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Reproducibility and construct validity of a food frequency questionnaire for

assessing dietary intake in rural and urban Asian Indian adults

Article in Asia Pacific Journal of Clinical Nutrition · January 2020

DOI: 10.6133/apjcn.202003_29(1).0025

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192 Asia Pac J Clin Nutr 2020;29(1):192-204

Original Article

Reproducibility and construct validity of a food

frequency questionnaire for assessing dietary intake in
rural and urban Asian Indian adults

Vasudevan Sudha MSc1, Ranjit Mohan Anjana MD, PhD2, Parthasarathy Vijayalakshmi
MSc1, Nagarajan Lakshmipriya MSc1, Natarajan Kalpana MSc1, Rajagopal Gayathri MSc1,
Rahavan Durga Priyadarshini MSc1, Hutgikar Madhav Malini MSc1,
Chandrasekaran Anitha MCA1, Mohan Deepa PhD3, Sekar Sathish Raj BSc3, Kumar
Parthiban MSc3, Rajappan Ramakrishnan BSc3, Gunasekaran Geetha MSc1, Kamala
Krishnaswamy MD1, Ranjit Unnikrishnan MD, FRCP2, Viswanathan Mohan DSc2
1
Department of Foods, Nutrition & Dietetics Research, Madras Diabetes Research Foundation, Chennai,
Tamil Nadu, India
2
Department of Diabetology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India
3
Department of Epidemiology, Madras Diabetes Research Foundation, Chennai, Tamil Nadu, India

Background and Objectives: To evaluate the reproducibility and construct validity of the Madras Diabetes Re-
search Foundation FFQ (MDRF-FFQ) with biomarkers for its use in epidemiological settings in India. Methods
and Study Design: The MDRF-FFQ was administered to 500 participants representing rural and urban areas of
10 Indian states, twice at an interval of 12 months. Reproducibility was assessed using intra cluster correlation
coefficients (ICC). Construct validity of carbohydrate and fat intake was assessed using baseline serum lipids by
regression analysis. Results: Reproducibility as measured by ICC was 0.50-0.77 for saturated fatty acids (SFA)
and energy in urban and 0.61-0.72 for protein and SFA in rural areas. The ICC for food groups was 0.53-0.77 for
whole grains, fruits and vegetables in urban and 0.50-0.89 for animal foods and whole grains in rural areas. After
adjusting for potential confounders, carbohydrate intake was positively associated with serum triglycerides (TG)
(β [SE]: +2.3 [0.72] mg/dL; p=0.002) and inversely with high density lipoprotein cholesterol (HDL) (β [SE]:-0.48
[0.12], p<0.001), while dietary fat and SFA (% Energy) were positively associated with HDL, low density lipo-
protein (LDL) and total cholesterol and inversely with TG. Conclusions: The MDRF-FFQ can be considered as a
reliable and valid tool to measure the long-term dietary exposure in respect of macronutrient intakes in Indian
populations despite diverse dietary practices.

Key Words: food frequency questionnaire, reproducibility, validity, biomarkers, serum lipid

INTRODUCTION es form the main courses of the daily meals irrespective

The increasing burden of non-communicable diseases of the population’s main dietary habits (vegetarian or
(NCD) globally as well as in India1 can be largely ex- non-vegetarian).5-7 Most of the National Surveys con-
plained by the adoption of unhealthy dietary practices2 ducted in India have used dietary records, dietary recalls
consequent on the so-called “nutrition transition”. As- or semi-structured interviews to assess the nutritional
sessment of long-term dietary habits in the population is status and time trends of food and nutrient intake, in rural
an essential first step in devising meaningful nutrition and urban areas. 8,9 Other noteworthy studies like the
strategies for prevention and management of NCDs. The
Food Frequency Questionnaire (FFQ) is the most widely Corresponding Author: Dr RM Anjana, Madras Diabetes Re-
used tool in large nutrition epidemiological studies.3 The search Foundation & Dr. Mohan’s Diabetes Specialities Centre,
use of validated FFQs enhances elucidation of the rela- WHO Collaborating Centre for Non-Communicable Diseases,
tionship of the diet to disease risk. ICMR Centre for Advanced Research on Diabetes, IDF Centre
Dietary intake assessments are challenging, especially of Excellence in Diabetes Care, 4, Conran Smith Road, Gopala-
puram, Chennai - 600 086, India.
in India where there exist diverse cuisines and a wide
Tel: (9144)4396 8888; Fax: (9144)2835 0935
variety of regional and cultural food habits and practices.4
Email: [email protected]
However, Indian diets are comprised, in general, of a ce- Manuscript received 05 September 2019. Initial review com-
real staple and are meal-based (breakfast, lunch and din- pleted 08 October 2019. Revision accepted 16 December 9
ner) in most regions of India. Cereal based food choic- doi: 10.6133/apjcn.202003_29(1).0025
 Reproducibility and validity of FFQ for Asian Indians 193

Figure 1. Regions across India where the FFQ data was collected.

