Assessing dietary intake in adolescents: the Role of food portion size evaluation in food frequency questionnaires

ii Vânia Martina Moreira Mendes Assessing dietary intake in adolescents: the role of food portion size evaluation in food frequency questionnaires Dissertação de candidatura ao grau de Mestre em Epidemiologia, apresentada à Faculdade de Medicina da Universidade do Porto Orientador: Professora Doutora Elisabete Ramos, Professora Auxiliar na Faculdade de Medicina da Universidade do Porto Porto 2014 iii Esta investigação foi realizada no Departamento de Epidemiologia Clínica, Medicina Preditiva e Saúde Pública da Faculdade de Medicina da Universidade do Porto e no Instituto de Saúde Pública da Universidade do Porto, sob a orientação da Professora Doutora Elisabete Ramos, Professora Auxiliar na Faculdade de Medicina da Universidade do Porto. iv ACKOWNLEDGEMENTS À Professora Doutora Elisabete Ramos, sem a qual este trabalho não teria sido possível, pela experiência partilhada, pela compreensão, apoio e incentivo em todos os momentos, que muito contribuirão para a minha formação enquanto profissional e enquanto pessoa. À Joana Araújo, por todo o apoio e amizade. À Prof.ª Doutora Carla Lopes, pela amabilidade com que me recebeu desde o primeiro contacto e pelo seu apoio. Ao Alexandre, Vítor, Inês, Maria, Lisa, Teresa e António, pela disponibilidade e contribuição para a realização deste trabalho. A todos os colegas do Serviço de Higiene e Epidemiologia e do Instituto de Saúde Pública que de alguma forma contribuíram para o meu crescimento profissional. Aos meus amigos e aos meus pais. v TABLE OF CONTENTS ACKOWNLEDGEMENTS ................................................................................................ iv List of figures .................................................................................................................... vi List of tables ..................................................................................................................... vii List of abbreviatons ........................................................................................................ viii Resumo............................................................................................................................. 1 Abstract ............................................................................................................................. 3 Introduction ....................................................................................................................... 5 1. Diet: a major determinant of health ....................................................................... 5 1.1. Diet and disease............................................................................................. 5 1.2. The importance of diet in adolescence .......................................................... 6 2. Measuring food intake ........................................................................................... 7 2.1. Overview of dietary assessment methods at the individual level .................. 8 3. Portion Size in dietary assessment ..................................................................... 15 3.1. Issues in portion size estimation: the effects of food characteristics .......... 17 3.2. Issues in portion size estimation: the effects of subjects’ characteristics ... 17 4. Diet intake measurement among adolescents .................................................... 18 Objectives ....................................................................................................................... 21 Methods .......................................................................................................................... 22 Results ............................................................................................................................ 29 Discussion ...................................................................................................................... 41 Conclusions .................................................................................................................... 46 References ..................................................................................................................... 47 vi LIST OF FIGURES Figure 1 – Extract of the FFQ version “no portion size”, applied to group 1 ________25 Figure 2 – Extract of the FFQ version “specified portion size”, applied to group 2 ___25 Figure 3 – Extract of the FFQ version “reported portion size”, applied to group 3____26 2 Resultados: Após a randomização, não foram encontradas diferenças estatisticamente significativas entre os três grupos para as variáveis observadas. Relativamente às estimativas de consumo alimentar obtidas através do QFA, foram encontrados resultados semelhantes para todos os grupos de alimentos. A exceção foram os refrigerantes, tendo o grupo “sem porção” revelado a mediana mais alta de consumo [194,6 g/dia (80,6 – 405,1)] e o grupo “porção para quantificar” o valor mais baixo [85,5 g/dia (44,0 – 223,5)]. Os resultados foram semelhantes quando comparadas as medianas de frequência de ingestão. A mediana mais elevada de ingestão energética foi encontrada no grupo “sem porção” [2342,75 Kcal/dia (1615,42 – 3153,86)] e a mais baixa no grupo “porção para quantificar” [1917,05 Kcal/dia (1428,42 – 3211,24)], no entanto sem significado estatístico (p=0,520). Não foram encontradas diferenças estatisticamente significativas entre os grupos relativamente à prevalência de estimativa imprecisa de ingestão energética. A proporção de estimativa plausível foi consideravelmente baixa (menos de 10%) em todos os grupos sobretudo por subestimativa, apresentados o grupo “sem porção” a prevalência mais baixa de subestimativa (53,6%). Relativamente à ingestão de macronutrientes foram encontrados valores semelhantes em todos os grupos de estudo.de uma forma geral, não foram encontradas diferenças estatisticamente significativas para outros nutrientes ou constituintes alimentares, com a exceção da cafeína, tendo o grupo “sem porção” apresentado a mediana a mais elevada [1,13 Kcal/dia (0,57 – 1,80)], e o grupo “porção para quantificar” amais baixa [0,88 Kcal/dia (0,48 – 1,53)] p=0,034. Considerando os dados do grupo que tinha de estimar a porção ingerida, verificamos que para a maioria dos itens foi selecionada a porção média por grande parte dos indivíduos que reportaram consumir esse alimento. Os alimentos que apresentaram menor escolha da porção média apresentada foram os vegetais, óleos e gorduras, queijo, bacon, bolachas, chocolate em pó ou em barra, sobremesas lácteas e açúcar. Conclusões: Os resultados sugerem que, em adolescentes, a inclusão num QFA de questões acerca da porção consumida não influencia as estimativas de ingestão alimentar e nutricional. As estimativas de ingestão energética obtidas usando a versão sem porção parecem fornecer estimativas mais próximas do consumo real dos adolescentes, suportando a opção de não inclusão de questões sobre a porção ingerida ao avaliar este grupo etário. 3 ABSTRACT Introduction: The growing awareness of the relationship between early dietary habits and the development of disease later in life, has led to an increased interest in food assessment of children and adolescents. Food frequency questionnaires (FFQs) are the primary instrument for dietary assessment in large epidemiological studies. However, the problem of whether or not to include a portion size section in the FFQ is still under debate, namely in populations groups with more difficulty in estimating portion sizes. The aim of this study is to understand the importance of portion size estimates in the assessment of food and nutritional intake data among adolescents, by comparing three different structures of a food frequency questionnaire. Methods: All students enrolled in 7th to 9th grades of two schools in Porto’s metropolitan were invited to participate. The 370 students (48.6%) who agreed to participate were randomly assigned to one of three groups, each one completing a different version of a FFQ. One FFQ had no portion size section, other had a portion size specified on the questionnaire for each item but no additional questions, and the third included a portion size section where respondents were asked to report for each food item if their usual portion size was equal, smaller or larger than a given reference medium portion size. One hundred and twenty five (33.8%) participants were allocated in the “no portion size” group; 125 (33.8%) adolescents were assigned to the “specified portion size” group and 120 (32.4%) adolescents were included in the “reported portion size” group. Data was collected through self-administered questionnaires comprising information on socio-demographic characteristics, health-related data, health-related habits d behaviors and diet. An anthropometric evaluation was also performed. Weight, height and waist circumference were measured by a trained professional, according to standard procedures. Energy intake misreporting was assessed using the Goldberg cut-off, based on physical activity level and compared with the ratio of energy intake to basal metabolic rate. Proportions were compared using the chi-square test and quantitative variables using the Kruskal-Wallis test. Results are presented as medians (25th – 75th percentiles). Results: After randomization, no statistically significant differences were found between the three groups, for all the observed variables. Regarding food intake estimates obtained from the FFQ, similar results were found between the three 4 questionnaire structures for all food groups. The only exception were soft drinks, with the “no portion size” group presenting the highest median value [194.6 g/day (80.6 – 405.1)] and the “reported portion size” group the lowest [85.5 g/day (44.0 – 223.5)]. The results were similar when we compared the median reported intake frequency. The highest median energy intake was found in the “no portion size” group [2342.75 Kcal/day (1615.42 – 3153.86)] and the lowest value was found among the reported portion size group [1917.05 Kcal/day (1428.42 – 3211.24)], but differences between groups did not reach statistical significance (p=0.520). No statistically significant differences have been observed between study groups regarding the prevalence of misreporting. In all groups the proportion of plausible reporters was considerably low (less than 10%). The no portion size group presented the lower prevalence of underreporting (53.6%), Considering macronutrients, similar intakes were found in all study groups. In general no significant differences were found for other nutrients and dietary constituents, with the exception of caffeine intake with the reported portion size group presenting the lowest median value [0.88 Kcal/day (0.48 – 1.53)] and the no portion size group the highest [1.13 Kcal/day (0.57 – 1.80)], p=0.034. Using data from the reported portion size group, we have found that for most of the food items assessed, a higher proportion of consumers selected the medium portion size. Foods presenting greater variation across participants were vegetables, fats and oils, cheese, bacon, biscuits, chocolate, dairy desserts and sugar. Conclusions: Our results suggest that the inclusion of questions assessing portion size in a food frequency questionnaire do not influence food and nutrient intake estimates of adolescents. Energy intake estimates provided by a food frequency questionnaire assessing only frequency of intake seem to provide estimates more closely related to actual intake of adolescents, indicating that it might be advantageous not to include portion size questions when assessing food intake among adolescents. 