
above mentioned nutrients or considered high in phytoestrogens were included on the food list.
The foods that contributed to 90 percent of any nutrient were identified by adding the
top contributors of the nutrients until a total of 90 percent was achieved. The following
example indicates how the percentage of contribution for food items was obtained.
Example;
amount of nutrient ( e.g. protein ) provided by the food item (e.g. milk) ------X 100 total amount of the nutrient consumed by the group ( e.g. protein)
3.3. DETERMINE FOOD PORTION SIZES.
As the amount of food consumed is every bit as important as the type of food consumed, the portion sizes of foods consumed were estimated. By collating all the various portion sizes consumed, a standard portion size was obtained based on the most frequently reported serve size. The most common portion sizes are listed in the food lists. One exception is meat as the portion size of meat varied considerably, therefore grams of meat are listed instead of serves. Beverages were also listed as total amounts consumed by the population as this appeared to give a greater outline of the actual fluid intake of the group as a whole.
36 3.4 FREQUENCY OF CONSUMPTION
This was determined in the study via a cross comparison of the 24 hour dietary recall data and the frequency food items were reported by the group as a whole. Using the data on food lists, portion sizes, and frequency information, a food frequency questionnaire
could be developed. The questionnaire addresses frequency as consumption over a
period of days, weeks, months or every 3 months. The response of consumption
frequency will vary from individual to individual.
37 CHAPTER 4 RESULTS
The 24 hour dietary recall data consisted ot 204 individual 24 hour recalls obtained from the sample group of middle aged Italian women. To begin with the 24 hour recalls collected were analysed to determine the average daily consumption for each individual.
This was achieved by dividing all foods listed in the four 24 hour recalls by 4. Once each individual had a list of foods that represented their average daily intake, all 51 subjects lists were compiled to produce a broad food list. This resulting list consisted of 263 food items. The food list was then shortened to 232 food items by grouping foods with similar nutrient composition together. Some examples of these groupings include;, white bread rolls grouped as 2 slices of white bread, chicken that was crumbed and fried was classified with Kentucky Fried Chicken, and cheeses that were either different brands of cheddar cheese, or unspecified types were classified together as cheddar cheese.
Using the list of 232 food items and the frequency of their consumption ( refer to appendix 1 ), a list of the 25 most frequently consumed foods was obtained.(refer to figure 4.1). From figure 4.1 it is apparent that the most frequently consumed foods included; white bread, margarine, sugar, water, Italian dressing, and parmesan cheese.
Many of these food items are considered to be Italian staples.
38 Figure 4.1 25 MOST COMMONLY CONSUMED FOODS IN THE ITALIAN WOMEN’S DIET
FOOD SERVE SIZE NUMBER OF SERVES CONSUMED
1. Bread,white 1 slice 59 2. Margarine 1 tsp. 53 3. Sugar 1 tsp. 53 4. Water 250ml 53 5. Italian dressing 1 Tbs. 36 6. Parmesan cheese 1 Tbs. 32 7. Lettuce 1 cup 31 8. Butter 1 tsp. 30 9. Tea 200ml - 30 10.Coffee,instant 200ml 30 11 .Mandarin 1 29 12.Raddichio 1 cup 29 13. Coffee,strong bl. 100ml 26 14.01ive oil 1 Tbs. 25 15.Bread, w/meal 1 slice 25 l6.Bread,brown 1 slice 23 17. Tomato l 21 18.Pasta white 1 cup 20 19.Cheese unspec. 30gm 20 20.Bread,multi 1 slice 18 21. Wine, white 125ml 17 22.Minestrone 1 cup 16 23 Wine,red 125ml 16 24.Apple 1 16 25.Napolitan sauce 3 Tbs. 15
The results also indicated that white bread was consumed far more frequently than higher fibre breads. In fact of the total number of bread slices consumed i.e., 66 slices, 59 slices were white bread. Therefore 89 percent of all bread consumed was white.
39 Figure 4.1 also indicates that the types of fats and oils most frequently used in cooking or as spreads, were more frequently of the polyunsaturated or monounsaturated varieties.
Margarine was consumed more frequently than butter, and olive oil was consumed more frequently than other oil varieties. The group did however frequently consume animal products such as cheese that are high contributors of saturated fats.Mandarins, apples, and pears were the most commonly consumed fruits, possibly due to seasonal availability. In the vegetable group, lettuce, raddichio, and tomatoes were the most frequently reported items.
Although there were no meats represented in figure 4.1, the most frequently consumed meats included, steak, chicken , and veal (refer to appendix 1). The traditional Italian meats such as mortadella, prosciutto, and salami were also commonly consumed.
Pasta was listed as the 18th most commonly consumed food item. This is because pasta is a common ingredient in many traditional Italian dishes such as; spaghetti bolognaise, fettuchini, ravioli, and lasagne. Overall it can been seen that several of the most frequently reported food items were reflective of the Italian women's migrant background.
40 Once the list of 232 food items was compiled nutritional analysis of the food items was
then required. To do this the foods were entered into the DIET 1 (NUTTAB) program.
The food items were analysed for the following nutrients;
FIBRE
TOTAL ENERGY (kj)
PROTEIN (gm)
TOTAL FAT (gm)
CARBOHYDRATES (gm)
VITAMIN A (retinol Equivalents ug)
CALCIUM (mg)
MONOUNSATURATED FAT (g)
POLYUNSATURATED FAT (g) and
SATURATED FAT (g)
The phytoestrogen content of the foods could not be analysed by this approach as a data
base for phytoestrogens is still unavailable in the DIET 1 or any other nutrition program.
Therefore the dietary fibre intake, which has been associated with phytoestrogen intake
was used as the determining factor
Table 4.2 contains the top 20 foods that contribute to dietary fibre consumption. The table shows the amount of fibre in grams for each food item, and the percentage of fibre each food item contributes to the overall fibre intake. This table indicates that vegetables have the most significant contribution to fibre intake, in particular broccoli which is listed as the most significant source of dietary fibre (refer to appendix 2 for the list of 54 food items that contribute to 90 percent of the dietary fibre intake). From the table in
41 appendix 2, vegetables were found to contribute 36.89 percent of the dietary fibre, and cereal/cereal products 30.70 percent, fruit 20.93 percent, and the remaining food items contributed to 11.48 percent. The breads and cereals were also found to contribute significantly to fibre intake, and all four varieties of bread were listed in table 4.2.
Although the fibre content of white bread is not high, its frequent consumption enabled it to contribute so significantly. An unusual food item listed in table 4.2 was black coffee.
This has a low fibre content, however it consumption frequency was so high it ranked as one of the most significant contributors. Fruits are also highly ranked and 5 of the 11 reported fruits are listed in table 4.2.
Table 4.2 MAJOR DIETARY SOURCES OF FIBRE
RANKING FOOD ITEM AMOUNT PERCENTAGE OF OF FIBRE TOTAL FIBRE (g) INTAKE(%)
1 broccoli 53 4.881 apple 50 4.605 J bread,w/meal 49 4.513 4 bread, white 45 4.144 5 all bran 42 3.872 6 pasta 38 3.500 7 tomato 35 3.223 8 mandarin 35 3.223 9 orange a a 3.039 10 lettuce 28 2.580 11 banana 28 2.580 12 endive,raw 27 2,490 13 bread,mix/gram 26 2.296 14 napolitan sauce 23 2.118 15 carrot 22 2.026 16 pear 20 1.842 17 black coffee 20 1.842 18 lentils 20 1.842 19 minestrone 19 1.750 20 bread,brown 19 1.750
42 Aside from the fibre content of foods, the food list items were also analysed for other significant nutrients. This was performed to allow the food frequency questionnaire developed to be utilised for other studies in the same population. These studies may be unrelated to phytoestrogen consumption,or may be to utilise new findings regarding the interaction of specific nutrients with phytoestrogens. These other nutrients were analysed and tabulated in the same way as for fibre.
The following tables show the major contributors of; overall energy in kilojoules^kj), protein in grams (g), carbohydrates in grams (g), total fat in grams (g), monounsaturated. polyunsaturated, and saturated fats in grams (g), calcium in milligrams (mg), vitamin C in milligrams (mg), and vitamin A in retinol equivalents (ug).
Table 4.3 shows the food items which were found to be major dietary contributors of total energy. Appendix 3 represents the total list of 85 food items which represent more than 90 percent of the total energy intake of the sample group.(refer to appendix 3).
Table 4.3 indicates that olive oil was the major contributor of energy , while white bread chicken, and full cream milk were also highly significant providers of kilojoules due to their high consumption rate.. Traditional Italian foods such as, parmesan cheese, pasta, salami, pizza, red wine, white wine, veal, Italian dressing, and minestrone were also listed in the table of the top 20 energy providers.
43 Table 4.3 MAJOR DIETARY SOURCES OF ENERGY (Kj)
RANKING FOOD ITEM AMOUNT OF PERCENTAGE OF ENERGY(KJ) TOTAL ENERGY INTAKE(%)
1 olive oil 17556 4.558 2 bread, white 17197 4.465 J milk,whole 13984 ' 3.361 4 chicken+skin 12094 3.137 5 salami 10758 2.793 6 pasta 10437 2.710 7 cheese,cheddar 10110 2.625 8 Italian dressing 9398 2.440 9 oil,unspecified 9129 2.370 10 minestrone 8815 2.289 11 white wine 8274 2.148 12 margarine 7588 1.970 13 veal,crumbed,fried 7047 1.830 14 bread,w/meal 7043 1.829 15 pizza 6546 1.695 16 bread,brown 6234 1.631 17 steak,blade 6183 1.605 18 cheese,parmesan 5917 1.537 19 red wine 5680 1.475 20 butter 5474 1.421
44 Table 4.4 represents the top 20 contributors of dietary protein (refer to appendix 4 for the food items that make up 90 percent of protein intake) From table 4.4, Vienna schnitzel,
(veal crumbed and fried) and blade steak are the two major sources of protein in the
Italian women's diet. Full cream milk, cheddar cheese, and white bread are also high contributors due to their high frequency of consumption and significant protein content.
An interesting aspect of table 4.4 is that 15 of the top 20 food items( 75 percent) are from animal sources. The remaining 5 items are pizza, which contains meat, and the frequently consumed foods, the 3 types of bread, and pasta.
Table 4.4 MAJOR SOURCES OF DIETARY PROTEIN
RANKING FOOD ITEM AMOUNT OF PERCENTAGE PROTEIN (g) OF TOTAL PROTEIN INTAKE (%)
1 veal,crumbed,fr 239 5.932 2 blade steak 217 5.383 J milk, whole 170 4.216 4 cheese, cheddar 152 3.770 5 bread, white 149 3.695 6 salami 130 3.224 7 cheese,parmesan 122 3.026 8 rump steak 96 2.381 9 pasta,white 84 2.083 10 pizza 83 2.058 11 minestrone 83 2.058 12 fish, steamed 83 2.058 13 chicken, skin 82 2.034 14 pork, roast 80 1.984 15 milk, red fat 79 1.959 16 bread w/meal 76 1.885 17 lamb, chop 75 1.860 18 beef, boneless 72 1.756 ’ 19 bread, brown 62 1.538 20 milk, skim 62 1.538
45 A total of 59 food items were required to provide 90 percent of the carbohydrate intake,
(refer to appendix 5). Table 4.5 shows the top dietary sources of carbohydrate in the
Italian women’s diet. In keeping with traditional Italian eating habits, white bread, and white pasta are the 2 major dietary sources of carbohydrate. Together these 2 food items provide over 15 percent of the total carbohydrate intake. Minestrone soup without beans was highly consumed and therefore contributed significantly. Apples, a popular winter fruit were also highly significant. Lemonade, orange juice, and sugar were also featured in table 4.5, as these food items provide carbohydrate in the form of simple sugars in significant quantities.
