J. Nutr.-1994-Thompson-2245s-317s

Supplement
Dietary Assessment Resource Manual1

FRANCES E. THOMPSON,*2
TIM BYEKSt
* national Cancer Institute, Diuision of Cancer Prevention and Control, Applied Research Branch,
Bethesda, MD 20892-7344
t Centers for Disease Control and Preuention, National Center for Chronic Disease Prevention and
Health Promotion, Diuision of Nutrition, Chronic Disease Prevention Branch, Atlanta, CA 30341-3724
I. INTRODUCTION
II. DIETARY ASSESSMENT
METHODS
Five families of assessment methods are reviewed

and critiqued in the following sections.
A. Dietary Records
For the dietary record approach, the respondent re
cords the foods and beverages and the amounts of each
consumed over a period of days. The amounts con
sumed may be measured, with a scale or household
measures (such as cups, tablespoons), or estimated,
using models, pictures, or no particular aid. Typically,
no more than 3 or 4 consecutive days are included.
Recording periods of more than 7 consecutive days
0022-3166/94
$3.00 1994 American Institute of Nutrition.
1 Published as a supplement
to The Journal of Nutrition.
Guest
editor for this publication was Lenore Kohlmeier, School of Public

Health, University of North Carolina at Chapel Hill, Chapel Hill,
NC 27599-7400.
1 Frances E. Thompson, Ph.D., NCI, DCPC, ARE, EPN Room
313, 6130 Executive Blvd MSC 7344, Bethesda, MD 20892-7344.
Telephone: (301) 496-8500 FAX: (301) 496-9949.
J. Nutr. 124: 2245S-2317S,
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This manual is intended to serve as a resource for

nutritionists and other health professionals who wish
to assess diet in a study or as part of clinical services.
It is not intended to be a comprehensive or technical
review of all dietary assessment methods; many re
views have been published (1-14). This manual is de
signed to help health professionals to understand the
advantages and disadvantages of alternative dietary
assessment methods and to choose the appropriate di
etary method for a particular need.
In the following chapters we provide:
A brief description and critical evaluation of each
common method of dietary assessment;
Advice on choosing the most appropriate dietary
assessment method for different study designs;
A discussion of selected issues to be considered
in assessing diet;
Examples of specific dietary assessment tools;
A listing of review articles and selected publica
tions on dietary assessment.
are usually unsatisfactory because of respondent fa

tigue. Theoretically, the reporting is done at the time
of the eating occasion, but it need not be done on pa
per. Dictaphones have been used (15) and hold special
promise for low literacy groups.
The respondent must be trained in the level of detail
needed to describe adequately the foods and amounts
consumed, including the name of the food (brand
name, if possible), preparation methods, recipes for
food mixtures, and portion sizes. In some studies this
is enhanced by contact and review of the report after
1 day of recording. At the end of the recording period,
a trained interviewer should review the records with
the respondent to clarify entries and to probe for for
gotten foods. Dietary records also can be recorded by
someone other than the subject. This often is done
with children or the institutionalized.
Although intake data using dietary records is typ
ically collected in an open-ended form, close-ended
forms also have been developed (16-18). These forms
consist of listings of food groups; the respondent in
dicates whether that food group has been consumed.
Portion size also can be asked, either in an open-ended
manner or in categories. In content, these "checklist"
forms resemble food frequency questionnaires (see
Section II. C.), but they are filled out either concurrent
with actual intake (for precoded records) or at the end
of a day for that day's intake (daily recall).
Strengths. The dietary record method has the po
tential for providing quantitatively accurate infor
mation on food consumed during the recording period.
For this reason, food records are often regarded as the
"gold standard" against which other dietary assess-
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increases and becomes more burdensome to complete

at each eating occasion. The checklist method may be
most appropriate in settings with limited diets or for
assessment of a limited set of foods or nutrients.
Validity. Several studies indicate that usual di
etary intake as reported on diet records may be seri
ously underestimated (20). In one such study, re
searchers found that the majority of individuals underreported their diets, with men reported dietary
intake 700 kcal below their metabolic requirements
(21). Underreporting on food records is probably a re
sult of the combined effects of incomplete recording
and the impact of the recording process on dietary
choices. Underreporting may be more common in
obese respondents (22), particularly women (23). More
research is needed to determine which populations
tend to underreport which foods. Some have seen the
need for a new "gold standard" for assessment of di
etary intake (24, 25).
B. The 24-Hour Dietary Recall
In the 24-hour dietary recall, the respondent is asked
to remember and report all the foods and beverages
consumed in the preceding 24 hours or in the preced
ing day. The recall typically is conducted by personal
interview, either computer-assisted (26) or using a paper-and-pencil form. Well-trained interviewers are
crucial in administering a 24-hour recall because much
of the dietary information is collected by asking prob
ing questions. Ideally, interviewers are dietitians with
education in foods and nutrition; however, nonnutritionists who have been trained in the use of a stan
dardized instrument can be effective. All interviewers
should be knowledgeable about foods available in the
marketplace and about preparation practices, includ
ing prevalent regional or ethnic foods.
The interview often is structured, usually with spe
cific probes, to help the respondent remember all foods
consumed throughout the day. One study found that
respondents with interviewer probing reported 25%
higher dietary intakes than did respondents without
interviewer probing (27). Probing is especially useful
in collecting necessary details, such as how foods were
prepared. It also is useful in recovering many items
not originally reported, such as common additions to
foods (e.g., butter on toast) and eating occasions not
originally reported (e.g., snacks and beverage breaks).
However, interviewers should be provided with stan
dardized neutral probing questions so as to avoid lead
ing the respondent to specific answers when the re
spondent really doesn't know or remember.
A quality control system to minimize error and in
crease reliability of interviewing and coding 24-hour
recalls is essential (28-30). Such a system should in
clude a detailed protocol for administration, training,
and retraining sessions for interviewers, duplicate
collection and coding of some of the recalls throughout
ment methods are compared. By recording foods as

