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Development of a quantitative food frequency questionnaire for Brazilian patients with type 2 diabetes

  • Roberta Aguiar Sarmento1,
  • Bárbara Pelicioli Riboldi2,
  • Ticiana da Costa Rodrigues1, 3,
  • Mirela Jobim de Azevedo1, 3 and
  • Jussara Carnevale de Almeida1, 2, 3Email author
BMC Public HealthBMC series ¿ open, inclusive and trusted201313:740

DOI: 10.1186/1471-2458-13-740

Received: 18 February 2013

Accepted: 7 August 2013

Published: 9 August 2013

Abstract

Background

To investigate the association between dietary components and development of chronic diabetic complications, the dietary evaluation should include a long period, months or years. The present manuscript aims to develop a quantitative food frequency questionnaire (FFQ) and a portfolio with food photos to assess the usual intake pattern of Brazilian patients with type 2 diabetes to be used in future studies.

Methods

Dietary data using 3-day weighed diet records (WDR) from 188 outpatients with type 2 diabetes were used to construct the list of usually consumed foods. Foods were initially clustered into eight groups: “cereals, tubers, roots, and derivatives”; “vegetables and legumes”; “fruits”; “beans”; “meat and eggs”; “milk and dairy products”; “oils and fats”, and “sugars and sweets”. The frequency of food intake and the relative contribution of each food item to the total energy and nutrient intakes were calculated. Portion sizes were determined according to the 25th, 50th, 75th, and 95th percentiles of intake for each food item.

Results

A total of 62 food items were selected based on the 3-day WDR and another 27 foods or how they are prepared and nine beverages were included after the expert examination. Also, a portfolio with food photos of each included food item and portion sizes was made to assist the patients in identifying the consumed portion.

Conclusions

We developed a practical quantitative FFQ and portfolio with photos of 98 food items covering those most commonly consumed in the past 12 months, to assess the usual diet pattern of patients with type 2 diabetes in Southern Brazil.

Keywords

Food frequency questionnaire Type 2 diabetes mellitus Food record Epidemiologic methods

Background

The field of nutritional epidemiology has been developed because of an interest in the concept that aspects of diet may influence the occurrence of human disease [1]. In the case of patients with diabetes, dietary advice and assessment of compliance with these recommendations are important for achieving metabolic goals, especially glycemic control [2].

There are several methods for the assessment of food and nutrient consumption as well as energy intake, including 24-hour recall, food records, food frequency questionnaire (FFQ), and biomarkers [3]. To investigate the association between dietary components and development of chronic diabetic complications, the dietary evaluation should include a long period, months or years, as is the case of FFQ. To date, four FFQs involving patients with diabetes have been validated and published in specific populations: Australian [4], Japanese [5], Malian [6], and Korean [7]; however, none was made for the Brazilian population. In fact, the FFQ should represent regional habits and the accuracy of such data needs to take this into account [8].

In drawing up an FFQ, careful attention must be given to the choice of foods, the clearness of the questions, and the format of the frequency response section. In addition, the choice of foods, especially if the FFQ is constructed to also include quantitative or semi-quantitative dietary evaluation, should be based on an accurate dietary tool [9]. In this way, the present manuscript aims to create an FFQ and a portfolio with food photos to assess the usual intake pattern of Brazilian patients with diabetes to be used in future studies.

Methods

Study population

Patients were identified belonged to the Group of Nutrition in Endocrinology (GNE), a cohort of outpatients with type 2 diabetes in southern Brazil [10]. The GNE study was designed to evaluate possible associations of dietary factors with chronic complications of diabetes. From a previously constructed database of patients with type 2 diabetes [11] data from consecutive registered patients who reported a plausible ratio of protein intake estimated from the 3-day weighed diet records (WDR) to protein intake from urinary nitrogen [12] were selected. The acceptable ratio between the two protein intake estimates ranged from 0.79 to 1.26 [12]. An equal seasonal distribution (1:1:1:1 spring, summer, autumn, and winter) and the same gender proportion (1:1 males and females) between each season were also considered inclusion criteria. Therefore, records from 188 patients with type 2 diabetes were analyzed.