Table 4.5 MAJOR SOURCES OF DIETARY CARBOHYDRATES
RANKING FOOD ITEM AMOUNT OF PERCENTAGE OF CARBOHYDRATES TOTAL (g) CARBOHYDRATE INTAKE (%)
1 bread, white 781 9.403 pasta 517 6.224 J minestrone 349 4.202 4 apple 307 3.670 5 bread, w/meal 292 3.516 6 bread,brown 270 3.251 7 milk, whole 237 2.853 8 banana 233 2.805 9 lemonade 229 2.757 10 bread,mix/grain 206 2.480 11 orange juice 196 2.360 12 sugar 186 2.239 13 rice,white 160 1.926 14 rice,sungold 143 1.722 15 mandarin 142 1.710 16 pizza 135 1.625 17 voghurtfruitXF 128 1.541 18 potato chips 124 1.493 19 white wine 124 1.493 20 ravioli 110 1.324
46 Table 4.6 shows the major dietary sources of total fat in the Italian women's diets. The group's dietary fat was also analysed for the major sources of polyunsaturated, monounsaturated, and saturated fats. These follow in tables 4.7, 4.8, and 4.9. From table
4.6. olive oil is the most abundant source of dietary fat. This was expected as it was the top provider of total energy and was frequently consumed. Chicken, including roast chicken with skin was the second major contributor to total fat. Unspecified oil, and
Italian dressing are both high in fat and were frequently consumed. These 2 food items ranked highly at 3rd and 4th respectively. Salami, margarine, and cheddar cheese were also significant sources of dietary fat. Potato chips are the only vegetable to feature in table 4.6. this is due to the frying used in preparation. Potato chips also feature in tables;
4.7, 4.8, and 4.9. Although the consumption rate of pork roast was not considered high, like salami its high fat content led to its appearance in tables 4.6-4.9.
Overall it took 54 food items to represent 90 percent of total fat intake.
(refer to appendix 6)
47 Table 4.6 MAJOR SOURCES OF DIETARY FAT
RANKING FOOD ITEM AMOUNT OF PERCENTAGE FAT(g) TOTAL FAT INTAKE (%)
1 olive oil 475 10.604 2 chicken,skin 289 6.452 oil. unspecified 247 5.514 4 Italian dressing 241 5.381 5 salami 226 5.046 6 margarine 205 4.577 7 cheese,cheddar 203 4.532 8 milk, whole 196 4.376 9 butter 148 3.304 10 cheese,parmesan 104 2.322 11 peanuts 93 2.076 12 blade steak 68 1.518 13 pizza 67 1.496 14 potato chips 66 1.474 15 veal,crumbed,fr 65 1.451 16 quiche 65 1.451 17 pork roast 63 1.407 18 shortbread 57 1.273 19 pistachio nuts 54 1.206 20 pork sausage 51 1.139
48 Table 4.7 represents the most significant dietary sources of polyunsaturated fat.
Vegetable sources of oil including Italian dressing, unspecified oil, olive oil, and margarine all rank as the highest contributors. These 4 food items collectively account for 49.7 percent of the total polyunsaturated fat intake. Chicken ranks 5th as it contains a moderate amount of polyunsaturated fat, and it was consumed frequently. This was also the case for napolitan sauce, its frequent consumption led to its high ranking, despite its moderate amount of polyunsaturated fat. Although peanuts were not consumed frequently by the group their significant polyunsaturated fat content enabled them to rank in the top 10.The 3 breads, white, brown and wholemeal, all featured in table 4.7, as their consumption rate was high. It took 37 food items to represent 90 percent of polyunsaturated fat intake, (refer to appendix 7)
TABLE 4.7 MAJOR DIETARY SOURCES OF POLYUNSATURATED FAT
RANKING FOOD ITEM AMOUNT OF PERCENTAGE OF TOTAL POLYUNSATURATED FAT POLYUNSATURATED FAT (g) INTAKE (%)
1 Italian dressing 119 15.671 oil unspecified 113 14.881 3 margarine 93 12.247 4 olive oil 53 6.980 5 chicken,baked skin 36 4.741 6 peanuts -> 4.346 7 salami 20 2.634 8 mayonnaise 18 2.370 9 tuna,in oil 15 1.975 10 bread, white 14 1.844 11 veal, crumbed,fried 12 1.580 12 napolitan sauce 11 1.449 13 pistachio nuts 10 1.317 14 quiche 9 1.185 15 bolognaise sauce 8 1.054 16 bread, w/meal 8 1.054 17 pork roast 8 1.054 18 bread.brown 7 0.922 19 ravioli 7 0.922 20 potato chips 7 0.922
49 Cheddar cheese, full cream milk, chicken, butter, parmesan cheese, and salami, are the 6 top sources o f saturated fat in the groups diet, (refer to table 4.8). These six items are all animal products, and in fact 12 of the top 20 food items are animal products. This result is not surprising as animal products are known to contain high amounts of saturated fat.
Due to their consumption rate both olive oil, and Italian dressing are also highly ranked food items. A total of 47 food items were required to total 90 percent of the groups sarurated fat consumption (refer to appendix 8).
Table 4.8 MAJOR DIETARY SOURCES OF SATURATED FAT
RANKING FOOD ITEM AMOUNT OF PERCENTAGE OF TOTAL SATURATED FAT SATURATED FAT INTAKE (g) (%)
1 cheese,cheddar 135 8.946 2 milk, whole 131 8.682
J chicken,baked skin 92 6.097 4 butter 88 5.832 5 salami 73 4.838 6 cheese,parmesan 69 4.573 7 olive oil 67 4.440 8 Italian dressing 37 2.452 9 margarine 31 2.054 10 blade steak,fat 30 1.988 11 pizza 30 1.988 12 potato chips 29 1.922 13 quiche 26 1.723 14 oil, unspec. 24 1.590 15 shortbread 23 1.524 16 milk red fat. 22 1.458 17 pork roast 21 1.392 18 veal crumbed,fried 21 1.392 19 pork sausage 20 1.325 20 biscuit,plain 19 1.259
50 Table 4.9 represents monounsaturated fat. Olive oil which is renowned for its high monounsaturated content heads the list. Italian dressing and unspecified oil also rank highly. Chicken with skin (baked chicken ), is the second highest contributor due to its high consumption rate, and significant monounsaturated fat content. Both peanuts, and pistachio nuts rank highly as they have a high monounsaturated fat content.( Appendix 9 lists the foods that total to give 90 percent of monounsaturated fat intake)
Table 4.9 MAJOR DIETARY SOURCES OF MONOUNSATURATED FAT
RANKING FOOD ITEM AMOUNT OF PERCENTAGE OF TOTAL MONOUNSATURATED MONOUNSATURATED FAT (g) FAT INTAKE (%)
1 olive oil JJ I 18.470 2 chicken baked,skin 141 7.868 n J salami 115 6.417 4 oil unspecified 99 5.524 5 Italian dressing 74 4.129 6 margarine 72 4.018 7 cheesexheddar 52 2.900 8 milk, whole 50 2.790 9 butter 47 2.623 10 peanuts 41 2.288 11 pistachio nuts 37 2.065 12 pork roast 30 1.674 13 blade steak,fat 29 1.618 14 veal,crumbed,fried 27 1.507 15 pizza 27 1.507 16 cheese,parmesan 27 1.507 17 potato chips 25 1.395 18 pork sausage 24 1.340 19 mortadella 24 1.340 20 quiche 23 1.283
51 It took 53 food items to represent 90 percent of the groups calcium intake (refer to appendix 10). Table 4.10 outlines the most significant dietary sources of calcium in the study groups diet. The top 6 food items in table 4.10 are dairy products, and dairy products alone contributed 56 percent of the total calcium intake (refer to appendix 10 ).
Full cream milk traditionally known to contain high amounts of calcium headed the list, while cheddar and parmesan cheese ranked high. White bread featured high on the list due to its high consumption frequency, as did minestrone, wholemeal bread, and brown bread.
TABLE 4.10 MAJOR DIETARY SOURCES OF CALCIUM
RANKING FOOD ITEM AMOUNT OF PERCENTAGE OF CALCIUM TOTAL INTAKE (%) (mg)
1 milk,whole 6192 16.573 2 cheese,cheddar 4638 12.413 J cheese, parmesan 3667 9.815 4 milk,reduced fat 2771 7.417 5 milk,skim 2120 5.674 6 yoghurt,fruit LF 1730 4.630 7 pizza 960 2.569 8 minestrone 942 2.522 9 bread, white 826 2.211 10 cheese,mozzarella 788 2.110 11 endive,raw 734 1.965 12 ravioli 564 1.510 13 quiche 506 1.354 14 bread, w/'meal 405 1.084 15 bread,brown 380 1.017 16 broccoli 377 1.010 17 wine,white 294 0.787 18 orange 283 0.757 19 sauce,napolitan 273 0.731 20 mineral water 264 0.707
52 It took only 19 food items to represent 90 percent of vitamin C intake, (refer to appendix
11). Table 4.11 presents the major dietary sources of vitamin C. All of the 20 foods listed originate from plants. The list contains 6 of the 9 fresh fruits reported in the 24 hour recalls. These fruits are mandarins, kiwifruits, oranges, apples, bananas, and grapefruit. Orange juice tops the list as the most abundant source of vitamin C in the group’s diet, and it represents 20 percent of the total vitamin C intake. Broccoli ranks 2nd
and contributes 13.5 percent of vitamin C intake. Tomato, endive, and lettuce, all rank
highly because of their high consumption frequency, and also their vitamin C content.
TABLE 4.11 MAJOR DIETARY SOURCES OF VITAMIN C.
RANKING FOOD ITEM AMOUNT OF PERCENTAGE OF VITAMIN C TOTAL VITAMIN C (mg) INTAKE (%)
1 orange juice 1644 20.100 2 broccoli 1105 13.512 J mandarin 831 10.162 4 kiwifruit 626 7.655 5 orange 508 6.212 6 tomato 488 5.967 7 cauliflower 454 5.551 8 endive, raw 287 3.509 9 orange drink 242 2.960 10 capsicum 216 2.641 11 potato 164 2.054 12 banana 153 1.871 13 cabbage 146 1.785 14 apple 125 1.529 15 zucchini 105 1.284 16 napolitan sauce 98 1.198 17 brussel sprouts 94 1.149 18 grapefruit 74 0.905 19 broad bean 74 0.905 20 lettuce 66 0.807
53 The final nutrient analysed was vitamin A (refer to table 4.12). Table 4.12 displays the top 20 sources of vitamin A in the groups diet measured in retinol equivalents. As expected the carrot renowned for its high vitamin A content heads the list contributing
32.4 percent of the total vitamin A content. Cheddar cheese, margarine, and napolitan sauce are also highly ranked, because o f both their high consumption rate, and significant vitamin A content. Full cream milk, butter, and tomatoes are also important sources of vitamin A.(Refer to appendix 12 for the list of food items that contribute 90 percent of vitamin A intake).