they are consumed, the problem of omission is less
ened and the foods are described more fully. Further,
the measurement of amounts of food consumed at
each occasion should provide more accurate portion
sizes than if the respondents were recalling portion
sizes of foods eaten previously.
Weaknesses. The method is subject to bias both
in the selection of the sample and in the measurement
of the diet. Dietary record keeping requires that re
spondents or respondent proxies be both motivated
and literate (if done on paper), which can potentially
limit the method's use in some population groups (e.g.,
low socioeconomic status, recent immigrants, chil
dren, and some elderly groups). The requirements for
cooperation in keeping records can limit the generalizability of the findings from the dietary records to
the broader population from which the study sample
was drawn. Research indicates that there is a signifi
cant increase in incomplete records as more days of
records are kept, and the validity of the collected in
formation decreases in the later days of a 7-day re
cording period in contrast to collected information in
the earlier days (19). Part of this decrease may occur
because many respondents develop the practice of fill
ing out the record at one time for a previous period.
When respondents record only once per day, the
record method approaches the 24-hour recall in terms
of relying on memory rather than concurrent record
ing. More importantly, recording foods as they are
being eaten can affect both the types of food chosen
and the quantities consumed. The prospective and de
manding task of recording food intake can, therefore,
alter the dietary behaviors the tool is intended to mea
sure. This effect is a weakness when the aim is to mea
sure usual dietary behavior. However, when the aim
is to enhance awareness of dietary behavior and change
that behavior, as in some intervention studies, this
effect can be seen as a strength.
As is true with all quantitative dietary information,
the information collected on dietary records can be
burdensome to code and can lead to high personnel
costs. Dietary assessment software that allows for eas
ier data entry using common spellings of foods can
save considerable time in data coding. Even with highquality data entry, maintaining overall quality control
for dietary records can be difficult because information
often is not recorded consistently from respondent to
respondent.
These weaknesses may be less pronounced for the
hybrid method of the "checklist" form, because
checking off a food item may be easier than recording
a complete description of the food, and the costs of
data processing can be minimal. The checklist can be
developed to assess particular "core foods" that con
tribute substantially to intakes of some nutrients.
However, as the comprehensiveness of the nutrients
to be assessed increases, the length of the form also
DIETARY ASSESSMENT MANUAL
3 Abbreviations
used: NHANES: National Health and Nutrition
Examination Survey; NCHS: National Center for Health Statistics;

BRFSS: Behavioral Risk Factor Surveillance System; CDC: Centers
for Disease Control and Prevention; Hispanic HANES: Hispanic
Health and Nutrition Examination Survey; HHHQ: Health Habits
and History Questionnaire; NFCS: Nationwide Food Consumption
Survey; CSFII: Continuing Survey of Food Intakes by Individuals,HIS: Health Interview Survey; CARDIA: Coronary Artery Risk De
velopment in Young Adults; NHLBI: National Heart, Lung, and
Blood Institute; NDS: Nutrition Data System; NCI: National Cancer
Institute; DHKS: Diet and Health Knowledge Survey.
24-hour recall to characterize an individual's usual