This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving patients were approved by the Hospital Ethics Committee. Written informed consent was obtained from all patients.

The new instrument: food frequency questionnaire

The most frequently consumed foods and their respective portion sizes were extracted from 3-day WDR (two nonconsecutive weekdays and one-weekend day) to create the FFQ and the food portfolio photo. All registered foods and preparation methods were listed and clustered into eight groups as proposed by the Food Guide for the Brazilian Population [13]: “cereals, tubers, roots, and derivatives”; “vegetables and legumes”; “fruits”; “beans”; “meat and eggs”; “milk and dairy products”; “oils and fats” and “sugars and sweets”. The caloric and non caloric beverages were added into a new group, according to the WDR description (“beverages group”).

Data analyses

A food item was classified according to its relative contribution, at least 80%, for daily energy or intake of a selected relevant nutrient (K nutrient) in its respective food group. The relative contribution was calculated by the equation proposed by Block et al. [14] [% K nutrient contribution by food = (amount of the K nutrient provided by food × 100) / amount of the K nutrient provided by all foods]. The most relevant nutrients in each food group were selected considering their influence on glucose metabolism [1518] and/or diabetic complications [15, 1922] and are described in Table 1. Information about the nutritional composition of each food and regional ingredients used in their preparation was based on NutriBase Clinical® software (1986-2013 CyberSoft, Inc. an Arizona corporation). This software used the USDA Nutrient Database for Standard Reference [23]. Nutrient data on frequently consumed foods were complemented if necessary with data obtained from local manufacturers of specific industrialized foods.
Table 1

The most relevant nutrients in each food group considering their influence on glucose metabolism and/or diabetic complications

Food group

Nutrients

Cereals, tubers, roots and derivatives

Carbohydrate

Vegetables and legumes

Fiber, iron, calcium, and potassium

Fruits

Carbohydrate, fiber, and potassium

Beans

Protein, fibers, and iron

Meat and eggs

Protein, lipids, and iron

Milk and dairy products

Protein, lipids, and calcium

Oils and fats

Lipids

Sugars and sweets

Carbohydrate

The size of servings of each food item was classified according to its respective weight distribution as registered in the WDR: small = 25th percentile, medium = 50th percentile, large = 75th percentile, and extra large = 95th percentile [24]. Figure 1 shows an example of food portions as illustrated in the food portfolio photo. The amount of each portion in grams or milliliters was transformed into household measures using the Table for Assessment of Food Intake in Household Measures [25]. The FFQ also included open questions about the frequency of food consumption and an option to include new foods according to personal eating habits. The frequency was described as the number of times the food was consumed and also if the intake occurred daily, weekly, monthly, or yearly.
https://static-content.springer.com/image/art%3A10.1186%2F1471-2458-13-740/MediaObjects/12889_2013_Article_5687_Fig1_HTML.jpg
Figure 1

Illustration of four portions of the same food (chayote cooked) photographed and included on the food portfolio.

In order to obtain an expert examination, the constructed FFQ was submitted to health researchers used to dealing with diabetes care: endocrinologists, nutritionists, and researchers from the GNE [10]. After the experts’ meeting, changes were made in the food list and definition of portion sizes. Regional dishes and seasonal foods were also included according to suggestions.

Portfolio with food photos

The construction of the portfolio with food photos was based on the methodology suggested by Monteiro et al. [26]. Digital photographs were taken of each portion of food from the FFQ and organized in the order in which they were mentioned, considering the four portion sizes and food groups (Figure 1). A numerical legend was also created to explain details about the each portion (amount in grams or milliliters) and keep patients blinded to serving sizes. The food portions were determined with an analytical scale (Marte ®, from 0.01 to 2000 g) and measuring cup (50-250 mL; Marinex, Brazil). The solid foods were arranged in the same plate meal size to perform the pictures, in order to help the patients acquire a perspective of size.

