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

  • Roberta Aguiar Sarmento1,

    Affiliated with

    • Bárbara Pelicioli Riboldi2,

      Affiliated with

      • Ticiana da Costa Rodrigues1, 3,

        Affiliated with

        • Mirela Jobim de Azevedo1, 3 and

          Affiliated with

          • Jussara Carnevale de Almeida1, 2, 3Email author

            Affiliated with

            BMC Public Health201313:740

            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.
            http://static-content.springer.com/image/art%3A10.1186%2F1471-2458-13-740/MediaObjects/12889_2013_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
            (3)
            Department of Internal Medicine, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul

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            33. Pre-publication history

              1. The pre-publication history for this paper can be accessed here:http://​www.​biomedcentral.​com/​1471-2458/​13/​740/​prepub

            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.