Indian Migration study (IMS)10 Chennai Urban Rural plasma lipids.13,14 It is known that obese and overweight
Epidemiology Study (CURES)7,11 and Prospective Urban individuals with higher intake of energy from either fat or
Rural Epidemiology (PURE) Study12 have used validated carbohydrate or both are likely to have higher blood li-
FFQs for diet-disease risk studies in India.7,10,12 These pids.13,14 However, such biomarker-based validation stud-
studies, however, have their own limitations; for instance, ies have not been carried out in India where carbohydrate
the IMS FFQ was restricted to a selected industrial and and fat together contribute almost 80-90% to the daily
rural migrant population while the CURES and PURE energy intake.11,15
developed FFQs separately for urban and rural popula- In view of this, a comprehensive, structured, quantita-
tions in India.7,10-12 The lack of a single common FFQ tive national FFQ covering a wide range of commonly
poses challenges in assessing rural and urban diets and consumed rural and urban Indian foods was developed
their association with chronic disease prevalence. Consid- and pre-tested with the help of visual aids by the Madras
ering the common availability of many regional food Diabetes Research Foundation (MDRF). The present
choices in both rural and urban areas10 today, it was study aims to evaluate the reproducibility of the Madras
thought worthwhile to develop a single common FFQ for Diabetes Research Foundation FFQ (MDRF-FFQ) over a
both rural and urban areas of India covering north, south, 12- month period and also to estimate the construct va-
east, west and northeastern regions. lidity for the measurement of carbohydrate and total fat
Reproducibility of an FFQ over longer periods of time intake using serum lipids as a biomarker in Asian Indian
(e.g. 12 months) points to the stability of food and nutri- adults from rural and urban areas of all the regions (north,
ent estimates and is a much-needed feature to assess the south, east, west and northeast) of India.
diet and chronic diseases risk in large epidemiological
studies. Biomarkers provide objective assessments, albeit METHODS
of an intermediate kind, and may minimize subjective Study participants
dietary measurement error (recall from memory) which The study was conducted during 7th May 2011 to 5th
often occurs with self -reported dietary intake. The use of June 2012. Urban and rural areas of 9 States and 1 Union
‘gold standard’ recovery biomarkers such as double- Territory representing north, south, east, west and north-
labeled water for energy intake and 24 hr urinary sodium eastern regions of India were randomly chosen for the
measurement for sodium intake are impractical in the study. These were: Karnataka and Tamil Nadu (southern
epidemiological setting due to the constraints of feasibil- region), Punjab and Chandigarh (Union Territory) from
ity and expense.3 Studies from the West have attempted the northern region, Bihar and Jharkhand (eastern region),
to validate macronutrient (carbohydrate and fats) intake Gujarat and Maharashtra (western region) and Arunachal
(as assessed by FFQs) with biochemical markers such as Pradesh and Tripura (northeastern region) (Figure 1). The
194 V Sudha, RM Anjana, P Vijayalakshimi, N Lakshmipriva, N Kalpana, R Gayathri et al

Figure 2. Reproducibility and Validity of MFFQ – Study design.

participants for this study were chosen using a stratified nutritionists and dietitians from each region were contact-
multistage sampling design (similar to the one employed ed to provide missing regional foods, if any, in the 24
in the India National Family Health Survey-3).16 From hour recall data. Based on these, an extensive list of
one district from each State/Union Territory, two census foods/food preparation methods was complied. Food
enumeration blocks (CEB) in urban areas and three vil- items with similar ingredients and method of preparation
lages in rural areas were randomly selected. From 10 ran- were grouped together to reduce the length of the ques-
domly selected households from each selected CEB or tionnaire. Thus, the MDRF-FFQ has a food list contain-
village, 1 adult participant (of either sex) was randomly ing 236 food items capturing both rural and urban food
selected (2 CEBs x 10 households = 20; 3 villages x 10 choices of India.
households = 30). Therefore, 50 participants (≥20 years) The food items listed in the MDRF-FFQ were catego-
from each State were selected, making for a total of 500 rized into the usually prepared portion sizes (small / me-
participants, of whom 463 participated in the study (re- dium / large) and portion utensils (ladle / cup / tsp / tbsp
sponse rate = 92.6%) (Figure 2). The Institutional Ethics etc.) based on the average weight of the food samples
Committee at MDRF approved the study and written in- collected from various commercial and non-commercial
formed consent was obtained from each participant before sources. Frequency of intake was measured using 5 cate-
commencing the study. The study is registered in the gories (“never,” “daily”, “weekly”, “monthly” and “year-
Clinical Trials Registry of India- ly”). Study participants were asked to report the usual
(REFCTRI/2008/000174). frequency (open ended) as the number of times that best
represented their dietary habits over the past one year [for
Reproducibility and construct validity of MDRF-FFQ instance a food item consumed 3 times weekly was
Information on the most frequently consumed foods was marked as “3” under the weekly column of the FFQ (us-
separately collected by a data driven approach using 24 h ing a visual Food Atlas as an aid)].
dietary recalls among randomly chosen individuals (not MDRF-FFQ is an interviewer administered self- re-
those individuals selected for the present study) from all ported paper-based questionnaire.7 Trained interviewers
the selected states. Single 24-hour recall was collected by (n=6) with good inter-rater agreement (ICC 0.84) admin-
face-to-face interview during the household visit (De- istered the MDRF-FFQ during the period of May 2011 to
cember 2010 to February, 2011). The 24-hour recall in- June 2012. To test reproducibility, the MDRF-FFQs were
cluded either a weekday or a weekend day. The partici- administered 2 times to the same participants (n=463) at
pants were requested to recall all the food and drinks con- an interval of 12 months (MDRF-FFQ 1 and MDRF-FFQ
sumed over the last 24 hours in a systematic way (from 2) with the visual aid of photographic Atlas of Indian
morning till night) with the help of visual aids. In addition, Foods containing the pictures of various portion sizes.17
 Reproducibility and validity of FFQ for Asian Indians 195

In this study, the reported carbohydrate and fat intake determined using the cut-off PAL value.22 Basal metabol-
expressed as percentage of energy were compared with ic rate (BMR) of the participants was calculated using
serum lipids-triglycerides; HDL cholesterol, total and low age- and sex-specific equations for Indians23 to test the
density lipoprotein (LDL) cholesterol respectively for extent of under-reporters of total energy using <1.2 ratio
estimating construct validity. of EI/BMR as cut off.24