Results

The main features of 188 patients with type 2 diabetes were: 61.1 ± 10.1 years of age (range 34-80 years), males 50.0%, 12 years (6-18 years) of diabetes duration, BMI of 28.8 ± 4.3 kg/m2; HbA1c of 7.5 ± 1.4%, 42.5% from lower middle class, and 84.4% self-identified as whites. The patients performed 3-day WDR, totaling 564 WDR during all seasons: 25% (n = 141) in winter, 25% (n = 141) in spring, 25% (n = 141) in summer, and 25% (n = 141) in autumn.

Initially, a list of 177 different food items was compiled based on data from the WDR and the number of food items in each food cluster was as follows: “cereals, tubers, roots, and derivatives” - 39 food items; “vegetables and legumes” - 34 food items; “fruits”- 22 food items; “beans” - 5 food items; “meat and eggs” - 27 food items; “milk and dairy products” - 14 food items; “oils and fats” - 7 food items; “sugars and sweets”- 16 food items; “beverages” - 13 food items. Subsequently, only 62 food types were included in the FFQ, considering the 80% cutoff contribution in its respective food group. The reported frequency of each included food item with respective relevant nutrient is shown in Table 2. The most frequently consumed foods by patients with diabetes included white rice (94.1%), papaya (87.2%), beans (78.2%), French or Vienna bread (75.5%), banana (71.8%), and tomato (71.3%). Furthermore, another four food items (lettuce, beef, chicken, and margarine) were reported by more than 50% of this patient sample. After expert examination, 21 regional foods (fruits, vegetables, sweets, and fats), six different types of food preparations, and nine beverages were included in the food list.
Table 2

Food list from food frequency questionnaire for diabetes: registered consumption frequency of 188 patients with type 2 diabetes and nutrient contribution

  

Nutrient contribution*

Foods

Subjects consuming this food

Calories

Carbohydrate

Protein

Lipid

Fiber

Iron

Calcium

Potassium

n

%

Cereals, tubers, roots and derivatives

          

  White rice

177

94.1

yes

yes

yes

no

yes

yes

no

yes

  French or Vienna bread

142

75.5

yes

yes

yes

yes

yes

yes

yes

yes

  Spaghetti pasta

76

40.4

yes

yes

yes

no

yes

yes

no

yes

  Wheat cracker

82

43.6

yes

yes

yes

yes

yes

yes

yes

yes

  Whole bread

78

41.4

yes

yes

yes

yes

yes

yes

yes

yes

  Cassava, boiled

41

21.8

yes

yes

no

no

yes

no

no

yes

  Cake

35

18.6

yes

yes

no

yes

yes

yes

no

yes

  Maize porridge

23

12.2

yes

yes

no

no

yes

yes

no

yes

  Potato, boiled/baked

82

43.6

yes

yes

no

no

yes

no

no

yes

  Homemade bread

24

12.7

yes

yes

no

no

no

yes

no

no

  White bread

35

18.6

yes

yes

no

no

no

yes

yes

no

  Milk cracker

27

14.3

yes

yes

no

yes

no

yes

yes

no

Vegetables and legumes

          

  Carrot

77

40.9

no

no

no

no

yes

no

yes

yes

  Cabbage

56

29.7

no

no

no

no

yes

yes

yes

yes

  Tomato

134

71.2

no

no

no

no

yes

no

no

yes

  Chayote

34

18.0

no

no

no

no

yes

no

no

yes

  Lettuce

112

59.5

no

no

no

no

no

yes

yes

yes

  Kale

37

19.6

no

yes

no

no

no

yes

yes

yes

  Broccoli

22

11.7

no

no

no

no

no

no

no

yes

  Pumpkin

17

9.0

no

no

no

no

no

no

no

yes

  Beet

20

10.6

no

no

no

no

no

no

no

yes

Fruits

          

