Testing and adapting dietary habits and food security questions for a national nutrition survey using cognitive interviews and expert consultation.

The aim of this paper is to describe innovations taking place in national nutrition surveys in the UK and the challenges of undertaking innovations in such settings. National nutrition surveys must be representative of the overall population in characteristics such as socio-economic circumstances, age, sex and region. High response rates are critical. Dietary assessment innovations must therefore be suitable for all types of individuals, from the very young to the very old, for variable literacy and/or technical skills, different ethnic backgrounds and life circumstances, such as multiple carers and frequent travel. At the same time, national surveys need details on foods consumed. Current advances in dietary assessment use either technological innovations or simplified methods; neither lend themselves to national surveys. The National Diet and Nutrition Survey (NDNS) rolling programme, and the Diet and Nutrition Survey of Infants and Young Children (DNSIYC), currently use the 4-d estimated diary, a compromise for detail and respondent burden. Collection of food packaging enables identification of specific products. Providing space for location of eating, others eating, the television being on and eating at a table, adds to eating context information. Disaggregation of mixed dishes enables determination of true intakes of meat and fruit and vegetables. Measurement of nutritional status requires blood sampling and processing in DNSIYC clinics throughout the country and mobile units were used to optimise response. Hence, innovations in national surveys can and are being made but must take into account the paramount concerns of detail and response rate.

Measures for Ascertaining Use of Colorectal Cancer Screening in Behavioral, Health Services, and Epidemiologic Research

Consider the last time you answered a questionnaire. Did it contain questions that were vague or hard to understand? If yes, did you answer these questions anyway, unsure if your interpretation aligned with what the survey developer was thinking? By the time you finished the survey, you were probably annoyed by the unclear nature of the task you had just completed. If any of this sounds familiar, you are not alone, as these types of communication failures are commonplace in questionnaires.1–,3 And if you consider how often questionnaires are used in medical education for evaluation and educational research, it is clear that the problems described above have important implications for the field. Fortunately, confusing survey questions can be avoided when survey developers use established survey design procedures. In 2 recent Journal of Graduate Medical Education editorials,4,5 the authors encouraged graduate medical education (GME) educators and researchers to use more systematic and rigorous survey design processes. Specifically, the authors proposed a 6-step decision process for questionnaire designers to use. In this article, we expand on that effort by considering the fifth of the 6 decision steps, specifically, the following question: “Will my respondents interpret my items in the manner that I intended?” To address this question, we describe in detail a critical, yet largely unfamiliar, step in the survey design process: cognitive interviewing. Questionnaires are regularly used to investigate topics in medical education research, and it may seem a straightforward process to script standardized survey questions. However, a large body of evidence demonstrates that items the researchers thought to be perfectly clear are often subject to significant misinterpretation, or otherwise fail to measure what was intended.1,2 For instance, abstract terms like “health professional” tend to conjure up a wide range of interpretations that may depart markedly from those the questionnaire designer had in mind. In this example, survey respondents may choose to include or exclude marriage counselors, yoga instructors, dental hygienists, medical office receptionists, and so on, in their own conceptions of “health professional.” At the same time, terms that are precise but technical in nature can produce unintended interpretations; for example, a survey question about “receiving a dental sealant” could be misinterpreted by a survey respondent as “getting a filling.”2 The method we describe here, termed “cognitive interviewing” or “cognitive testing,” is an evidence-based, qualitative method specifically designed to investigate whether a survey question—whether attitudinal, behavioral, or factual in nature—fulfills its intended purpose (B O X). The method relies on interviews with individuals who are specifically recruited. These individuals are presented with survey questions in much the same way as survey respondents will be administered the final draft of the questionnaire. Cognitive interviews are conducted before data collection (pretesting), during data collection, or even after the survey has been administered, as a quality assurance procedure. During the 1980s, cognitive interviewing grew out of the field of experimental psychology; common definitions of cognitive interviewing reflect those origins and emphasis. For example, Willis6 states, “Cognitive interviewing is a psychologically oriented method for empirically studying the way in which individuals mentally process and respond to survey questionnaires.” For its theoretical underpinning, cognitive interviewing has traditionally relied upon the 4-stage cognitive model introduced by Tourangeau.7 This model describes the survey response process as involving (1) comprehension, (2) retrieval of information, (3) judgment or estimation, and (4) selection of a response to the question. For example, mental processing of the question “In the past year, how many times have you participated in a formal educational program?” presumably requires a respondent to comprehend and interpret critical terms and phrases (eg, “in the past year” and “formal educational program”); to recall the correct answer; to decide to report an accurate number (rather than, for example, providing a higher value); and then to produce an answer that matches the survey requirements (eg, reporting “5 times” rather than “frequently”). Most often, comprehension problems dominate. For example, it may be found that the term “formal educational program” is variably interpreted. In other words, respondents may be unsure which activities to count and, furthermore, may not know what type of participation is being asked about (eg, participation as a student, teacher, or administrator). More recently, cognitive interviewing has to some extent been reconceptualized as a sociological/anthropological endeavor, in that it emphasizes not only the individualistic mental processing of survey items but also the background social context that may influence how well questions meaningfully capture the life of the respondent.8 Especially as surveys increasingly reflect a range of environments and cultures that may differ widely, this viewpoint has become increasingly popular. From this perspective, it is worth considering that the nature of medical education may vary across countries and medical systems, such that the definition of a term as seemingly simple as “graduate medical education” might itself lack uniformity.