diet. Data from single 24-hour recalls should not be
used to estimate the proportion of the population that
has adequate or inadequate diets (e.g., the proportion
of individuals with less than 30% of calories from fat
or who are deficient in vitamin C intake) (33). This is
because the true distribution of usual diets is much
narrower than is the distribution of daily diets (there
is variation in usual intake not only between people
but also from day to day for each person). The principal
use of a single 24-hour recall is to describe the average
dietary intake of a group.
Validity. Estimates of group mean nutrient in
takes from 24-hour dietary recalls have been compared
with those from diet records for the same individuals
with mixed results, as summarized by Bingham (4).
Some studies show similar estimates, whereas others
show one method giving substantially higher estimates
than the other. This highlights the facts that dietary
instruments with the same name can differ greatly,
and similar instruments may perform differently in
different populations. The choice of instrument has
to be tailored to the particular population and research
purpose.
The validity of the 24-hour dietary recall has been
studied by comparing respondents' reports of intake
with intakes unobtrusively recorded or weighed by
trained observers. In general, group mean nutrient es
timates from 24-hour recalls were similar to observed
intakes (19, 34), although respondents with lower ob
served intakes tended to overreport, and those with
higher observed intakes tended to underreport their
past intakes (34).
C. Food Frequency
The food frequency approach asks respondents to
report their usual frequency of consumption of each
food from a list of foods for a specific period (8, 35,
36). Only information on frequency (and sometimes
also quantity) of a list of foods is collected, with little
detail on other characteristics of the foods as eaten,
such as the methods of cooking or the combinations
of foods in meals. To estimate relative or absolute nu
trient intakes, many food frequency tools also incor
porate portion size questions, or specify portion sizes
as part of each question. The term "semiquantitative
dietary history" is used by some to indicate a general
food frequency questionnaire that allows for a limited
quantification of serving size. Overall nutrient intake
estimates are derived by summing over all foods the
products of the reported frequency of each food by
the amount of nutrient in a specified (or assumed)
serving of that food.
There are many food frequency instruments, and
many continue to be developed for different popula
tions and different purposes. Section VI includes ex
amples of several instruments.
the study period, and the use of a computerized data

base system for nutrient analysis. Data entry can be
costly, but these costs can be reduced with computer
software specially designed for dietary data entry.
Strengths. There are many advantages to the 24hour recall. An interviewer administers the tool and
records the responses, therefore, literacy of the re
spondent is not required. Because of the immediacy
of the recall period, respondents generally are able to
recall most of their dietary intake. About 20 minutes
is the usual time required to complete a 24-hour recall.
Because there is relatively little burden on the respon
dents, those who agree to give 24-hour dietary recalls
are more likely to be representative of the population
than are those who agree to keep food records. Thus,
the 24-hour recall method is useful across a wide range
of populations. In addition, interviewers can be trained
to capture the detail necessary so that the foods eaten
by any population can be researched later by the coding
staff and coded appropriately. Finally, in contrast to
diary methods, dietary recalls occur after the food has
been consumed, so there is less potential for the as
sessment method to interfere with dietary behavior.
Direct coding of the foods reported during the in
terview is now possible. This is being done in the Na
tional Health and Nutrition Examination Survey
(NHANES)3 surveys using automated software that
specifies the details needed to code each response (31).
The potential benefits of automated software include
substantial cost reductions for processing dietary data,
less missing data, and greater standardization of in
terviews (32). However, a potential problem in direct
coding of interview responses is the loss of the re
spondent's reported description of the food, in contrast
to paper records of the interview, which are then
available for later review and editing. If direct coding
of the interview is done, easy methods for the inter
viewer to enter nonmatching additional foods should
be available and these methods should be reinforced
by interviewer training and quality control procedures.
Weaknesses. Individuals may not report their food
consumption accurately for various reasons related to
memory and the interview situation. These cognitive
influences are discussed in more detail in Section V. G.
Because most individuals' diets vary greatly from day
to day, it is not appropriate to use data from a single
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naires without the additional respondent burden of

reporting serving sizes (8). Others cite small improve
ments in the performance of food frequency ques
tionnaires that ask the respondents to report a usual
serving size for each food (43, 44).
Development of the food list is crucial to the success
of the food frequency method (45). The full variability
of an individual's diet, which includes many different
foods, brands, and preparation practices, cannot be
captured fully with a finite food list. Obtaining ac
curate reports for foods eaten both alone and in mix
tures is particularly problematic. Food frequency
questionnaires can ask the respondent to report either
a combined frequency for a particular food eaten both
alone and in mixtures, or separate frequencies can be
asked. The first approach is cognitively complex, but
the second approach may lead to double counting. Of
ten food frequency questionnaires will include similar
foods in a single question (e.g., hamburger, steak, roast
beef). However, such groupings can create a cogni
tively complex question (e.g., for someone who often
eats hamburger but never eats steak). In addition,
when a group of foods is asked as a single question,
assumptions about the relative frequencies of intake
of the foods constituting the group must be made when
calculating nutrient estimates. These assumptions of
ten are not based on information from the study pop
ulation; true eating patterns may differ considerably
across population subgroups and over time.
Food frequency methods most commonly are used
to rank or group study subjects for the purpose of as
sessing the association between dietary intake and
disease risk, such as in case-control or cohort studies
(46, 47). For estimating relative risks, the degree of
misclassification of subjects from their correct quartile
of intake is more important than is the quantitative
scale on which the ranking is made (48). Although
analyses on the extent of misclassification by the food
frequency method indicate that the amount of extreme
misclassification (e.g., from lowest quartile to the
highest) is small, even a small amount of such misclassification can create a large bias in estimates of
associations (49, 50).
Validity. The definitive validity study for a food
frequency-based estimate of usual diet would require
nonintrusive observation of the respondent's total diet
over a long time. No such studies have been done. The
most practical approach to examining the concordance
of food frequency responses and usual diet is to use
multiple food recalls or records over a period as an
indicator of usual diet. This approach has been used
in many studies examining various food frequency
methods (8, 51-58). This type of study is more prop
erly called a "calibration study" rather than a "vali
dation study" (see Section V. K.) because recalls and
records themselves may not represent the time period
of interest, may contain error, and may underestimate
nutrient intakes by nearly 20% (21, 22). The correla-
Strengths. The food frequency approach is de