  Banana

135

71.8

yes

no

no

no

yes

yes

no

yes

  Apple

92

48.9

yes

yes

no

no

yes

no

no

yes

  Orange

58

30.8

yes

yes

no

no

yes

no

yes

yes

  Tangerine

51

27.1

yes

yes

no

no

yes

no

yes

yes

  Papaya

164

87.2

yes

yes

no

no

yes

no

yes

yes

  Mango

16

8.5

no

no

yes

no

no

no

no

no

  Pear

19

10.1

no

no

no

no

yes

no

no

no

Beans

          

  Beans (all types)

147

78.1

yes

yes

yes

no

yes

yes

yes

yes

  Lentil

16

8.5

yes

yes

no

no

yes

yes

no

yes

Meat and eggs

          

  Beef, boiled/baked

122

64.8

yes

no

yes

yes

no

yes

yes

yes

  Chicken, boiled/baked

123

65.4

yes

no

yes

yes

no

yes

yes

yes

  Ground beef

63

33.5

yes

no

yes

yes

no

yes

yes

yes

  Beef steak

64

34.0

yes

no

yes

yes

no

yes

no

yes

  Luncheon/bologna

43

22.8

yes

no

yes

yes

no

yes

no

yes

  Fish, boiled/baked

21

11.1

yes

no

yes

yes

no

no

no

yes

  Pork

28

14.8

yes

no

yes

yes

no

yes

no

yes

  Fish, fried

9

4.7

yes

no

no

yes

no

no

no

yes

  Chicken, fried

14

7.4

yes

no

yes

no

no

no

no

yes

  Frankfurter wiener, hot dog

15

7.9

no

no

no

yes

no

no

no

no

  Mortadella

35

18.6

no

no

no

yes

no

no

no

no

  Salami

23

12.2

no

no

no

yes

no

no

no

no

  Beef, fried

8

4.2

no

no

no

yes

no

no

no

no

  Egg, boiled/fried

22

11.7

no

no

no

yes

no

no

no

no

  Beef liver

6

3.1

no

no

no

no

no

yes

no

no

  Ham

48

25.5

no

no

no

no

no

no

no

yes

Milk and dairy products

          

  Muenster cheese

76

40.4

yes

no

yes

yes

no

no

yes

no

  Milk, fluid, 3.25% fat

73

38.8

yes

yes

yes

yes

no

no

yes

yes

  Milk, fluid, nonfat

78

41.4

yes

yes

yes

no

no

no

yes

yes

  Goat cheese, soft type

32

17.0

no

no

no

yes

no

no

yes

no

  Muenster cheese

12

6.3

no

no

no

yes

no

no

yes

no

  Milk, fluid, 2% fat

19

10.1

no

no

no

no

no

no

yes

yes

  Yogurt, plain

10

5.3

no

no

no

no

no

no

yes

no

  Milk type C

10

5.3

no

no

no

no

no

no

yes

no

  Yogurt, plan, skim

8

4.2

no

no

no

no

no

no

yes

no

  Milk, dry, whole

10

5.3

no

no

no

no

no

no

yes

no

  Yogurt, fruit

6

3.1

no

no

no

no

no

no

yes

no

  American cheese

11

5.8

no

no

no

no

no

no

yes

no

Oils and fats

          

  Margarine

101

53.7

yes

no

no

yes

no

no

no

no

  Goose pate

23

12.3

no

no

no

yes

no

no

no

no

  Mayonnaise

19

10.1

no

no

no

yes

no

no

no

no

Sugars and sweets

          

  Flan and/or pudding diet

8

4.2

no

no

no

no

no

no

yes

no

*Nutrient contribution defined as contribution of at least 80% of total energy or relevant nutrient intake in the respective food group.