Anthropometric assessments Statistical analysis

Anthropometric measurements and blood pressure were Analyses were carried out using the statistical analysis
assessed using standardized methods. 15 Height (in centi- software (SAS version 9.0; SAS Institute Inc. Cary, NC).
meters) was measured using a stadiometer (SECA Model The individual’s average daily nutrient intake of the listed
214, Seca Gmbh Co, and Hamburg, Germany) and weight food items in the FFQ was computed by multiplying the
(in kilograms) by an electronic weighing scale (SECA reported frequency with serving size and per-portion nu-
Model 807, SecaGmbh Co). Waist circumference was trient content using the in-house EpiNu [food and nutrient]
measured with a non-stretchable measuring tape. Individ- database (Version 1 India: Madras Diabetes Research
uals were asked to keep both feet together and look Foundation; 2006). The EpiNU database consists of a
straight ahead. The smallest horizontal girth between the collection of a wide range of recipes gathered from dif-
iliac crest and the coastal margins at the end of expiration ferent sources. In addition to available data for Indian
was measured as the waist circumference.18 Body mass foods, other nutrient composition tables like United State
index was calculated using the formula weight in kilo- Department of Agriculture (USDA) database and Malay-
grams/height in meters squared. Blood pressure was rec- sian food composition tables were used to ensure the best
orded in the sitting position in the right arm to the nearest possible assessment of nutrient data. Similarly, glycaemic
1 mmHg using the electronic OMRON machine (Omron index (GI) values of Indian foods were derived from
Corporation, Tokyo, Japan). Two readings were taken 5 those available in the International GI table in addition to
minutes apart and their mean was taken as the blood pres- published literature on GI of Indian foods (Epinu 2006).25
sure. All food groups and nutrients were adjusted for total en-
ergy to reduce the measurement error and between-person
Biochemical assessments variation in the food and nutrient intake, using the residu-
Blood samples were obtained after 8-10 hours of fasting al method with total energy intake as the independent
for biochemical assessments only during the FFQ1 die- variable and the absolute nutrient and food group intake
tary data collection time point. The fasting venous sample as the dependent variable. Significance of differences
was centrifuged within 1 hour of collection at the survey between regions was tested using Kruskal Wallis test as
site, and serum was transferred to separate labeled vials the data was not normally distributed and Chi square test
and temporarily stored in cold boxes until they were was used to test categorical variables. As the data was not
transferred to minus 80◦C freezers in the central laborato- normally distributed it was further log transformed. For
ry of the Madras Diabetes Research Foundation at Chen- evaluating the reproducibility of the FFQ, intra-cluster
nai. All the analyses for the study were performed at the associated correlation coefficients (ICC) were calculated
National Accreditation Board for Testing and Calibration for both nutrients and food groups using FFQ1 and FFQ2
Laboratories (NABL) and College of American collected at an interval of 12 months and are presented for
Pathologists (CAP)-accredited central laboratory at Dr both rural and urban participants. Nutrients and food
Mohan’s Diabetes Specialities Centre in Chennai. Two group intakes were categorized into quartiles, with the
percent of the fasting plasma samples were analyzed for cut-off points for the FFQ1 (original survey) variables
quality control. Accurate coding system was followed to also applied to the repeat FFQ2 variables. A ‘proc mixed’
ensure anonymity of samples and also to facilitate track- model was used to compute the adjusted ICC using the
ing of specific samples if the need arose. SAS. Agreement was tested with Bland Altman analy-
Serum cholesterol (cholesterol esterase oxidase- sis26for the total energy intake reported in FFQ1 and
peroxidase-amidopyrine method), serum triglycerides FFQ2. Multivariate regression analysis was used to assess
(glycerol phosphate oxidase-peroxidase-amidopyrine the construct validity of FFQ using serum lipid (triglycer-
method) and HDL cholesterol (direct method poly- ides and total, LDL and HDL cholesterol) biomarkers
ethylene-glycol-pretreated enzymes) were measured us- collected during the FFQ 1 time point as the dependent
ing the Beckman Coulter AU 2700/480 Autoanalyser variables and carbohydrate (%E); glycemic load, dietary
[Beckman AU (Olympus), Ireland]. LDL cholesterol was fat (%E), dietary SFA%E as continuous independent var-
calculated using the Friedewald formula.19 The coeffi- iables. Potential confounders like age, sex, BMI, blood
cients of variation for the biochemical assays ranged from pressure, fasting blood glucose, blood cholesterol, LDL-C,
3.1 to 7.6%.20 physical activity levels, cooking oil, energy intake, re-
fined grains, milk and its products and fruits and vegeta-
Other assessments bles were adjusted in the model. The ratio of energy in-
Demographic data and detailed information on smoking take (EI) to basal metabolic rate (BMR)24 was ascertained
and alcohol consumption were collected by trained inter- as a measure to identify the proportion of under-reporters
viewers. The validated MDRF Physical Activity Ques- (EI/BMR 1.2) for total energy intake. All tests of signif-
tionnaire (MPAQ) was used to assess physical activity icance were two-tailed and a p value of <0.05 was con-
levels [PAL (as covariate)] of the participants.21 The sidered significant.
physical activity level category of the participants was
196 V Sudha, RM Anjana, P Vijayalakshimi, N Lakshmipriva, N Kalpana, R Gayathri et al