signed to estimate the respondent's usual intake of
foods. It also can be used to circumvent recent changes
in diet (e.g., changes due to disease) by obtaining in
formation about individuals' diets as recalled about a
prior time period. Food frequency responses can be
used to rank individuals according to their usual con
sumption of foods or groups of foods and, when por
tion size estimates are included, to rank individuals
according to nutrient intake. Some food frequency in
struments have been designed to be self-administered
and to require little time to complete. Some also are
optically scannable to reduce data entry costs. Because
the costs of data collection and processing and the re
spondent burden are typically much lower for food
frequency methods than for multiple diet records or
recalls, the food frequency method has become a com
mon way to estimate usual dietary intake.
Weaknesses. The major limitation of the food fre
quency method is that many details of dietary intake
are not measured, and the quantification of intake is
not as accurate as with recalls or records. Inaccuracies
result from an incomplete listing of all possible foods,
from errors in frequency estimation, and from errors
in estimation of usual serving sizes. As a result, the
scale for nutrient intake estimates from a food fre
quency questionnaire may be shifted considerably,
yielding inaccurate estimates of the average intake for
the group. In general, longer food frequency lists
overestimate intake, whereas shorter lists underesti
mate intake (37). In the absence of knowledge about
the true usual intake of the population, it is unknown
how closely the distribution of intake estimates from
food frequency questionnaires reflects the distribution
of true intake in that population.
There has been controversy over whether it is proper
to use the food frequency method to estimate quan
titative parameters of a population's dietary intake
(38-42). Although some food frequency question
naires seem to produce estimates of population aver
age intakes that are reasonable (38), different food fre
quency questionnaires will perform in often unpre
dictable ways in different populations, so the levels of
nutrient intakes estimated by food frequency ques
tionnaires should best be regarded as only approxi
mations (39). Food frequency questionnaires are much
better suited for ranking subjects according to food or
nutrient intake than for estimating the levels of intake.
Serving size of foods consumed is difficult for re
spondents to evaluate and thus is problematic for all
dietary history instruments (see Section V. A.). How
ever, the inaccuracies involved in respondents at
tempting to estimate usual serving size in food fre
quency questionnaires may be even greater. The im
portance of this error has been debated widely. Because
frequency is believed to be a greater contributor than
typical serving size to the variance in intake of most
foods, some prefer to use food frequency question
tions between the methods for most foods and nu

trients are in the range of 0.4 to 0.7. Food frequency
instruments with a very long list of foods tend to yield
higher estimates of food and nutrient intake than do
the quantitative methods of 24-hour recall and the
food record. This overestimation of intake with very
long food lists can produce estimates of caloric intake
that are unrealistic for some respondents (e.g., 4,000
kcal/d) and is one reason many investigators statisti
cally adjust for total caloric intake when analyzing nu
trient intake estimates derived from food frequency
questionnaires.
D. Brief Dietary Assessment
Methods
takes of dietary fat using 13 questions and fruits and

vegetables using 6 questions (65) (see Section VI. T.).
Because the cognitive processes for answering food
frequency-type questions can be complex, some at
tempts have been made to reduce respondent burden
by asking questions that require only "yes-no" an
swers. Kristal et al. (66) developed a questionnaire
containing 44 food items for which respondents are
asked whether they eat the items at a specified fre
quency. A simple index based on the number of "yes"
responses was found to correlate well with diet as
measured by 4-day records and with food frequency
questionnaires assessing total diet. This same "yesno" approach to questioning for a food list also has
been used as a modification of the 24-hour recall
(67,68).
Often, interventions are designed to target specific
food preparation or consumption behaviors rather
than frequency of consuming specific foods. Examples
of such behaviors might be trimming the fat from red
meats, removing the skin from chicken, or choosing
low-fat dairy products. Many questionnaires have been
developed in different populations to measure these
types of dietary behaviors, and several have been com
pared with more complete dietary assessments. A ninequestion instrument designed to measure high-fat food
consumption behaviors of Mexican Americans was
shown to correspond with fat estimates from 24-hour
recalls (69), and, in the United Kingdom, brief ques
tions on high-fat behaviors correlated with fat-intake
estimates from a food frequency questionnaire (70)
and with blood-cholesterol change (71). In rural North
Carolina, an eight-item questionnaire was found to
correlate with fat intake from 3-day food records (72).
Kristal et al. (73) developed brief questionnaires for
characterizing behaviors related to fat intake (see Sec
tion VI. Q.) that compare well to fat intake estimates
derived from a combination of diet records, 24-hour
dietary recalls, and food frequency measures (74).
The brevity of these methods and their correspon
dence with dietary intake as estimated by more exten
sive methods create a seductive option for investiga
tors who would like to measure diet at a low cost.
Although brief methods have many applications, they
have several limitations. The measures are not quan
titatively meaningful and, therefore, estimates of di
etary intake for the population cannot be made. Often,
brief methods are only designed to capture informa
tion about a single nutrient, therefore, the entire diet
cannot be assessed. Finally, the specific food behaviors
found to correlate with dietary intake in a particular
study may not correlate similarly in another popula
tion or even in the same population in another time
period. Investigators should consider carefully the
needs of their study and their own population's dietary
patterns before choosing an "off-the-shelf" instrument
designed for brief measurement of either food fre
quency or specific dietary behaviors.
Several brief dietary assessment methods have been

