Development of dish-based population-specific food frequency questionnaire for dietary assessments in Afghanistan

doi:10.21203/rs.3.rs-1592326/v1

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Development of dish-based population-specific food frequency questionnaire for dietary assessments in Afghanistan

https://doi.org/10.21203/rs.3.rs-1592326/v1

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Background: The burden of chronic diseases is increasing worldwide. Contribution of dietary intakes to such increasing trend is important. Meanwhile dietary intake assessment has an essential role in chronic disease studies and general public health outcomes. To measure dietary intakes in epidemiologic studies, various dietary assessment methods are used such as 24-hour recalls, food records or diaries and food frequency questionnaires (FFQs). FFQs can provide useful measures of dietary intakes.

Aim: This study aimed to report the development of a population-specific dish-based food frequency questionnaire (DFQ) to assess long-term usual dietary intakes in Afghanistan.

Method: We followed the Willet format to develop the appropriate DFQ for Afghanistan. We followed these steps to develop the questionnaire: listing commonly consumed Afghani foods, determining food groups, defining portion sizes and determining the frequency response options for each food item.

Result: We prepared a comprehensive list of foods and dishes commonly used in Afghanistan, based on the information we took from local people based on usual dietary intakes in Afghanistan. To simplify the questionnaire, we categorized dishes and food items in the questionnaire into eight major groups. Portion sizes for food items and mixed dishes were defined based on the most commonly consumed and understandable portion sizes for each item among Afghan general population. The frequency response options for each food item were defined separately in a row against the food list. The frequency option varied from “never or once a month” to “6 or more per day".

Conclusion: Finally a specific DFQ for Afghanistan, containing 103 food items or dishes was developed.

Food frequency questionnaire

Afghanistan

diet

epidemiologic studies

national nutrition surveys

nutrition assessment tool

Dietary intake assessment has an essential role in chronic disease studies and general public health outcomes [1–3]. Improving dietary habits along with environmental and lifestyle factors, is a major target in the prevention of non-communicable diseases (NCDs), such as cancer, cardiovascular diseases, diabetes and chronic kidney diseases [3, 4]. NCDs are rapidly increasing in low-income and low-middle income countries [5]. The potential causes of this rising burden need more investigations and taking preventative policies by the governments.

It has been demonstrated that long-term dietary intakes affect the risk of chronic conditions [3]. To measure dietary intakes in epidemiologic studies, various dietary assessment methods are used such as 24-hour recalls, food records or diaries and food frequency questionnaires (FFQs) [6, 7]. Methods such as 24-hour recalls and food records are associated with high subject burden[8]. FFQs can provide useful measures of dietary intakes [7]. It has widely been used in investigating the association between diet and chronic diseases in large population-based studies [9–13]. The advantage of this method includes its easy application, low respondent burden, self-administered method of use, less training of research staff and assessment of diet for long-term [12, 14]. Besides providing information on usual intakes of a particular food or a food group of interest, FFQs are particularly useful in identifying dietary patterns at the population level [14]. Measurement errors, which refer to the difference between reported dietary intake over a specified time period and true usual dietary intake, that might result in participants’ misclassification in terms of dietary intakes is a big concern in FFQ [11]. These errors can arise from the incomplete list of foods included in the questionnaire as well as inaccurate portion sizes.

Despite the availability of many FFQs in the world, there is a great variability in the foods consumed and in dietary culture in diverse populations [15–17]. A FFQ which is valid for one population may not be valid when applied to a second population [18]. On the other hand, most information on diet-disease association came from western and developed countries and such information is scarce in developing countries [19] and to the best of our knowledge almost nothing in Afghanistan.

As the burden of chronic diseases is increasing worldwide [20], the contribution of dietary intakes to such increasing trend is important [20]. To examine diet-disease associations in Afghanistan, development of a FFQ to measure long-term dietary intakes is mandatory. This study is therefore aimed to develop a population-specific FFQ to assess long-term usual dietary intakes in Afghanistan.

Development of the DFQ

In the current study, the Willet format was applied to develop a population-specific DFQ for Afghanistan [14]. Commonly, FFQs are used for the purpose of ranking individuals according to food or nutrient intake rather than for estimating absolute amounts of intake [15]. Meanwhile Willett’s FFQ, using a close-ended format, was developed with the primary objective of ranking individuals according to their usual dietary intake [21] but Block’s instrument was developed in the open-ended format to rank individuals as well as to estimate the absolute intake of several nutrients [21]. Therefore we preferred Willet format rather than Block Format for development of current DFQ. This effort was done to develop a suitable dietary assessment tool to examine usual dietary intakes in adult people in Afghanistan. The questionnaire was developed by taking the following steps. First, we listed commonly consumed Afghani foods. Then, definition of portion sizes was done and finally, frequency response options for each food item were defined. Development process of this DFQ is summarized in (Fig. 1). Here, we described each step in detail.