The final version of the FFQ consisted of 98 food items and beverages distributed into nine groups: eight food groups and one of beverages. The preparation options (fried, boiled, cooked or roasted) were considered in food items of the “cereals, tubers, roots, and derivatives” and “meats and eggs” groups. The FFQ is shown in Additional file 1. All included food items contributed 95% of the total energy and nutrient intake as follows: total energy (94.2%), protein (96.8%), carbohydrate (92.8%), fat (94.6%), fiber (90.3%), iron (93.4%), calcium (95.3%), and potassium (92.2%). The portions of each food in grams or milliliters and its respective number of portions in household measures are shown in Table 3.
Table 3

Final food list in the food frequency questionnaire: portions in grams or milliliters and household measures

Food group

Small (25th)

Medium (50th)

Large (75th)

Extra large (95th)

Cereals, tubers, roots, and derivatives

        

  White rice

2 full tablespoon

50 g

4 full tablespoon

100 g

5 full tablespoon

125 g

8 full tablespoon

200 g

  Spaghetti pasta

3 full tablespoon

75 g

4 full tablespoon

100 g

1 paten

200 g

1 full paten

320 g

  Cassava, boiled/fried

2 pieces

60 g

3 pieces

90 g

4 pieces

120 g

6 pieces

240 g

  Potato, boiled/baked/fried

2 full tablespoon

60 g

3 full tablespoon

90 g

4 full tablespoon

120 g

6 full tablespoon

180 g

  Maize porridge, boiled/fried

1 serving spoon

60 g

2 full tablespoon

90 g

3 full tablespoon

150 g

1 paten

325 g

  French or Vienna bread

½ unit

25 g

1 unit

50 g

1 and ½ unit

75 g

2 units

100 g

  White bread

1 slice

25 g

2 slice

50 g

2 and ½ slices

62.5 g

3 and ½ slices

87.5 g

  Whole bread

½ slice

15 g

1 slice

30 g

2 slices

60 g

3 slices

90 g

  Homemade bread

2/3 slice

60 g

1 slice

68 g

1 and ½ slice

86 g

2 and ½ slices

145 g

  Cake

1 small slice

50 g

1 medium slice

70 g

1 large slice

90 g

2 medium slices

140 g

  Wheat cracker

4 units

20 g

6 units

30 g

9 units

45 g

20 units

100 g

  Milk cracker

5 units

25 g

8 units

40 g

11 units

55 g

32 units

160 g

Vegetables and legumes

        

  Carrot

2 full tablespoon

24 g

3 full tablespoon

36 g

5 full tablespoon

60 g

10 full tablespoon l

120 g

  Tomato

3 small slices

30 g

5 small slices

50 g

7 small slices

70 g

7 medium slices

100 g

  Chayote

1 full tablespoon

30 g

2 full tablespoon

60 g

3 and ½ full tablespoon

100 g

5 full tablespoon

145 g

  Cabbage

4 full tablespoon

40 g

7 full tablespoon

70 g

10 full tablespoon

100 g

6 full medium skimmer

150 g

  Lettuce

1 tagger

20 g

2 taggers

30 g

5 medium leaf

50 g

1 full paten

80 g

  Watercress

1 full dessert plate

20 g

2 taggers

30 g

1 full paten

80 g

2 full patens

160 g

  Kale, spinach

2 full tablespoon

40 g

3 full tablespoon

60 g

5 full tablespoon

100 g

9 full tablespoon

180 g

  Broccoli, cauliflower

1 small bunch

30 g

1 medium bunch

60 g

1 large bunch

100 g

2 medium bunches

130 g

  Snap bean

2 level tablespoon

30 g

2 full tablespoon

40 g

5 full tablespoon

100 g

15 full tablespoon l

300 g

  Pumpkin

1 medium piece

50 g

2 medium pieces

100 g

2 and ½ medium pieces

125 g

6 medium pieces

300 g

  Beet

2 medium slices

30 g

5 medium slices

60 g

8 medium slices

90 g

12 medium slices

140 g

Fruits

        