To evaluate the association between maternal employment and breastfeeding (both duration and status) in Mexican mothers using data from three National Health and Nutrition Surveys conducted in 1999, 2006 and 2012. We analyzed data from the 1999 National Nutrition Survey, the 2006 National Nutrition and Health Survey, and the 2012 National Nutrition and Health Survey (NNS-1999, NHNS-2006 and NHNS-2012) on 5,385 mothers aged 12-49 years, with infants under 1 year. Multivariate logistic regression models were used to analyze the association between breastfeeding and maternal employment adjusted for maternal and infant's socio-demographic covariates. Maternal formal employment was negatively associated with breastfeeding in Mexican mothers with infants under 1 year. Formally employed mothers were 20 % less likely to breastfeed compared to non-formally employed mothers and 27 % less likely to breastfeed compared to unemployed mothers. Difference in median duration of breastfeeding between formally employed and unemployed mothers was 5.7 months for NNS-1999, 4.7 months for NNHS-2006 and 6.7 months for NNHS-2012 respectively (p < 0.05). In NHNS-2006 and NHNS-2012, health care access was associated with longer breastfeeding duration. Maternal employment has been negatively associated with breastfeeding in Mexican mothers of <1 year infants at least for the last 15 years. For Mexicans involved in policy design, implementation or modification, these data might offer robust evidence on this negative association, and can be used confidently as basis for conceiving a more just legislation for working lactating women.

Asian regions have been suffering from growing double burden of nutritional health problems, such as undernutrition and chronic diseases. National nutrition survey plays an essential role in helping to improve both national and global health and reduce health disparities. The aim of this review was to compile and present the information on current national nutrition surveys conducted in Asian countries and suggest relevant issues in implementation of national nutrition surveys. Fifteen countries in Asia have conducted national nutrition surveys to collect data on nutrition and health status of the population. The information on national nutrition survey of each country was obtained from government documents, international organizations, survey website of governmental agencies, and publications, including journal articles, books, reports, and brochures. The national nutrition survey of each country has different variables and procedures. Variables of the surveys include sociodemographic and lifestyle variables; foods and beverages intake, dietary habits, and food security of individual or household; and health indicators, such as anthropometric and biochemical variables. The surveys have focused on collecting data about nutritional health status in children aged under five years and women of reproductive ages, nutrition intake adequacy and prevalence of obesity and chronic diseases for all individuals. To measure nutrition and health status of Asian populations accurately, improvement of current dietary assessment methods with various diet evaluation tools is necessary. The information organized in this review is important for researchers, policy makers, public health program developers, educators, and consumers in improving national and global health.

Assessment of the status of health and nutrition of a population is imperative to design and implement sound public health policies and programmes. The various extensive national health and nutrition surveys provide national-level information on different domains of health. These provide vital information and statistics for the country, and the data generated are used to identify the prevalence and risk factors for the diseases and health challenges faced by a country. This review describes the various national health and nutrition surveys conducted in India and also compares the information generated by each of these surveys. These include the National Family Health Survey, District Level Household Survey, Annual Health Survey, National Nutrition Monitoring Bureau Survey, Rapid Survey on Children and Comprehensive National Nutrition Survey.