Food list construction

First, we created a comprehensive list of foods and dishes commonly used in Afghanistan, based on the information we took from local people. We asked local Afghan people to list their usual consumed foods in different meals (breakfast, lunch and dinner and snacks) throughout the year. This method was done in order to prevent missing major food items in different meals. Based on this listing of foods, we found that consumption of mixed dishes is high among Afghan population. Therefore, we aimed to design a dish-based FFQ rather than a food-item based questionnaire because it is bothersome for people to estimate usual intake of ingredients of mixed dishes. For example, Afghans consume meat in the form of several mixed dishes such as Kebab, Kofteh (meat balls), Manto, Dopiazeh, Qabli etc. Indeed, it is too difficult to estimate total meat intake of a person in the preceding 12 months, because the frequency consumption of meat in such a long period of time is extremely hard for participants to remember. Estimating the usual meat intake that comes from different sources would be very difficult for a person and might confuse participants. In addition, it is highly possible that some meat-containing dishes might be forgotten. On the other hand, estimating the amount and frequency of consuming every single dish is rather easy. Previous studies showed that questionnaire length has an important role in the survey response rate, as lengthy questionnaires may cause exhaustion and decrease the cooperation of participants [13, 22, 23]. As Afghans consume different mixed dishes, including all ingredients of these dishes would make the questionnaire too lengthy. Therefore, in order to shorten the DFQ and facilitate responding, we have included dishes and collapsed together some other dishes that have the same ingredients.

Foods and dishes that were nutrient-rich were included in the food list. In other words, nutritious food and dishes were included in the list. In addition, foods and dishes that had considerable contribution to between-person variation was also included. To find such foods and dishes, we discussed all foods and dishes in our prior comprehensive list and then selected the ones that might be different in different regions of the country. Then, a group of health specialists from Afghanistan discussed all the items and the foods rarely consumed were not included in the questionnaire.

Determination of Food Groups

To simplify the questionnaire, we categorized dishes and food items in the questionnaire into eight major groups: 1. Mixed dishes (cooked or canned), 2. Grains 3. Dairy products, 4. Sweets, 5. Fruits, 6. Vegetables, 7. Beverages, and 8. Miscellaneous food items.

Portion Size Determination

After determination of food groups, we discussed the portion size section. There was much diversity observed in portion sizes of foods and dishes common among Afghans. In addition, common portion sizes may vary from one region to another. Although, portion size estimation does not contribute significantly to between-person variation in dietary intake and might not help better ranking of individuals in terms of their dietary intakes, several well-designed FFQs in the world have portion size section [22]. In the current DFQ, portion sizes for each food item and mixed dishes were defined based on the most commonly consumed and understandable portion sizes among Afghan general population. Common portion sizes for each food item and a certain dish was discussed by a group of local health specialists. To make sure that public people understand the units and portion sizes in the questionnaire, we pilot tested the preliminary DFQ by administering it to a group of volunteer Afghans before its finalizations.

Frequency response options

According to Harvard FFQ [24], we used multiple choice frequency response options to facilitate responding. The frequency response options for each food item were separately defined in a row against the food list, rather than mentioning them in a column at the top of the page. Although this is different from the one used in Harvard FFQ[13], we believe that this can result in reducing errors in estimating frequency of foods and dishes consumed. The categories we used in this questionnaire varied from "never or less than once a month” to “6 or more times per day”. Participants should indicate their average frequency of consumption by checking 1 of the 9 frequency categories. Number of frequency response categories is not constant for all foods. For frequently consumed foods, we included 6–9 options and for infrequently consumed foods, we omitted options of high frequency.

Calculation of food and nutrient intakes

As mentioned above, the developed DFQ consisted of foods and dishes with standard portion sizes, usually consumed by Afghan people. To compute nutrient intakes from this newly-developed DFQ, we will convert all reported consumption frequencies of foods into grams per day by using household measures. To convert dishes into grams, first we listed the ingredients of the dishes listed in our DFQ. The ingredients of the dishes were discussed in a group of 3–4 local housewives and their consensus on ingredients was considered as the final ingredients of that specific dish in Afghanistan. To identify nutrient intakes for each individual, we converted all foods and dishes in the questionnaire to 103 individual foods. Then, using Nutritionist IV software, we computed total calorie, macronutrients and micronutrients for each individual by summing up nutrients from all foods.