RESULTS in nutrients and 0.53 for whole grains to 0.77 for fruits
Region-wise demographic, anthropometric and biochemi- and leafy vegetables (g/day) (among food groups). The
cal assessments of the participants are presented in Table overall adjusted ICC for nutrients ranged from 0.54 for
1. Significant differences between regions were seen with dietary fiber (g/day) to 0.87 for energy (kcal/day) respec-
respect to body weight, BMI, diastolic blood pressure, tively, while for food groups, it ranged from 0.50 for an-
serum total cholesterol, LDL-C and physical activity lev- imal foods (g/day) to 0.75 for pulses and legumes (g/day).
els. The average energy-adjusted ICCs with respect to sex
The region wise intake of nutrients and food groups by was 0.69 for nutrients and 0.60 for food groups among
the study participants is given in supplementary table. males and 0.68 for nutrients and 0.59 for food groups in
The intake of energy was found to be highest in the North females (Table 3).
followed by the East, while Northeastern and Southern Figure 3 shows the Bland-Altman plot for agreement
regions reported the highest intake of carbohydrate and between FFQ1 and FFQ2 for reported energy intake. The
protein. The Southern region reported the highest intake agreement plot revealed heteroscedasticity by visual in-
of fat (mainly as saturated fatty acid and poly unsaturated spection using residual plot and Kendall’s Tau test.30
fatty acids while the intake of mono-unsaturated fatty Accordingly, the data was log transformed and the mean
acid was highest in the North. With regard to food groups, bias and the limits were -0.0037, +0.29 and -0.29.
the intake of refined cereal and animal foods was reported In the present study, the ratio of self -reported energy
to be highest in the Northeast, while intake of whole intake (EI) from FFQ1 to the basal metabolic rate (BMR)
grains, milk and milk products was highest in the North. was used to measure the extent of under-reporting of en-
The intake of fruits, fats and edible oils was found to be ergy intake 3 and the details are presented in Table 4.
highest in the West. About 12% of rural adults, 9% of urban adults, 12% male
Reproducibility between the two FFQs (FFQ1 and and 10% of the female population were found to be un-
FFQ2) collected from the same participant at a 12 der-reporters in the present study.
months’ interval, assessed using intra-cluster correlation Table 5 and 6 show the multivariate adjusted associa-
coefficients (ICC) for energy-adjusted nutrients and food tion of Carbohydrates (%E), glycaemic load (GL), dietary
groups, and stratified as rural /urban is presented in Table fat (%E) and SFA (%E) with the lipid profile after adjust-
2. ing for potential confounders such as age, sex, literacy,
The energy adjusted ICCs ranged from 0.61 for protein BMI, blood pressure, fasting blood glucose, blood choles-
(g/day) to 0.72 for SFA (g/day) for nutrients and from terol, LDL-C, physical activity levels, cooking oil, energy
0.50 for animal foods and fruits to 0.89 for whole grains intake, refined grains, milk and milk products and fruits
among food groups in the rural population. The adjusted and vegetables. For every unit increase in carbohydrates
ICCs between the two FFQs in the urban population (%E), there was a significant rise in triglycerides [β (SE):
ranged from 0.50 for SFA (g/day) to 0.77 for total energy +2.29 (0.72), p=0.002] while HDL cholesterol levels de-

Figure 3. Bland-Altman plot showing the difference between total energy intake from the FFQ 1 and FFQ 2 versus the mean of these two
measures. †Mean energy intake from FFQ1 and FFQ2 collected at an interval of 12 months from both urban and rural subjects. Data was
log transformed due to heteroscedasticity by visual inspection using residual plot and Kendall’s Tau test31
 Reproducibility and validity of FFQ for Asian Indians 197

Table 1. Region wise demographic, anthropometric and biochemical characteristics of 463 rural and urban participants from 10 Indian states

East West North South Northeast

Description
Median IQR Median IQR Median IQR Median IQR Median IQR
Age (yrs) 35.0 25.3 42.0 20.5 36.0 18.0 42.0 24.3 40.0 23.5
Weight (kg)** 50.0 13.3 54.0 18.5 61.5 20.0 54.0 18.0 54.9 13.9
Height (cm) 156 13.3 156 13.0 160 14.3 157 13.0 158 11.4
Body mass index (kg/m2)** 20.3 5.0 21.9 7.0 23.9 6.0 21.3 6.2 21.4 4.7
Systolic blood pressure (mmHg) 122 21.5 126 19.9 127 19.3 127 20.9 127 24.5
Diastolic blood pressure (mmHg)** 73.5 15.4 78.5 11.4 77.0 13.3 79.0 14.5 81.0 14.0
Serum cholesterol (mg/dL†)** 140 44.8 161 46.0 165 62.0 155 57.5 149 50.5
Serum triglyceride (mg/dL†)* 115 74.0 101 61.5 102 86.5 118 79.8 132 93.5
Serum high density lipoprotein (mg/dL†) 37.0 12.0 40.0 21.0 42.0 14.0 37.0 13.5 37.0 11.0
Serum low density lipoprotein (mg/dL†)** 74.2 34.7 97.8 37.1 93.7 41.8 95.5 41.3 84.8 41.7
Physical activity level (PAL)‡§**, n (%)
Sedentary (PAL value 1.40-1.69) 36 (38.3) 39 (60.0) 65 (72.2) 71 (62.3) 42 (42.0)
Moderate (PAL value 1.70-1.99) 35 (37.2) 19 (29.2) 17 (18.9) 30 (26.3) 46 (46.0)
Vigorous (PAL value 2.00-2.40) 23 (24.5) 7 (10.8) 8 (8.9) 13 (11.4) 12 (12.0)
PAL: Physical Activity Level
†
To convert mg/dL cholesterol to mmol/L, multiply mg/dL by 0.0259. To convert mmol/L cholesterol to mg/dL, multiply mmol/L by 38.7. Cholesterol of 193 mg/dL¼5.00 mmol/L.
‡
p value for categorical variable test using chi-square
§
Based on FAO/WHO cut off for physical activity26
*
p<0.05, **p value <0.001
198 V Sudha, RM Anjana, P Vijayalakshimi, N Lakshmipriva, N Kalpana, R Gayathri et al

Table 2. Reproducibility study: Energy adjusted intra cluster correlation coefficients (ICC) of nutrients and food groups from the self-reported food frequency questionnaires collect-
ed twice at the interval of 12 months in urban and rural Asian Indian adults (n=463)

