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Pilot Study of the Validity and Reliability of Brief Fruit, Juice and Vegetable Screeners among Inner City African-American Boys and 17 to 20 Year Old Adults

Department of Behavioral Science-Box 243, The University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Boulevard, Houston, Texas (K.W.C., T.B., J.B., C.d.M.)
Quintiles, P. O. Box 13979, Research Triangle Park, North Carolina (D.H.)

Address reprint requests to: Karen Cullen DrPH, RD, LD, Department of Behavioral Science-Box 243, UT M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX 77030-4095

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS DISCUSSION APPLICATION REFERENCES

 
Objective: Compare the validity and reliability of a one-week fruit, juice and vegetable (FJV) food frequency questionnaire (FFQ) that does not require averaging in response categories and one-week food recognition form (FRF) against three to four 24-hour dietary recalls (24hdr) among mostly African-American boys and 17 to 20 year-old adults for possible use in subsequent intervention studies.

Design: In Study One, the FFQ was administered to 40 boys in four Boy Scout (BS) troops on two occasions separated by two weeks. The FRF was administered to 36 boys in four other BS troops after school on six school days, covering seven consecutive days. All these boys completed four 24hdr, including one Sunday. In Study Two, 56 17 to 20 year-old adults completed the FFQ during telephone interviews on two occasions two weeks apart. In between, they completed three 24hdr by telephone interview on one weekend and two weekdays.

Subjects/Setting: Participants in Study One were members of eight urban BS troops, and in Study Two were high school (HS) seniors and recent HS graduates. BS data were collected at times scheduled for troop meetings or immediately after school. The young adult group completed telephone interviews in the evenings and on weekends.

Main Measures: This research compared a FJV FFQ and a FJV FRF (incorporating the same 24 foods) against three to four 24hdr conducted using NDS software from the University of Minnesota.

Statistical Analyses Performed: Descriptive statistics, intraclass correlations, Spearman correlations, corrections for attenuation.

Results: The first FFQ provided substantially higher mean consumption estimates for both groups. The FFQ had moderate reliability across assessments and moderate validity coefficients for fruit and total FJV combined for the BS sample. The FRF had higher validity coefficients for juice. The FFQ had moderate reliability and poor validity among the young adult group. Correction for measurement error in the 24hdr substantially increased validity coefficients to high levels for BS fruit and total FJV and to moderate levels for the HS groups, with some exceptions.

Applications/Conclusions: FFQ more validly assessed fruit and combined FJV consumption for the nine to 14 year-old BS but overestimated mean values. FRF means were closer to those of the 24hdr and were more valid for assessing juice consumption. The FFQ had moderate validity among the young adult group but overestimated consumption. Further research is needed on simpler methods of reporting diet in these age groups.

Key words: fruit, juice, vegetables, food frequency questionnaire, boy scouts, young adults, reliability, validity, food recognition form, 24-hour dietary recall

	INTRODUCTION

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Dietary behavior change trials require some dietary assessment method to evaluate the impact of the intervention on consumption. Methods should be valid and reliable, yet impose a reasonable burden on participants. Since each target group and social setting for conducting dietary assessments (e.g. schools, Boy Scout troop meetings, public housing projects) impose different constraints on the methods for dietary data collection (e.g. time available, competing activities, comprehension and educational level), validation studies need to be conducted in each new setting.

A standard for measuring dietary intake has been the food record. While seven-day food records (FR) obtained among students in elementary schools may obtain reasonably accurate reporting of foods consumed on any included day [1], the substantial day-to-day variability in food records implies that multiple weeks of consumption may be necessary to assess dietary intake of fruit, juice and vegetables (FJV) at a desired level of reliability of 0.8 [2]. Requiring 30 to 60 minutes per day, multiple weeks of daily assessments impose a substantial burden on participants and disruption of the schools they attend, are more expensive to administer, code, and evaluate [2,3], and provide minimal opportunity to prompt and verify record completion [1,2].

Less intensive methods such as food frequency questionnaires (FFQ) assess usual intake over specified periods of time, e.g., one month, one year. FFQs have been shown to provide moderately reliable and valid (as determined by correlations) estimates of adult subjects’ nutrient intakes, but not mean dietary intake [3–8]. FFQs assessing diet over one-week to one-year time periods have been tested among elementary school children [4,6,9,10] and adolescents [3,6]. Several FFQs have demonstrated substantial reliability [1,4,6,11] in ranking children’s and adolescents’ nutrient intake, but not precise mean intake [3,6,8]. However, these FFQs have had negligible validity in regard to foods consumed by children across several studies [4,9]. Part of the validity problem may have been difficulty in recalling foods consumed over a lengthy period of time [12,13] and the substantial day-to-day variability of intake [2] that requires participants to perform arithmetic computations to average usual consumption to fit into the usual FFQ response categories. Abbreviating the time of report, e.g. to one week, limiting selections to FJV items and simplifying the response format to reporting only the number of servings consumed in the past week address these problems and may improve FFQ validity for children. If shown to be valid, this FJV-FFQ could then be used as a measure of mean FJV intake among both children and adolescents.