5 INTRODUCTION 1. Diet: a major determinant of health 1.1. Diet and disease The burden of chronic diseases is rapidly increasing worldwide. In 2001, chronic diseases contributed with approximately 60% of the 56.5 million total reported deaths in the world and with approximately 46% of the global burden of disease (1). The proportion of the burden of chronic diseases is expected to increase to 57% by 2020 (1). Chronic diseases that present a greater public health burden, either in terms of direct cost to society and government, or in terms of disability adjusted life years (DALYs) are mainly cardiovascular diseases, obesity, cancers, diabetes and chronic respiratory diseases (2). Global cancer deaths are projected to increase from 7.1 million in 2002 to 11.5 million in 2030, and global cardiovascular deaths from 16.7 million in 2002 to 23.3 million in 2030 (3). Moreover, chronic diseases are largely preventable diseases (4). Up to 80% of heart disease, stroke, and type 2 diabetes and over a third of cancers could be prevented by eliminating shared risk factors, such as tobacco use, unhealthy diet, physical inactivity and alcohol use (4). In the past decades, the importance of dietary habits in health and disease has been increasingly recognized among population. Scientific evidence has helped to clarify the role of diet in preventing and controlling morbidity and premature mortality resulting from chronic diseases. Some of the specific dietary components that increase the probability of occurrence of these diseases in individuals, and interventions to modify their impact, have also been identified. Nutrition is nowadays regarded as a major modifiable determinant of chronic disease (1). It is known that alterations in dietary habits have strong effects on health throughout life, both positive and negative and explain much of the different patterns of health and disease observed, in children and adults. 6 1.2. The importance of diet in adolescence Adolescence is a crucial period in life and implies multiple physiological and psychological changes that affect nutritional needs and habits. This is a period of rapid growth, where up to 45% of skeletal growth takes place and 15 to 25% of adult height is achieved (5). During the growth spurt of adolescence, up to 37% of total bone mass may be accumulated (6). Nutrition influences growth and development throughout infancy, childhood and adolescence. However, it is during the period of adolescence that nutrient needs are the greatest (7). Adolescents are considered to be a nutritionally vulnerable group for a number of specific reasons, including their high requirements for growth, their eating patterns and lifestyles, their risk-taking behaviors and their susceptibility to environmental influences. Inadequate nutrition in adolescence can potentially retard growth and sexual maturation. Besides the important role that diet plays on physical development and health status in early life stages, diet may not only influence present health, but it also may determine whether or not an individual will develop disease much later in life. There are critical aspects of adolescence that have an impact on chronic diseases, such as the development of risk factors during this period and their tracking throughout life. It has been reported that behavioral aspects contributing either to disease risk in adulthood, often originate in childhood and adolescence (4) and tend to persist throughout life, indicating that these life stages have a determinant impact on health later on. With increasing age, adolescents’ personal choices and preferences gain priority over eating habits acquired in the family, and they have progressively more control over what they eat (8, 9). Compared to young children and adults, adolescents may be regarded as an ideal target for nutrition education. In younger children, parents are in charge and need to be influenced. In adults, it may be more difficult to modify already well-established patterns. Furthermore, adolescents may not only adopt healthy eating patterns for themselves, but they also have the potential to have a stronger influence on their peers, family and other community members. Additionally, many habits acquired during adolescence will last throughout life. Adolescence is therefore a key period for intervention and health promotion. However to design an adequate intervention is essential to have better knowledge about dietary habits on the population, which has led to an increased interest in food assessment of children and adolescents. 7 2. Measuring food intake The assessment of dietary intake is paramount in order to conduct epidemiological and clinical research regarding the association of diet and health outcomes, to monitor the nutritional status of individuals, to make policy decisions and to develop and evaluate nutrition interventions. Health-care professionals and policy makers use dietary data to set nutrition standards and to evaluate the progress towards them (10). Food consumption may be measured at the national level (per capita), household level, or individual level (13). Measurement of food intake is one of the most challenging aspects of nutrition research. Diet represents an unusually complex set of exposures that are strongly intercorrelated. All individuals are exposed to potential causal factors, thus exposures cannot be categorized as present or absent. – rather, they are continuous variables, usually with a small range of variation. Often, the time scope in which researchers are interested is in measuring long term dietary intake. For most epidemiologic purposes, long-term diet, rather than intake on any specific day or small number of days is the period of interest. However, individuals rarely make clear changes in their diet at identifiable points in time, which will most certainly affect the ability of individuals to provide accurate information regarding their eating habits. Finally, individuals are generally not aware of the content of foods they eat and the nutrient intake is usually determined indirectly based on the reported use of foods or on the level of biochemical measurements. For these reasons, the most serious limitation to research in nutritional epidemiology has been the lack of practical accurate methods to measure diet. To estimate individual intake on large populations questionnaires were usually used, by self-reported or by interviewer, since these methods present lower costs than alternative methods, such as the use of biomarkers or clinical indicators. In a general way, methods to measure individual dietary intake can be divided into two basic categories: methods that collect data recorded at the time of eating occasion, i.e. prospective methods and methods that collect data about foods eaten in the immediate, recent or distant past – retrospective methods (11). The choice of the most appropriate method to measure diet depends on the type of information needed, on whether the study purpose is to describe intakes or to study the association between diet and an outcome, on the time period of interest, level of accuracy and precision needed and of course, on research constrains in terms of costs, staff and respondent characteristics. 8 It has been widely acknowledged that no dietary assessment method is free from error and none can provide a fully accurate measure (12). All dietary assessment methods rely on consumption estimates reported by individuals and considering the great within-subject variability of food intake over time, it is expected that measurement errors will occur. This will inevitably also have consequences when deriving nutrient and food intake estimates, and when estimating epidemiological associations between risk factors and health outcomes. The lack of detailed information on sources of measurement error is primarily due to the absence of a gold standard for dietary assessment, which evidences the need of developing studies on methodological issues. Over the last few years, a great deal of attention has been given to the development and improvement of adequate methods to measure individual dietary intake. However, the measurement properties of dietary assessment methods in terms of the reliability and validity are not quite established for most nutrients and dietary components. 2.1. Overview of dietary assessment methods at the individual level Methods described below are the most commonly used within the population context for measuring the food consumption of individuals. 2.1.1. Food Records In the food record method, the respondent records all foods and beverages, as well as the amounts consumed, over a specific period of time, usually one or more days (13). The recording is performed at the time of consumption in order to avoid reliance on memory. Detailed descriptions of all foods and beverages, including brand names, and their method of preparation and cooking are also recorded. For mixed dishes, a detailed description of the recipe may also be provided. Regarding the amounts consumed, they may be quantified by weighting, using a scale, or they may be estimated, using household measures, with the help of food models, pictures or no aid. The number of days included varies, depending on day-to-day variability of food groups or nutrients of interest and on precision required. If multiple days are recorded, they are usually consecutive and no more than 7 days are included. However, as the food intake on consecutive days may be related, it may be advantageous to collect 9 nonconsecutive days to increase the representativeness of the individual’s diet. Weekend days should always be proportionately included in the dietary survey period to account for potential day-of-the-week effects on food and nutrient intakes. Recording periods of more than 4 days may unsatisfactory, as reported intakes decrease due to respondent burden (14) and individuals who comply may differ from those who do not. Research indicates that incomplete records increase significantly as more days of records are kept, and the validity of the collected information decreases in the later days of a 7-day recording period, in opposition to collected information in the earlier days (14). One advantage of food records is that recording foods as they are consumed will in theory reduce the memory bias. Even in the case of estimated food records, the estimation of amounts of food at the time they are consumed should provide more accurate portion sizes reports than if the respondents were recalling portion sizes of foods previously eaten, as in retrospective methods. Nevertheless, data obtained from estimated food records underestimates energy intake in more than 20%, compared with weighted food records (15). Therefore, weighted food records are often considered to have less measurement errors as the reporting of food intake is not dependent on participants’ ability to conceptualize portion sizes. For this reason, food records with weighing of the served portions are regarded as the gold standard for dietary assessment and have been used as a reference method to determine the relative validity of other methods (16). However, despite its advantages, food records have also some limitations to be considered. Recording foods as they are being eaten may lead to eating behavior changes, affecting both the types of food and the amounts consumed (11). Changes in eating while keeping the food record may be due to minimizing the burden associated with recording foods or to a tendency to select foods that are more socially acceptable to report, for instance, foods considered to be healthier. Moreover, and even though memory is usually not a source of bias, participants sometimes delay recording their intakes for several hours or more, in which case they will rely on memory to report food intake. Several studies have shown that reported energy and protein intakes on food records are underestimated compared to energy expenditure measure by doubly labeled water or protein intake measure by urinary nitrogen (17, 18), probably as a result of incomplete recording and of the recording impact on dietary choices leading to undereating (19). Due to these findings, food records are considered an imperfect gold standard. Another disadvantage of food records is that they require highly literate subjects what may potentially compromise the method’s use in some population groups and 10 jeopardize the generalization of findings to the broader population. Because keeping the record places a substantial burden on participants, this method also requires a high level of motivation and can lead to a poor response rate. Food records also place a high burden of coding the collected data which can also lead to high personnel costs. Quality of data collected by food records may be difficult to ensure because information is often not recorded consistently from respondent-to-respondent, which may also affect consistency in the coding process between different coders. 