Urban (n= 128) Rural (n= 335)

Median (95% CI) Median (95% CI)
MDRF-FFQ 1 MDRF-FFQ 2 ICC (95% CI)† MDRF-FFQ 1 MDRF-FFQ 2 ICC (95% CI)†
(May 2011) (June 2012) (May 2011) (June 2012)
Energy (kcal) 2426 (2406-2650) 2478 (2374-2594) 0.77 (0.72-0.84) 2302 (2189-2333) 2321(2224-2379) 0.63 (0.61 - 0.66)
Carbohydrate (g/d) 364 (361-374) 366 (362-377) 0.76 (0.71 - 0.83) 369 (367-375) 372 (371.2-381) 0.69 (0.57 - 0.83)
Protein (g/d) 62.8 (62.7-66.7) 65.4 (65.1-70.7) 0.67 (0.60 - 0.77) 61.9 (62.3-64.4) 63.1 (63.2-66.1) 0.61 (0.59 - 0.64)
Total fat (g/d) 66.8 (62.9-68.2) 72.7 (69.4-75.7) 0.69 (0.62 - 0.77) 65.9 (62.8-66) 69 (67.7-71.5) 0.63 (0.61 - 0.66)
Total SFA (g/d) 22.1 (20.5-23.2) 23.9 (23.3-26.5) 0.5 (0.46 - 0.59) 20.6 (20.2-21.9) 20.5 (20.6-22.7) 0.72 (0.7 - 0.75)
Total MUFA(g/d) 21.8 (20.9-23.8) 22.8 (21.1-23.9) 0.63 (0.54 - 0.76) 23.5 (22.4-24.1) 22.3 (21.6-23.4) 0.63 (0.60 - 0.66)
Total PUFA(g/d) 16 (16.9-19.7) 16.8 (16.7-19.8) 0.7 (0.67 - 0.72) 15 (16.3-17.7) 16 (16.7-18.3) 0.69 (0.62 - 0.79)
Dietary fibre (g/d) 33.6 (32.6-36.2) 29.9 (29.8-33.9) 0.76 (0.71 - 0.83) 34.9 (33.2-35.2) 31.4 (31.4-33.7) 0.71 (0.69 - 0.73)
Glycemic Index 60.7 (60.2-61.3) 61.4 (61.1-62.7) 0.6 (0.57 - 0.66) 61.1 (60.4-61.3) 62 (61.8-62.8) 0.58 (0.56 - 0.61)
Glycemic Load (g/d) 195 (193-204) 194 (186-203) 0.62 (0.58 - 0.67) 199 (200-207) 203 (204-213) 0.63 (0.61 - 0.65)
Refined cereals (g/d) 200 (195-231) 198 (183-223) 0.59 (0.54 - 0.65) 199 (203-227) 203 (199-223) 0.51 (0.48 - 0.54)
Whole grains (g/d) 60.5 (68-95.4) 56.9 (64.7-90.7) 0.53 (0.48 - 0.61) 65.4 (70.1-86) 71.4 (77.7-95.2) 0.61 (0.59 - 0.63)
Pulses and legume (g/d) 44.2 (41.3-50) 44.6 (43.1-52.8) 0.69 (0.66 - 0.72) 40.2 (41.3-46.8) 42.7 (42.2-48.2) 0.52 (0.50 - 0.55)
Milk and milk products (g/d) 244 (246-320) 260 (257-336) 0.61 (0.53 - 0.72) 225 (235-280) 224(237-283) 0.52 (0.48 - 0.57)
Fats and edible oils (g/d) 36.7 (35.8-39.8) 36.2 (35.3-39.4) 0.56 (0.52 - 0.63) 38.9 (36.1-38.7) 36.9 (37.1-39.8) 0.56 (0.54 - 0.59)
Fruits(g/d) 134 (135-173) 133 (137-176) 0.77 (0.72 - 0.84) 129 (132-149) 124 (128-146) 0.89 (0.89 - 0.9)
Leafy vegetables (g/d) 16.1 (21.3-33.3) 18.2 (22.5-35.5) 0.77 (0.72 - 0.84) 13.2 (18.1-24.4) 13.9 (18.5-24.6) 0.69 (0.67 - 0.72)
Other vegetables (g/d) 46.8 (55.8-82.5) 45 (55.5-84.4) 0.74 (0.68 - 0.81) 42.1 (59.3-76.8) 31.3 (49.7-65.4) 0.72 (0.70 - 0.74)
Roots and tuber s(g/d) 224(193-263) 194 (198-256) 0.73 (0.67 - 0.79) 248 (224.0-285) 213 (210-266) 0.71 (0.70 - 0.74)
Animal foods (g/d) 28.1 (33.3-53.4) 27.9 (29.7-60) 0.58 (0.47 - 0.76) 25.7 (35.5-46) 26 (31.5-41.8) 0.5 (0.46 - 0.56)

MDRF-FFQ: Madras Diabetes Research Foundation Food Frequency Questionnaire; ICC: intra cluster correlation coefficients; SFA: Saturated fatty acid; MUFA: Mono-unsaturated fatty acid; PUFA: Poly-
unsaturated fatty acid
†
ICC measures agreement between FFQ1 and FFQ
 Reproducibility and validity of FFQ for Asian Indians 199

Table 3. Reproducibility study: Energy adjusted intra class correlation coefficients (ICC) of nutrients and food groups from the self-reported food frequency questionnaires Asian
Indian adults based on gender (n=463)

Male (n=216) Female (n= 247)