TABLE 4.12 MAJOR DIETARY SOURCES OF VITAMIN A (RETINOL Eq)
RANKING FOOD ITEM AMOUNT OF PERCENTAGE OF VITAMIN A TOTAL VITAMIN A (jig) INTAKE (%)
1 carrot 12616 32.410 2 cheese,cheddar 2330 5.986 J margarine 2266 5.821 4 napolitan sauce 2194 5.636 5 milk whole 1574 4.044 6 tomato 1558 4.002 7 butter 1491 3.830 8 endive 1170 3.006 9 pumpkin 1137 2.921 10 cheese, parmesan 1098 2.821 11 spinach 796 2.045 12 broccoli 761 1.955 13 chicken,baked 720 1.850 14 minestrone^beans 688 1.770 15 pizza 650 1.670 16 quiche 482 1.238 17 zucchini 349 0.897 18 veakcrumb,fried 347 0.891 19 bolognaise sauce 324 0.832 20 milk red,fat 324 0.832
54 4.2 FOOD LIST
Once the food items that contributed to 90 percent of the reported nutrients were identified, they were compiled into a food list. This food list aims at being representative of the dieatry habits of the Italian women used in this study. Any food items on the original 24 hour dietary recall data list, that were not eaten in significant quantities , or had no significant nutritional value were excluded from the final list. The exception to this rule were foods that are considered to contain phytoestrogens or their precursors, foods reported in the literature as significant sources of phytoestrogens that were not reported in the 24 hour recalls were added to the final list.
Table 4.13 lists the food items represented in the final food list. The table is set out to display the foods in their respective food groups. The food items listed either contribute to 90 percent of the specified nutrients,or energy, or are known to be sources of phytoestrogens. Chocolate is an exception to this rule, as the chocolate consumed by the group was analysed as various different types, eg chocolate bars, after dinner mints, chocolate coated bisacuits, and plain chocolate. As a result all the seperate chocolate sources missed out on making it onto the food list. If all chocolate was analysed together it would have been a significant contributor to energy, fat, and carbohydrate.
55 TABLE 4.13 FOOD LIST
BREADS AND CEREALS MEATS.ETC.
BREAD WHITE PORK, CHOP FAT BREAD W/MEAL PORK SAUSAGE BREAD,BROWN PORK, GRILLED BREAD,MIXED GRAIN PORK,ROAST BREAD,FRUIT BEEF,CHUCK STEAK BREAD GARLIC BEEF,BLADE STEAK BREAD,MUFFIN MINCE,COOKED BREAD,SCONE BEEF,BONELESS BREAD,CROISSANT VEAL,PAN FRIED VIENNA SCHNITZEL BISCUITS LAMB CHOP CHICKEN BAKED + SKIN BISCUITS,PASTRY(SAO) CHICKEN CRUMBED AND FRIED BISCUITS, PLAIN SWEET CHICKEN NO SKIN BISCUITSJTALLAN S/BREAD SALAMI/COPPA/SAPRESSA BISCUITS, SHORTBREAD MORTADELLA BISCUITS,WHEATMEAL SAUSAGE ROLL/MEAT PIE PIZZA EGG BOILED BREAKFAST CEREALS EGG FRIED QUICHE CEREAL,FIBRE INCR. eg ALL BRAN FISH, STEAMED CEREAL,CORNFLAKES/SPECIAL K FISH, CRUMBED AND FRIED CEREAL,MUESLI TOASTED TUNA, IN OEL/BRINE CEREAL,OATBRAN CEREAL,ROLLED OATS NUTS/LEGUMES CEREAL, WEETBIX/VITABRITS BEANS ANY TYPE CAKES BEANS, SOYA* LENTILS CAKE,PLAIN,HOME/COMMERCIAL PEANUTS/MIXED NUTS CAKE,CHOCOLATE PISTACCHIO NUTS CAKE,ICED CAKE,DOUGHNUT CAKE, CHEESECAKE
RICE,PASTA *DENOTES FOODS INCLUDED DUE PASTA, WHITE TO THEIR PHYTOESTROGEN PAST A,RA VIOLI CONTENT RICE, SUNGOLD BARLEY* RYE* LASAGNE POLENTA
56 TABLE 4.13, FOOD LIST CONT...
BEVERAGES MILK AND DAIRY PRODUCTS
ALCOHOLBEER* MILK.FULL CREAM (REGULAR) ALCOHOURED WINE MILK. SKIM ALCOHOL,WHITE WINE MILK, REDUCED FAT COFFEE, STRONG BLACK MILK, SOYA* JUICE ORANGE 100% CHEESE,CHEDDAR JUICE,ORANGE 25% CHEESE, PARMESAN SOFT DRINK, COLA CHEESE,RICOTTA SOFT DRINK,LEMONADE CHEESE, SWISS WATER, MINERAL YOGHURT,ALL VARIETIES ICE CREAM VEGETABLES FATS AND OILS ALFALFA BROCCOLI OIL.UNSPECIFIED BRUSSEL SPROUTS OLIVE OIL CABBAGE ANISE OIL* CAPSICUM ITALIAN DRESSING CARROT BUTTER CAULIFLOWER MARGARINE CELERY MAYONAISE CORN PEANUT BUTTER EGGPLANT FENNEL* SWEETS/SNACKS GREEN BEANS LETTUCE HONEY ENDIVE/RADDICHIO SUGAR OLIVES LIQUORICE* PEAS CHOCOLATE POTATO POTATO CRISPS/CHEEZELS ETC POTATO CHIPS MASHED POTATO POTATO SALAD FRUITS PUMPKIN SPINACH APPLE TOMATO BANANA ZUCCHINI GRAPEFRUIT KIWIFRUIT CHERRY* SOUPS/SAUCES MANDARIN ORANGE MINESTRONE SOUP PEAR MINESTRONE^ BEANS POMEGRANATE* BOLOGNAISE SAUCE ROCKMELON NAPOLITAN SAUCE DRIED FIG TOMATO SAUCE SULTANAS
57 The number of food items in table 4.13 totals 137. Of these 137 items,26 items are in the meat and meat alternatives group, 24 items are vegetables, 33 items belong to the breads and cereals group, sweets and snacks have 5 items, there are 12 fruits, 10 dairy products,8 types of fats and oils, 9 beverages, and finally 5 soups and sauces. Some foods in the food list are placed together as the nutrient analysis of several foods were unable to be obtained. This was because the DIET 1 program did not contain nutrient profiles for all reported foods. Table 4.14 outlines the different names food items were referred to by.
Table 4.14 ALTERNATIVE NAMES OF FOOD ITEMS REPORTED IN 24 HOUR RECALLS.
FOOD ITEM CLASSIFICATION NAME
Scotch finger biscuit Shortbread biscuit
Italian shortbread Biscuit, plain sweet (less fat than shortbread)
Coppa/Pancetta/Sapressa Salami or Salami
Prosciutto Ham
Chicken schnitzel or Chicken crumbed and fried fried chicken eg KFC
Boneless chicken fillet Chicken, baked+skin. ffied/baked + skin (boneless)
Chinotto/Pepsi/Coke Soft drink,cola
Pickled eggplant or Pickles artichoke
Radicchio/Chicory Endive
Marinara mix Prawns
Cough lollies/barley Confectionary,lollies sugar butterscotch
58 FOOD ITEM CLASSIFICATION NAME
C otecchino/Luganega Pork sausage, fatty
Napolitan sauce Tomato based sauce, (home)
Torteilini Ravioli
Noodles White spaghetti
Beef stew/Casserole Beef boneless
Osso Bucco Veal, steak
Hamburger/Rissole Mince, cooked or Meatball
Curried chicken Chicken,boneless
Lettuce Cos/Romano
Crostoli Chips
Grappa Brandy
Cassata Ice cream
Cheese,unspecified Cheddar cheese
Bread rolls Bread 2 slices
59 4.3 SERVING SIZE- FOOD PORTION SIZES
The most suitable food portion sizes were determined by utilisation of the most frequently reported serving size. This serve size was selected for use as a standard in the developed questionnaire. The respondents are required to compare their usual serve size to the standard, i.e. either smaller than the standard, the same size or larger. For food items such as fruits, breads or yoghurt, the natural serve size as one whole piece of fruit, slice of bread, or yoghurt tub, was used as one portion
4.4 THE FOOD FREQUENCY QUESTIONNAIRE
The questionnaire format is outlined in figure 4.1 below. From figure 4.1 it can be noted that the questionnaire contains a food list, and a response section. In the response section the respondent is required to record his/her portion size as either small medium or large, and his/her frequency of consumption as never, daily, weekly, monthly, or every 3 months. The questionnaire also begins with instructions for its completion.
60 F igu re 4 .1
FOOD FREQUENCY QUESTIONNAIRE - FORMAT
GUIDLINES FOR COMPLETING YOUR QUESTIONNAIRE
The questionnaire provided aims to assess your dietary intake during the winter months, i.e. June, July, August. It requires you to recall how often you eat the listed foods and in what quantity during these winter months.
Once you have recognised the food you do eat, the table below shows how to record how often you eat that particular food and how much of that food.
If you eat bread for example, how often do you eat it?
Once a DAY...... write ID twice a DAY...... write 2D , three times a DAY...... write 3D four times a DAY...... write 4D, and so on (5D,6D,etc)
If you eat it less than once a day. Then do you eat it?
Once a WEEK...... write 1W twice a WEEK...... write 2W three times a WEEK...... write 3W, and so on (4W,5W,and 6W).
If you eat it less than once a week. Then do you eat it?
About once a MONTH...... write 1M About Twice a MONTH...... write 2M About three times a MONTH...... write 3M
If you eat it less than once a month, then write how often you have eaten it in the past three months.
About once in the last 3.MONTHS.... write 1-3M About twice in the last 3 MONTHS.... write 2-oM
If you never eat bread write....NO.
61 The amount of food eaten is also important. In this questionnaire a standard serve size is next to each food listed. If your serving size is smaller or larger than the serving size listed, circle the correct serving size.
Example.
FOOD SERVING
Bread 1 slice
Circle;
S (Small) if your usual serving is less than 1 slice M (medium) if your usual serve is about 1 slice E (Large) if your usual serve is more than 1 slice.
62 FOOD FREQUENCY QUESTIONNAIRE.
DAIRY FOODS
If you use milk, which type of milk do you usually use?
1. Regular, full cream milk
2. Skim milk or shape
3. Reduced fat milk (eg Farmers Best or Lite white)
4. Soy milk (please circle)
5. NEVER use milk.
DAIRY FOODS SERVING YOUR HOW OFTEN SIZE SERVE S,M,L D,W,\I,3m or NO
Milk 200ml
Yoghurt All 200g varieties
Ice cream 2 scoops
Cheddar cheese 50g
Parmesan cheese 1 Tablespoon
Swiss cheese 50g
Ricotta cheese 1/2 cup
Mozzarella cheese 50g
(Refer to Appendix 13 for the full questionnaire)
63 CHAPTER 5
DISCUSSION
5.1 DISCUSSION
This research project aimed to develop a food frequency questionnaire which is specific for the winter dietary habits of pre menopausal Italian women residing in the Illawarra area of N.S.W. The developed questionnaire aims to enable ranking of the Italian women in accordance with their phytoestrogen intake.
The data obtained for the development of the food frequency questionnaire was in the form of four 24hour recalls taken dunng winter 1993. Of the four recalls three were of weekdays, and one was of a weekend day.