2.1.2. 24-Hour Dietary Recall In the 24-hour recall method, the respondent is asked to report all foods and beverages consumed in the previous 24-hours or previous day. The recording is usually performed by an interviewer, although it may also be self-administered. The interview is often structured and performed by a trained subject with education in the food and nutrition area. Standardized probe questions should be used to elicit details for each food item by asking questions in a manner that facilitates the ability to recall the previous day’s intake. Specific probes for additional foods and food preparation methods are often used, including the type of food product, brand name (if appropriate). There are many advantages considering the 24-hour recall method. If the recording is performed with the assistance of and interviewer, the literacy of the respondent is not required and, although it relies on subject recall, as there is a very short time gap between the intake and the recording moment, respondents are generally able to recall most of their dietary intake. As this is a retrospective method, it is unlikely that the recording process interferes with the respondent eating behavior. This method also implies less respondent burden, and consequently, those who agree to give 24-hour recalls are more likely to be representative of the broader population, comparing to those who agree to complete food records. The consistency in recording may also be improved, as the interviewers may be trained to capture the information with the necessary detail improving the coding process. However, it still implies high staff costs and burden, when compared to other dietary assessment methods such as the FFQ. Regarding the 24-hour recall method disadvantages, individuals may not respond accurately for reasons related to knowledge of foods and food preparation, memory and interview situation (e.g. providing answers more socially acceptable). Moreover, although a single 24-hour recall may be used to describe average intake of 11 a population, multiple days over several months are required to evaluate the population’s usual intake and to study their relationships with other factors (20). 2.1.3. Diet History The diet history method was originally conceived to estimate individuals’ usual intake and meal pattern over a relatively long period of time and it included three elements: a detailed interview about usual pattern of eating (which sometimes includes a 24-hour recall), a food list asking for amount and frequency usually eaten and a 3day food record (21). The detailed interview is the central feature of the dietary history, with the food frequency list and the 3-day food record serving as cross-checks of the interview. Many variations of this method have been developed and used in a variety of settings (22, 23) or adapted for self-administration use (24). The major strength of the diet history is the assessment of meal patterns and details of food intake rather than intakes for a short period of time and or only frequency of food consumption. Details of cooking methods can be helpful in better characterizing nutrient intake, as well as exposure to other factor in foods. Although a meal pattern interview approach requires more time from the respondent than it does a food-based approach, it may provide more cognitive support for the recall process. A limitation of the method is that respondents are asked to make many judgments about both the usual foods consumed and the amounts of those foods, which may be difficult for many respondents. The meal-based approach is not suitable for individuals who have no particular eating pattern or for individuals who have not defined mealtimes. If the diet history is conducted by interviewers, the diet history requires trained nutritional professionals which represent high personnel costs. Furthermore, the diet history is not a well standardized method and is thus difficult to reproduce, making comparisons across studies problematic. 2.1.4. Food Frequency Questionnaires Food Frequency Questionnaires have emerged in the 1970’s. In this period two instruments were developed and remain the two most widely used FFQs: the FFQ developed by Willett et al. (25) and the FFQ developed by Block et al. (26). Throughout the years many other instruments were also developed and modifications of the standard Willett and Block questionnaires are now commonplace. 18 conceptualization. Respondents differ in their ability to accurately estimate portion sizes visually. As a result, it seems likely that age plays a significant role in the ability to estimate portion size. Some studies have found that older people tend to overestimate portion size (69), while young children seem not to have mastered the abilities needed in order to quantify food intake (79). However, older children and adolescents also experience difficulty in reporting portion size, and even though they are cognitively more similar to adults, this suggests that the ability of children to estimate food amounts may not be age-dependent. Consequently, some authors have argued that age is not an important factor regarding portion size estimation (55, 80). Results regarding the effect of sex on portion size estimation have been controversial, with some studies reporting that women are more able to estimate portion sizes (81), probably because they usually have greater experience in measuring food amounts. However, no studies have yet compared this effect on men and women with equivalent experience in food handling. Other studies reported none or minimal differences between both sexes (80). Individuals from lower socioeconomic status and with lower educational levels also seem to have higher levels of portion size underestimation (17, 82). However, some authors have considered that socioeconomic status may not be relevant in portion size estimation accuracy (83). Some authors have demonstrated that social desirability is a determinant factor (80). Portion sizes of socially desirable foods (i.e. foods considered to be healthy) are usually overestimated and those of socially undesirable foods are usually underestimated. According to many authors, BMI is the strongest determinant factor for portion size estimation and a positive association between high BMI and underestimation of portion size has been observed (17, 55, 69). 4. Diet intake measurement among adolescents Assessing dietary intake of children and adolescents presents unique challenges. In younger children, dietary reporting is usually task of parents or caregivers and it is unlikely to happen unsupervised inand out-of-home eating. It is generally thought that, before the age of 8 years old, children’s recall skills, their ability to estimate and indicate portion size and knowledge of foods are limited, which would restrain their ability to self-report their food intake without parental assistance (72). From the age of 8 years there is a rapid increase in the ability of children to self-report 19 food intake and according to some authors, by the age of 10 children are able to report food intake similarly to adults. However, while cognitive abilities should be fully developed by adolescence and similar to that of adults, some other issues arise and should be taken into account when assessing dietary intake of this age group. By the age of 11 to 14, reporting accuracy is highly variable, but the novelty and curiosity of assisting in or of self-reporting food intake which may contribute to sustain the compliance in dietary reporting starts to wane and the assistance of parents is seen as an intrusion (84, 85). More accurate reports of food intake was found to be common in younger rather than in older adolescents (86). Underreporting is common among adolescents and there is an overall trend for the magnitude of dietary misreporting to increase with increasing age throughout adolescence (87). Moreover, older adolescents seem to have a tendency to guess portion sizes rather than to refer to available portion size measurement aids (63, 84). As in adults, obese adolescents underreport significantly more than their normal weight counterparts and the extent of misreporting increases with age during this stage. Energy intake in obese adolescents may be underreported up to 40%. Even among normal weight adolescents, it has been shown a positive association between underestimation of food intake and increased body fatness and overweight (85). Furthermore, considering the increased concern with body image and body weight, which is pervasive during adolescence, particularly among girls it is likely that obese teenagers may also feel more stigmatized about their fatness than obese adults and thus be more prone to reporting bias (77). For adolescents that are confronted with body weight problems, the social pressure concerning eating (both with respect to the type of food they are eating and the amounts of food) are expected to add to the already mentioned problems. Some psychosocial factors such as peer influence, dieting and weight consciousness, rebellion against authority, body shape and body image concerns also assume a relevant role (77). During adolescence there is a reduced interest in providing accurate reports of food intake (88). Reporting food intake is inconvenient and time consuming, which is aggravated in adolescence since they are expected to be more prone to reporting bias as part of their general tendency towards a more immature behavior, and some reluctance in participating in initiatives taken by adults. Frequent snacking, unstructured eating patterns, meals at unusual times frequent meal skipping and a significant degree of out-of-home eating occasions, also contribute to inaccurate food intake estimates (77). Additionally, outside home eating also increases, which may particularly affect data if reporting is perceived as too burdensome (77). Adolescents 20 also may lack sufficient knowledge of foods or preparation methods, when compared to adults. Considering these factors it seems to be reasonable to assume that the collection of accurate dietary intake data among adolescents may be even more difficult than in adults. 21 OBJECTIVES FFQ is the most common methodology used on population-based studies but no consensus exists regarding the utility of including a portion size section to improve accuracy. Adolescents present higher difficulties than adults to estimate the portion size and are usually less prone to participate on dietary assessments. This further increase the difficulty of valuing the advantages and disadvantages of asking participants to report the portion size consumed. The aim of this study is to understand the importance of portion size estimates in the assessment of food and nutritional intake data among adolescents, by comparing three different structures of a food frequency questionnaire. One FFQ had no portion size section, other had a portion size specified on the questionnaire for each item but with no additional questions, and the third included a portion size section where respondents were asked to report for each food item if their usual portion size was equal, smaller or larger than the given reference medium portion size. 22 METHODS Participants Two schools in Porto’s metropolitan area that provided teaching from the 7th to the 9th grade were invited to participate in the study. The executive boards of each school were approached by the research team to present the study’s purposes and procedures and to obtain their consent to perform the study. At both schools all students enrolled in 7th to 9th grades were invited to participate. Parents and adolescents received a written description of the study and the informed consent form. All students who agreed to participate were included in the study, and then randomly assigned to one of three groups, each one completing a different version of a FFQ. Of the 762 adolescents who were eligible for the study, 370 (48.6%) agreed to participate. These 370 adolescents were then randomized into one of three different FFQ versions. 