Nutrient and food group In- Median (95% CI) Median (95% CI)
take MDRF-FFQ 1 MDRF-FFQ 2 ICC† (95% CI)‡ MDRF-FFQ 1 MDRF-FFQ 2 ICC† (95% CI)‡
(May 2011) (June 2012) (May 2011) (June 2012)
Energy (kcal) 2410 (2349-2539) 2443 (2357-2543) 0.89 (0.89-0.90) 2267 (2157-2321) 2210 (2179-2354) 0.88 (0.88-0.89)
Carbohydrate (g/d) 371 (366-377) 373 (368-381) 0.72 (0.70-0.74) 365 (365-373) 369 (368-379) 0.74 (0.73-0.76)
Protein (g/d) 62.9 (63.3-66.4) 63.9 (64.7-68.9) 0.75 (0.74-0.77) 61.5 (61.5-63.9) 63.7 (62.8-66) 0.75 (0.73-0.76)
Total fat (g/d) 64.7 (61.2-65.4) 66.8 (66.8-71.7) 0.65 (0.62-0.67) 67.3 (64.1-67.8) 72.3 (69.3-73.6) 0.74 (0.73-0.75)
Total SFA (g/d) 19.8 (19.5-21.6) 20.2 (19.9-22.6) 0.61 (0.58-0.64) 22 (21-22.9) 23 (22.6-24.7) 0.78 (0.77-0.79)
Total MUFA (g/d) 23.1 (21.3-23.5) 22.3 (21.3-23.6) 0. 70 (0.68-0.72) 23.9 (22.5-24.4) 22.6 (21.5-23.5) 0.72 (0.71-0.74)
Total PUFA (g/d) 14.9 (16.1-18) 16.7 (16.8-19) 0.70 (0.69-0.72) 15.7 (16.7-18.5) 16 (16.6-18.4) 0.71 (0.69-0.73)
Dietary fibre (g/d) 33.3 (31.8-34.6) 30.8 (30.4-33.4) 0.64 (0.61-0.67) 35.1 (34-36.3) 31.4 (31.3-34.1) 0.64 (0.62-0.66)
Glycemic Index 61.2 (60.5-61.7) 62.3 (61.9-63.3) 0.66 (0.64-0.69) 60.8 (60.2-61) 61.5 (61.3-62.4) 0.71 (0.70-0.73)
Glycemic Load (g/d) 200(199-209) 201 (199-210) 0.70 (0.68-0.72) 197 (196-204) 197 (199-210) 0.70 (0.69-0.72)
Refined cereals (g/d) 204 (210-240) 215 (203-236) 0.60 (0.57-0.63) 192 (193-219) 197 (187-213) 0.64 (0.62-0.66)
Whole grains (g/d) 55.4 (64.4-85) 59.8 (67.7-90.5) 0.67 (0.65-0.70) 72.8 (73.7-92.1) 72.2 (78.7-97.5) 0.66 (0.64-0.69)
Pulses and legume (g/d) 38 (39.3-46.7) 39.8 (40.5-48.7) 0.71 (0.70-0.73) 42.3 (42.9-48.6) 44.6 (43.9-50.3) 0.68 (0.67-0.71)
Milk and Milk products (g/d) 210.5 (228-289) 216 (231-292) 0.51 (0.47-0.55) 246 (245-295) 256 (252-305) 0.57 (0.54-0.60)
Fats and edible oils (g/d) 37.4 (34.7-37.9) 36.1 (35.5-39.1) 0.60 (0.57-0.63) 39.3 (37.2-40) 37.3 (37.4-40.3) 0.61 (0.58-0.63)
Fruits(g/d) 131 (133-158) 129 (134-161) 0.55 (0.51-0.59) 130 (132-155) 124 (126-148) 0.50 (0.45-0.57)
Leafy vegetables (g/d) 12 (16-22.1) 13.1 (17.1-24.2) 0.60 (0.58-0.63) 16.3 (21.8-30.9) 15.6 (21.9-30.5) 0.50 (0.47-0.55)
Other vegetables (g/d) 46.4 (61.3-83.4) 36.5 (57.9-81.8) 0.60 (0.57-0.63) 41.8 (55.1-74.7) 32.3 (45.6-61.2) 0.54 (0.51-0.57)
Roots and tubers (g/d) 219 (227-266) 202 (213-242) 0.52 (0.47-0.60) 215 (227-262) 195(204-230) 0.52 (0.47-0.58)
Animal foods (g/d) 34.8 (41.8-57.7) 30.9 (36.1-56) 0.51 (0.47-0.55) 19.6 (29-39.5) 22.2 (27-38.4) 0.62 (0.59-0.65)
MDRF-FFQ: Madras Diabetes Research Foundation Food Frequency Questionnaire; ICC: Intra class correlation; SFA: Saturated fatty acid; MUFA: Mono-unsaturated fatty acid; PUFA: Poly-unsaturated fatty acid
†
ICC measures agreement between FFQ1 and FFQ.
‡
ICC- Nutrients and food groups were log transformed and further adjusted for covariates age (in years), sex (male/female), BMI (kg/m2), regions (North, South, East, west and North east), income (INR) (>2000,
2000-5000, 5000-10000, >10000) and education (illiterate, primary, higher secondary and college education).
200 V Sudha, RM Anjana, P Vijayalakshimi, N Lakshmipriva, N Kalpana, R Gayathri et al.