In the development of the food frequency questionnaire several techniques were considered. These included Wiilets (1990) food list that is suitable for use in studies involving multiculturalism such as this one. The major technique used in the food frequency development however, was the method used by Block et al (1985). This technique was favoured as the study on the Italian sample group was small,(51 participants), and the data analysed was open ended in the form of 24 hour recalls.
The food frequency developed consists of a food list, and a response section that enables the respondent to supply information on both the portion size and frequency of consumption of foods in the food list.(refer to sample questionnaire appendix 15)
64 The final food list obtained from statistical analysis of the open ended data provided by the 24 hour recalls, contained foods from a diverse range of cultures. The most significant cultural influences were Italian, and Australian. Many of the food items listed in the final food list are considered to be traditionally Italian. Some examples include; pasta, ravioli, napolitan and bolognaise sauce, parmesan cheese, olive oil, Italian dressing, and Italian processed meats (salami, mortadella etc.).
The food list contains 137 food items that represent 90 percent of the Italian women's energy intake and 90 percent of selected nutrients. The food list also contains several foods that did not rank in the top 90 percent but are known to be high contributors of phytoestrogens.
Aside from the food list the questionnaire contains a response section. This response section allows the respondent to indicate both the portion size and frequency of consumption of food list items. The frequency section allows the respondents to describe how often they consume the portion size of the food items listed.
5.2 PHYTOESTROGENS
At present the information on dietary sources of phytoestrogens is limited. The information that is available indicates that the actual phytoestrogen content of foods is variable, and a quantitative measure of the phytoestrogen content of foods already consumed may be impossible to determine accurately. In this study in order to enable ranking of individual study participants, a broad association between fibre and dietary phytoestrogens was drawn. Adlercreutz et al (1982) and Goldin et al (1986) concluded that a high dietary fibre consumption was indicative of a high urinary excretion of mammalian lignans and hence may be indicative of a high dietary phytoestrogen intake.
65 Rose (1992) also indicated that plants such as legumes and vegetables are the most predominant sources of phytoestrogens, while also being abundant in dietary fibre. This study therefore concentrates on the assumption that dietary fibre intakes correlates with dietary phytoestrogen intake. Hence analysis of the dietary fibre intake of the pre menopausal Italian women's diet is used as the major tool to identify their dietary phytoestrogen intake for the purpose of ranking individuals.
Other sources of phytoestrogens are also considered but as quantitative measures are not well defined they are not considered in the ranking of the Italian women.
Of the foods reported in the 24 hour recalls, those considered to contain significant quantities of phytoestrogens included; carrots, soya products (beans and soya milk),
pulses, fennel, apples, alfalfa, com, rice, hops (beer) and wheat flour ( in bread). These
foods were included onto the food list regardless of whether they represented 90 percent
of any nutrient. Some foods were not reported in the 24 hour recalls but were identified
in the literature as containing phytoestrogens these foods were also added to the food list.
They were; liquorice, rye, pomegranate, cherry, french bean, anise oil, and barley. (Price
and Fenwick 1985). They were added to the food list to ensure accurate estimates of
phytoestrogen consumption, and possibly aid in the ranking of individuals who consume
equal amounts of fibre.
Overall in terms of the phytoestrogen consumption of the study group, only a small
portion of foods consumed could be considered as good sources of phytoestrogens. The
study group did however consume approximately 21 grams of fibre per person per day.
This amount could be considered as a moderate fibre intake, and hence, potentially a
moderate phytoestrogen consumption.
66 5.3 COMPUTER ANALYSIS OF FOOD ITEMS
As mentioned previously in chapter 4 the results section, not all the foods reported in the
24 hour recalls were present in the data base used for analysis. The data base used was the DIET 1 program by NUTTAB. As the DIET 1 program is an Australian based program, problems arose, particularly with the traditional Italian food items such as coppa and prosciutto. Foods such as these had to be classified as foods that resembled them nutritionally, e.g. salami and ham respectively. This technique could have led to inaccurate results. If data was not available for food items, and they were not considered similar to other food items in the data base, McCance, and Widdowson’s (1978) food tables were used.
A limiting factor in using a data base such as DIET 1 , is the difficulty in actually deciding under which food descriptor a food item best fits. On several occasions when a food was entered into the data base, several different descriptors were displayed.
Discussions therefore had to be made. If a person reported eating steak for example, the
Diet 1 program asked for more specific information. Was the steak rump, was it boneless, was it baked, grilled, or fried etc. In some cases the decision making proved to be rather difficult, particularly when 24 hour recall techniques are a retrospective method of data collection. On several occasions the unspecified descriptor was used to classify foods. An example is oil unspecified which was used to classify oil reported in the 24 hour recalls that was not identified as a particular type. This unspecified descriptor was also used for fruits and vegetables on several occasions.
Mixed dishes that are common in Italian cuisine were also hard to analyse. Many of the mixed dishes recorded in the 24 hour recalls, were accompanied by ingredient lists. This
67 made analysis of these dishes easier as they were classified as their separate food items.
Nutrition profiles of some of the more familiar dishes such as bolognaise sauce, quiche, and pizza, were available on the DIET 1 program.
5.4 FOOD FREQUENCY QUESTIONNAIRE; DEVELOPMENT AND STRUCTURE
In the development of this food frequency questionnaire several methods of food frequency development and structure were considered. The technique used by Block et al
(1985), which outlined food items that contribute most significantly to the sample groups nutritional intake was found to be the most appropriate. It was considered the most suitable approach because imprecise data obtained from 24hour recalls were used in a small sample study group.
The resultant food frequency questionnaire contains two major sections. The first section
is the food list and the second section is the response section. The response section
allows the respondent to supply quantitative information on portion sizes. The portion
sizes selected for the food frequency questionnaire were established from the most frequently reported portion sizes in the 24 hour recalls. The respondent is asked to
classify their usual food serving size according to the standard recorded in the questionnaire. It also allows the respondent to supply information on the frequency of consumption of food list items.
68 The food list developed for use in the food frequency addressed the following nutrients;
TOTAL ENERGY.
PROTEIN.
FAT
SATURATED FAT
MONOUNSATURATED FAT
POLYUNSATURATED FAT
VITAMIN A
VITAMIN C
CALCIUM
CARBOHYDRATE and the most important in terms of phytoestrogen consumption, FIBRE.
The food list represents over 90 percent of the women's intake of these selected nutrients and total energy. The broad range of nutrients was selected to enable the developed questionnaire to be useful in future studies of the Italian women's eating habits. The food list includes foods that are either commonly eaten or contribute significantly to the analysed nutrients. In doing this the list eliminates any foods that are either insignificant in terms of the nutrients analysed or are infrequently eaten. (Block et al 1985). Although some food items such as soya milk or products were consumed in small quantities by the group and therefore did not account for 90 percent of any nutrient, they were added to the food list due to their high phytoestrogen concentration.
The food list used in the development of the food frequency questionnaire, contains 137 food items. This food list with only 137 food items could be considered small. As the
69 food list is small, the food frequency questionnaire could be described as having a short respondent burden time.
The food frequency questionnaire also contains an opening paragraph on instructions for its completion, this is aimed at making the questionnaire easy to complete.
The format chosen for the questionnaire allows the Italian women to supply information on the type, quantity, and frequency of consumption of food list items. The results obtained from the completed questionnaires may therefore be useful to enable ranking of the respondents according to their energy intake, specified nutrients and phytoestrogens.
5.5 COMPARISONS WITH OTHER RELEVANT STUDIES
Comparisons between diet intake studies are hard to obtain. This is because of differences in intake methodology, subject numbers, subject ages, and different study times. This project however shows some similarities with other studies in the area of multicultural eating habits (Baghurst and Record 1983).
In this study as in the study by Margetts et al (1980), the Italian women were found to consume both traditional" Italian foods" (e.g. pasta) along with traditional "Australian foods", (e.g. meat pie) This study also showed similar findings to the study performed by
Trevisan et al (1990). Both studies indicated that bread, pasta and cheese were significant dietary staples. Comparisons with the Victorian Health Survey. (Baghurst et al
1988) can also be made. The latter study focused on the differences in food consumption between migrants and Australian bom women. In Baghurst et al's study, they found the main contributors of dietary fibre were; Cereals 37 percent, vegetables 32 percent, and fruit 21 percent. This can be compared the current study which found the major source of fibre to be vegetables which contributed 37 percent of the overall fibre intake. While
70 cereals contributed 32 percent and fruit 21 percent. Cross study comparisons such as this one may however not be significant as this study concentrated on only one season whereas the study by Baghurst et al concentrated on annual consumption rates.
As mentioned previously , it is difficult and possibly misleading to draw comparisons and conclusions from studies performed on different populations. This fact is of particular significance when the studies use different dietary intake methods to collect data, the subjects in the studies differ in age/ sex or years since migration, and the studies are performed during different seasons or time spans.
The food frequency questionnaire developed in this project is specific for middle aged
Italian women living in the Illawarra area of N.S.W. during the winter months of 1993.
Therefore this questionnaire may be utilised to assess this subgroups phvtoestrogen and
nutrient intake. Changes to the format and content of the questionnaire may be required
in the future to keep up with changing dietary trends, and new dietary information on
phytoestrogens.
71 CHAPTER 6
LIMITATIONS OF THE STUDY and AREAS FOR FURTHER INVESTIGATIONS
6.1 PHYTOESTROGENS.
At present the information regarding the phytoestrogen content of food items is still limited, and further study into the phytoestrogen content of individual foods and mixed dishes is required. ■
A specific quantitative measure of the dietary intake of phytoestrogens in the sample group in this study is unattainable, as the phytoestrogen content of foods is so variable and data is limited at present. A good example of the variability of the phytoestrogen content of foods are the coumestans and the resorcyclic acid lactones. The concentration of these two phytoestrogens in plants is dependent upon attack by fungus or mould. The higher the contamination the higher the phytoestrogen concentration. This poses a problem in this research project as the actual phytoestrogen content of foods would be impossible to ascertain unless analysis of the food item occurred prior to its consumption.
Species variation has also been shown to affect the concentration of phytoestrogens, as does age and the mode of harvesting. The current published literature on the phytoestrogens found in foods is based on studies performed in various parts of the world. This also poses a problem as geographic location often effects phytoestrogen content of foods. A particular food found to have a high phvtoestrogen content in one part of the world may have different concentrations elsewhere. Because of these factors
72 which influence the phytoestrogen concentration of plants, hence foodstuffs, it would be inappropriate to consider the effect all these dietary sources of phytoestrogens have on the Italian women. A broad association was therefore required to enable the women to be ranked according to their phytoestrogen consumption. This was achieved by utilising the principle outlined in several studies including. Adlercreutz et al (1982), and Goldin et al (1986). i.e. these studies relate dietary lignan consumption with increased urinary mammalian lignan production. It is thought that an increased dietary fibre consumption correlates with an increased dietary consumption of phytoestrogens. This method does provide a means of ranking the individuals according to their proposed phytoestrogen intake, however it may not be as accurate as the inclusion of all known dietary sources of phytoestrogens. '
6.2 RAW DATA COLLECTION.
In this study the raw data collected were in the form of four 24hour dietary recalls. The
24hour dietary recall technique of data collection depends on the study participants ability to recall the foods they consumed in the previous 24 hours. As this technique of data collection relies on the participant's memory the accuracy of this method of data collection needs to be taken into consideration.
