Development of the HELIUS Food Frequency Questionnaires: Ethnic-Specific Questionnaires to Assess the Diet of a Multiethnic Population in the Netherlands
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European Journal of Clinical Nutrition (2015) 69, 579–584 © 2015 Macmillan Publishers Limited All rights reserved 0954-3007/15 www.nature.com/ejcn ORIGINAL ARTICLE Development of the HELIUS food frequency questionnaires: ethnic-specific questionnaires to assess the diet of a multiethnic population in The Netherlands MH Beukers1,2, LH Dekker1, EJ de Boer2, CWM Perenboom3, S Meijboom3, M Nicolaou1, JHM de Vries3 and HAM Brants2 OBJECTIVES: Ethnic minorities are often not included in studies of diet and health because of a lack of validated instruments to assess their habitual diets. Given the increased ethnic diversity in many high-income countries, insight into the diets of ethnic minorities is needed for the development of nutritional policies and interventions. In this paper, we describe the development of ethnic-specific food frequency questionnaires (FFQs) to study the diets of Surinamese (African and South Asian), Turkish, Moroccan and ethnic Dutch residents of The Netherlands. METHODS: An existing Dutch FFQ was adapted and formed the basis for three new FFQs. Information on food intake was obtained from single 24 h recalls. Food items were selected according to their percentage contribution to and variance in absolute nutrient intake of the respective ethnic groups. A nutrient database for each FFQ was constructed, consisting of data from the Dutch Food Composition table; data on ethnic foods were based on new chemical analyses and available international data. RESULTS: We developed four ethnic-specific FFQs using a standardised approach that included ~ 200 food items each and that covered more than 90% of the intake of the main nutrients of interest. CONCLUSIONS: The developed FFQs will enable standardised and comparable assessment of the diet of five different ethnic groups and provide insight into the role of diet in differences in health between ethnic groups. The methodology described in this paper and the choices made during the development phase may be useful in developing similar FFQs in other settings. European Journal of Clinical Nutrition (2015) 69, 579–584; doi:10.1038/ejcn.2014.180; published online 17 September 2014 INTRODUCTION not require highly trained interviewers and may be self- Assessing habitual dietary intake is one of the greatest challenges in administered in the participant’s preferred language. A problem dietary research, especially in ethnic minority groups. To date, is that FFQs should be adapted to the food habits of the target ethnic minorities have been underrepresented in studies on diet population, which may hamper comparability of collected intake and disease. Issues such as language, culture and the relatively low data between different populations. fi socioeconomic status of ethnic minorities have formed barriers for We aimed to develop comparable ethnic-speci c FFQs to assess fi their inclusion in research. Furthermore, differences in dietary the habitual dietary intake of ve ethnic groups living in The habits, a lack of food composition data on ethnic foods1 as well as a Netherlands: Moroccan, Turkish, South Asian-origin Surinamese, lack of validated dietary assessment tools further complicate the African-origin Surinamese and ethnic Dutch. These FFQs are 1,2 intended to enable research into the role of diet in ethnic collection of accurate and representative dietary intake data. differences in chronic disease risk, with a focus on cardiovascular European populations have become increasingly ethnically disease. diverse. In The Netherlands, the predominant ethnic minority groups, that is, African-origin Surinamese, South Asian Surina- mese, Turkish and Moroccans, form ~ 23% of the population in MATERIALS AND METHODS Amsterdam.3 Diet is an important modifiable risk factor for chronic 4 Basis for the FFQs disease including cardiovascular disease. In The Netherlands, the We adapted an existing validated 183-item semiquantitative FFQ prevalence of cardiovascular disease risk factors is higher among developed for the ethnic Dutch group.11 This questionnaire was adjusted 5–9 ethnic minorities than in the ethnic Dutch population. The role to reflect the foods usually consumed by the different ethnic groups. A of dietary patterns in these differences is unclear. Therefore, it is single FFQ for the two Surinamese groups, African origin and South Asian, important to include these groups in monitoring surveys and in was developed because of similarities in commonly eaten foods.12 studies on diet and health to guide the development of public Nutrients and food groups that have been recognised to have a role in health strategies to promote healthy diets and reduce health chronic disease risk were the focus of the developed FFQs. In addition, we aimed to measure the intake of nutrients that have previously been inequalities. identified as potentially inadequate by the ethnic minority groups.13,14 Food frequency questionnaires (FFQs) are an acceptable Table 1 provides an overview of the nutrients and food groups prioritised 10 method for assessing usual dietary intake. FFQs can provide in each of the newly developed FFQs; the original, Dutch, FFQ was adapted data on habitual dietary intake, while their administration does to measure the same nutrients and food groups. 