Table 4. Percent under reporters from the ratio of energy intake and BMR in rural and urban India (n=450)

EI/BMR ratio Percentage below the EI/BMR (<1.2)†

FFQ 1 n
(mean±SD) n (%)
Rural 330 1.75 (0.52) 38 (11.5)
Urban 120 1.83 (0.48) 11 (9.2)
Male 216 1.73 (0.53) 26 (12.0)
Female 234 1.81 (0.49) 23 (9.8)
Overall 450 1.77 (0.51) 49 (10.9)
EI/BMR: energy intake/basal metabolic rate.
†
EI/BMR <1.2 are considered as under-reporters and the BMR was calculated from the age- and gender- specific prediction equation23

Table 5. Multivariate adjusted regression coefficients for association of carbohydrates (%E), glycemic load with TG
and HDL as a measure of construct validity from MDRF FFQ 1 (May 2011))

TG (mg/dL†) HDL (mg/dL†)

Description *
β SE p value β SE p value
Carbohydrates (% Energy) 2.29 0.72 0.002 -0.48- 0.12 <0.001
Energy adjusted glycemic load 0.38 0.15 0.01 -0.11 0.02 <0.001
TG: triglyceride; HDL: High density lipoprotein; MDRF FFQ: Madras Diabetes Research Foundation Food Frequency Questionnaire
†
To convert mg/dL cholesterol to mmol/L, multiply mg/dL by 0.0259. To convert mmol/L cholesterol to mg/dL, multiply mmol/L by
38.7. Cholesterol of 193 mg/dL¼5.00 mmol/L.
*
p<0.001 considered to be statistically significant

creased [β (SE): -0.48 (0.12), p<0.001]. Energy adjusted sent study are in agreement with the above stated studies
glycemic load (a measure of the carbohydrate quantity (Table 2), thereby reiterating the reliability of the MDRF-
and quality) also showed a trend similar to that of carbo- FFQ.
hydrates (%E). However, for a unit increase in dietary fat, Validation of food and nutrient intake by FFQ against
total cholesterol [β (SE): 1.10 (0.51), p=0.032], LDL [β biomarkers has enormous value in nutritional epidemio-
(SE): 0.96 (0.43), p=0.025] and HDL cholesterol [β (SE): logical studies. Biomarkers could reduce subjectivity
0.57 (0.12), p<0001] significantly increased while tri- compared to validation studies with diet records or multi-
glycerides decreased [β (SE): -1.88 (0.76), p=0.014]. A ple 24 hour recalls as reference method as the latter is
similar trend was observed for SFA (%E). prone to subjectivity like the FFQ. While biomarkers are
also prone to errors of estimation and physiological varia-
DISCUSSION tions, these are unrelated to errors with self-reported die-
The present study evaluates, for the first time in India, the tary assessments3 and can thereby reflect relationships
reproducibility and construct validity of an interviewer with nutrient intake as they are based on the biological
administered comprehensive quantitative national FFQ processes in the body (construct validity). Several studies
for adults of both sex residing in rural and urban areas of have shown the effect of intake of carbohydrates and fats
all regions of India including the Northeast. The MDRF- on blood lipids.13,14,32 Hence, in the present study, the
FFQ is a reliable tool to assess the dietary measures of energy intake from carbohydrates, fat and SFA reported
macronutrients and food groups reported by Asian Indian in FFQ1 were tested against lipid parameters such as tri-
urban and rural adults. Moderate to good correlation coef- glycerides and HDL, total and LDL cholesterol to evalu-
ficients were found between FFQ1 and the repeat FFQ2 ate construct validity, which is a first for any FFQ in In-
collected at an interval of 12 months for both nutrients dia.
and food groups even when stratified by sex, suggesting Nettleton et al. 200914 and Ma et al. 200633 reported
consistent performance. Construct validity was assessed that an increase in carbohydrate calories was associated
only with limited biomarkers of blood lipids with the re- with a significant increase in triglyceride concentration
ported intakes of macronutrients such as carbohydrates and decrease in HDL cholesterol concentration. The pre-
(%E), glycemic load, total dietary fat (%E) and SFA sent study also reported similar findings, after adjusting
(%E). for potential non-dietary and dietary factors that may af-
The results of the present study by and large agree with fect these lipids. Furthermore, an increase in triglyceride
other studies that have reported a moderate to substantial levels and decrease in HDL-c was observed with an in-
agreement (>0.40 to <0.80) for both nutrients and food. crease in GL evaluated from the FFQ (Table 5 ), similar
However, SFA, milk and milk products and roots and to reports from the West34,35 Ours is the first study to as-
tubers in this study showed a lower agreement than that sess dietary glycemic load (GL) from the MDRF-FFQ
cited elsewhere27,28 especially among urban participants. across rural and urban areas of different regions of India.
Several national studies have reported similar ICCs for The GL is relevant in diet-disease relationship as it has
majority of nutrients (0.40-78) and food groups (0.86- been well associated with risk of diabetes both in Indian
0.99).7,11,29 Similarly, international studies had shown and western populations.36,37
moderate to high ICC for majority of nutrients (0.42-0.91) Willett et al. 200113 reported an increase in HDL-C
and food groups (0.28-0.91).30,31 The results of the pre- and a decrease in triglyceride when carbohydrate energy
 Reproducibility and validity of FFQ for Asian Indians 201

Table 6. Multivariate adjusted regression coefficients for association of total dietary Fat, SFA with lipid profile as a
measure of construct validity from MDRF FFQ 1 (May 2011)

Cholesterol
TG (mg/dL†) HDL (mg/dL†) LDL (mg/dL†)
(mg/dL†)
Description *
p p p p
β SE β SE β SE β SE
value value value value
Total Fat
1.10 0.51 0.03 -1.88 0.76 0.01 0.57 0.121 <0.001 0.96 0.43 0.03
(% Energy)
Total SFA
0.68 0.30 0.02 -1.34 0.59 0.02 0.28 0.094 0.003 0.60 0.25 0.026
(% Energy)
TG: triglyceride; HDL: high density lipoprotein cholesterol, LDL: Low density lipoprotein cholesterol; MDRF FFQ: Madras Diabetes
Research Foundation Food Frequency Questionnaire
†
To convert mg/dL cholesterol to mmol/L, multiply mg/dL by 0.0259. To convert mmol/L cholesterol to mg/dL, multiply mmol/L by
38.7. Cholesterol of 193 mg/dL¼5.00 mmol/L.
‡
Adjusted for: age (yrs), sex (M/F), BMI (kg/m2), region, rural/urban, physical activity category (sedentary 1.40-1.69; moderate: 1.70-
1.99; vigorous: 2.0-2.40), systolic and diastolic blood pressure (mmHg), fasting blood glucose (mg/dL), literacy (yes/ no), main cooking
oil, total energy (kcal/d) intake
*
p<0.001 considered to be statistically.