The 24hour recall has several other shortcomings however, those which were considered during data collection were;
1. The 24hour dietary recall does not allow for seasonal variation. This was overcome in the larger study by the collection of four individual sets of 24hour recalls, i.e.
Summer, Winter, Spring and Autumn.
73 2. The 24hour recall technique does not allow for accurate information on food portion
sizes to be given, to overcome this standard food models were used.
3. The 24hour recall does not account for inter individual variation, however in this study
the inclusion of 3 weekdays, and one weekend days food intake were compiled to
provided the average daily consumption and therefore minimise inter individual
variation.
6.3 NUTRIENT ANALYSIS OF SELECTED FOOD ITEMS.
As some foods are considered as "Typically Italian" the software used (NUTTAB DIET
1) in the nutrient analysis failed to provide nutrient profiles for several of these food
items. Proscuiotto for example is an Italian processed meat, in this study due to the
absence of its nutritional profile it was classified as Ham. This type of food classification
was required on several occasions and has the potential to result in inferior nutrient
profiles of the non listed food items. This in turn influences the contribution of these
food items to the overall nutrient intake of the study group.
74 6.4 AREAS FOR FURTHER INVESTIGATION
To improve the effectiveness of this project several areas need to be investigated further.
To begin with further research into the phytoestrogen content of food items commonly consumed by the Italian migrant group needs to be performed. This research needs to consider the effects of potential phytoestrogen concentration influencing factors such as, cooking and food preparation, food spoilage, age, species variation, geographic location and harvesting techniques. The information obtained from this further research would increase the current data available on concentration of phvtoestrogens in foods. This would allow a more accurate picture of the actual dietary phvtoestrogen intake of the sample study group of middle aged Italian women.
A food frequency questionnaire has already been developed for sample groups Autumn intake, and as this questionnaire focuses on the winter food consumption, further study is required to develop questionnaires for both the summer and spring. This will allow investigation of the Italian women's annual phvtoestrogen intake and take into account seasonal variations.
75 CHAPTER 7
CONCLUSIONS
This project enabled the development of a food frequency questionnaire which will aid in the ranking of Italian women living in the Iliawarra according to their phytoestrogen
intake.
This project showed that at present the Italian women studied only consume a small
proportion of foods considered to be significant sources of phytoestrogens. They were
however found to consume a moderate fibre intake. Fibre intake has been related to
phytoestrogen intake by Adlercreutz et al (1986). Of the foods consumed by the group
those considered to be good phvtoestrogen sources were also significant contributors of
fibre.
The dietary habits of the group as a whole were reflective of their migrant Italian
background. Bread was reported as the most frequently consumed food item, and
traditional Italian foods such as, pasta, parmesan cheese, and olive oil were also
frequently eaten.
The questionnaire developed in this project contains a food list ot 1 j 7 items, and a
response section. These food list items are either representative of 90 percent of energy-
intake, intake of specified nutrients, or are good sources of phytoestrogens.
76 The food frequency questionnaire developed in this project will be used in a larger study to investigate the potential effects of dietary phytoestrogen consumption and the incidence of menopausal symptoms.
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87 APPENDICES
88 APPENDIX 1
FOOD LIST (DAILY AVERAGE OF 51 SUBJECTS)
BREAD AND CEREAL PRODUCTS SERVE SIZE TOTAL BREAD.WHITE SLICE 59 BREAD, W/MEAL SLICE 25 BREAD,BROWN SLICE 23 BREAD.MULTIGRAIN SLICE 18 BREAD,RAISIN SLICE 2 BREAD,LAVASH SLICE 0.25 BREAD,GARUC SLICE 5 BREAD, VIENNA SLICE 3 BREAD,MUFFIN 1 2 SREAD,SCONE 1 2 BREAD,CROSSIANT 1 1 BISCUITS.RICECAKE 1 2 BISCUITS,SAO 1 4 BISCUITS.RYVITA 1 5 BIS CU ITS, VITAWE ET 1 2 BISCUITS, CROSTOLI 1 4 ISCUITSPLAINSWEET 1 29 BISCUITS ITALIAN SHORTBREAD 1 17 BISCUITS,SCOTCH FINGER 1 3 BISCUITSA.LMOND 1 2 BIS CU ITS, CREAM 1 2 BISCUITS,CHOCOLATE 1 3 CEREALALLBRAN CUP 1.25 CEREAL CORNFLAKES CUP 1.25 CEREALJUST RIGHT CUP 1 CEREALMUESU CUP 1 CEREALOATBPAN CUP 0.5 CEREALPORRIDGE CUP 2.5 CEREAL WEETBIX 1 10 CEREALVITABRITS 1 1 LECITHIN 1 tsp 1 OATBRAN 1tsp 3 CAKE, PLAIN 50g 2 CAKE, CREAM 50g 2 CAKE,NUT 50g 3 CAKECHOCOLA.TE 50g 4 CAKELEMON 50g 0.5 CAKE.LAMINGTON 1 0.5 CAKEROCK 1 0.5 CAKEDOUGHNUT 1 1.5 CAKECHEESE 100g 1.25 PASTAWHITE CUP 23.5 PASTASPAGHETTI, WHITE CUP 6.5 PASTATORTELUNI CUP 5 PASTAPAVlOLi CUP 2.5 PASTALASAGNE 300g 0.5 CHICORY IN OIL CUP 1 POLENTA 50g 4 RICEBOILED CUP 3 RICEFRIED CUP 0.5 RICE, RISOTTO CUP 2.75 89 VEGETABLES SERVE SIZE TOTAL
ALFALFA 1/2 CUP 1 ARTICHOKE.HEART IN OIL 1 1 ASPARAGUS SPEARS 1 3 AVOCADO 1 0.25 BEETROOT 1 SLICE 2 BROCCOLI 1/2 CUP 11.5 BRUSSEL SPROUTS 1/2 CUP 2 CABBAGE 1/2 CUP 6 'CAPSICUM 1/2 CUP 2 CARROT 1/2 CUP 7 CAULIFLOWER 1/2 CUP 5 CELERY 1/2 CUP 4 CORN 1/2 CUP 1.5 EGGPLANT 1/2 CUP 2 EGGPLANTPICKLED IN OIL 1/2 CUP 1 FENNEL 1/2 CUP 3 GARLIC CLOVE 12 GREEN BEANS 1/2 CUP 5 LETTUCE RADDICHIO CUP , 29.5 LETUCEROMANO CUP 0.5 LETTUCE CUP 3 MUSHROOMS 1/2 CUP 31 OUVES.BLACK 1 4 OUVES.GREEN 1 22 PEAS 1/2 CUP 1 POTATO 1 13 POTATO, CHIPS CUP 5 POTATO,CRISPS 50gm 1 POTATO,MASHED 1/2 CUP 4 POTATO,SALAD 1/2 CUP 3 PUMPKIN 1/2 CUP 3 SAUERKRAUT 1/2 CUP 0.5 SPINACH 1/2 CUP 3 SWEDE 1/2 CUP 0.5 TOMATO 1 21 ZUCCHINI 1 5
FRUIT SERVE SIZE TOTAL APPLE 1 1 BANANA 1 10 GRAPEFRUIT 1 1 KIWIFRUIT 1 11 LEMON 1 1 MANDARIN 1 29 ORANGE 1 3 PEAR 1 6 ROCKMELON 1/2 CUP 1 APR1COTDRIED 1 HALF 4 FIG, DRIED 1 2 MIXED FRUIT, DRIED 1/4 CUP 2 PRUNES 1 2 SULTANAS 1/4 CUP 2
SOUPS/SAUCE SERVE SIZE TOTAL 90 MINESTRONE+BEANS CUP 7.5 MINESTRONE CUP 16 VEGETABLE CUP 0.5 PASTA+VEGETABLE CUP 0.5 CONFECTIONARY SERVE SIZE TOTAL
CHOCOLATE SQUARE 3 CHOCOLATE,BAR BAR 0.5 CHOCOLA.TE,DINNER MINT 1 0.5 CHOCOLATEPEANUTS 50g 0.5 LOLLIE, COUGH 1 1 LOLLIE,HARDBOILED 1 2
MILK AND DAIRY PRODUCTS SERVE SIZE TOTAL
MILK,FULL CREAM ml 5000 MILK.SKIM ml 1380 MILK.UTE WHITE ml 1550 MILK.SHAPE ml 325 MILKPARMERS BEST ml 300 MILK,SOYA ml 80 CHEESE,UNSPECIRED 30gm 20 CHEESEPARMESAN 1 TBS 32 CHEESE,MOZZARELLA 30gm 3 CHEEEPICOTTA gm 80 CHEESE, COTTAGE gm 70 CHEESE.BLUE VEIN gm 10 CHEESE, JA.RLSBURG gm 20 CREAM TBS 1 YO G H U RT, LI G HT, FRU IT 200gm 5 ICE CREAM SCOOP 4
FATS AND OILS SERVE SIZE TOTAL
OILUNSPECIRED TBS 13 OILOLIVE TBS 25 ITALIAN DRESSING TBS 36 BUTTER tsp 30 MARGARINE tsp 53 MAYONNAISE TBS 2
CONDIMENTS SERVE SIZE TOTAL
HONEY tsp 5 JAM,STRAWBERRY tsp 9 VEGEMITE tsp 3 SUGAR tsp 53 CHILLI, POWDER tsp 1 OREGANO.DRIED tsp 5 BASILDRIED tsp 3 PARSLEY,DRIED tsp 2 CURRY POWDER tsp 1
BEVERAGES SERVE SIZE TOTAL
ALCOHOLBRANDY 30 ml 1 ALCOHOLBEER 200 ml 1 CHINOTTO 200 ml 3.25 ALCOHOLREDWINE 125 ml 16 ALCOHOLWHITEWINE 125 ml 17 COFFEJNSTANT 200 mi 29.75 COFFEE.UNSPECIFIED 200 ml 3 91 SOFTD RINK, COLA 200 ml 4 SOFTD RINK, LEMONADE 200 ml 4.5 SOFTDRINK.LEMON SQUASH 200 ml 1 CORDIAL 200 ml 1.25 TEA CAMMONMILE 200 ml 5 TEA LEMON 200 ml 1.5 TEA HERBAL 200 ml 4 TEA 200 mi 29.75 WATER 200 ml 53 WATER MINERAL 200 ml 7.75