125 (33.8%) participants were allocated in group 1 and completed the “no portion size” version of the FFQ; the group 2 consisting of 125 (33.8%) adolescents completed the “specified portion size” version; and the 120 (32.4%) adolescents in group 3 completed the “reported portion size” version of the FFQ. Data Collection After adolescents returned signed informed consents, visits of the research team to the schools were arranged (may to june, 2014), in order to collect the data through a self-administered questionnaire and to perform an anthropometric evaluation. The evaluation lasted approximately 45 minutes and took place during a physical education class. All procedures were similar in the three groups, with the exception of the FFQ version. For this reason, at the beginning of the evaluation, students of each class were divided according to the random assignment and each group received oral instructions with a different member of the research team. The instructions given by the researchers were standardized and differed only regarding the explanation of how to complete the FFQ. The questionnaire comprised information on socio-demographic characteristics, health-related data, health-related habits and behaviors and diet. 23 Socio-demographic characteristics In this section, general demographic information, such as sex and age, was collected, as well as household composition and profession and occupation of the mother and father. Parental educational level was assessed as the highest successfully completed degree of formal schooling and adolescents were classified based on the parent with the highest educational level. Additionally, school performance was also evaluated through grade retention and a question about the self-perception of performance at school. Health-related data Adolescents were asked to self-rate their general health status, according to five options (excellent, very good, good, reasonable or poor). The use of supplements of vitamins and minerals was registered regarding the previous 12 months. An openended question was used to obtain information on previous diagnosis of pathological conditions needing relevant medical care, and other question inquired about food allergies. Adolescents were also asked if their current weight corresponded to the ideal weight, or if it was above or under their ideal weight. Health-related habits and behaviors The usual practice of sports was inquired considering only the extracurricular activities; participants were asked to register the sports they practiced at least once a week. Additionally, the self-perception of leisure time activity was evaluated according to four subjective intensity categories (mainly sitting, mainly standing, active, and very active). Regarding sedentary activities, the time spent watching television was registered separately for weekends and weekdays. Two other questions about the frequency of TV viewing during meals (lunch or dinner), and about screen time (TV, computer and videogames) during other less structured meals were included in this section. Tobacco and alcohol use were inquired, and the frequency and volume of different alcoholic beverages (wine, beer and distilled drinks) intake was asked. Self-perceived body shape and desired body shape were evaluated using the Stunkard figures rating scale (89). Body dissatisfaction was assessed as the difference between self-perceived body shape and desired body shape. Participants were classified as satisfied with their body shape (difference = 0), as having a larger body shape than that desired (difference ≥ 1) and as having a thinner body shape than that desired (difference ≤ -1). 24 Diet Several questions related to diet were included in this section: special diet (vegetarian, gluten-free, or other); number of fruit portions consumed per week, frequency of vegetables intake (excluding soup) per week, frequency of eating out and frequency of involvement in meals preparation. Changes in diet in the prior 12 months were also evaluated and participants were asked to report for how long the changes had occurred and which alterations were made. Dieting was assessed using the question, “How many times have you dieted (changed the way you eat in order to lose weight) in the previous 12 months?” According to the variable distribution participants were categorized into “never” or “once or more times”. Additionally, participants completed one of the three versions of the food frequency questionnaire. Food Frequency Questionnaire The food frequency questionnaire was developed in the Department of Clinical Epidemiology, Predictive Medicine and Public Health, University of Porto Medical School. The questionnaire was designed according to Willett et al. (90) and adapted for the Portuguese adult population, according to available national dietary data, namely the Portuguese food balance sheets and other specific studies (91). Foods with similar nutrient composition were grouped as a single food item, in a total of 86 food or beverages items. FFQ evaluates food intake regarding the prior 12 months, through a frequency section with nine possible responses ranging from never or less than 1 per month to 6 or more times a day. The questionnaire also includes an open-ended section for foods not listed in the questionnaire, but eaten at least once per week. In order to address seasonal variation of food consumption, for each item respondents are asked to indicate if the respective food or food group is consumed seasonally. This is a semi-quantitative FFQ, and for each item participants are asked to report if the portion usually consumed correspond to the average portion reported in the questionnaire, or if it is smaller or larger than the mean portion size. This questionnaire was validated for the adult population by comparison with four 7-day food records (each in a different season of the year) (91). The FFQ was then adapted for adolescents by including foods more frequently consumed by this age group, comprising a total of 90 food or beverages items. The adolescents’ version did not include specific questions on portion size and a standard portion size is considered for nutrient calculation. 25 Since the objective of this study was to test differences in the estimation of food and nutrients intake using FFQs differing in portion size assessment, three versions of the FFQ were used. The three versions differed only in the portion size section; the 90 items from the adolescents’ FFQ and the frequency and seasonality sections remained the same in all versions. Each participant was randomized into one of the three FFQ version. Version 1. “No portion size” Group 1 was asked to complete a FFQ including questions assessing only the intake frequency and seasonality of each food item/food group. In this structure no mention to foods portion size was made and participants were not asked regarding the portion size of each food item. Figure 1. Extract of the FFQ version “no portion size”, applied to group 1. Version 2. “Specified portion size” The FFQ proposed to group 2 presented a similar structure to the version 1, but included an additional column describing a standard medium portion size for each food item. Participants were asked to report the frequency of consumption of each food item/food group. Figure 2. Extract of the FFQ version “specified portion size”, applied to group 2. 26 Version 3. “Reported portion size” Regarding the FFQ administered to group 3, additionally to the intake frequency, the questionnaire included a section were the participant must state their usual portion size. For each food item/food group, participants were asked to report if the average amount consumed was smaller, the same or larger than a given reference medium portion size. If the chosen frequency category was “never or less than 1 per month”, the portion size section should be left unchecked. Figure 3. Extract of the FFQ version “reported portion size”, applied to group 3. Food intake data was then obtained by multiplying the frequency of consumption of each food item by the nutrient content of the standard portion size in the version 1 and 2, and by the reported portion size in version 3. For all structures nutrient intake was estimated using the software Food Processor Plus®, version 7.02 (ESHA Research, Salem, OR, USA) based on values from the US Department of Agriculture. Values for typical Portuguese foods were added, based on the Portuguese tables of food composition, typical recipes and data from previous studies (92). Nutrient content of food items which are usually consumed cooked was estimated by considering cooking and processing. To simplify presentation of food intake results, the 90 food items assessed in the FFQ were combined in 15 food groups, according to nutritional similarities. Food groups and the description of food items included are presented in table 1. 27 Food Groups Food items Number of items included in food group Dairy Products Milk, yogurts and cheese 5 Eggs Eggs 1 Meat Chicken, turkey, rabbit, beef, pork, lamb, viscera, ham, chorizo, peperoni, smoked ham, sausages and bacon 8 Seafood Oily fish, white fish, canned fish, molluscs and crustaceans 6 Fats & Oils Olive oil and other vegetable oils, margarine and butter 4 Starchy Foods Bread, cereal flakes, rice, pasta, potatoes and simple biscuits 9 Vegetables Cabbage, kale, broccoli, cauliflower, brussels sprout, spinach, green beans, lettuce, carrot, tomato, pepper, cucumber 14 Legumes Beans, chickpeas, peas 2 Soup Vegetable soup 1 Fruits Fresh fruit (including tropical fruit and fresh fruit juice), canned fruit, olives and nuts 16 Sweets & Pastry Other biscuits apart from simple ones, croissants, pastry, doughnuts, cakes, chocolates, chocolate snacks, dairy desserts, ice creams, quince jam, compote, jelly, honey, sugar, candy 9 Soft Drinks Soda, juice, fruit juice 3 Fast Food Pizza, hamburger, mayonnaise, ketchup, salted snacks, chips 7 Coffee & Tea Coffee, barley coffee, black tea, green tea 2 Alcoholic Beverages Wine, beer and spirits 3 Anthropometric measures All measurements were obtained with the subject standing, in light indoor clothes and no shoes, by a trained observer according to international guidelines. Weight was measured in kilograms, to the nearest tenth, using a digital scale and height was measured in centimeters, to the nearest tenth, using a portable stadiometer. Body mass index (BMI) was calculated as weight (Kg) divided by the square height (m). Participants were classified according to the ageand sex-specific BMI references from the World Health Organization (WHO) (93) and then classified as overweight if their BMI was at or above the 85th percentile and below the 95th percentile and as obese if their BMI was at or above the 95th percentile. As the proportion of participants who were underweight (< 5th percentile) was very small (2.7%), this category was merged with normal weight (< 85th percentile).Waist circumference was measured in centimeters, to the nearest tenth, midway between the lower limit of the rib cage and the iliac crest, using a flexible and nondistensible tape. Table 1. Description of 15 food groups, combined according to nutritional similarities 34 Table 5.2. Median intake of micronutrients and dietary constituents, according to study group Nutrient/ dietary constituent FFQ No portion size n=125 (33.8%) Specified portion size n=125 (33.8%) Reported portion size n=120 (32.4%) Median (25th P – P75th P) p† Vitamin A (% Kcal) 83.69 (53.72 – 125.50) 91.34 (61.23 – 128.36) 80.95 (54.76 – 117.36) 0.191 Thiamin (% Kcal) 0.08 (0.07 – 0.09) 0.09 (0.08 – 0.10) 0.08 (0.07 – 0.09) 0.472 Riboflavin (% Kcal) 0.11 (0.09 – 0.13) 0.11 (0.10 – 0.13) 0.11 (0.10 – 0.13) 0.536 Niacin (% Kcal) 1.10 (0.98 – 1.24) 1.14 (0.99 – 1.26) 1.11 (0.95 – 1.23) 0.350 Pantothenic Acid (% Kcal) 0.23 (0.19 – 0.26) 0.23 (0.20 – 0.26) 0.23 (0.19 – 0.26) 0.780 Vitamin B6 (% Kcal) 0.11 (0.09 – 0.13) 0.11 (0.10 – 0.13) 0.11 (0.09 – 0.13) 0.292 Folate (% Kcal) 16.25 (13.45 – 20.82) 16.18 (13.12 – 20.86) 15.89 (12.21 – 19.31) 0.413 Vitamin B12 (% Kcal) 0.44 (0.34 – 0.67) 0.45 (0.33 – 0.64) 0.42 (0.31 – 0.55) 0.373 Vitamin C (% Kcal) 6.92 (4.88 – 9.58) 6.65 (4.70 – 9.34) 6.21 (4.06 – 9.49) 0.581 Vitamin D (% Kcal) 0.19 (0.14 – 0.28) 0.19 (0.14 – 0.27) 0.18 (0.14 – 0.25) 0.374 Vitamin E (% Kcal) 0.37 (0.32 – 0.45) 0.38 (0.33 – 0.46) 0.38 (0.29 – 0.49) 0.598 Vitamin K (% Kcal) 0.80 (0.51 – 1.22) 0.90 (0.47 – 1.30) 0.83 (0.51 – 1.25) 0.695 Calcium (% Kcal) 41.98 (33.32 – 51.30) 42.30 (35.11 – 52.83) 44.89 (34.80 – 57.88) 0.111 Copper (% Kcal) 0.08 (0.07 – 0.09) 0.08 (0.07 – 0.09) 0.08 (0.07 – 0.09) 0.655 Iron (% Kcal) 0.75 (0.64 – 0.86) 0.75 (0.66 – 0.86) 0.71 (0.61 – 0.83) 0.196 Magnesium (% Kcal) 15.44 (13.55 – 17.10) 15.19 (13.75 – 16.60) 15.66 (14.00 – 17.12) 0.639 Manganese (% Kcal) 0.16 (0.13 – 0.18) 0.15 (0.13 – 0.19) 0.15 (0.12 – 0.15) 0.405 Phosphorus (% Kcal) 67.28 (59.65 – 75.15) 67.44 (60.94 – 74.53) 69.71 (60.61 – 79.52) 0.246 Potassium (% Kcal) 161.59 (140.08 – 185.42) 163.97 (144.11 – 181.61) 166.53 (145.05 – 193.46) 0.493 Selenium (% Kcal) 4.60 (3.93 – 5.55) 4.83 (4.07 – 5.52) 4.64 (4.03 – 5.36) 0.599 Sodium (% Kcal) 97.36 (87.95 – 110.62) 94.97 (84.18 – 107.22) 97.52 (81.15 – 109.78) 0.578 Zinc (% Kcal) 0.58 (0.52 – 0.65) 0.58 (0.52 – 0.65) 0.59 (0.52 – 0.66) 0.824 Alcohol (% Kcal)* 0.00 (0.00 – 2.87) 0.00 (0.00 – 3.07) 0.00 (0.00 – 1.83) 0.454 Caffeine (% Kcal) 1.13 (0.57 – 1.80) 1.15 (0.66 – 1.96) 0.88 (0.48 – 1.53) 0.034 †Kruskal-Wallis test; *Results are presented as median (min – max) In order to evaluate a possible reporting bias we estimated the proportion of misreporters, and no statistical significant differences have been verified between 35 groups. In all groups the proportion of plausible reporters was considerably low (less than 10%). The no portion size group presented the lower prevalence of underreporting (53.6%) and the higher prevalence of over-reporting (40.0%) (table 6). Table 6. Proportion of misreporting, according to study group Misreporting categories FFQ No portion size n=125 (33.8%) Specified portion size n=125 (33.8%) Reported portion size n=120 (32.4%) n (%) p* Under-reporters 67 (53.6) 78 (62.4) 76 (63.3) 0.326 Plausible reporters 8 (6.4) 11 (8.8) 8 (6.7) Over-reporters 50 (40.0) 36 (28.8) 36 (30.0) * Chi-square test In order to assess the variation in portion sizes categories, we have used data from the reported portion size group and calculated for each food item the proportion of individuals who reported the small, medium or large portion size category. Tables 7.1 to 7.9 show proportions of consumers (≥ once a month) for each food item, and for those individuals, we also present the median frequency of intake and the proportion of consumers in each portion size category. Regarding dairy products (table 7.1), for most food items 60% or more of consumers have reported the medium portion size category. In this food group, the only exception was cheese with 23.3% of the participants reporting the small and also 23.3% reporting the large portion size. Yogurts were the food item with a higher proportion of consumers, while semi-skimmed milk was the item with higher median intake frequency. Table 7.1. Proportion of participants in the reported portion size group consuming dairy products, frequency of intake and reported portion sizes* Dairy Products Proportion of consumers n (%) Median frequency of intake by day (times/d)† (25th P – 75th P) Reported portion size† Smaller n (%) Medium n (%) Larger n (%) Whole milk 10 (8.3) 0.89 (0.33 – 1.00) 0 (0.0) 7 (70.0) 3 (30.0) Semi-skimmed milk 97 (80.8) 1.00 (0.79 – 1.00) 5 (5.2) 77 (79.4) 15 (15.5) Skimmed milk 31 (25.8) 0.43 (0.14 – 1.00) 2 (6.5) 25 (80.6) 4 (12.9) Yogurt 109 (90.8) 0.79 (0.43 – 1.00) 15 (13.8) 85 (78.0) 9 (8.3) Cheese (any type of cheese including fresh cheese and cottage cheese) 86 (72.3) 0.43 (0.14 – 0.79) 20 (23.3) 46 (53.5) 20 (23.3) †Participants who reported no consumption are excluded 36 Considering eggs and the items that compose meat and seafood groups (table 7.2), bacon presented the lower agreement with the presented medium portion size, but this item was among those less consumed (only reported by 58%) and with a relatively small frequency of intake [0.07 (0.07 – 0.14)]. Eggs and chicken were the food items with a higher proportion of consumers and for both more than 70% of participants reported the medium portion. Table 7.2. Proportion of participants in the reported portion size group consuming eggs, meat and seafood, frequency of intake and reported portion sizes* Eggs, Meat & Seafood Proportion of consumers n (%) Median frequency of intake (times/d)† (25th P – 75th P) Reported portion size† Smaller n (%) Medium n (%) Larger n (%) Eggs 116 (97.5) 0.14 (0.14 – 0.43) 21 (18.1) 84 (72.4) 11 (9.5) Chicken 116 (98.3) 0.14 (0.14 – 0.43) 19 (16.4) 87 (75.0) 10 (8.6) Turkey, rabbit 98 (84.5) 0.14 (0.07 – 0.14) 26 (26.5) 67 (68.4) 5 (5.1) Beef, pork, lamb 112 (96.6) 0.14 (0.14 – 0.43) 19 (17.0) 87 (77.7) 6 (5.4) Liver: beef, pork or chicken 31 (26.1) 0.07 (0.07 – 0.14) 11 (35.5) 20 (64.5) 0 (0.0) Other types of viscera 16 (13.4) 0.07 (0.07 – 0.14) 3 (18.8) 12 (75.0) 1 (6.3) Ham, chorizo, peperoni, smoked ham 109 (92.5) 0.14 (0.07 – 0.42) 31 (28.4) 70 (64.2) 8 (7.3) Sausages 104 (87.4) 0.14 (0.07 – 0.36) 30 (28.8) 66 (63.5) 8 (7.7) Bacon 69 (58.0) 0.07 (0.07 – 0.14) 25 (36.2) 41 (59.4) 3 (4.3) Oily fish 106 (89.1) 0.14 (0.07 – 0.43) 25 (23.6) 79 (74.5) 2 (1.9) White fish 107 (92.2) 0.14 (0.07 – 0.14) 25 (23.4) 79 (73.8) 3 (2.8) Cod 88 (74.6) 0.07 (0.07 – 0.14) 23 (26.1) 60 (68.2) 5 (5.7) Canned fish: tuna, sardines 101 (86.7) 0.07 (0.07 – 0.14) 28 (27.7) 69 (68.3) 4 (4.0) Squids, octopus 81 (68.6) 0.07 (0.07 – 0.14) 12 (14.8) 63 (77.8) 6 (7.4) Shrimp, clams, mussel 69 (59.5) 0.07 (0.07 – 0.10) 15 (21.7) 48 (69.6) 6 (8.7) †Participants who reported no consumption are excluded Fats and oils were one of the food groups presenting higher variations in reported portion size, with most of those who have not reported the median portion size reporting a smaller portion. In this food group, olive oil was the most consumed food item and was also the food item with the lower proportion of participants reporting the medium portion size (table 7.3). Table 7.3. Proportion of participants in the reported portion size group consuming oils and fats, frequency of intake and reported portion sizes* Oils & Fats Proportion of consumers n (%) Median frequency of intake (times/d)† (25th P – 75th P) Reported portion size† Smaller n (%) Medium n (%) Larger n (%) Olive oil 106 (88.3) 0.43 (0.12 – 0.79) 44 (41.5) 51 (48.1) 11 (10.4) Seed oils: sunflower, corn, soybean 69 (58.0) 0.14 (0.07 – 0.43) 26 (37.7) 40 (58.0) 3 (4.3) Margarine 57 (47.5) 0.14 (0.07 – 0.43) 20 (35.1) 31 (54.4) 6 (10.5) Butter 105 (88.2) 0.43 (0.14 – 1.00) 27 (25.7) 66 (62.9) 12 (11.4) †Participants who reported no consumption are excluded 37 A very large proportion of participants reported the intake of starchy foods and most of them selected the medium portion as their usual portion size. Simple biscuits presented the lower proportion of participants reporting the medium portion size, with discordance equally distributed between smaller and larger portions (table 7.4). Table 7.4. Proportion of participants in the reported portion size group consuming starchy foods, frequency of intake and reported portion sizes* Starchy Foods Proportion of consumers n (%) Median frequency of intake (times/d)† (25th P – 75th P) Reported portion size† Smaller n (%) Medium n (%) Larger n (%) White bread or toasts 110 (91.7) 0.43 (0.14 – 1.00) 14 (12.7) 87 (79.1) 9 (8.2) Whole wheat bread, rye bread, mixed bread (or toasts) 91 (75.8) 0.43 (0.14 – 0.79) 18 (19.8) 67 (73.6) 6 (6.6) “Broa” 74 (62.3) 0.07 (0.07 – 0.14) 19 (25.7) 48 (64.9) 7 (9.5) Cereal flakes (muesli, corn flakes, chocapic) 103 (86.6) 0.43 (0.14 – 1.00) 15 (14.6) 73 (70.9) 15 (14.6) Rice 119 (99.2) 0.43 (0.43 – 1.00) 15 (12.6) 87 (73.1) 17 (14.3) Pasta 117 (97.5) 0.43 (0.43 – 1.00) 17 (14.5) 80 (68.4) 20 (17.1) French fries 98 (82.4) 0.14 (0.07 – 0.43) 23 (23.5) 69 (70.4) 6 (6.1) Potatoes: boiled, baked, steamed and mashed 105 (88.2) 0.14 (0.14 – 0.43) 22 (21.0) 73 (69.5) 10 (9.5) Semisweet biscuits, cream crackers or whole wheat crackers 105 (87.5) 0.14 (0.07 – 0.61) 22 (21.0) 60 (57.1) 23 (21.9) †Participants who reported no consumption are excluded With the exception of vegetable soup, lettuce and tomato, vegetables were consumed by a small proportion of adolescents and a large proportion of consumers selected the smaller portion size (table 7.5). 38 Table 7.5. Proportion of participants in the reported portion size group consuming vegetables, vegetable soup and legumes, frequency of intake and reported portion sizes* Vegetables, vegetable soup and legumes Proportion of consumers n (%) Median frequency of intake (times/d)† (25th P – 75th P) Reported portion size† Smaller n (%) Medium n (%) Larger n (%) White and savoy cabbage 58 (48.3) 0.14 (0.07 – 0.43) 23 (39.7) 33 (56.9) 2 (3.4) Portuguese cabbage 42 (35.9) 0.07 (0.07 – 0.14) 17 (40.5) 23 (54.8) 2 (4.8) Kale 41 (35.3) 0.07 (0.07 – 0.14) 14 (34.1) 25 (61.0) 2 (4.9) Broccoli 54 (45.8) 0.14 (0.07 – 0.43) 14 (25.9) 33 (61.1) 7 (13.0) Cauliflower, Brussels sprout 38 (32.2) 0.10 (0.07 – 0.43) 17 (44.7) 20 (52.6) 1 (2.6) Turnip greens, spinach 51 (43.2) 0.14 (0.07 – 0.43) 18 (35.3) 30 (58.8) 3 (5.9) Green beans 58 (48.3) 0.07 (0.07 – 0.14) 17 (29.3) 35 (60.3) 6 (10.3) Lettuce, watercress 89 (74.8) 0.43 (0.14 – 1.00) 21 (23.6) 53 (59.6) 15 (16.9) Onion 72 (60.0) 0.14 (0.07 – 0.70) 21 (29.2) 44 (61.1) 7 (9.7) Carrot 95 (80.5) 0.14 (0.07 – 0.79) 22 (23.2) 67 (70.5) 6 (6.3) Turnip 45 (37.5) 0.14 (0.07 – 0.43) 18 (40.0) 24 (53.3) 3 (6.7) Fresh tomato 82 (68.3) 0.43 (0.14 – 1.00) 14 (17.1) 58 (70.7) 10 (12.2) Pepper 42 (35.3) 0.14 (0.07 – 0.43) 13 (31.0) 27 (64.3) 2 (4.8) Cucumber 42 (35.3) 0.07 (0.07 – 0.43) 9 (21.4) 31 (73.8) 2 (4.8) Vegetable Soup 100 (83.3) 0.79 (0.14 – 1.75) 12 (12.0) 73 (73.0) 15 (15.0) Pulses: beans, chickpeas 77 (64.2) 0.14 (0.07 – 0.43) 25 (32.5) 47 (61.0) 5 (6.5) Peas, broad beans 66 (55.5) 0.14 (0.07 – 0.43) 22 (33.3) 38 (57.6) 6 (9.1) †Participants who reported no consumption are excluded In general fresh fruit was consumed by most of the adolescents, and most of them reported the medium portion size. Nuts and olives were less consumed and a relatively higher proportion of participants reported smaller portion size than the given reference medium size (table 7.6). Table 7.6. Proportion of participants in the reported portion size group consuming fruits, frequency of intake and reported portion sizes* Fruits Proportion of consumers n (%) Median frequency of intake (times/d)† (25th P – 75th P) Reported portion size† Smaller n (%) Medium n (%) Larger n (%) Apple, pear 114 (95.0) 0.43 (0.14 – 1.00) 10 (8.8) 90 (78.9) 14 (12.3) Orange, tangerine 108 (90.0) 0.43 (0.14 – 0.79) 12 (11.1) 83 (76.9) 13 (12.0) Banana 109 (91.6) 0.43 (0.14 – 0.79) 14 (12.8) 87 (79.8) 8 (7.3) Kiwi 75 (65.2) 0.14 (0.07 – 0.43) 10 (13.3) 59 (78.7) 6 (8.0) Strawberries 101 (87.8) 0.14 (0.07 – 0.43) 8 (7.9) 80 (79.2) 13 (12.9) Cherries 77 (67.5) 0.04 (0.02 – 0.11) 5 (6.5) 66 (85.7) 6 (7.8) Peach, plum 84 (73.0) 0.04 (0.02 – 0.11) 14 (16.7) 66 (78.6) 4 (4.8) Melon, watermelon 93 (81.6) 0.04 (0.02 – 0.11) 9 (9.7) 72 (77.4) 12 (12.9) Persimmon 52 (44.1) 0.04 (0.02 – 0.11) 6 (11.5) 41 (78.8) 5 (9.6) Figs, loquats, apricot 53 (44.5) 0.04 (0.02 – 0.20) 5 (9.4) 42 (79.2) 6 (11.3) Grapes 86 (72.9) 0.14 (0.07 – 0.43) 15 (17.4) 62 (72.1) 9 (10.5) Tropical fruits 64 (54.2) 0.07 (0.07 – 0.14) 9 (14.1) 51 (79.7) 4 (6.3) Fresh fruit juices 99 (83.9) 0.14 (0.07 – 0.43) 20 (20.2) 71 (71.7) 8 (8.1) Canned fruits: peach, pineapple 62 (52.5) 0.12 (0.07 – 0.14) 11 (17.7) 44 (71.0) 7 (11.3) Almonds, hazelnuts, walnuts, peanuts, pistachio nuts, etc. 72 (60.0) 0.12 (0.07 – 0.18) 22 (30.6) 43 (59.7) 7 (9.7) Olives 55 (47.0) 0.14 (0.07 – 0.43) 13 (23.6) 36 (65.5) 6 (10.9) †Participants who reported no consumption are excluded 39 A large proportion of adolescents reported sweets intake, and those usually used in bread (as jam and chocolate spread) presented the lower proportion of consumers. In general, the choice of the portion is not homogeneous and a relatively large of adolescents reported the smaller portion size. The items with a large proportion of consumers choosing the medium portion size were “croissants and cakes” and ice creams (table 7.7). Table 7.7. Proportion of participants in the reported portion size group consuming sweets and pastry products, frequency of intake and reported portion sizes* Sweets & Pastry Proportion of consumers n (%) Median frequency of intake (times/d)† (25th P – 75th P) Reported portion size† Smaller n (%) Medium n (%) Larger n (%) Other types of biscuits apart from simple biscuits 104 (87.4) 0.14 (0.14 – 0.43) 20 (19.2) 62 (59.6) 22 (21.2) Croissant, pastries, doughnuts or cakes 100 (84.0) 0.14 (0.07 – 0.43) 16 (16.0) 75 (75.0) 9 (9.0) Chocolate (bars or powder) 103 (86.6) 0.14 (0.07 – 0.43) 23 (22.3) 60 (58.3) 20 (19.4) Chocolate snacks (Mars, Twix, Kit Kat) 96 (80.7) 0.14 (0.07 – 0.43) 28 (29.2) 59 (61.5) 9 (9.4) Dairy desserts: pudding, “aletria”, crème brûlée 83 (70.9) 0.07 (0.07 – 0.14) 28 (33.7) 49 (59.0) 6 (7.2) Ice cream 109 (91.6) 0.07 (0.04 – 0.20) 26 (23.9) 76 (69.7) 7 (6.4) Chocolate spread 75 (63.0) 0.07 (0.07 – 0.14) 16 (21.3) 49 (65.3) 10 (13.3) Marmalade, jam, jelly, honey 78 (65.0) 0.14 (0.07 – 0.43) 16 (20.5) 55 (70.5) 7 (9.0) Sugar 103 (86.6) 0.14 (0.14 – 0.79) 35 (34.0) 59 (57.3) 9 (8.7) †Participants who reported no consumption are excluded Regarding items classified as fast food, most of the consumers reported the medium portion size, but the majority of those who reported other portion size category, have chosen the smaller one (table 7.8). Table 7.8. Proportion of participants in the reported portion size group consuming fast foods, frequency of intake and reported portion sizes* Fast Foods Proportion of consumers n (%) Median frequency of intake (times/d)† (25th P – 75th P) Reported portion size† Smaller n (%) Medium n (%) Larger n (%) Pizza 107 (89.2) 0.07 (0.07 – 0.14) 19 (17.8) 69 (64.5) 19 (17.8) Hamburger 102 (85.0) 0.07 (0.07 – 0.14) 15 (14.7) 77 (75.5) 10 (9.8) Chips 100 (83.3) 0.14 (0.07 – 0.43) 23 (23.0) 66 (66.0) 11 (11.0) Salty snacks (Cheetos, etc.) 74 (62.2) 0.07 (0.07 – 0.14) 19 (25.7) 50 (67.6) 5 (6.8) Croquettes, patties 95 (79.8) 0.07 (0.07 – 0.14) 17 (17.9) 68 (71.6) 10 (10.5) Mayonnaise 66 (55.5) 0.07 (0.07 – 0.14) 19 (28.8) 43 (65.2) 4 (6.1) Tomato sauce, ketchup 83 (69.7) 0.07 (0.07 – 0.14) 22 (26.5) 54 (65.1) 7 (8.4) †Participants who reported no consumption are excluded 40 Regarding drinks, soft drinks were the most consumed items and the proportion of consumers that reported the medium size for those items was higher than 70%. The remaining beverages assessed are consumed by a very small part of the adolescents (table 7.9). Table 7.9. Proportion of participants in the reported portion size group consuming coffee, tea, soft drinks and alcoholic drinks, frequency of intake and reported portion sizes* Coffee, tea, soft drinks and alcoholic drinks Proportion of consumers n (%) Median frequency of intake (times/d)† (25th P – 75th P) Reported portion size† Smaller n (%) Medium n (%) Larger n (%) Coffee (including added to other drinks) 46 (38.7) 0.14 (0.07 – 0.43) 11 (23.9) 32 (69.6) 3 (6.5) Black and green tea 43 (36.8) 0.07 (0.07 – 0.14) 9 (20.9) 29 (67.4) 5 (11.6) Coke, pepsi or other cokes 84 (71.2) 0.14 (0.07 – 0.43) 18 (21.4) 60 (71.4) 6 (7.1) Ice-tea 106 (89.8) 0.14 (0.07 – 0.43) 20 (18.9) 77 (72.6) 9 (8.5) Other types of soda, fruit juices or fruit nectars 85 (70.8) 0.14 (0.07 – 0.14) 18 (21.2) 60 (70.6) 7 (8.2) Wine 3 (2.5) 0.07(0.07 – 0.43)‡ 1 (33.3) 2 (66.7) 0 (0.0) Beer 14 (11.7) 0.07 (0.07 – 0.14) 2 (14.3) 12 (85.7) 0 (0.0) Spirits 10 (8.3) 0.07 (0.09 – 0.14) 2 (20.0) 6 (60.0) 2 (20.0) †Participants who reported no consumption are excluded ‡Results are presented as median (min – max) 41 DISCUSSION In this study we have compared three different structures of a food frequency questionnaire in a sample of adolescents, distinguished only by how portion sizes were assessed. One FFQ had no portion size section, other had a portion size specified on the questionnaire for each item but with no additional questions for the respondent, and the third included a portion size section where respondents were asked to report for each food item if their usual portion size was equal, smaller or larger than the given reference medium portion size. We have found median values for food and nutrient intakes to be quite similar between the three approaches, indicating that specifying an average portion size in the questionnaire or including portion size questions to assess the amounts consumed does not improve the adolescents’ food and nutrient intake estimates. Although no statistical significant differences have emerged for energy intake between study groups, the no portion size group yielded the highest median energy intake. On the other hand the reported portion size group presented the lowest median value. According to WHO (97), daily energy requirements for a 14-year-old adolescent with a moderate physical activity level are 2,449 Kcal for a female and 2,990 Kcal for a male. By comparing our results on median energy intake with those standard energy requirements, we may infer that food intake has been underestimated in all study groups. In order to investigate this issue, we estimated the prevalence of misreporting and we have found a high proportion of misreporters in all study groups. Misreporting of energy intake, particularly under-reporting, is known to be a common phenomenon among adolescents (87, 98, 99). With the intent of assessing if portion size estimations would influence energy misreporting, we have compared misreporting prevalence between study groups. Although no statistical significant differences were found, the no portion size group presented the lower proportion of under-reporters compared to other groups, whereas the proportion of over-reporters was relatively higher. Since our estimates of caloric intake seem to be under-estimated, this suggests that intake estimates provided by a FFQ with no portion size may be more close to the actual intake of adolescents. Additionally, underestimation of energy intake seemed to increase with increasing complexity of the portion size specification. The purpose of dietary assessment is to collect information that allows an accurate estimation of food intake for each individual. However when designing dietary assessment instruments, this must be balanced with the effort that is required from respondents, as well as with their ability to provide valid information on all the 42 evaluated components. In this context, it is necessary to weigh the advantages and disadvantages of assessing consumed portion sizes. Regarding the FFQ with no portion size section, in order to derive nutrient intake data from food intake estimates, an average portion size must be used. This average portion is intended to represent the median amount consumed within the study population. However, for individuals who usually consume food amounts below or above the population average, the nutrient intake estimates will be biased and consequently, those individuals will be misclassified. Nevertheless, if the average portion size is well estimated, this approach allows a good overall estimative for the population, minimizing the effort required from the respondent, which contributes to higher participation rates and to the improvement of the general quality of data. Concerning the FFQ with a specified portion size for each item, although the estimation of consumed portion size is not requested from the respondent, this approach may present significant cognitive challenges for subjects, particularly when the respondent does not consume the food item in the amounts specified (39). Under these circumstances, it is expected that the subject will select a different frequency category to allow the difference in portion size. In our study, comparing the version with no portion size section and the specified portion size version (with no additional questions on portion size), similar results were found when we compared medians of food intake frequency. These results indicate that either the specified portion size is actually representing the average amount consumed by these adolescents or that they may be simply ignoring the specified portion size when they indicate the frequency of consumption. When portion size questions are included in a FFQ, theoretically this would allow for better food intake estimates, since the subject is able to report his usual portion size. However, this increases the complexity of reporting food intake because, aside from estimating an average frequency of consumption, the respondent must also provide an estimation of the amount usually consumed, which requires participants to be able to accurately estimate portion size. Variability of portion sizes among the population in study is also one of the main factors to be considered in choosing to whether or not include portion size questions in a food frequency questionnaire. If there is little variation in consumed portion sizes between subjects then its assessment may not be necessary. The existence of a usual portion size for an individual is an implicit assumption made when inquiring about consumed amounts, but it is also a questionable postulate. Previous research has shown that within-person variance in portion sizes is higher than between-person variance (45, 46). In a study, the ratio of intra-individual to interindividual variance was 3.4 on average, indicating a smaller 43 contribution of interindividual variance to total variance in food portion size estimates (45). This suggests that the concept of usual portion size is complex, and that subjects may experience substantial difficulty in specifying their usual portion size. On the other hand, if portion sizes vary within the population, the use of standard portion size applied equally to all subjects may reduce its sensitivity (49). In order to understand the variation of reported portion sizes we have used data from the study group in which food amounts were enquired and we have calculated the proportion of individuals reporting the smaller, medium and larger categories for each food item. Consumers have selected the medium portion size for most of the 90 food items assessed in the FFQ. As discussed in the previous study group, these results show that the given medium reference portion size may be actually representing the average amount consumed by these adolescents. Another possible explanation is that participants have reported the medium portion size due to difficulties in estimating their usual portion size, as an attempt of minimizing the cognitive necessary effort in order to report the portion, they select the option which seems to be more “safe” to report. Several studies have observed a small relationship between estimated and measured portion size (46, 58, 100). Although accuracy in portion size estimation may vary across different foods, correlations with actual portion sizes are usually low (101, 102). Foods presenting greater variation across participants were vegetables, fats and oils, cheese, bacon, biscuits, chocolate (in bars or powder), dairy desserts and sugar, but most of these foods were consumed either by a small proportion of individuals or with low median intake frequency, compared to other food items. Cheese, olive oil, biscuits, chocolate and sugar, had a high proportion of consumers with an also high frequency of intake. It is interesting to observe that these items are usually not consumed in unit sizes, which are easier to estimate. Perhaps the wider variation in reported portion sizes found in our study also reflects more accurate estimates provided by adolescents. However this is not possible to assess without a reference method to compare. Nevertheless, since most of the foods with larger variability on the reported portion size were less consumed, the error on portion size estimation will have little impact on the overall nutrient intake estimation. 