developed. These instruments can be useful in situa
tions that do not require either assessment of the total
diet or quantitative accuracy in dietary estimates. For
example, a brief diet assessment might be used to triage
large numbers of individuals into groups to allow more
focused attention on those at greatest need for inter
vention or education. Measurement of dietary intake,
no matter how crude, also can serve to activate interest
in the respondent to facilitate nutrition education.
These brief methods may, therefore, have utility in
clinical settings or in situations where health pro
motion and health education is the goal.
Such methods can be simplified food frequencies or
may focus on eating behaviors other than the fre
quency of intake of specific foods. Complete food fre
quency questionnaires typically must contain 100 or
more food items to capture the range of foods con
tributing to the many different nutrients in the diet.
If an investigator is interested only in estimating the
intake of a single nutrient or a single type of food,
however, then far fewer foods need to be included.
Often, only 15-30 foods might be required to account
for most of the intake of a particular nutrient in the
diet of a population (59, 60).
Several brief food frequency questionnaires have
been developed and compared with multiple days of
food records, complete food frequency questionnaires,
or both. Block et al. (61) selected those 13 foods that
accounted for most of the intake of fat in the diets of
American women to develop a brief "fat screener" for
use in selecting women for a dietary intervention trial
(see Section VI. O.). The correlation between the fat
index derived from those 13 questions and fat intake
from multiple records (r = 0.58) was similar to cor
relations using more complete food frequency ques
tionnaires. Similar sets of questions have been devel
oped by others to briefly characterize dietary fat intake
(62-64). Brief telephone-administered food frequency
questionnaires have been developed by the Centers
for Disease Control (CDC) as part of the Behavior Risk
Factor Surveillance System (BRFSS)to assess the in
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E. Diet History
III. DIETARY ASSESSMENT

SITUATIONS
IN SPECIFIC
The primary research question must be clearly

formed and questions of secondary interest should be
recognized as such. Projects can fail to achieve their
primary goal because of too much attention to sec
ondary goals. The choice of the most appropriate di
etary assessment tool depends on many factors (47).
Questions that must be answered in evaluating which
dietary assessment tool is most appropriate for a par
ticular research need include:
Is information needed about foods, nutrients,
other food constituents, or specific dietary
behaviors?
Is the average intake of a group or the intake of
each individual needed?
Is absolute or relative intake needed?
What level of accuracy is needed?
The term "diet history" is used in many ways. In

the most general sense, a dietary history is any dietary
assessment that asks the respondent to report about
past diet. Originally, as coined by Burke (75, 76), the
term "dietary history" referred to the collection of
information not only about the frequency of intake of
various foods but also about the typical make-up of
meals. Many now imprecisely use the term "dietary
history" to refer to the food frequency method of di
etary assessment. However, several investigators have
developed diet history methods that provide infor
mation about usual food intake patterns beyond sim
ple food frequency data (77). Some of these methods
characterize foods in much more detail than is allowed
in food frequency lists (e.g., preparation methods and
foods eaten in combination), and some of these meth
ods ask about foods consumed at every meal (78). The
term "diet history" is therefore probably best reserved
for diet assessment methods that ascertain a person's
usual food intake in which many details about char
acteristics of foods as usually consumed are assessed
in addition to the frequency and amount of food in
take.
The Burke diet history included three elements: a
detailed interview about usual pattern of eating, a food
list asking for amount and frequency usually eaten,
and a 3-day diet record (75, 76). The detailed interview
(which sometimes includes a 24-hour recall) is the
central feature of the Burke dietary history, with the
food frequency checklist and the 3-day diet record used
as cross-checks of the history. The original Burke diet
history has not often been reproduced exactly because
of the effort and expertise involved in capturing and
coding the information if it is collected by an inter
viewer. However, many variations of the Burke
method have been developed and used in a variety of
settings (77, 79-81). These variations attempt to as
certain the usual eating patterns for an extended period
of time, including type, frequency, and amount of
foods consumed; many include a cross-check feature
(82, 83). More recently, the method has been auto
mated, eliminating the need for an interviewer to ask
the questions. This has been completed as a software
program to be administered by computer, with text
on the screen. A newer version is incorporating sound,
orally delivered questions and dialogue, and pictures
of foods to improve communication and motivation
(78). Short-term recalls or records, if also administered,
often are used for validation or calibration rather than
as a part of the tool.
Strengths. The major strength of the diet history
method is its assessment of usual meal patterns and
details of food intake rather than intakes for a short
period of time (as in records or recalls) or only fre
quency of food consumption. Details about how foods
were prepared can be helpful in better characterizing
nutrient intake (e.g., frying vs. baking), as well as ex