is replaced by fat in a Western population. Recent find- recall bias.46 Micronutrients were not evaluated for repro-
ings from 18 countries in the Prospective Urban Rural ducibility and construct validity owing to budgetary con-
Epidemiology study (PURE) have shown that a higher straints and incomplete micronutrient composition pro-
percentage energy from fat and SFA was associated with vided in food composition tables. Besides, another limita-
a higher total cholesterol, HDL and LDL-C and lower tion was that the serum lipids were measured at only one
triglyceride.38 These agree with the present study findings. time, which might not account for intra-individual varia-
Similar findings were also reported in studies done else- bility in these parameters. Further, due to budget con-
where.39-41 This reiterates the MDRF-FFQ’s ability to straints and feasibility challenges, assessment of recovery
provide a valid measure of dietary fat that could further biomarkers like doubly-labelled water for energy intake
show the physiologically relevant associations with total and 24 –hour urine for sodium intake could not be carried
cholesterol, TG, LDL and HDL-C (Table 6). out.
Generally, misreporting of dietary intakes affects the
construct validity of the assessment tool and is a barrier in Conclusion
understanding diet-disease relationship.42 The underesti- MDRF-FFQ can be considered a realistic, practical and
mation of nutrient intakes may be associated with under- economical tool for assessing usual dietary habits of
reporting of total energy intake. Livingstone and Black Asian Indian populations, based on the evaluation of the
2003 and Black et al. 1991,43,44 reported widespread prev- major macronutrients, carbohydrates and fat, that pro-
alence of under-reporting in various nutritional studies. vides 3/4th of daily energy. MDRF-FFQ has validity for
However, the proportion of under-reporters in this study the measurement of physiologically important variations
(11%) is much lower than that reported by Bedard et al in macronutrient intake and presumptively, in the assess-
(43%).45 ment of long-term dietary exposure in studies of chronic
In general, however, studies on FFQ validity are chal- disease in India.
lenging to undertake in a sufficiently large and repre-
sentative sample of the population for which they have ACKNOWLEDGEMENTS
been developed. In addition, there is no gold standard We would like to acknowledge the laboratory team for their
reference method to validate FFQ. One of the important support in biochemical assessments as well as the information
strengths of the MDRF-FFQ is its ability to assess dietary technology team for their assistance in the dietary data extrac-
tion.
habits of the population in both rural and urban settings of
all the regions of India. One may argue that regional diets
AUTHOR DISCLOSURES
are diverse and hence separate FFQs are needed for each All authors declare that there is no conflict of interest.
region. In fact, diets in all regions of India including both
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Supplementary table 1. Region-wise intake of nutrients and food groups

East West North South Northeast

Nutrient and food group intake
Median IQR Median IQR Median IQR Median IQR Median IQR
Energy (kcal) 2412 1014 2158 676 2681 592 2263 750 2062 903
Carbohydrate (g/d) 373 29 351 29.6 355 27.5 375 37.8 380 53.1
Protein (g/d) 58.4 8.2 58.0 10.2 61.2 9.6 63.9 11.6 66.6 12.7
Fat (g/d) 65.1 12.2 77.2 13.4 72.7 11.5 63.8 14.7 56.3 19.3
SFA (g/d) 19.1 7.0 28.4 5.5 24.7 7.9 20.8 8.7 15.7 8.4
MUFA (g/d) 28.9 6.6 21.5 8.1 30.1 6.2 21.0 8.0 16.3 8.4
PUFA (g/d) 13.1 2.5 22.5 9.8 13.5 3.5 16.2 10.5 18.2 7.4
Dietary fibre (g/d) 37.9 8.2 40.3 8.4 41.0 10.7 29.7 9.3 25.1 10.4
Glycemic Index 62.0 3.5 57.8 5.1 58.9 3.4 61.4 2.8 63.1 4.2
Glycemic load (g/d) 203.0 48.7 179 37.6 1736 41.5 212 37.3 227 56.0
Refined cereals (g/d) 197.1 81.2 118 86.8 118 48.4 229 79.6 311 162
Whole grains (g/d) 120.4 80.0 89.1 108 157 61.2 31.5 39.8 22.3 54.1
Pulses and legumes (g/d) 43.7 25.8 44.3 32.3 42.6 30.4 46.1 20.6 30.5 21.5
Milk and milk products (g/d) 157 189 302 250 345 229 246 199 138.3 166.6
Fats and edible oils (g/d) 39.8 9.4 46.2 9.1 41.3 10.7 34.5 13.7 32.5 14.4
Fruits (g/d) 139 70.7 152 71.4 151 100 117 65.2 108 59.7
Leafy vegetables (g/d) 6.9 10.8 17.3 16.7 10.4 31.4 23.1 19.5 11.7 15.3
Other vegetables (g/d) 29.9 48.9 23.7 27.6 38.5 53.7 47.1 32.1 104 164
Roots and tuber s(g/d) 98.5 53.2 110 51.5 96.0 48.8 85.6 33.6 110 59.2
Animal foods† (g/d) 17.0 31.9 8.1 22.0 5.1 24.0 40.2 54.0 60.5 67.8
IQR: Inter Quartile Range; SFA: saturated fatty acids; MUFA: monounsaturated fatty acids; PUFA: Polyunsaturated fatty acids
†
Animal foods include meat, poultry, egg, fish and other sea foods.

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