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Health Behaviour in School-aged Children (HBSC) study: international report from the 2009/2010 survey. Copenhagen: WHO Regional Office for Europe, 2012. 109. Mendes V, Araújo J, Lopes C, Ramos E. Determinants of Weight Loss Dieting Among Adolescents: A Longitudinal Analysis. Journal of Adolescent Health 2014.54(3):360-3. 110. Fraga S, Severo M, Costa D, Lopes C, Ramos E. Clustering behaviours among 13-yearold Portuguese adolescents. J Public Health. 2011;19(1):21-7. 54 ANNEXE A – FOOD FREQUENCY QUESTIONNAIRE (VERSION 1) 60 O questionário seguinte tem como objetivo avaliar a tua alimentação. Por favor, tenta responder às questões de uma forma sincera, indicando aquilo que realmente comes e não o que gostarias de comer, ou pensas que seria correto comer. Exemplo 1: Uma pessoa que bebe leite 2 vezes por dia e o leite que bebe é meio gordo; se a maior parte dos gelados que come é no verão e nessa época come um gelado por dia, deve assinalar: Exemplo 2: Uma pessoa que come sopa uma vez por dia, mas 1 vez por semana é canja e não sopa de legumes deve assinalar: ID Preencha assim: Não preencha assim: Outros Alimentos CANJA 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou + por dia Frequência alimentar s a z o n a l 6 ou + por dia s a z o n a l Frequência alimentar VIII. BEBIDAS E MISCELANEAS 85. Sopa de legumes 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 ou 5 por dia O questionário pretende identificar o consumo de alimentos do ano anterior. Assim para cada alimento, deves assinalar, no respetivo círculo, quantas vezes por dia, semana ou mês comeste em média, nos últimos 12 meses, cada um dos alimentos referidos nesta lista. Não te esqueças de assinalar os alimentos que nunca comeste, ou que comeste menos de 1 vez por mês na coluna nunca ou menos de 1 por mês. Não te esqueças de ter em conta as vezes em que o alimento é consumido sozinho e aquelas em que é adicionado a outros alimentos ou pratos (ex: café do café com leite, ovos das omeletas, etc.). Para os alimentos que só comeste em determinadas épocas do ano (por ex: cerejas ou diospíros), assinala as vezes em que comeste o alimento nessa época, colocando uma cruz (x) na última coluna (Sazonal). No item nº 86, anota a frequência com que comeste sopa de legumes. Se tiveres consumido caldo verde, canja ou sopa instantânea, com uma frequência de pelo menos 1 vez por semana, deves assinalar a frequência com que comeste este alimento no quadro existente para "OUTROS ALIMENTOS", tendo o cuidado de não o contar na frequência que referes para a sopa de legumes. Se houver algum alimento não mencionado na lista de alimentos e que tenhas consumido pelo menos 1 vez por semana, assinala, no quadro que existe para "OUTROS ALIMENTOS", a respetiva frequência e indica a quantidade média que costumas comer de cada vez. Por ex: alheiras, cevada, frutos secos: figos, ameixas, alperces, etc. Nunca ou menos de 1 por mês Nunca ou menos de 1 por mês s a z o n a l I. PRODUTOS LÁCTEOS 1. Leite gordo 2. Leite meio-gordo 3. Leite magro 7. Gelados Nunca ou menos de 1 por mês Frequência alimentar 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou + por dia Draft ISPUP PDFaid.Com #1 Pdf Solutions s a z o n a l II. OVOS, CARNES E PEIXES 9.Frango 10.Peru, coelho 11.Carne: vaca, porco,cabrito 12. Figado: de vaca, porco, frango 8.Ovos 16. Toucinho, bacon 17. Peixe gordo: sardinha, cavala, carapau, salmão, etc 18. Peixe magro: pescada, faneca, dourada, etc 19.Bacalhau 20.Peixe conserva: atum, sardinhas,etc 13 Língua, mão de vaca, tripas, chispe, coração, rim 15. Salsichas 21.Lulas, polvo 22.Camarão, amêijoas, mexilhão, etc 14.Fiambre, chouriço, salpicão, presunto, etc 1 por dia Frequência alimentar Nunca ou menos de 1 por mês 1 a 3 por mês 2 a 4 por semana 1 por semana 5 a 6 por semana 2 a 3 por dia 4 a 5 por dia 6 ou + por dia s a z o n a l I. PRODUTOS LÁCTEOS 1. Leite gordo 2. Leite meio-gordo 3. Leite magro 4. Iogurte 5.Queijo (de qualquer tipo incluindo queijo fresco e requeijão) 6. Sobremesas lácteas: pudim, aletria e leite creme, etc 7. Gelados Pensa nos últimos 12 meses quantas vezes por dia, semana ou mês, em média, comeste cada um dos alimentos referidos. Não te esqueças de assinalar os alimentos que nunca comeste, ou comeste menos de 1 vez por mês na coluna (Nunca ou menos de 1 por mês) . No grupo I. PRODUTOS LÁCTEOS - Se bebes leite já achocolatado, em pacote ou garrafa, não consideres aqui e regista na tabela " OUTROS ALIMENTOS ". Regista aqui o restante leite que bebes e não te esqueças de considerar o leite que bebes com o café ( exemplo : meia de leite, galão,...). Nunca ou menos de 1 por mês Frequência alimentar 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou + por dia No grupo II. OVOS, CARNES E PEIXES - considera também as vezes que comeste cada um destes alimentos como elementos de outros pratos, por exemplo: o frango do arroz de frango, os ovos das omoletas, as salsichas dos cachorros. Draft ISPUP Frequência alimentar 6 ou + por dia 4 a 5 por dia 1 por dia 2 a 3 por dia 5 a 6 por semana 2 a 4 por semana 1 por semana 1 a 3 por mês Nunca ou menos de 1 por mês s a z o n a l 35. Batatas cozidas, assadas, estufadas e puré IV.PÃO, CEREAIS E SIMILARES 27. Pão branco ou tostas 28. Pão (ou tostas), integral,centeio, mistura 30. Flocos cereais (muesli, corn-flakes, chocapic,etc.) 29. Broa, broa de avintes 31. Arroz 32. Massas: esparguete, macarrão, etc. 33. Batatas fritas caseiras 34. Batatas fritas de pacote Nunca ou menos de 1 por mês 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou + por dia Frequência alimentar s a z o n a l No grupo III. ÓLEOS E GORDURAS - responde apenas ao que é adicionado em saladas, no prato, no pão, etc, e não consideres a utilizada para cozinhar. No grupo IV. PÃO CEREAIS E SIMILARES - não te esqueças de considerar também o que comeste fora das refeições, por exemplo: as batatas fritas da refeição e as que comeste fora das refeições. No grupo V. DOCES E PASTEIS - no item 42 (açúcar) considera quantas colheres ou pacotes de açúcar adicionas aos teus alimentos. 25. Margarina 26. Manteiga III. ÓLEOS E GORDURAS 24. Óleos: girassol, milho, soja 23. Azeite Nunca ou menos de 1 por mês 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou + por dia Frequência alimentar s a z o n a l V.DOCES E PASTÉIS 37. Outras bolachas ou biscoitos 38. Croissant, pasteis, bolicao, doughnut ou bolos 39.Chocolate (tablete ou em pó) 40. Snacks de chocolate (Mars, Twix, Kit Kat, etc ) 36. Bolachas tipo maria, água e sal ou integrais 41. Marmelada, compota, geleia, mel 42. Açúcar Draft ISPUP No grupo III. ÓLEOS E GORDURAS - responde apenas ao que é adicionado em saladas, no prato, no pão, etc, e não consideres a utilizada para cozinhar. No grupo IV. PÃO CEREAIS E SIMILARES - não te esqueças de considerar também o que comeste fora das refeições, por exemplo: as batatas fritas da refeição e as que comeste fora das refeições. Frequência alimentar s a z o n a l No grupo V. DOCES E PASTEIS - no item 42 (açúcar) considera quantas colheres ou pacotes de açúcar adicionas aos teus alimentos. Frequência alimentar s a z o n a l 25. Margarina 26. Manteiga III. ÓLEOS E GORDURAS 24. Óleos: girassol, milho, soja 23. Azeite Frequência alimentar s a z o n a l Porção Média 1 colher de sopa 1 colher de sopa 1 colher de chá 1 colher de chá 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou mais por dia 35. Batatas cozidas, assadas, estufadas e puré IV. PÃO, CEREAIS E SIMILARES 27. Pão branco ou Tostas 28. Pão (ou tostas), integral,centeio, mistura 30. Flocos cereais: muesli, corn-flakes, chocapic,etc. 29. Broa, Broa de avintes 31. Arroz 32. Massas: esparguete, macarrão, etc. 33. Batatas fritas caseiras 34. Batatas fritas de pacote Um ou 2 tostas Um ou 2 tostas 1 fatia 1 chávena (sem leite) ½ prato ½ prato ½ prato 1 pacote pequeno 2 batatas médias Porção Média 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou mais por dia V.DOCES E PASTÉIS 37. Outras bolachas ou Biscoitos 38. Croissant, Pasteis, Bolicao, Doughnut ou Bolos 39.Chocolate (tablete ou em pó) 40. Snacks de chocolate (Mars, Twix, Kit Kat, etc) 36. Bolachas tipo maria, água e sal ou integrais 41. Marmelada, Compota, Geleia, Mel 42. Açúcar 3 bolachas 3 bolachas Um; 1 fatia 3 quadrado; 1 colher sopa Um 1 colher sobremesa 1 colher sobremesa; 1 pacote Porção Média 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou mais por dia Nunca ou menos de 1 por mês Nunca ou menos de 1 por mês Nunca ou menos de 1 por mês Draft ISPUP No grupo VI - HORTALIÇAS E LEGUMES - responde pensando nos que são consumidos no prato (cozidos ou em saladas) e não nos que entram na confecção da sopa. Nos que comeste só numa determinada época do ano não te esqueças de assinalar na coluna sazonal (x). No grupo VII - FRUTOS - recorda que para os alimentos que só comeste em determinadas épocas do ano (por exemplo, cerejas), deves assinalar as vezes em que comeste o alimento nessa época, colocando uma cruz (x) na última coluna (Sazonal). ¼ de prato ¼ de prato ¼ de prato ¼ de prato ¼ de prato ¼ de prato ¼ de prato ¼ de prato 1 média 1 médio 3 rodelas ½ médio ½ prato ¼ médio ¼ de prato ½ média Porção Média 54. Tomate fresco 53. Nabo 52. Cenoura 51. Cebola 44. Penca, Tronchuda 45. Couve galega 46. Brócolos 47. Couve-flor, Couve-bruxelas 48. Grelos, Nabiças, Espinafres 43. Couve branca, Couve lombarda 49. Feijão verde 50. Alface, Agrião VI. HORTALIÇAS E LEGUMES 58. Ervilha em grão, Fava 57. Leguminosas: feijão, grão de bico 56. Pepino 55. Pimento Frequência alimentar s a z o n a l 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou mais por dia 67. Diospiro VII. FRUTOS 59. Maça, pêra 69. Uvas frescas 70. Frutos conserva: pêssego, ananás 71. Amêndoas, Avelãs, Nozes, Amendoins, Pistachio, etc. 72. Azeitonas 60. Laranja, Tangerinas 62. Kiwi 61. Banana 63. Morangos 64. Cerejas 65. Pêssego, Ameixa 68. Figo fresco, Nêsperas,Damascos 66. Melão, Melancia Porção Média 1 média 1 cacho médio 2 metades ou rodelas ½ chávena descascado 6 unidades 1 média; 2 médias 1 média 1 médio 1 chávena 1 chávena 1 médio; 3 médias 3 médios 1 fatia média 1 médio Frequência alimentar s a z o n a l 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou mais por dia Nunca ou menos de 1 por mês Nunca ou menos de 1 por mês Draft ISPUP No grupo VIII - BEBIDAS E MISCELANEAS - neste grupo não consideres os sumos naturais (estes devem ser registados na tabela "OUTROS ALIMENTOS"), não te esqueças dos que são adicionados a outras bebidas, por exemplo: café da meia de leite. Coloca neste quadro informação relativa aos restantes alimentos ou bebidas que não estejam na lista anterior e que tenhas consumido pelo menos 1 vez por semana mesmo em pequenas quantidades, ou numa época em particular. Por exemplo: alheiras, cevada, frutos secos (figos, ameixas, alperces), etc. Frequência alimentar s a z o n a l 81. Croquetes, Rissóis, Bolinhos de bacalhau, etc. 84. Pizza 83. Molho de tomate, ketchup 82. Maionese 74. Cerveja 75. Bebidas brancas: whisky, aguardente, brandy, vodka, etc. 76. Coca-cola, Pepsi-cola ou outras colas 77. Ice-tea 78.Outros refrigerantes, Sumos de fruta ou Néctares embalados 73. Vinho 79.Café (incluindo o adicionado a outras bebidas) 80. Chá preto