posure to other factors in foods (e.g., charcoal broiling).
When the information is collected separately for each
meal, analyses of the joint effects of foods eaten to
gether is possible (e.g., effects on iron absorption of
concurrent intake of tea or foods containing vitamin
C). Although a meal-based approach often requires
more time from the respondent than a food-based ap
proach, it provides more cognitive support for the re
call process and therefore may be more accurate. For
example, the respondent may be better able to report
total bread consumption by reporting bread as con
sumed at each meal.
Weaknesses. Respondents are asked to make
many judgments both about the usual foods and the
amounts of those foods eaten. These subjective tasks
may be difficult for many respondents. Burke cau
tioned that nutrient intakes estimated from these data
should be interpreted as relative rather than absolute.
All of these limitations are shared with the food fre
quency method. The meal-based approach is not useful
for individuals who have no particular eating pattern
and may be of limited use for individuals who "graze,"
i.e., eat small bits throughout the day, rather than eat
at defined meals. The approach, when conducted by
interviewers, requires trained dietitians.
Validity. The validity of diet history approaches
is difficult to assess because we lack independent
knowledge of the individual's usual long-term intake.
As with food frequency questionnaires, nutrient es
timates from diet histories often have been found to
be higher than nutrient estimates from tools that mea
sure intakes over short periods, such as recalls or re
cords (84, 85). However, results for these types of
comparisons depend on both the approach used and
study characteristics.
What time period is of interest?

What are the research constraints in terms of
money, time, staff, and respondent characteris
tics?
A. Cross-Sectional Surveys
B. Case-Control (Retrospective) Studies

A case-control study design classifies individuals
with regard to disease status currently (as cases or
controls) and relates this to past (retrospective) ex
posures. For dietary exposure, the period of interest
could be either the recent past (e.g., the year before
diagnosis) or the distant past (e.g., 10 years ago or in
childhood). Because of the need for information about
diet before onset of disease, dietary assessment meth
ods that focus on current behavior, such as the 24hour recall, are not useful in retrospective studies. The
food frequency and diet history methods are well
suited for assessing past diet and are therefore the only
good choices for case-control (retrospective) studies.
In any food frequency or diet history interview, the
respondent is not asked to call up specific memories
of specific eating patterns but is asked to respond on
the basis of general perceptions of how frequently he/
she ate a food. In assessing past diet, an additional
requirement is to orient the respondent to the appro
priate period. In case-control studies, the relevant pe
riod is often the year before diagnosis of disease or
onset of symptoms or even a time many years in the
past. Cognitive factors may greatly affect the perfor
mance of this method.
Long-term reproducibility of various food fre
quency questionnaires has been assessed in various
populations by asking participants from past dietary

studies to recall their diet from that earlier time (86).
Correspondence of retrospective diet reports with the
diet as measured in the original study usually has been
greater than correspondence with diet reported by
subjects for the current (later) period. This observation
implies that if diet from years in the past is of interest,
then it may be better to ask respondents to recall it
than to simply consider current diet as a proxy for past
diet. The current diets of respondents may affect their
retrospective reports about past diets. In particular,
retrospective diet reports from seriously ill individuals
may be biased by their more recent dietary changes
(87). Studies of groups in whom diet was measured
previously indicate no consistent differences in the
accuracy of retrospective reporting between those who
recently became ill and others (86, 88).
C. Cohort (Prospective) Studies

In a cohort study design, exposures of interest are
assessed at baseline in a group (cohort) of people and
disease outcomes occurring over time (prospectively)
are then related to the baseline exposure levels. In pro
spective dietary studies, dietary status at baseline is
measured and related to later incidence of disease. In
studies of many chronic diseases, large numbers of
individuals need to be followed for years before
enough new cases with that disease accrue for statis
tical analyses. A broad assessment of diet usually is
desirable in prospective studies, because many dietary
exposures and many disease end-points ultimately will
be investigated.
To relate diet at baseline to the eventual occurrence
of disease, a measure of the usual intake of foods by
study subjects is needed. Although a single 24-hour
recall or a food record for a single day would not ad
equately characterize the usual diet of study subjects
in a cohort study, such information could be analyzed
later at the group level for contrasting the average di
etary intakes of subsequent cases with those who did
not acquire the disease. Multiple dietary recalls, re
cords, diet histories, and food frequency methods all
have been used effectively in prospective studies. Cost
and logistic issues tend to favor food frequency meth
ods, as many prospective studies require thousands of
respondents.
Even in large studies using food frequency instru
ments, it is desirable to include multiple recalls or re
cords in subsamples of the population (preferably be
fore beginning the study) to construct or modify the
food frequency instrument and to calibrate it (see Sec
tion V. K.). Information on the foods consumed could
be used to ensure that the questionnaire includes the
major food sources of key nutrients, with reasonable
portion sizes. Because the diets of individuals change
over time, it is desirable to measure diet throughout
the follow-up period rather than just at baseline. If
One of the most common types of studies is the