  Banana

1 small unit

40 g

1 medium unit

70 g

1 large unit

90 g

2 medium units

140 g

  Apple, pear

1 small unit

90 g

1 and ½ small unit

135 g

1 medium unit

150 g

1 large unit

230 g

  Orange, tangerine

1 small unit

90 g

1 and ½ small unit

135 g

1 large unit

180 g

2 medium units

225 g

  Papaya

½ small slice

80 g

1 medium slice

100 g

¼ unit

135 g

½ unit

270 g

  Mango

1 small piece

60 g

2 small pieces

120 g

1 medium pieces

140 g

6 small pieces

360 g

  Grape

8 units

64 g

14 units

112 g

1 small bunch

170 g

1 medium bunch

350 g

  Persimmon

1 small unit

85 g

1 large unit

150 g

2 medium units

220 g

3 small units

255 g

  Casaba melon

½ small slice

78 g

1 small slice

125 g

1 medium slice

200 g

1 large slice

300 g

  Watermelon

1 small slice

143 g

1 medium slice

200 g

1 large slice

282 g

2 medium slices

350 g

Beans

        

  Beans (all types)

1 small full scoop

65 g

1 level medium scoop

80 g

2 small full scoop

130 g

2 level medium scoop

160 g

  Lentil

1 level medium scoop

100 g

1 medium full scoop

160 g

2 level medium scoop

200 g

2 medium full scoop

320 g

Meat and eggs

        

  Beef, boiled/baked/fried

1 small slice

70 g

4 small pieces

80 g

1 large slice

135 g

2 large slices

270 g

  Ground beef

2 full tablespoon

50 g

3 full tablespoon

75 g

4 full tablespoon

100 g

8 full tablespoon

200 g

  Beef steak

½ small unit

40 g

1 small unit

80 g

1 medium unit

100 g

2 medium units

200 g

  Beef liver

½ large unit

75 g

1 small unit

80 g

1 medium unit

100 g

1 large unit

150 g

  Chicken thigh, boiled/baked/fried

1 medium piece

60 g

1 large piece

95 g

2 medium pieces

110 g

3 medium pieces

180 g

  Chicken breast, boiled/baked/fried

1 medium piece

60 g

1 large piece

95 g

2 medium pieces

110 g

3 medium pieces

180 g

  Fish, boiled/baked/fried

½ small piece

60 g

1 small piece

100 g

1 large piece

155 g

2 large pieces

310 g

  Pork, boiled/baked/fried

1 small slice

60 g

1 medium slice

90 g

1 large slice

120 g

2 medium slices

180 g

  Luncheon/bologna

½ unit

30 g

1 unit

60 g

1 and ½ units

90 g

2 and ½ units

150 g

  Frankfurter wiener, hot dog

1 unit

42 g

1 and ½ unit

63 g

2 units

84 g

3 and ½ units

147 g

  Mortadella, ham, salami

1 medium slice

15 g

1 large slice

25 g

2 medium slices

30 g

2 large slices

50 g

  Egg, boiled/fried

½ unit

25 g

1 unit

50 g

1 and ½ unit

75 g

3 units

150 g

Milk and dairy products

        