1Department of Public Health, Academic Medical Centre, Amsterdam, The Netherlands; 2Centre for Nutrition, Prevention and Health Services, National Institute for Public Health and the Environment (RIVM), Bilthoven, The Netherlands and 3Division of Human Nutrition, Wageningen University, Wageningen, The Netherlands. Correspondence: Dr M Nicolaou, Academic Medical Centre, University of Amsterdam, PO Box 22660, 1100 Amsterdam, The Netherlands. E-mail: [email protected] Received 21 June 2013; revised 30 June 2014; accepted 18 July 2014; published online 17 September 2014 Food frequency questionnaires for ethnic minorities MH Beukers et al 580 2. Comparable food groups were included in each of the ethnic-specific Table 1. Nutrients and food groups prioritised in the four FFQs to maximise their comparability. Thus, food items were considered fi ethnic-speci c FFQs for selection if they were included in one of the other FFQs. When this was not feasible, highly specific food items—for example, antroewa, a Nutrients Food groups Surinamese vegetable—were included as a single food. Other reasons for inclusion of food items were an increasing trend in consumption in Total energy intake Fruits and vegetables recent years, based on the DNFCS 2007–2010 (Dutch National Food Macronutrients Milk and dairy Consumption Survey)18—for example, breakfast drinks, as well as face Mono- and disaccharides Meat Polysaccharides Poultry validity, as detailed in the paragraph pretesting FFQs (see below). Finally, Dietary fibre Fish to account for the consumption of foods not included in the FFQ, an open question was included at the end of the questionnaire. Food items added Animal protein Soya and other meat substitutes fi Vegetable protein Nuts and seeds by respondents in this open eld are individually evaluated by the Total fat researchers and, where appropriate, are included in an existing Fatty acid clusters questionnaire item. (saturated, monounsaturated, polyunsaturated and trans-fatty Layout of the FFQs acids) The questionnaire layout was based on the existing Dutch FFQ. Where Alcohol possible, food items are asked together based on the order that they are Micronutrients usually consumed during the day; thus, the questionnaire begins with Calcium foods commonly consumed at breakfast. Ethnic-specific food habits were Iron (haem and non-haem) also accounted for in ordering the questions; for example, in the Turkish Vitamin A FFQ, foods related to breakfast also include questions about sliced raw Vitamin B2 vegetables and olives, which are consumed as part of a traditional Turkish Folate breakfast. In addition, foods consumed at a particular meal are ordered so Vitamin B2 that less commonly used foods are mentioned before more common Vitamin C items. For example, a question on different types of crackers precedes the Vitamin D question on bread rolls and croissants, which in turn comes before the question on sliced bread. In this way, we hope to minimise the chance of Abbreviation: FFQ, food frequency questionnaire. overreporting, as participants are forced to think about all bread products before the question about sliced bread, which they presumably eat more frequently, is asked. Respondents were asked to report the frequency of The food items for the ethnic-specific FFQs were selected on the basis of consumption over the last 4 weeks in 10 categories, followed by the usual single 24 h recalls. Data originated from the LASER study, including quantity eaten on a consumption day, based on standardised units, Moroccan and Turkish participants,15 the SUNSET study, which included household measures or colour photos. For many food items participants — African-origin and South Asian Surinamese participants,12 and a study were asked to specify the types of foods usually eaten for example, among Moroccan and Turkish women in The Netherlands.16 These studies orange juice or other fruit juice and/or the preparation methods used, for were conducted between 1998 and 2005 and included, in total, 154 example, boiled or fried. Box 1 illustrates the layout of questions, using Moroccan, 275 Turkish and 109 Surinamese adults. soup as an example. The differences in the types of soup eaten per ethnic group are also illustrated here. The language used in all FFQs is Dutch. The Turkish