In the current study, we reported the strategies used to develop a new population-specific DFQ in Afghanistan to assess long-term dietary intakes in epidemiological studies (Fig. 2). Many culture-specific FFQs have been developed to evaluate the dietary habits of culturally diverse population groups [25–29]. Designing a culture-specific FFQ includes some main steps, namely development of a complete and precise food list, determination of culture-specific food groups, and the definition of culturally appropriate portion sizes. Therefore, considering other studies [25, 26, 30, 31], our methodology was based on the above-mentioned guideline. The questionnaire was designed based on Willett- format [13], included 103 food items and mixed dishes along with appropriate portion sizes.

The FFQ has widely been used in investigating the association between diet and chronic diseases in large population-based studies [9–11, 13]. It is easy applicable and can reflect long-term usual dietary intakes. Although the accuracy of data from this type of dietary assessment method is lower than other methods, its low cost and easy-to-use format along with reflecting usual long-term dietary intakes has made this dietary assessment tool as an appropriate method in epidemiologic studies [14]. It is also useful in identifying dietary patterns at the population level [14]. Measurement errors, incomplete list of foods and inaccurate portion sizes have been considered as potential disadvantages of FFQs [11].

The main focus of the current study was to develop a population-specific easy-to-use comprehensive DFQ for assessment of dietary patterns and diet-disease association in epidemiological studies in Afghanistan. Considering the use of several mixed dishes in Afghanistan and low literacy of public in the country, we decided to design a dish-based questionnaire because most people, in particular men, are not aware of ingredients of the dishes.

Furthermore accuracy and precision of data collection may be improved by inclusion of dishes in the list of FFQ food items due to the following two reasons [32]. First, Non-communicable diseases (NCDs) are related to culture-specific cooking methods and ingredients [32–34]. Second, people may not report invisible components of a mixed dish in the FFQs without dishes because they are neither contributed in their cooking process nor can see the ingredients of different recipes. As a result, they cannot remember the consumption of mentioned foods [35].

Earlier studies in Iran, with a very close culture to Afghanistan, have also reported the development of a dish-based FFQ for assessment of dietary intakes. The same activity was also done in Korea, Bangladesh and Iran [15, 23, 35–37]. Almost all available studies have shown that DFQs can facilitate the evaluation of dietary intakes over a long period at populations with a high consumption of mixed dishes [23, 35]. The DFQ we developed in the current study contained 103 items (28 mixed dishes and 75 food items), while the one in Iran had 106 and 142 items [15, 35]. Number of foods and dishes in the DFQs developed in Bangladeshi and Korean was 42 and 112 items, respectively [23, 36]. We tried to develop a comprehensive questionnaire for assessment of dietary intakes. This is also the same for the questionnaires developed in Iran. However, the variability in the number of food items might be due to the cultural difference in the consumption of varied foods and dishes in a specific country as well as the main objective of the investigators.

In the current DFQ, we followed the Willet format [13]. However, the frequency response options in this DFQ was included in a row against each food item which is in contrast to Harvard Format [21]. The Willet format is widely used in FFQs developed in other parts of the world due to its easy application. The same approach has also been used in Iranian Dish-based FFQs with cultural similarity to Afghanistan [35]. However, it provides a categorical data, which might not provide enhanced precision in reporting dietary intakes [13].

In a conclusion, we developed a new population-specific DFQ in Afghanistan, which can be used as an instrument for assessment of long-term dietary intakes as well as diet-disease associations in Afghanistan. The next step should be assessment of validity and reliability of this questionnaire before its application in large scale studies among Afghan population.

This DFQ is not validated yet and we are working on its validation.

Acknowledgements

Not applicable

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors

Availability of data and materials

The dataset generated and/or analyzed during the current study are available from the corresponding author on a reasonable request.

Conflict of interests

Not declared

Ethics approval and consent to participate
This is study is approved by Tehran University of Medical Sciences (TUMS) ethical committee with approval ID 0f TUMS.VCR.REC.1399.567.
Informed consents were obtained from all study participants.
Helsinki Declaration is considered through all stages of this study and all methods were carried out in its accordance.
Authors’ contributions

All three authors have made important contribution to this article: MRJ and AE designed the study, MRJ and AMB prepared the food list. MRJ drafted the manuscript. AE edited the manuscript. All three authors reviewed the manuscript and approved the final version.

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No competing interests reported.

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Development of dish-based population-specific food frequency questionnaire for dietary assessments in Afghanistan

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