Children’s memory of foods consumed appears to seriously deteriorate beyond the first day [12]. A simple daily food recognition form (FRF) [14], which taps recognition memory for consumption of foods on a list as opposed to recall memory [5], may speed daily food intake recording and thereby capture the accuracy of the seven-day food record in less time.

No brief dietary assessment tool has been validated as a measure or mean intake with predominantly African-American (AA) youth or with young adults. No study has validated the FRF with AA youth.

This paper describes the validity of a one-week FFQ as a measure of fruit, juice and vegetable intake among these two groups: 17 to 20 year-old young adults and an inner city group of nine to 14 year-old boys enrolled in urban Boy Scouts. This paper also compares the accuracy of a FRF as a measure of FJV consumption among nine to 14 year-old urban Boy Scouts.

	MATERIALS AND METHODS

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Participants
This research was conducted with two separate groups during the spring of 1997. The African-American boys were involved in the developmental phase of a project adapting the GIMME 5 curriculum for increasing FJV consumption among elementary school children [15] to the practices, abilities and circumstances of inner-city African-American Urban Boy Scouts [16]. African-American males were targeted because of their high rates of prostate cancer [17]. Urban Scouting is a program designed to bring Boy Scouting into areas where there are few volunteer leaders [16]. The scouts for this research were recruited from eight urban boy scout troops. All scouts provided signed assent, and their parents provided signed informed consent.

The 17 to 20 year-old young adults were a convenience sample of 59 HS seniors and recent HS graduates who were recruited at a local HS. All 17 to 20 year-old participants provided signed consent, and parents of students less than 18 years old provided informed consent. Both projects were approved by the UT-MDACC Institutional Review Board.

Design
Urban Boy Scouts.
Eight troops were randomly assigned to complete either the FFQ or the FRF. Troops in the FFQ group completed a first FFQ at one troop meeting and a second FFQ at a troop meeting two weeks later, under the direction of trained data collectors. In the interim, the boys completed four 24hdr conducted by trained data collectors (undergraduate dietetic students) who met the boys after school. The data collectors completed three days of training and passed the NDS certification test. In most cases one of these recalls covered a Sunday to assess weekend consumption. A two-week time interval was employed to minimize the obtrusiveness of four 24hdr on children’s dietary recording.

Troops in the FRF group completed the FRF for the day of the first troop meeting and each day of the week until the next week’s troop meeting. Four 24hdr were conducted by trained data collectors (undergraduate dietetic students) in the time immediately after school and one of the recalls covered a Sunday. All boy scouts received small gifts for participating.

Young adults.
Participants agreed to five phone interviews over a two-week period, scheduled in advance at the participants’ convenience. The FFQ was completed at calls one and five. At calls two to four, three 24hdr were obtained, representing one weekend and two weekdays. Participants received $25 for completing all five interviews.

Dietary Assessment Methods
Food Frequency Questionnaire (FFQ).
The FJV FFQ included 24 fruit, juice and vegetable items identified from the 1994 CSFII [18] data as the most common sources for youth aged nine to 20 years. One open-ended item labeled "other fruit or juice" and another labeled "other vegetables" were provided. To minimize memory burden, the time interval was the previous week or seven days. To minimize issues in arithmetic conversions (dealing with variability across days in consumption and the conversions required by usual word response categories), seven categories of response identifying number in previous week were employed: none, 1 serving, 2–3 servings, 4–6 servings, 7 servings, 8–14 servings, 15 or more servings in the last week. The FFQ was a single-page optical scanning form with instructions at the top of the form, including: "A serving of F or V is a single helping. If you have seconds, you count that as two servings." Boys were instructed in completion of the form and then allowed to complete it by themselves, with a staff member present to answer questions. During the telephone interview, the young adults were asked how many servings of each FJV were eaten in the past week and were read the response categories.