92 MEAT AND ALTERNATIVE SERVE SIZE TOTAL PORK DICED gm 120 PORK ROAST gm 170 PORK FRIED gm 80 PORK CHOP 1 2 PORK SPARERIB, GRILLED 1l 4 PORK SAUSAGE 1 1 HAM gm 190 BACON rasher 3 BEEF CHUCK STEAK gm 60 BEEF STEAK gm 770 BEEF RUMP gm 310 BEEF MINCE gm 220 BEEF ROAST gm 240 BEEF STEWED gm 60 VEAL CHOPS 1 2 VEAL PANFRIED gm 410 VEAL SCHNITZEL gm 450 VEAL STEAK gm 30 VEAL STEWED gm 120 LAMB CHOP 1 4 LAMB CUTLET 1 1 LAMB ROAST gm 90 CHICKEN BREAST gm 380 CHICKEN DRUMSTICK 1 4 CHICKEN ROAST gm 150 CHICKEN WING 1 4 CHICKEN SCNITZEL gm 210 RABBIT gm 80 TURKEY gm 50 COPPA gm 30 CORNED BEEF gm 20 LUGANEGA 1 2 PROSCUITTO gm 60 SUPRESSO gm 20 MORTADELLA slice 9 PANCETTA slice 2 SALAMI slice 13 MEAT PIE 1 0.5 SAUSAGE ROLL 1 1 6 PIZZA slice 40 TRIPE gm 4 EGG, BOILED 1 4 EGG, FRIED 1 230 QUICHE grn 60 FISH. BREAM gm 220 FISH, BATTERED grn 260 FISH, FRIED gm 80 TUNA BRINE gm 120 TUNA OIL gm 50 m a r in a r a mix- gm 60 p r a w n . CURRY gm
93 NUTS AND LEGUMES SERVE SIZE TOTAL
BEANS, CANNELLiNI 1/4 cup 2 BEANS, BARLOTT! 1/4 cup 4 LENTILS 1/4 cup 12 CASHEWS 1/4 cup -1\ ALMONDS 1/4 cup 1 PEANUTS 1/4 cup i PISTACCHIC 1/4 cup 4 MIXED, NUTS 1/4 cup 3 PEANUT BUTTER TBS 2
94 APPENDIX 2
MAJOR DIETARY SOURCES OF FIBRE
RANKING FOOD ITEM FIBRE PERCENTAGE (g) TOTAL %
1 broccoli 53 4.881 2 apple 50 4.605 J bread, w/meal 49 4.513 4 bread, white 45 4.144 5 all bran 42 3.872 6 pasta 38 3.500 7 endive raw 35 3.223 8 mandarin 35 3.223 9 tomato -> 'y 3.039 10 lettuce 28 2.580 11 kiwifruit 28 2.580 12 banana 27 2,490 13 bread,mix/grain 26 2.296 14 lentils 23 2.118 15 carrot 22 2.026 16 pear 20 1.842 17 black coffee 20 1.842 18 orange 20 1.842 19 napolitan sauce 19 1.750 20 bread,brown 19 1.750 21 potato, mashed 19 1.750 22 chips 18 1.660 23 weetbix/vitabrits 17 1.566 24 minestrone 17 1.566 25 pizza 17 1.566 26 peanuts 16 1.474 27 cauliflower 15 1.381 28 potato 15 1.381 29 minestrone-i-beans 15 1.381 30 pistachio 14 1.289 31 spinach 14 1.289 32 cabbage 13 1.197 J J ravioli 12 1.105 34 zucchini 11 1.013 35 broad bean 11 1.013 36 beans 10 0.921 37 sultanas 10 0.921 38 muesli 10 0.921 39 orange juice 8 0.737 40 dried fig 8 0.737 41 Italian dressing 8 0.737
95 42 rolled oats 8 0.737 43 corn 7 0.645 44 eggplant 7 0.645 45 garlic bread 6 0.553 46 fennel 6 0.553 47 biscuit plain 6 0.553 48 oatbran 5 0.461 49 Italian shortbread 5 0.461 50 lasagne 5 0.461 51 olives 5 0.461 52 peas 5 0.461 53 rice, white 5 0.461 54 rice,sungold 5 0.461
TOTAL PERCENTAGE OF FIBRE 90.634
96 APPENDIX 3
MAJOR DIET ARY SOURCES OF ENERGY (KJ)
RANKING FOOD ITEM ENERGY PERCENTAGE (KJ) TOTAL %
1 oil.olive 17556 4.558 2 bread,white 17197 4.465 3 milk, whole 13984 3.361 4 chicken,baked, skin 12084 3.137 5 salami 10758 2.793 6 pasta, white 10437 2.710 7 cheese,cheddar 10110 2.625 8 Italian dressing 9398 2.440 9 oil. unspecified 9129 2.370 10 minestrone 8815 2.289 •. 11 wine,white 8274 2.148 ‘ 12 margarine 7588 1.970 13 veal, crumbed,fried 7447 1.933 14 bread,w/meal 7043 1.829 15 pizza 6546 1.695 16 bread,brown 6234 1.631 17 beef, blade steak 6183 1.605 18 cheese, parmesan 5917 1.537 19 wine,red 5680 1.475 20 butter 5474 1.421 21 apple 5267 1.367 potato, chips 4869 1.264 23 bread, mixed grain 4884 1.251 24 peanuts 4682 1.216 25 biscuit plain sweet 4637 1.204 26 ravioli 4341 1.127 27 milk,reduced fat 4329 1.124 28 banana 4156 1.086 29 orange juice 3872 1.005 30 softdrink, lemonade 3683 0.956 31 biscuit, shortbread 3500 0.909 32 sauce,napolitan 3491 0.906 33 yoghurt, fruit lowfat 3450 0.896 34 sugar 3116 0.809 35 beef, rump steak 3029 0.786 36 rice, white 2981 0.774 37 pork roast 2935 0.763 38 mandarin 2866 0.744 39 garlic bread 2849 0.740 40 chicken, crumbed,fried 2847 0.739 41 pork sausage 2832 0.735. 42 rice,sungold 2725 0.708 43 Italian shortbread 2711 0.704 44 lentils 2659 0.690
97 45 quiche 2604 0.676 46 milk, skim 2561 0.664 47 lamb, chop 2465 0.639 48 mortadella 2459 0.638 49 pork chop 2434 0.632 50 pistachio 2336 0.606 51 minestrone+beans 2323 0.603 52 sauce,bolognaise 2309 0.599 53 pork,grilled 2266 0.588 54 beef,mince,cooked 2214 0.575 55 weetbix/vitabrit 2190 0.569 56 cake, doughnut 2138 0.555 57 beef,boneless 2124 0.551 58 cake,cheesecake 2093 0.543 59 potato 2053 0.532 60 potato, mashed 1986 0.516 61 bacon 1975 0.513 62 cake,plain,home 1968 0.511 63 muesli 1857 0.482 64 cake,iced 1854 0.481 65 ,pear 1778 0.462 66 cake,plain,comm. 1774 0.461 67 fish, steamed 1771 0.460 68 fish, crumbed,fried 1769 0.459 69 kiwifruit 1750 0.454 70 biscuit, pastry( sao) 1609 0.418 71 sausage roll 1559 0.402 72 soft drink, cola 1530 0.397 73 orange 1523 0.395 74 tomato 1517 0.394 75 egg,fried 1497 0.389 76 ice cream, vanilla 1497 0.389 77 tuna,in oil 1454 0.377 78 rolled oats 1378 0.358 79 biscuit, wheatmeal 1315 0.342 80 broccoli 1313 0.339 81 veal, shoulder 1292 0.336 82 peanut butter 1291 0.335 83 potato salad 1220 0.317 84 egg,hard boiled 1213 0.315 85 potato crisps 1095 0.284
TOTAL ENERGY PERCENTAGE 90.040
98 APPENDIX 4
MAJOR DIETARY SOURCES OF PROTEIN
RANKING FOOD ITEM PROTEIN PERCENTAGE TOTAL (g) (%)
1 veal, cru m bed .fried 239 5.932 2 blade steak 217 5.383 3 milk,whole 170 4.216 4 cheese,cheddar 152 3.77 5 bread.white 149 3.695 6 salami 130 3.224 7 cheese, parmesan 122 3.026 8 rump steak 96 2.381 9 pasta, white 84 2.083 10 pizza 83 2.058 11 minestrone 83 , 2.058 12 fish,steamed 83 2.058 13 chicken, baked+skin 82 1.984 14 pork, roast 80 1.959 15 milk.reduced fat 79 1.885 16 bread,w/meal 76 1860 17 iamb chop 75 1.756 18 beef,boneless 72 1.538 19 bread, brown 62 1.538 20 milk,skim 62 1.513 21 broccoli 61 1.488 22 mi nee,cooked 60 1.488 23 ravioli 60 1.414 24 veal shoulder 57 1.414 25 pork grilled 57 1.265 26 bread,mix grain 51 1.265 27 yoghurt.fruit.LF 51 1.24 28 peanuts 50 1.19 29 lentils 48 1.19 30 fish,crumbed,fried 48 1.14 31 chicke.crum bed .fried 46 0.942 32 bolognaise sauce 38 0.942 33 veal, lean 38 0.794 34 quiche 32 0.769 35 mortadella 31 0.744 36 ham 30 0.744 37 pork, butterfly 30 0.694 38 pork sausage 28 0.67
99 39 tomato 27 0.645 40 lamb, boneless 26 0.62 41 minestrone+beans 25 0.62 42 egg,hard boiled 25 0.62 43 bacon 25 0.62 44 tuna in oil 25 0.596 45 endive 24 0.57 46 egg,fried 23 0.57 47 Napolitan sauce 23 0.57 48 cheese,mozzarella 23 0.521 49 chuck,steak 21 0.5 50 tuna,brine 20 0.5 51 potato 20 0.5 52 all bran 20 0.5 53 coffee, black 20 0.42 54 potato chips 19 0.446 55 weetbix,vitabrits 18 0.446 56 cauliflower 18 0.446 57 broad bean 18 0.446 58 banana ' 17 0.422 59 pistacchio 17 0.422 60 mandarin 16 0.397 61 garlic bread 16 0.397 62 biscuit, plain 16 0.397 63 lettuce 15 0.372 64 potato 14 0.342 65 chicken drumstick 13 0.322 66 rice,white 13 0.322 67 rice.sungold 13 0.322 68 kiwifruit 12 0.298 69 lasagne 11 0.273 70 peanut butter 11 0.273 71 Italian shortbread 11 0.273 72 cake, plain, home. 11 0.273
Total protein percentage 90.211
100 APPENDIX 5
MAJOR SOURCES OF DIETARY CARBOHYDRATES
RANKING FOOD ITEM CARBOHYDRATES PERCENTAGE' (9) (%)
1 bread .white 781 9.403 2 pasta 517 6.224 3 minestrone 349 4.202 4 apple 307 3.67 5 bread,w/meal 292 3.516 6 bread, bran 270 3.251 7 milk.whole 237 2.853 3 banana 233 2.2805 9 lemonade 229 2.757 10 bread,mix grain 206 2.48 11 orange juice 196 2.36 12 sugar 186 2.239 13 biscuit,plain 174 2.095 14 rice, white 160 1.926 15 rice.sungold 143 1.722 16 mandarin 142 1.71 17 pizza 135 1.25 18 yoghurtfruit.LF 28 1.541 19 potato chips 124 1.493 20 white,wine 124 1.493 21 ravioli 110 1.324 22 milk,reduced fat 108 1.303 23 pear 107 1.288 24 w eetbixA/itabrits 103 1.24 25 potato 100 1.204 26 lentils 98 1.18 27 softdrink.cola 95 1.144 1.144 28 italian shortbread 95 1.12 29 sultanas 93 1.059 30 milk.skim 88 1.059 31 garlic bread 88 1.011 32 kiwifruit 84 0.951 33 shortbread 79 0.927 34 mashed potato 77 0.927 35 orange 77 0.807 36 minestrone+ beans 67 0.807 37 cake, iced 67 0.746 38 cake, plain, home 62