The UK population is living longer; therefore, promoting healthy ageing via positive nutrition could have widespread public health implications. Moreover, dietary fibre intake is associated with health benefits; however, intake is below UK recommendations (30 g/d). Utilising national dietary survey data can provide up-to-date information on a large representative cohort of UK older adults, so that tailored solutions can be developed in the future. This study used cross-sectional data from the National Diet and Nutrition Survey (years 2008–2009 to 2018–2019) for older adults’ (n 1863; 65–96 years) dietary fibre intake (three-to-four-day food diaries), top ten dietary fibre-rich foods, associated factors (demographics, dietary/lifestyle habits) and various health outcomes (anthropometric, blood and urine). Mean dietary fibre intake was 18·3 g/d (range: 2·9–55·1 g/d); therefore, below the UK dietary recommendations, with compliance at 5·7 %. In addition, there were five significant associations (P < 0·05) related to lower dietary fibre intake such as increasing age group, without own natural teeth, impaired chewing ability, lower education leaving age and poor general health. Older adults’ key foods containing dietary fibre were mainly based on convenience such as baked beans, bread and potatoes. Positively, higher dietary fibre consumption was significantly associated (P = 0·007) with reduced diastolic blood pressure. In summary, the benefits of dietary fibre consumption were identified in terms of health outcomes and oral health were key modulators of intake. Future work should focus on a life course approach and the role of food reformulation to help increase dietary fibre intake.

P61 Relationship Between Adults’ Dietary Habits and Food Security Status Amid COVID-19

BackgroundHigh-risk groups for COVID-19, such as ethnic minorities, also experience the greatest risk for micronutrient deficiencies including Vitamin D. Vitamin D may positively impact COVID-19 prevention and treatment, however, further...

Health benefits have been attributed to omega-3 long chain polyunsaturated fatty acids (n-3 LCPUFA). Therefore it is important to know if Australians are currently meeting the recommended intake for n-3 LCPUFA and if they have increased since the last National Nutrition Survey in 1995 (NNS 1995). Dietary intake data was obtained from the recent 2011–2012 National Nutrition and Physical Activity Survey (2011–2012 NNPAS). Linoleic acid (LA) intakes have decreased whilst alpha-linolenic acid (LNA) and n-3 LCPUFA intakes have increased primarily due to n-3 LCPUFA supplements. The median n-3 LCPUFA intakes are less than 50% of the mean n-3 LCPUFA intakes which highlights the highly-skewed n-3 LCPUFA intakes, which shows that there are some people consuming high amounts of n-3 LCPUFA, but the vast majority of the population are consuming much lower amounts. Only 20% of the population meets the recommended n-3 LCPUFA intakes and only 10% of women of childbearing age meet the recommended docosahexaenoic acid (DHA) intake. Fish and seafood is by far the richest source of n-3 LCPUFA including DHA.

SummaryThis review describes and present the findings of a survey of the diet and nutrition of young people aged 4–18 years living in private households in the UK, carried out between January 1997 and January 1998. The National Diet and Nutrition Survey (NDNS) of young people aged 4–18 years forms part of the NDNS programme, which aims to provide a comprehensive, cross‐sectional picture of the dietary habits, nutrient intakes and nutritional status of the British population by studying representative samples of defined age groups. The survey components included a detailed interview covering dietary habits, lifestyle and socio‐demographic characteristics; a 7‐day weighed dietary record; a 7‐day physical activity diary; measurements of height, weight, mid‐upper arm, waist and hip circumferences, and blood pressure; a blood sample for analysis of a range of nutritional status indices; a single urine sample; and an oral health interview and dental examination. A total of 1701 young people provided 7‐day dietary records, representing a response rate of 64%. Results have been published in two volumes covering the diet and nutrition survey and the oral health survey. The reports present results for boys and girls separately in four age groups: 4–6 years; 7–10 years; 11–14 years and 15–18 years. Results are also presented by region and by socio‐economic characteristics. This review summarises some of the main findings of the diet and nutrition survey, including: the proportion of young people who ate selected foods; energy and nutrient intakes compared with UK Dietary Reference Values; nutritional status; physical measurements; and physical activity.