e verde VIII. BEBIDAS E MISCELANEAS 86. Sopa de legumes 85. Hambúrguer 3 unidades 1 colher sobremesa 1 colher sopa Meia pizza-média 1 garrafa ou 1 lata 1 cálice 1 garrafa ou 1 lata 1 garrafa ou 1 lata 1 garrafa ou 1 copo 1 copo 1 chávena café 1 chávena Porção Média 1 médio 1 prato 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou mais por dia Nunca ou menos de 1 por mês s a z o n a l Nunca ou menos de 1 por mês 1 a 3 por mês 1 por semana 2 a 4 por semana 5 a 6 por semana 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou + por dia Frequência alimentar OUTROS ALIMENTOS Tulicreme, Nutella Snacks salgados (cheetos, etc.) Sumo de fruta natural Frutos tropicais Porção Média 1 porção média 1 copo 1 colher de sobremesa 1 pacote pequeno Draft ISPUP 66 ANNEXE C – FOOD FREQUENCY QUESTIONNAIRE (VERSION 3) O questionário seguinte tem como objetivo avaliar a tua alimentação. Por favor, tenta responder às questões de uma forma sincera, indicando aquilo que realmente comes e não o que gostarias de comer, ou pensas que seria correto comer. Exemplo 1: Uma pessoa que bebe leite 2 vezes por dia e o leite que bebe é meio gordo; se a maior parte dos gelados que come é no verão e nessa época come um gelado por dia, deve assinalar: Exemplo 2: Uma pessoa que come sopa uma vez por dia, mas 1 vez por semana é canja e não sopa de legumes deve assinalar: ID O questionário pretende identificar o consumo de alimentos do ano anterior. Assim para cada alimento, deves assinalar, no respetivo círculo, quantas vezes por dia, semana ou mês comeste em média, nos últimos 12 meses, cada um dos alimentos referidos nesta lista. Não te esqueças de assinalar os alimentos que nunca comeste, ou que comeste menos de 1 vez por mês na coluna nunca ou menos de 1 por mês. Não te esqueças de ter em conta as vezes em que o alimento é consumido sozinho e aquelas em que é adicionado a outros alimentos ou pratos (ex: café do café com leite, ovos das omeletas, etc.). Para os alimentos que só comeste em determinadas épocas do ano (por ex: cerejas ou diospíros), assinala as vezes em que comeste o alimento nessa época, colocando uma cruz (x) na última coluna (Sazonal). No item nº 86, anota a frequência com que comeste sopa de legumes. Se tiveres consumido caldo verde, canja ou sopa instantânea, com uma frequência de pelo menos 1 vez por semana, deves assinalar a frequência com que comeste este alimento no quadro existente para "OUTROS ALIMENTOS", tendo o cuidado de não o contar na frequência que referes para a sopa de legumes. Se houver algum alimento não mencionado na lista de alimentos e que tenhas consumido pelo menos 1 vez por semana, assinala, no quadro que existe para "OUTROS ALIMENTOS", a respetiva frequência e indica a quantidade média que costumas comer de cada vez. Por ex: alheiras, cevada, frutos secos: figos, ameixas, alperces, etc. Na coluna da quantidade, tendo em conta a porção média, assinala se a porção que comeste é: mais pequena (menor), igual (média) ou maior que a porção média. Preencha assim: Não preencha assim: s a z o n a l Frequência alimentar 86. Sopa de legumes 1 prato MaiorMédia Menor A tua porção é: VIII. BEBIDAS E MISCELANEAS 1 a 3 por mês 1 por sem 2 a 4 por sem 5 a 6 por sem 1 por dia 2 a 3 por dia 4 a 5 por dia Porção Média Quantidade s a z o n a l Frequência alimentar OUTROS ALIMENTOS 1 a 3 por mês 1 por sem 2 a 4 por sem 5 a 6 por sem 1 por dia 2 a 3 por dia 4 a 5 por dia Porção Média Quantidade CANJA PRATO Nunca ou menos de 1 por mês Nunca ou menos de 1 por mês 6 ou + por dia 6 ou + por dia s a z o n a l Maior Frequência alimentar Menor Média A tua porção é: Quantidade I. PRODUTOS LÁCTEOS Porção Média 1. Leite gordo 1 chávena 2. Leite meio-gordo 1 chávena 1 chávena 3. Leite magro 7. Gelados Um ou 2 bolas Nunca ou menos de 1 por mês 1 a 3 por mês 1 por sem 2 a 4 por sem 5 a 6 por sem 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou + por dia Draft ISPUP PDFaid.Com #1 Pdf Solutions Média 1 por dia s a z o n a l II. OVOS, CARNES E PEIXES Maior Frequência alimentar Menor Média A tua porção é: Quantidade I. PRODUTOS LÁCTEOS Porção Média 1. Leite gordo 1 chávena 2 peças ou ¼ de frango 9.Frango 10.Peru, coelho 11.Carne vaca, porco,cabrito 12. Figado: de vaca, porco, frango 2. Leite meio-gordo 1 chávena 1 chávena 3. Leite magro 4. Iogurte Um 5.Queijo (de qualquer tipo incluindo queijo fresco e requeijão) 1 fatia 6. Sobremesas lácteas: pudim, aletria e leite creme, etc Um ou 1 prato sobremesa 7. Gelados Um ou 2 bolas Um8.Ovos 16. Toucinho, bacon 17. Peixe gordo: sardinha, cavala, carapau, salmão, etc. 18. Peixe magro: pescada, faneca, dourada, etc. 19.Bacalhau 20.Peixe conserva: atum, sardinhas,etc. 13 Língua, mão de vaca, tripas, chispe, coração, rim 15. Salsichas 21.Lulas, polvo 22.Camarão, amêijoas, mexilhão, etc. 14.Fiambre, chouriço, salpição, presunto, etc. Nunca ou menos de 1 por mês 1 a 3 por mês 1 por sem 2 a 4 por sem 5 a 6 por sem 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou + por dia Frequência alimentar 1 a 3 por mês 2 a 4 por sem 1 por sem 5 a 6 por sem 2 a 3 por dia 4 a 5 por dia Porção Média Menor A tua porção é: Maior Quantidade s a z o n a l Pensa nos últimos 12 meses quantas vezes por dia, semana ou mês, em média, comeste cada um dos alimentos referidos. Não te esqueças de assinalar os alimentos que nunca comeste, ou comeste menos de 1 vez por mês na coluna (Nunca ou menos de 1 por mês) . No grupo I. PRODUTOS LÁCTEOS - Se bebes leite já achocolatado, em pacote ou garrafa, não consideres aqui e regista na tabela " OUTROS ALIMENTOS ". Regista aqui o restante leite que bebes e não te esqueças de considerar o leite que bebes com o café ( exemplo : meia de leite, galão,...). No grupo II. OVOS, CARNES E PEIXES - considera também as vezes que comeste cada um destes alimentos como elementos de outros pratos, por exemplo: o frango do arroz de frango, os ovos das omoletas, as salsichas dos cachorros. 1 porção média ou 2 peças 1 porção média 1 porção média 2 fatias ou 3 rodelas 3 médias ou 1 grande 2 fatias 1 porção média 1 porção média 1 posta média 1 lata ¼ de prato 1 prato de sobremesa 1 porção média Nunca ou menos de 1 por mês 6 ou + por dia Draft ISPUP 25. Margarina 26. Manteiga s a z o n a l III. ÓLEOS E GORDURAS 1 a 3 por mês 1 por sem 2 a 4 por sem 5 a 6 por sem 1 por dia 2 a 3 por dia 4 a 5 por dia Frequência alimentar Quantidade Porção Média Menor Média Maior A tua porção é: 24. Óleos: girassol, milho, soja 23. Azeite 1 colher sopa 1 colher sopa 1 colher chá 1 colher chá No grupo III. ÓLEOS E GORDURAS - responde apenas ao que é adicionado em saladas, no prato, no pão, etc, e não consideres a utilizada para cozinhar. Um ou 2 tostas Um ou 2 tostas 1 fatia 1 chávena (sem leite) ½ prato ½ prato ½ prato 1 pacote pequeno 2 batatas médias 35. Batatas cozidas, assadas, estufadas e puré Maior Frequência alimentar s a z o n a l Menor Média A tua porção é: Quantidade 4 a 5 por dia 1 por dia 2 a 3 por dia 5 a 6 por sem 2 a 4 por sem 1 por sem 1 a 3 por mês IV.PÃO, CEREAIS E SIMILARES Porção Média 27. Pão branco ou tostas 28. Pão (ou tostas), integral,centeio, mistura 30. Flocos cereais (muesli, corn-flakes, chocapic, etc.) 29. Broa, broa de avintes 31. Arroz 32. Massas: esparguete, macarrão, etc. 33. Batatas fritas caseiras 34. Batatas fritas de pacote No grupo IV. PÃO CEREAIS E SIMILARES - não te esqueças de considerar também o que comeste fora das refeições, por exemplo: as batatas fritas da refeição e as que comeste fora das refeições. 3 bolachas 3 bolachas Um; 1 fatia 3 quadrados; 1 colher sopa Um 1 colher sobremesa 1 colher sobremesa; 1 pacote Quantidade V.DOCES E PASTÉIS 1 a 3 por mês 1 por sem 2 a 4 por sem 5 a 6 por sem 1 por dia 2 a 3 por dia 4 a 5 por dia Frequência alimentar Porção Média Menor Maior A tua porção é: s a z o n a l Média 37. Outras bolachas ou biscoitos 38. Croissant, pasteis, bolicao, doughnut ou bolos 39.Chocolate (tablete ou em pó) 40. Snacks de chocolate (Mars, Twix, Kit Kat, etc. ) 36. Bolachas tipo maria, água e sal ou integrais 41. Marmelada, compota, geleia, mel 42. Açúcar No grupo V. DOCES E PASTEIS - no item 42 (açúcar) considera quantas colheres ou pacotes de açúcar adicionas aos teus alimentos. Nunca ou menos de 1 por mês 6 ou + por dia Nunca ou menos de 1 por mês 6 ou + por dia 6 ou + por dia Nunca ou menos de 1 por mês Draft ISPUP s a z o n a l Frequência alimentar 54. Tomate fresco 53. Nabo 52. Cenoura 51. Cebola 44. Penca, Tronchuda 45. Couve galega 46. Brócolos 47. Couve-flor, Couve-bruxelas 48. Grelos, Nabiças, Espinafres 43. Couve branca, couve lombarda 49. Feijão verde 50. Alface, Agrião MaiorMédia Menor A tua porção é: VI. HORTALIÇAS E LEGUMES 1 a 3 por mês 1 por sem 2 a 4 por sem 5 a 6 por sem 1 por dia 2 a 3 por dia 4 a 5 por dia Porção Média Quantidade 58. Ervilha grão, Fava 57. Leguminosas: feijão, grão de bico 56. Pepino 55. Pimento No grupo VI - HORTALIÇAS E LEGUMES - responde pensando nos que são consumidos no prato (cozidos ou em saladas) e não nos que entram na confecção da sopa. Nos que comeste só numa determinada época do ano não te esqueças de assinalar na coluna sazonal (x). ¼ de prato ¼ de prato ¼ de prato ¼ de prato ¼ de prato ¼ de prato ¼ de prato ¼ de prato ½ média 1 média 1 médio 3 rodelas ½ médio ¼ médio ½ prato ¼ de prato No grupo VII - FRUTOS - recorda que para os alimentos que só comeste em determinadas épocas do ano (por exemplo, cerejas), deves assinalar as vezes em que comeste o alimento nessa época, colocando uma cruz (x) na última coluna ( Sazonal ). s a z o n a l 67. Diospiro Maior Frequência alimentar Menor Média A tua porção é: Quantidade 4 a 5 por dia 1 por dia 2 a 3 por dia 5 a 6 por sem 2 a 4 por sem 1 por sem 1 a 3 por mês VII. FRUTOS Porção Média 59. Maça, pêra 1 média 1 cacho médio 69. Uvas frescas 70. Frutos conserva pêssego, ananás 2 metades ou rodelas 71. Amêndoas, avelãs, nozes, amendoins, pistachio, etc. ½ chávena (descascado) 72. Azeitonas 6 unidades 60. Laranja, Tangerinas 1 média; 2 médias 1 média 62. Kiwi 61. Banana 1 médio 63. Morangos 1 chávena 64. Cerejas 1 chávena 65. Pêssego, Ameixa 1 médio; 3 médios 3 médios 68. Figo fresco, Nêsperas, Damascos 66. Melão, Melancia 1 fatia média 1 médio Nunca ou menos de 1 por mês 6 ou + por dia 6 ou + por dia Nunca ou menos de 1 por mês Draft ISPUP s a z o n a l 81. Croquetes, rissóis, bolinhos de bacalhau, etc. Frequência alimentar 3 unidades 1 colher sobremesa 1 colher sopa Meia pizza-média 84. Pizza 83. Molho de tomate, ketchup 82. Maionese 74. Cerveja 1 garrafa ou 1 lata 75. Bebidas brancas: whisky, aguardente, brandy, vodka, etc. 1 cálice 76. Coca-cola, pepsi-cola ou outras colas 1 garrafa ou 1 lata 77. Ice-tea 1 garrafa ou 1 lata 78.Outros refrigerantes, sumos de fruta ou néctares embalados 1 garrafa ou 1 copo 73. Vinho 1 copo 79.Café (incluindo pingo, meia de leite e outras bebidas com café) 1 chávena café 80. Chá preto e verde 1 chávena MaiorMédia Menor A tua porção é: VIII. BEBIDAS E MISCELANEAS 1 a 3 por mês 1 por sem 2 a 4 por sem 5 a 6 por sem 1 por dia 2 a 3 por dia 4 a 5 por dia 6 ou + por dia Porção Média Quantidade 1 médio 1 prato 86. Sopa de legumes 85. Hambúrguer Outros Alimentos 1 a 3 por mês 1 por sem 2 a 4 por sem 5 a 6 por sem 1 por dia 2 a 3 por dia 4 a 5 por dia Frequência alimentar Quantidade Porção Média s a z o n a l No grupo VIII - BEBIDAS E MISCELANEAS - neste grupo não consideres os sumos naturais (estes devem ser registados na tabela "OUTROS ALIMENTOS"), não te esqueças dos que são adicionados a outras bebidas, por exemplo: café da meia de leite. Coloca neste quadro informação relativa aos restantes alimentos ou bebidas que não estejam na lista anterior e que tenha consumido pelo menos 1 vez por semana mesmo em pequenas quantidades, ou numa época em particular. Por exemplo: alheiras, cevada, frutos secos (figos, ameixas, alperces), etc. 87. Frutos tropicais 88. Sumos de fruta natural 89. Tulicreme, Nutella 90. Snacks salgados (cheetos, etc.) 1 porção média 1 copo 1 colher de sobremesa 1 pacote pequeno Menor Média Maior A tua porção é: Nunca ou menos de 1 por mês 6 ou + por dia Nunca ou menos de 1 por mês Draft ISPUP