101 39 muesli 61 0.734 40 all-bran 60 0.722 41 doughnut 58 0.698 42 cake,plaim,comm 56 0.674 43 rolled oats 55 0.662 44 polenta 52 0.626 45 tomato 51 0.614 46 orange fruit drink 50 0.602 47 biscuit,pastry, Sao 47 0.566 48 cheesecake 44 0.529 49 quiche 42 0.506 50 ice cream 41 0.494 51 potato salad 41 0.494 52 biscuit,w/meal 40 0.487 53 fruit bread 40 0.487 54 Italian dressing 39 0.47 55 scones 38 0.457 56 carrot 38 0.457 57 sausage roll 34 0.409 58 honey ■ 32 0.385 59 tomato sauce 30 0.362 Total carbc percentage 90.032
102 APPENDIX 6
MAJOR SOURCES OF DIETARY FAT
RANKING FOOD ITEM FAT PERCENTGE TOTAL (9 ) (%)
1 olive oil 475 10.6 2 chicken,skn 289 6.452 3 oil 247 5.514 4 Italian dressing 241 5.381 5 salami 226 5.046 6 margarine 205 4.577 7 cheese.cheddar 203 4.532 8 milk 196 4.376 9 butter 148 3.304 10 parmesan 104 2.332 11 peanuts 93 2.076 12 blade steak 68 1.518 13 pizza 67 1.496 14 potato chips 66 1.474 15 veal 65 1.451 16 quiche 65 1.451 17 pork roast 53 1.407 18 shortbread 57 1.273 19 pitachhio 54 1.206 20 pork sausage 51 1.139 21 napolitan sauce 50 1.116 22 mortadella 48 1.072 23 chicken,crumbed 47 1.049 24 pork,grilled 43 0.96 25 bacon 42 0.938 26 bolognaise sauce 41 0.915 27 bread, white 41 0.915 28 ravioli 40 0.893 29 biscuit,plain 40 0.893 30 minestrone 39 0.879 31 rump steak 38 0.848 32 pork chop 35 0.781 33 milk,red fat 35 0.781 34 cheesecake 33 0.737 35 mince 32 0.74 36 lamb chop 32 0.714 37 egg,fried 30 0.67 38 maynaise 30 0.67
103 39 doughnut 29 0.647 40 garlic bread 29 0.647 41 tuna in il 28 0.625 42 peanut butter 27 0.602 43 beef boneless 24 0.536 44 sausage roll 23 0.513 45 bread .w/meal 22 0.492 46 egg,boiled 21 0.469 47 ice cream 20 0.447 48 mozzarella 20 0.447 49 m i nestro n e+bean s 20 0.447 50 cake,plain home 20 0.447 51 fish crumbed,fried 19 0.424 52 biscuit pastry 19 0.424 53 cake plain 18 0.402 54 muesli 18 0.402 Total fat percentage 90.115
104 APPENDIX 7
MAJOR DIETARY SOURCES OF POLYUNSATURATED FAT
RANKING FOOD ITEM POLYUNSATURATED FAT PERCENTAGE (g) TOTAL %
1 Italian dressing 119 15.671 2 oil,unspecified 113 14.881 3 margarine 93 12.247 4 olive oil 53 6.980 5 chicken, baked skin 36 4.741 -> 'y 6 peanuts JJ 4.346 7 salami 20 2.634 8 ' mayonaise 18 2.370 9 tuna, in oil 15 1.975 10 bread,white 14 1.844 11 veal,crumbed,fried 12 1.580 12 apolitan sauce 11 1.449 13 pistachio nuts 10 1.317 14 quiche 9 1.185 15 bolognaise sauce 8 1.054 16 bread,w/meal 8 1.054 17 pork roast 8 1.054 18 bread,brown 7 0.922 19 ravioli 7 0.922 20 potato chips / 0.922 21 peanut butter / 0.922 bread,mixed,grain 6 0.790 23 potato salad 6 0.790 24 pizza 6 0.790 25 fish, crumbed,fried 6 0.790 26 cheese,cheddar 5 0.658 27 tomato sauce 5 0.658 28 chicken crumbed, fr 5 0.658 29 mortadeila 5 0.658 30 milk,whole 5 0.658 31 egg,fried 5 0.658 32 garlic bread 4 0.527 biscuit shortbread 4 0.527 34 pork sausage 4 0.527 35 butter 4 0.527 36 pork grilleds 4 0.527 37 muesli 3 0.395
TOTAL POLYUNSATURATED FAT PERCENTAGE 90.208
105 APPENDIX 8
MAJOR DIETARY SOURCES OF SATURATED FAT
RANKING FOOD ITEM SATURATED FAT PERCENTAGE (g) TOTAL %
1 cheese, cheddar 135 8.946 2 milk, whole 131 8.682 J"> chicken, baked skin 92 6.097 4 butter 88 5.832 5 salami 73 4.838 6 cheese, parmesan 69 4.573 7 olive oil 67 4.440 8 Italian dressing 37 2.452 9 margarine 31 2.054 ■. 10 blade steak,fat 30 1.988 '' 11 pizza 30 1.988 12 potato chips 29 1.922 13 quiche 26 1.723 14 oil, unspec. 24 1.590 15 shortbread 23 1.524 16 milk red fat. 1.458 17 pork roast 21 1.392 18 veal crumbed,fried 21 1.392 19 pork sausage 20 1.325 20 biscuit,plain 19 1.259 ^ 1i cheesecake 18 1.193 Italian shortbread 17 1.127 23 bacon 17 1.127 24 rump steak 17 1.127 25 mortadella 17 1.127 26 lamb chop 17 1.127 27 doughnut 16 1.060 28 napolitan sauce 16 1.060 29 ravioli 16 1.060 30 biscuit, pastry 16 1.060 31 pork grilled 15 0.994 32 bolognaise sauce 14 0.928 33 mince,cooked 14 0.928 34 peanuts 14 0.928 35 chicken, crumb, fried 14 0.928 36 ice cream 13 0.861 37 sausage roll 12 0.795 38 pork chop, fat 12 0.795 39 beef,boneless 11 0.729 40 garlic bread 10 0.663 41 bread,white 10 0.663 42 cake, plain 9 0.596 43 cake, chocolate 9 0.596
106 44 cake, plain, comm 9 0.596 45 egg,fried 8 0.530 46 croissant 8 0.530 47 cake, iced 8 0.530 48 muesli 8 0.530 49 pork sausage 7 0.463
TOTAL SATURATED FAT PERCENTAGE 90.126
107 APPENDIX 9
MAJOR DIETARY SOURCES OF MONOUNSATURATED FAT
RANKING FOOD ITEM MONOUNSATURATED PERCENTAGE FAT (g) TOTAL %
1 olive oil 331 18.470 2 chicken baked,skin 141 7.868 ^ ' J salami 115 6.417 4 oil unspecified 99 5.524 5 Italian dressing 74 4.129 6 margarine 72 4.018 7 cheese,cheddar 52 2.900 8 milk,whole 50 2.790 9 butter 47 2.623 10 peanuts 41 2.288 11 pistachio nuts 37 2.065 12 pork roast 30 1.674 13 blade steak,fat 29 1.618 14 veal,crumbed, fried 27 1.507 15 pizza 27 1.507 16 cheese,parmesan 27 1.507 17 potato chips 25 1.395 18 pork sausage 24 1.340 19 mortadella 24 1.340 20 quiche 23 1.283 21 chicken,crumbed,fr. 22 1.228 22 pork grilled 20 1.116 23 napolitan sauce 20 1.116 24 shortbread 19 1.060 25 bacon 19 1.060 26 bolognaise sauce 17 0.947 27 pork chop,fat 17 0.947 28 biscuitplain 16 0.893 29 rump steak 16 0.893 30 mince,cooked 14 0.781 31 ravioli 14 0.781 32 peanut butter 14 0.781 33 garlic bread 13 0.725 34 egg,fried 13 0.725 35 lamb chop 12 0.670 36 cheesecake 11 0.614
108 37 doughnut 10 0.560 38 beef boneless 10 0.560 39 sausage roll 9 0.502 40 egg,hard boiled 9 0.502 41 Italian shortbread 9 0.502 42 milk reduced fat 9 0.502 43 cake,plain 8 0.446
TOTAL PERCENTAGE OF TJRATED FAT 90.174
109 APPENDIX 10
MAJOR DIETARY SOURCES OF CALCIUM.
RANKING FOOD ITEM CALCIUM PERCENTAGE TOTAL (m g ) (%)
1 milk,whole 6192 16.573 2 cheese,Cheddar 4638 12.413 3 cheese, parmesan 3667 9.815 4 milk,reduced fat 2771 7.417 5 milk,skim 2120 5.674 6 yoghur,fruit,LF. 1730 4.63 7 pizza 960 2.569 8 minestrone 942 2.522 9 bread .white 826 2.211 10 cheese,mozzareila 788 2.11 11 endive, raw 734 1.965 12 ravioli 564 1.51 13 quiche 506 1.354 14 bread,w/meal 405 1.084 15 bread,brown 380 1.017 16 broccoli 377 1.01 17 wine, white 294 0.787 18 orange 283 0.757 19 napoitan sauce 273 0.731 20 mineral water 264 0.707 21 lettuce 264 0.707 22 bread,miexd grain 262 0.704 23 carrot 252 0.674 24 pistachio nus 250 0.669 25 ice cream 239 0.64 26 tomato 217 0.581 27 potato 213 0.57 28 orange juice 212 0.568 29 kiwifruit 206 0.551 30 black coffee 200 0.535 31 cheese,ricota 178 0.476 32 cheese,swiss 168 0.436 33 cheesecake 162 0.434 34 salami 156 0.418 35 pasta 147 0.393 36 wine,red 140 0.375 37 cabbage 138 0.369 38 apple 125 0.335 39 garlic bread 121 0.324
110 RANKING FOOD ITEM CALCIUM PERCENTAGE TOTAL (m g ) (%) 40 minestrone-*- beans 119 0.319 41 veal.crumbedand fried 111 0.29 42 pork sausage 110 0.294 43 spinach 109 0.292 44 cauliflower 105 0.281 45 green bean 105 0.281 46 beef,blade steak 100 0.268 47 fish,steamed 95 0.254 48 celery 36 0.23 49 muffin 86 0.23 50 fig,dried 84 0.225 51 bolognaise sauce 83 0.222 52 egg,boiled 83 0.222 53 cake, plain 83 0.222
Total percentage of calcium 90.271
111 APPENDIX 11
MAJOR DIETARY SOURCES OF VITAMIN C
RANKING FOOD ITEM VITAMIN C PERCENTAGE TOTAL (mg) (%)
1 orange juice 1644 20.1 2 broccoli 1105 13.512 3 mandarin 831 10.162 4 kiwi fruit 626 7.655 5 orange 508 6.212 6 tomato 488 5.967 7 cauliflower 454 5.551 8 endive, raw 287 3.509 9 orange drink 242 2.96 10 capsicum 216 2.641 11 potato 164 2.054 12 banana 153 1.871 13 cabbage 146 1.785 14 apple 125 1.529 15 zucchini 105 1.284 16 Napolitan sauce 98 1.198 17 brussel sprouts 94 1.149 18 grape fruit 74 0.905 19 broad bean 74 0.905
total percentage of vitamin C 90.949
112 APPENDIX 12
MAJOR DIETARY SOURCES OF VITAMIN A (RETINOL EQ.).