Monitoring nutritional status of the population is essential in the development and evaluation of national or local health policies. In this study, we aimed to demonstrate analysis on the trends in dietary intake of energy and macronutrients, as well as Na, in Japanese population using the data of series of cross-sectional national surveys - the National Nutrition Survey (NNS) and the National Health Nutrition Survey (NHNS) - during the period from 1995 to 2016. The NNS and NHNS participants aged 20-79 years were included in the analysis. Dietary intake was estimated using 1-d household-based dietary record. The trend in total energy intake, energy intake from macronutrients (fat and protein), Na intake and energy-adjusted Na intake were analysed using regression models adjusted to 2010 age distribution and anthropometry status. A total of 94 270 men and 107 890 women were included the analysis. Total energy intake showed a decreasing trend in both men and women. Similarly, energy intake from protein decreased, but energy intake (%) from fat increased in both sexes. Energy-adjusted Na intake showed a decreasing trend in both men and women. This study identified the decrease in total energy intake and energy intake from protein, whereas there were inverse trends in energy intake from fat among Japanese adults. Continued monitoring of trends in dietary intake will be needed, and there should be efforts to increase the accuracy of current survey procedures.

Development of an accurate and efficient dietary method is required for national nutrition surveys. Some countries conduct dietary surveys and combine 24-h dietary records or 24-h dietary recalls with dietary questionnaires. This scoping review aimed to summarize studies that used results from national surveys that combined detailed dietary surveys (dietary records or 24-h dietary recall) and dietary questionnaires and identify the purpose of combining the two methods. The PubMed database and manual searches were used for the literature review. We extracted 58 articles from 16 national nutrition surveys from 14 countries. Most studies used 24-h dietary recall for detailed dietary surveys and the food frequency questionnaire (FFQ) or food propensity questionnaire (FPQ) for questionnaire surveys. Among 37 studies from eight countries, the purpose of combining the two dietary survey methods was to estimate energy and nutrient intakes from detailed dietary surveys and habitual food intake from questionnaires. These findings are useful as a reference when introducing new dietary survey methods in future national nutrition surveys.

The eight well-known food security indicators were developed in 1997 using a stepwise process that involved five focus group interviews (one Māori, one Pakeha, two Pacific, and one mixed ethnicity) of 8-16 people, all of whom were either on a low income or were government beneficiaries(1). As part of the development of the tools and methods for a future New Zealand National Nutrition Survey, these eight indicators were considered for inclusion. The Māori and Technical Advisory Groups convened for the development of the National Nutrition Survey foresaw issues with the interpretation of some of the questions given the changes in the food environment and sources of food assistance in the last 25 years and recommended that cognitive testing should be conducted to see if changes were required. Participants were recruited through two community organisations, a local marae, and community Facebook pages. Participants were given the option of participating in a one-on-one interview or as part of a focus group. During each session, participants were asked five (three original and two new) questions relating to food security (running out of basics, use of food assistance, household food preparation and storage resources). After each question, the participants were asked a series of additional probing questions to ascertain whether they had interpreted the question as intended. All interviews were audio recorded and transcribed, and a qualitative analysis was performed on the transcripts to determine areas of concern with each question. A total of 46 participants completed the cognitive testing of the food security questions, including 26 aged 18-64 years, and 20 aged 65+ years. Participants also spanned a range of ethnicities including 8 Māori, 15 Pasifika, 15 Asian, and 8 New Zealand European or Other. Just over half of the participants (n=24) reported themselves to be financially secure, 16 participants reported that their financial security was borderline, 1 participant reported that they were not at all financially secure, and 5 participants declined to answer. Variable interpretations of terms by participants were found in all questions that were tested. Therefore, answers to the food security questions may have not reflected the actual experience of participants. This study also identified other dimensions of food security not assessed by the current eight indicators (e.g., lack of time, poor accessibility). These findings indicate that the food security questions need to be improved to ensure they are interpreted as intended and that new questions are needed that considers all dimensions of food insecurity (i.e., access, availability, utilisation, and stability). These new and amended questions should be cognitively tested in groups that are more likely to be experiencing food insecurity.

To the Editor: The hypothesis that salt intake is a driver of soft drink consumption1 is an interesting one, but unfortunately this study takes us no further than speculation. Having experience in epidemiological analysis of the National Diet and Nutrition Survey, I beg to differ with the calculations in this article and also the authors’ interpretations. Specifically, I suggest the following: (1) the energy from soft drinks in the National Diet and Nutrition Survey is half what these authors estimate; (2) their study does not “demonstrate that salt is a major determinant of fluid and sugar-sweetened soft drink consumption during childhood” (only ≈2% of the …