simple cross-sectional survey, a "snapshot" of the di
etary practices of a population at a particular point in
time. The population can be defined variously as the
entire country (as in the NHANES and USDA surveys),
the residents of a state (as in the BRFSS surveys), or
individuals who attend a particular facility such as a
health clinic. Most commonly, 24-hour recalls are used
to estimate the population's diet in surveys. This al
lows for quantitative accuracy in estimating average
daily food and nutrient intake in the population stud
ied. Multiple recalls or records are required to be col
lected from each respondent (or at least a sample of
respondents) if the intent is to describe the true dis
tribution of usual food and nutrient intake of the pop
ulation. Otherwise, the prevalences of high or low in
takes in the population will be overestimated. Food
frequency techniques that measure usual individual
diet also have been used in surveys, but they are lim
ited by their lack of quantitative accuracy. Short
methods designed to measure specific diet behaviors
also may be useful in some dietary surveys.
2251S
2252S
SUPPLEMENT
diet is measured repeatedly over the years, repeated

calibration also is desirable. Information from cali
bration studies can be used for three purposes: to give
design information, e.g., the sample size needed (48);
to show how values from the food frequency tool (or
a brief food list thus derived) relate to values from the
recalls/records (89); and to determine the degree of
attenuation in the estimates of association observed
in the study (e.g., between diet and disease) (90, 91).
D. Intervention Studies
Accurate measurement of intake is not always re

quired to meet the study's goals. For some goals, a
crude indication of dietary habits to screen for prob
able dietary risk is adequate. The brief "fat screener"
of Block et al. (61) (see Section VI. O.) was developed
originally as a crude screening tool to classify women
for entry into a low-fat intervention trial. The screen
ing questionnaire developed as part of the Nutrition
Screening Initiative (see Section VI. P.) is another ex
ample of a crude instrument intended only to identify
a group of respondents who might be in need of nu
tritional and/or medical counseling (98, 99). In fact,
many of the questions on the Nutrition Screening Ini
tiative questionnaire are not at all specific to dietary
intake (e.g., medical and dental conditions and eco
nomic limitations).
In clinical settings, the caregiver generally is inter
ested in assessing an individual's usual dietary prac
tices but only has limited time. Accurate information
may be needed, such as for counseling on medically
prescribed diets. Qualitative information about usual
dietary practices and behaviors is, however, usually
sufficient. Dietary recalls, diet histories, and food fre
quency methods are useful as crude methods to classify
("screen") individuals in clinical settings. Although
24-hour dietary recalls can provide useful quantitative
information, there is a danger in interpreting yester
day's recalled diet as the individual's usual intake.
Food frequency approaches may provide adequate in
formation to qualitatively assess usual dietary prac
tices. Brief questionnaires can serve to identify indi
viduals who may be at dietary risk from, for example,
often eating high-fat foods (61). Short forms that mea
sure specific dietary behaviors (e.g., choosing low-fat
salad dressings or dairy products) may provide useful
information about specific intervention points for
counseling (66, 73, 100).
When accurate individual estimates on all patients
is not required, combinations of various dietary as
sessment methods for dietary screening can maximize
opportunities for qualitative assessment of individuals
and quantitative assessment of the group. For example,
all patients (or those of a certain type) could fill out a
brief dietary screen for food frequency and food be
haviors, with a recall performed on only a sample (e.g.,
every 20th patient). This method would provide a
time-efficient way to screen for dietary risk of indi
viduals and, at the same time, quantitatively and con
tinuously measure the average diet of the population
served in the clinic.
F. Dietary Surveillance or Monitoring
Nutritional surveillance is increasingly acknowl
edged as important at the national level and state level
as a way to recognize problems, evaluate interventions,
Measurement of the dietary changes resulting from