Food Recognition Forms (FRF).
Similar to earlier versions of this form [10,13], the FRF included separate lists of FJV foods for breakfast, lunch, after school snack, supper/dinner and after supper/dinner snack. For each meal/snack, the boys selected from a list of where that meal/snack was eaten in order to prompt their memory for that meal/snack, followed by a listing of foods (from the same list of 24 used for the FFQ) likely to have been consumed at that meal/snack. Lunch and dinner included separate complete lists of the 24 foods. Each meal/snack had open ended "other 100% juice," "other fruit" and "other vegetable" options for write in. Students were instructed about what juices were 100% fruit juice. The FRF was a five-page optical scanning form with circles to be filled for each of seven consecutive days. Instructions at the top of the first page specified a "serving of F or V is a single helping." The task was to fill in a circle if a child had a serving or more of that F, J or V at that meal/snack for each day (with no indication of number of servings). The forms were completed at the end of the school day. To minimize data loss, project data collectors distributed forms each day, instructed the boys in completion and allowed them to complete the form for the previous 24 hours. A staff member was always present to answer questions.

24 Hour Dietary Recalls (24hdr).
The 24hdrs were conducted according to the Gimme 5 New Orleans protocol [19], using a laptop computer and NDS software [20], including plastic food models and dimensional and volume reporting aids for the boy scouts. The young adults received a set of 2-dimensional food models. According to NDS procedures, food consumption for the previous day is first prompted sequentially by meal and recorded in the computer. With a near complete list, more detailed information is requested for each food. Additional foods consumed are often remembered during the detailed probing. At the end of the probing, the data collector reads what she or he has recorded and asks for verification and completeness. At the end of the recall, the data collector shows pictures displaying collages of foods to make a final memory prompt. A copy of the protocol is available from the senior author on request. 24hdr, using NDS, have been demonstrated to be valid among children [21]. 24hdr completed by telephone have been found to provide accurate data from adolescents [22,23].

Coding of 24 Hour Dietary Recalls.
FJV consumption was hand-coded from the 24hdr [1,2]. A protocol was developed that categorized fruit, vegetables and 100% fruit juice by food group and/or mixed food item. For this behavioral approach to determining FJV intake, serving sizes were those identified in the Food Guide Pyramid: 1/2 cup cooked vegetable, 6 ounces 100% fruit or vegetable juice, 1 piece of fruit, 1 cup leafy vegetable, and 1/2 cup canned fruit. Mixed dishes had to provide at least 1/2 serving of fruit juice or vegetable per usual serving of the item and were categorized as high fat, if appropriate. Standard recipes were used to estimate amounts. For example, one cup of beef stew with vegetables was credited with providing one serving of vegetable. A hamburger sandwich with two slices of tomato and lettuce was credited with providing 1/2 serving of vegetable. No credit was given to condiments.

Data Analyses
Means and standard deviations were calculated for both samples, for each method of data collection. Intra-class correlations (ICC) using individual as the between group factor were calculated to assess reliability of assessment across days (intraindividual variability) for the 24hdr and the FRF (Table 3). This reliability ICC_R uses the single assessment ICC_S and factors in the number of days of assessment:

Spearman correlations estimated the validity of assessment between methods. Due to documented low reliability (low ICCs) in the standard, the relationships between methods were corrected for the ICC by dividing the correlation by the square root of the ICC [11].

	RESULTS

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A first FFQ was completed on 40 urban boy scouts, a second FFQ and up to four 24hdr were collected on 32 scouts (see Table 1). These scouts were predominantly African-Americans and 10 to 12 years of age (see Table 1). Fifty-nine young adults completed the first FFQ, and 56 completed the second and three 24hdr (see Table 1). A completed seven-day FRF and up to four 24hdr were collected on 36 urban boy scouts.

View larger version (32K): [in this window] [in a new window]   Fig. 1. Mean number of servings of fruit, juice and vegetables combined for 25 randomly selected cases in the 24-hour dietary recall group where the ICC=0.48.

View larger version (33K): [in this window] [in a new window]   Fig. 2. Mean number of servings of fruit, juice and vegetables combined for 25 simulated cases with an ICC=0.80 across four days.

View larger version (36K): [in this window] [in a new window]   Fig. 3. Mean number of servings of fruit, juice and vegetables combined for 25 randomly selected cases in food recognition form where the ICC=0.78.

The Spearman correlations between methods to assess validity varied by food group and form (see Table 4). Correlations were higher for the first BS-FFQ with vegetables and FJV combined. The validity coefficients corrected for the ICC were substantially higher than the uncorrected values, but the patterns did not change. Among the HS group, the Spearman correlations were low between the FFQ1 and 24hdr, and higher for fruit and juice on the second FFQ administration. The corrected coefficients increased validity to a modest level for the first administration.