RANKING FOOD ITEM RETINOL Eq. PERCENTAGE («g) TOTAL %
1 carrot 12616 32.410 2 cheese,cheddar 2330 5.986 3 margarine 2266 5.821 4 napolitan sauce 2194 5.636 5 milk whole 1574 4.044 6 tomato 1558 4.002 7 butter 1491 3.830 8 endive 1170 3.006 9 pumpkin 1137 2,921 10 cheese, parmesan 1098 1821 11 spinach 796 2.045 12 broccoli 761 1.955 13 chicken,baked 720 1.850 14 minestrone+beans 688 1.770 15 pizza 650 1.670 16 quiche 482 1.238 17 zucchini 349 0.897 18 veal, crumb,fried 347 0.891 19 bolognaise sauce 324 0.832 20 milk red,fat 324 0.832 21 egg,hard boiled 284 0.730 egg,fried 280 0.719 23 beans 268 0.689 24 mandarin 257 0.660 25 lettuce 245 0.629 26 cake,plain home 244 0.627 27 ice cream 237 0.609 28 garlic bread 235 0.604 29 orange juice 208 0.534
TOTAL PERCENTAGE OF RETINOL Eq 90.258
113 APPENDIX 13
FOOD FREQUENCY QUESTIONNAIRE - FORMAT
GUIDLINES FOR COMPLETING YOUR QUESTIONNAIRE
The questionnaire provided aims to assess your dietary intake during the winter months, i.e. June, July, August. It requires you to recall how often you eat the listed foods and in what quantity during these winter months.
Once you have recognised the food you do eat, the table below shows how to record how often you eat that particular food and how much of that food.
If you eat bread for example, how often do you eat it?
Once a DAY...... write ID twice a DAY...... write 2D three times a DAY...... write 3D four times a DA.Y...... write 4D, and so on (5D,6D,etc)
If you eat it less than once a day. Then do you eat it?
Once a WEEK...... write 1W twice a WEEK...... write 2W three times a WEEK...... write 3W, and so on (4W,5W,and 6W).
If you eat it less than once a week. Then do you eat it9
About once a MONTH...... write 1M About Twice a MONTH...... write 2M About three times a MONTH...... write 3M
If you eat it less than once a month, then write how often you have eaten it in the past three months.
About once in the last 3.MONTHS.....write lo M About twice in the last 3 MONTHS....write 2-3M
If you never eat bread write.... NO.
114 The amount of food eaten is also important. In this questionnaire a standard serve size is next to each food listed. If your serving size is smaller or larger than the serving size listed, circle the correct serving size.
Example.
FOOD SERVING
Bread 1 slice
Circle;
S (Small) if your usual serving is less than 1 slice M ( medium) if your usual serve is about 1 slice L (Large) if your usual serve is more than 1 slice.
115 FOOD FREQUENCY QUESTIONNAIRE.
DAIRY FOODS
If you use milk, which type of milk do you usually use?
1. Regular, full cream milk
2. Skim milk or shape
3. Reduced fat milk (eg Farmers Best or Lite white)
4. Soy milk (please circle)
5. NE VER use milk.
DAIRY FOODS SERVING YOUR HOW OFTEN SIZE SERVE S,M,L D,\V,M,3m or NO
Milk 200ml
Yoghurt All 200g varieties
Ice cream 2 scoops
Cheddar cheese 50g
Parmesan cheese 1 Tablespoon
Swiss cheese 50g
Ricotta cheese 1/2 cup
Mozzarella cheese 50g
116 BREADS AND CEREALS SERVING YOUR HOW OFTEN SIZE SERVE S,M,L DWM3MORNO
White bread 1 slice or 1/2 roll
Brown bread l slice or 1/2 roll
Wholemeal bread 1 slice or 1/2 roll
Mixed/Multigrain bread 1 slice or 1/2 roll
Fruit/Raisin bread 1 slice or 1/2 bun
Garlic bread 3 rounds or/1/2 roll
Muffin/ crumpet 1 slice
Croissant 1 whole
Scone 1 whole
Pasta,spaghetti etc. 2 cups
Ravioli 1 cup
Lasagne 1 cup
Rice 1 cup
Polenta 50 g
Barley/Rye 50 g
117 BREAKFAST CEREALS
SERVING YOUR SERVE HOW OFTEN SIZE S,M,L D,W,M,3M,OR NO High fibre cereals ( eg All bran/weetbix) 1 cup or, 2 biscuits Low fibre cereals (eg. Cornflakes) 1 cup
Sweet cereals (eg.Nutrigrain) 1 cup
Porridge, rolled oats 1 cup (Natural muesli)
When you eat these cereals;
How many teaspoons of sugar/honey do you add?
Please write the amount of sugar/honey Teaspoons or
if none circle NONE
How much milk do you usually add to your cereal?
( circle most appropriate)
1. more than 2 cups 2 about 2 cups 3. about 1.5 cups 4 about 1 cup 5 about half a cup 6 none.
118 What type of milk do you usually add to your cereal?
1. Regular,full cream 2. Reduced fat Farmers bestlite white, hi lo 3.Skim , Skim, shape 4.soya milk. (please circle)
CAKES/BISCUITS/SNACKS
SERVING YOUR SERVE HOW OFTEN SIZE S,M,or L D,W,M,3M, NO Plain cake 1 slice
Iced cake 1 slice
Chocolate cake 1 slice
Cream cake 1 slice
Doughnut 1 medium
Cheesecake 1 slice
Biscuit plain sweet 1 biscuit
Biscuitshortbread 1 biscuit
Italian shortbread 1 biscuit
Wheatmeal biscuit l biscuit
Biscuit, pastry( Sao) 1 biscuit
Chocolate 50g/l bar
Liquorice 30g/l stick
N uts,peanuts/mixed 1/2 cup
Pistachio nuts 1/2 cup
Crisps/Cheezels 50 g
119 MEAT/FISH/POULTRY/LEGUMES SERVING YOUR HOW OFTEN SIZE SERVE S,M,L D,W,\I,3Yl,orNO Pork, Roast/Grilled lOOg
Pork,Chop/'rib 1 medium
Ham/Proscuitto 1 slice
Bacon 1 rasher
Sausage/Luganega or Cotecchino 1 medium
Mince/Meatballs or Rissoles 60g
Veal lOOg
Vienna Schnitzel 10°g •
Steak lOOg
Beef, Casserole or Stew lOOg
Lamb roast lOOg
Lamb chop 1 medium
Chicken roast 2 sm pieces
Chicken breast lOOg
Chicken, Crumbed 2 sm pieces
Salami/Sapressa or Coppa 1 slice
Mortadella 1 slice
Sausage roll or Meat Pie 1 medium
Pizza 1 slice
Fish, crumbed and fried 80g
Fish, steamed or stew 80g
120 FOOD SERVING YOUR SERVE HOW OFTEN SIZE S,M,L D,W,M,3M,OR NO Tuna,in oil 100g
Egg, boiled 1 Egg, fried 1
Quiche lOOg
Soya beans 1/2 cup
Beans,legumes 1/2 cup
Lentils 1/2 cup SAUCES/SOUPS SERVING YOUR SERVE HOW OFTEN SIZE S,M,L D.W.M.3M,OR NO Bolognaise sauce 1/4 cup
Napolitan/T omato based sauce 1/4 cup
Minestrone or Vegetable soup 1 cup
Minestrone-beans or Legume soup 1 cup FRUITS SERVING YOUR SERVE HOW OFTEN SIZE S,M,L D,W,M,3M,OR NO Apples 1 medium
Pears 1 medium
Bananas 1 medium
Oranges 1 medium
Mandarins 1 medium
Kiwi fruits 1 medium
Pomegranates 1 medium
Rockmelon 1/4 medium
Cherries 1/2 cup
Dried fruit 1/4 cup Canned/Stewed fruit 3/4 cup
121 VEGETABLES- FRESH,FROZEN, AND CANNED SERVING YOUR SERVE HOW OFTEN SIZE S,M,L D,W,M,3M,OR NO Alfalfa 1/2 cup
Broccoli 1/2 cup
Brussel sprouts 3 medium C abbage/Sauercraut or Coleslaw 1/2 cup
Capsicum 1/2 medium
Carrot 1/2 cup
Cauliflower 1/2 cup
Celery 1 stick
Com 1/2 cup '
Eggplant 1/2 medium
Fennel 1/2 cup
Green beans 1 cup
Lettuce 1 cup
Endive/Radicchio 1 cup
Olives 3 medium
Peas 1/4 cup
Potato 1 medium
Hot chips 1/2 cup
Potato salad 1/2 cup *
Mashed potato 1 cup
Pumpkin 1/2 cup
Spinach 1/2 cup
Zucchini 1 medium
Tomato 1/2 medium
122 FATS and OILS
From the list of fats and oils provided what type of fat/oil is most frequently used:
FAT/OIL
a)01ive oil b) Vegetable oil c) Solid fateg lard d) Anise oil e) Butter f) Margarine g) Other h) Nothing
1 .In cooking, Meat/Fish and vegetables...... 2.In cooking cakes, biscuits etc...... 3.On vegetables (eg potato,or salad)...... 4. On bread/toast or crackers...... DRINKS SERVING YOUR HOW OFTEN SIZE SERVE S,M,L D,W,M,3M,or NO Beer 200ml
Red wine 125 ml
White wine 125 ml
Mineral water 200ml
Soft drink (Fizzy) 200ml
Cordial or Fruit drink 200ml
Orange Juice (100%) 200ml Coffee: Strong/Perculated 120ml Instant 200ml
123 When you drink coffee/tea do you add milk? (Please tick) YES.. NO... (PLEASE CIRCLE) How much sugar do you add to your coffee/tea?
1. NONE 2. 1 teaspoon 3. 2 teaspoons 4. More than 2 teaspoons (PLEASE CIRCLE)
THANK YOU FOR ANSWERING THIS QUESTIONNAIRE.
124 APPENDIX 14 RECIPES
MINESTRONE SOUP ( source;study participant)
INGREDIENTS; 5 Litres of water
5 potatoes
2 carrots
2 celery sticks
2 onions
4 shallots
1/2 cup of cabbage
2 spinach leaves
1 cup pumpkin
1 garlic clove
1 cup of peas
2 cups of pasta (cooked)
2 stock cubes + salt & pepper
METHOD. Boil all ingredients together until desired consistency
is obtained. SERVES; 10 cups
2. MINESTRONE + BEANS
INGREDIENTS; As for Minestrone plus 300g of dried Barlotti
beans.
METHOD. As for minestrone, but soak beans overnight, or us
tinned beans.
125 3. BOLOGNAISE SAUCE. (sources Fulton 1992 page 13)
INGREDIENTS; 20g butter
60g bacon (diced)
1 onion (diced)
1 carrot(diced)
1 celery stick (diced)
375g minced beef
2 tablespoons of flour
2 cups of beef stock
1 tablespoon of tomato paste
salt&pepper
METHOD; Melt butter and fry bacon, onion, carrot, and celery
gently for 10 minutes. Add beef and cook until brown.
Stir in flour and cook for 2 minutes. Add stock and tomato
paste, season with salt and pepper. Bring to boil, and
cover and simmer for 1 hour. SERVE WITH PASTA.
Serves 4
4. NAPOLITAN SAUCE. ( source Fulton 1992 page 15)
INGREDIENTS: 2 tablespoons of olive oil
2 cloves of garlic crushed
625g ripe tomatoes skinned
1 teaspoon of sugar
salt & pepper 1 tablespoon of oregano,basil, and parsley
METHOD; Fry garlic in oil, and add remaining ingredients.
Cook till tomatoes are tender. Serve as a garnish or on
pasta. Makes about 1.5 cups. Allbook Bindery 91 Ryedale Road West Ryde 2114 Phone:807 6026