  Milk, fluid, 3.25% fat

½ cup

100 ml

¾ cup

150 ml

1 cup

200 ml

1 mug

300 ml

  Milk, fluid, 2% fat

½ cup

100 ml

¾ cup

150 ml

1 cup

200 ml

1 mug

300 ml

  Milk, fluid, nonfat

¾ cup

150 ml

1 cup

200 ml

1 glass

240 ml

1 and ½ cups

250 ml

  Milk, dry

1 full tablespoon

16 g

2 full dessert spoon

18 g

2 full tablespoon

32 g

4 full tablespoon

36 g

  Mozzarella cheese

1 slice

20 g

1 and ½ slice

30 g

2 slices

40 g

3 slices

60 g

  Ricotta cheese

1 small slice

15 g

1 medium slice

35 g

1 large slice

45 g

2 large slices

90 g

  Muenster cheese

1 small slice

25 g

1 medium slice

35 g

1 large slice

50 g

2 medium large slices

70 g

  Sour cultured, Cream half-half

1 teaspoon

10 g

1 level tablespoon

15 g

1 full tablespoon

25 g

4 level tablespoon

60 g

  American cheese

1 level dessert spoon

10 g

1 level tablespoon

15 g

1 full tablespoon

30 g

2 full tablespoon

60 g

  Yogurt, plan

½ pot

100 g

1 pot

200 g

1 and ½ pots

300 g

2 pots

400 g

  Yogurt, fruit

1 pot

100 g

1 and ½ pots

150 g

2 pots

200 g

3 pots

300 g

Oils and fats

        

  Margarine

1 level teaspoon

4 g

1 full teaspoon

8 g

1 level dessert spoon

13 g

1 full dessert spoon

23 g

  Butter

1 level teaspoon

4 g

1 full teaspoon

8 g

1 level dessert spoon

13 g

1 full dessert spoon

23 g

  Mayonnaise

1 full teaspoon

6 g

2 full teaspoon

12 g

1 full dessert spoon

17 g

2 full dessert spoon

34 g

  Goose pate

1 full teaspoon

8 g

2 full teaspoon

16 g

1 full dessert spoon

21 g

3 full dessert spoon

63 g

  Oil, add

1 teaspoon

2 ml

2 teaspoon

4 ml

1 dessert spoon

5 ml

1 tablespoon

8 ml

Sugars and sweets

        

  Sago

3 full tablespoon

90 g

4 full tablespoon

120 g

5 full tablespoon

150 g

6 full tablespoon

180 g

  Chocolate

2 pieces

15 g

3 pieces

30 g

4 pieces

40 g

8 pieces

80 g

  Flan, pudding

1 full tablespoon

50 g

2 full tablespoon

90 g

3 full tablespoon

130 g

5 full tablespoon

220 g

  Ice cream

1 full tablespoon

55 g

1 ball

75 g

1 cup

100 g

2 balls

150 g

  Gelatin

2 full tablespoon

50 g

3 full tablespoon

75 g

5 full tablespoon

125 g

12 full tablespoon

300 g

  Condensed milk

1 level teaspoon

10 g

1 level dessert spoon

15 g

1 full tablespoon

40 g

2 full dessert spoon

50 g

  Jelly

1 full teaspoon

10 g

2 full teaspoon

20 g

1 full tablespoon

34 g

2 full tablespoon

68 g

  Honey

1 dessert spoon

10 g

1 tablespoon

15 g

2 dessert spoon

20 g

2 tablespoon

30 g

  Chocolate, dry

1 level dessert spoon

7 g

1 level tablespoon

11 g

1 full tablespoon

16 g

2 full tablespoon

32 g

Beverages

        

  Coffee, brewed

¼ cup

50 ml

½ cup

100 ml

¾ cup

150 ml

1 cup

200 ml

  Coffee, instant

1 teaspoon

1.5 g

2 teaspoon

3 g

4 teaspoon

6 g

6 teaspoon

9 g

  Tea

¾ cup

150 ml

1 cup

200 ml

1 and ¼ cups

250 ml

1 mug

300 ml

  Soft drink

1 cup

200 ml

1 full glass

250 ml

1 can

350 ml

2 full glass

500 ml

  Fruit juice raw

¾ cup

150 ml

1 cup

200 ml

1 full glass

250 ml

2 cups

400 ml

  Fruit juice artificial

¾ cup

150 ml

1 cup

200 ml

1 full glass

250 ml

2 full glass

500 ml

  Soymilk

¾ cup

150 ml

½ glass

175 ml

1 cup

200 ml

1 full glass

250 ml

  Beer

1 glass

300 ml

1 bottle

600 ml

1 and ½ bottles

900 ml

6 bottles

3600 ml

  Wine

½ glass

75 ml

¾ glass

115 ml

1 glass

150 ml

2 glass

300 ml

The FFQ also included open questions about frequency of food consumption and eight queries about food preferences and usual dietary practices: number of meals per day, type of sweetener added in beverages, type and amount of fat used in food preparation, if intake of visible fat from meats, the habit of salt added in prepared foods and salads, and other foods and/or seasonings not listed but regularly consumed.