	DISCUSSION

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Focusing on the first FFQ as most comparable to common use of this method, the Spearman correlations for servings of foods within the fruit, vegetable and total FJV categories, between the FFQ and 24-hour recalls for the boy scouts in this study are somewhat higher than those obtained between FFQ and seven-day food records obtained from fourth and fifth grade students [4] and similar for nutrient values unadjusted for total calories consumed among nine to 18 year-old youth [6]. However, the Spearman correlations for the HS sample were lower than previous work with older adolescents and college-age students [3,6,8]. The generally higher correlations for the BS group (except for juice) could be due to the shorter FFQ (24 vs. 45 items), the simplified frequency method of reporting or the somewhat older sample in this study. Random variation is also a potential explanation. The first previous study did not use juice as a separate reporting category [4]; this may account for its lower validity for fruit and juices combined.

For the BS, the FFQ exhibited substantially higher corrected correlations with 24hdr for fruit and FJV, but the FRF exhibited substantially higher correlations for fruit and juice and FJV. The corrected values for the HS sample were also similar to those reported in previous research [3,6,8]. The mean values were much higher for the FFQ than the FRF or 24hdr for all three groups. This pattern of findings suggests that the FFQ with simplified response categories is the preferred method for assessing a week’s FJV consumption, unless the focus is juice consumption or a precise estimate of mean consumption is desired. The reason for the differential validity of the FFQ versus the FRF by food group is not clear. Adjustment for unreliability in the 24hdr increased many of the validity coefficients into the high levels.

The ICCs were low to moderate for the BS 24hdr, somewhat higher for the HS group and substantially higher across days of the FRF for the BS group. The low ICCs reflect the substantial day-to-day variability of consumption of FJV as reported in other papers [2] and seen in Figs. 1 and 3. The higher ICC values for the HS sample, based on only three days, suggests substantially less day-to-day variability (or higher consistency) in FJV consumption in the HS, than the BS, samples. The values were higher for the FRF because of the larger number of days of assessment [3] than for the 24-hour recalls [3] as can be seen in the high variability for an ICC=.78 for seven days (Fig. 3) versus four days (Fig. 2). These low to moderate ICCs minimize the attractiveness of 24hdr for assessing usual consumption because of the large number of days or even weeks necessary to reliably assess diet [24]. Other research supports the accuracy (validity) of the FRF for assessing consumption for a particular day [13] and as a measure of group intake [25]. The moderate correlations between FFQs in both samples suggest that these FFQs be administered more than once in studies to achieve higher levels of reliability.

The second administration of the FFQ revealed lower mean consumption for both the HS and BS groups (Table 2), as reported elsewhere [3,9]. While this could be interpreted as a learning effect (from multiple administrations of the FFQ and 24-hour recalls), the generally lower correlations among boy scouts of the second FFQ with the twenty-four recalls for vegetables and FJV (Table 4) suggest that the lower values reflect either a lower attentiveness to diet or to an overburdening with reporting required during a short period of time, e.g. boredom with assessment. Lower correlations of the second FFQ with a standard were not found in school samples elsewhere [9] or among the HS group, suggesting that displacement of usual school activities by dietary assessment might be valued by students, but displacement of voluntary boy scout activity time is not valued. Other differences between studies, however, include the all-male and slightly older nature of the current sample. No declines in correlations with a standard were detected across annual assessments of an FFQ among third-to-fifth-grade students [11], further suggesting boredom with assessment over so many determinations in a short period of time in the current study.

The strengths of this study include the minority group composition of the samples and the sophisticated analyses. The sample size is comparable to others in the literature and has the statistical power to detect meaningful food correlations in research or validations of dietary assessment methods. Using only three to four 24hdr for assessing the criterion limits the reliability of criterion assessments, but corrections for this unreliability were estimated. Neither group was a random sample, limiting generalization to general population. All data were from self-report. Collecting more days of 24hdr to enhance the reliability is not feasible with most participants and could result in even worse validity with the boy scout sample.

	APPLICATION

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Among nine to 14 year-old African-American boys, a one-week FFQ with simplified response categories is the preferred method of dietary assessment for fruit, vegetables, and fruit, juice and vegetables combined (if accurate estimates of mean consumption are not needed), but a FRF is preferred for juice consumption. For young adults, the one-week FFQ appears comparable to other brief FFQ instruments for use in epidemiological research, but is not an accurate measure of mean FJV consumption. Further research needs to confirm these results and explain the differences in methods.

	ACKNOWLEDGMENTS

 
Portions of this research were supported by the National Cancer Institute (CA 73503) under a Minority Enhancement Award.

	FOOTNOTES

 
Portions of this manuscript were presented at the Third International Conference on Diet Assessment Methods, Arnheim, The Netherlands, in May 1998.

Received December 1, 1998. Accepted May 1, 1999.

	REFERENCES

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