Discussion

Patients with diabetes are encouraged to comply with specific dietary recommendations to achieve optimal glucose, lipid, and blood pressure control as well as a healthy body weight [2]. These aspects can modify the food intake of patients with diabetes as compared to the general population. We constructed a quantitative FFQ and a portfolio with photos of 98 food items distributed into nine food groups and based on WDR performed by patients with type 2 diabetes. This is the first FFQ for Brazilian type 2 diabetes patients.

The development of an FFQ should take into account some important aspects such as drawing up the food list, definition of portion intake [8], and how representative of the dietary habits of a population-based sample is the food list [1]. Our FFQ took into account the foods most commonly consumed by patients with type 2 diabetes and, as recommended, represents the regional dietary habits [1] in Southern Brazil. In addition, the cultural and clinical appropriateness of food items included in our FFQ was assured by using as reference the 3-day WDRs, a dietary instrument previously standardized, validated [12, 27], and widely used in diabetic patients by our research group [11, 2830]. It is also important to keep in mind that these WDR were performed throughout the year because it is known that portion sizes and food types can vary according to season [31] and the gender distribution was equal, since gender also influences food intake [31].

The final food list was drawn up considering the contribution criteria of each relevant nutrient to minimize the omission of usually consumed food [14]. It should be noted that nutrients known to influence glucose, lipid, or blood pressure control, or that have been associated with chronic diabetic complications were considered to choose the relevant nutrients for the food list. The number of food items in the final version of the FFQ is appropriate according to suggestions found in the literature [32] and similar to other FFQs for diabetes around the world [57]. Small food lists (less than 50 items) may underestimate food intake, and very long lists (more than 100 items) may tire respondents and overestimate food intake [32].

The FFQ in the present study also includes a quantitative evaluation of food intake. The size of portions (quartiles of intake) was based on the weight of consumed foods assessed by 3-day WDR. These portions, specific for each food item, were shown as photos and as household measures in the food portfolio and can be easily used for respondents to select their own portion size [8]. Finally, the FFQ structure including open questions provides greater freedom to choose the actual frequency of food intake and reduces the error of consumption categories by the patients [32]. The frequency of food consumption was considered in this FFQ (day, week, month, or year). However, care should be taken when assessing the consumption of a particular food per year. The diary conversion of intake is necessary to minimize the contribution of the foods scarcely consumed in evaluating the eating habits of the individual [8].

Conclusions

In conclusion, we developed a practical quantitative FFQ and a portfolio with 98 food items covering the past 12 months and representing the usual food intake of patients with type 2 diabetes in Southern Brazil. This relatively long-term evaluation of food intake can be particularly relevant for prospective studies that evaluate associations of diet with chronic diabetic complications. However, this dietary instrument should be validated in other samples of patients.

Declarations

Acknowledgments

This study was partially supported by Fundo de Incentivo à Pesquisa e Eventos – Hospital de Clínicas de Porto Alegre and Fundação de Amparo à Pesquisa do Estado do Rio Grande do Sul (ARD-FAPERGS 01/2010). RAS received scholarships from Fundação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES), and BPR from Programa Institucional de Bolsas de Iniciação Científica - Conselho Nacional de Desenvolvimento Científico e Tecnológico.

Authors’ Affiliations

(1)
Endocrinology Division, Hospital de Clínicas de Porto Alegre, Universidade Federal do Rio Grande do Sul
(2)
Nutrition Graduate Program, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre
(3)
Department of Internal Medicine, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul, Porto Alegre

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Copyright

© Sarmento et al.; licensee BioMed Central Ltd. 2013

This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://​creativecommons.​org/​licenses/​by/​2.​0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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