an intervention requires a valid measure of diet before,
during, and after the intervention period. Very little
work has been done on the development of valid
methods to measure dietary change in individuals or
in populations (92-94). Measurement of specific di
etary behaviors in addition to (or even in place of) di
etary intake should be considered in intervention
evaluations when the nature of the intervention in
volves education about specific behaviors. If, for in
stance, a community-wide campaign to choose lowfat dairy products were to be evaluated, food selection
and shopping behaviors specific to choosing those
items should be measured. Intentional behavior
change is a complex and sequential phenomenon,
however, as has been shown for tobacco cessation (95).
A complex sequence of events also may lead to dietary
change (96). The effects of educational interventions
also might be assessed by measuring knowledge, at
titudes, beliefs, barriers, and perceptions of readiness
for dietary change (see Section VI. V., Figure 40), al
though the reliability of these types of questions has
not been well assessed.
Whether an intervention is targeting individuals or
the entire population, repeated measures of diet among
study subjects can reflect reporting bias in the direction
of the change being promoted. Even though not in
tending to be deceptive, respondents tend to want to
tell the investigators what they think they want to
hear. Though there has been little methodological re
search in measuring dietary change, behavioral ques
tions and the food frequency method, because of their
greater subjectivity, may be more susceptible to re
porting biases than the 24-hour recall method. Because
all subjective reports are subject to bias in the context
of an intervention study, an independent assessment
of dietary change should be considered. One such
method useful in community-wide interventions is
monitoring food sales. Often, cooperation can be ob
tained from food retailers (97). Because of the large
number of food items, only a small number should be
monitored, and the large effects on sales of day-to-day
pricing fluctuations should be considered carefully.
Another method to consider is measuring changes in
biomarkers of diet in the population.
E. Dietary Screening in Clinical Settings
2253S
TABLE 1
A summary
of recent major dietary intake surveys conducted
Years
Survey
National
SurveysNHANES
Health and Nutrition
INHANES
Approximate number
interviewed
Dietary assessment
method
Examination
IINHANES
IIIHispanic
Health and Nutrition
in the United States
Examination
recall19
frequency24-hr
item food
recall26
frequency24-hr
item food
recall62
frequency24-hr
item food
recall22
Survey (HANES|1971-741976-801989-941982-8428,00025,00035,00014,00024-hr
item food frequency
Nationwide Food Consumption Survey

NFCS
87-88NFCS
77-78Continuing
(CSFII)National
Survey of Food Intakes of Individuals
record24-hr
recall, 2-day
recordmultiple
recall, 2-day
recalls24-hr24-hr
recordtwo
recall, 2-day
recalls60
24-hr
SurveyHIS
Health Interview
frequency68
item food
(19871HIS
frequency6
item food
(1992)Behavioral
Risk Factor Surveillance System (BRFSS)1987-881977-781985-861989-911994-9619871992Annual10,00036,0009,00015,00015,000'22,00012,0002,000
per state24-hr
item food frequency
1 Projected.
and guide policy. The components of nutritional sur

veillance range from the regular monitoring of mor
tality, morbidity, and risk factor trends to knowledge
of the information sources and knowledge level of the
populations of interest (101). Assessment of the di
etary intakes of the population is one aspect of this.
In addition to assuring that the data are being analyzed
and reported rapidly, the special requirement is that
the methods for collecting data, including the sampling
procedures, must be similar through time (102). Food
composition data bases must remain comparable for
this purpose but also must reflect true changes in actual
food composition over time. The status of efforts to
monitor diet in the United States is summarized in
reports on the National Nutrition Monitoring and
Related Research Program (103-107) and elsewhere
(92, 108, 109).
Both the National Center for Health Statistics
(NCHS) and USDA conduct periodic surveys of the
health and nutritional status of representative samples
of Americans (106, 110-128). Those surveys are sum
marized in Table 1 (see also Sections VI. B. and L.).
National surveys of knowledge and attitudes about
nutrition and health also are conducted periodically.
Examples of such surveys are the Food and Drug Ad
ministration's Health and Diet Survey, and USDA's
Diet and Health Knowledge Survey, which is admin
istered in conjuction with the Continuing Survey
of Food Intakes of Individuals (CSFII) (see Section
VI. W.). Other nutrition monitoring activities spon
sored by federal and state agencies are listed in The
Directory of Federal and State Nutrition Monitoring
Activities (106).
The type of information required for a surveillance

or monitoring system can vary. For some purposes
quantitative estimates of intake are needed, whereas,
for other purposes, only qualitative estimates of in
take, such as food frequency or behavioral indicators,
are needed. There is a particular need to monitor di
etary trends at the local level. To help provide local
data, the Centers for Disease Control and Prevention
(CDC) has developed brief food frequency question
naires for administration on the telephone, as part of
the BRFSS,to assess the intake of dietary fat (13 ques
tions) and fruits and vegetables (6 questions) (see Sec
tions II. D. and VI. T.).
IV. DIETARY ASSESSMENT

POPULATIONS
IN SPECIAL
A. Surrogate Reporters
In many situations, respondents are unavailable or
unable to report about their diets. For example, in casecontrol studies, surrogate reports may be obtained for
cases who have died or who are too ill to interview.
Although the accuracy of surrogate reports has not
been examined, comparability of reports by surrogates
and subjects has been studied in hopes that surrogate
information might be used interchangeably with in
formation provided by subjects (129). Common sense
indicates that individuals who know the most about
a subject's lifestyle would make the best surrogate re
porters. Adult siblings provide the best information
2254S
SUPPLEMENT
To examine the suitability of the initial data base,

baseline recalls or records with accompanying inter
views should be collected from individuals in the eth
nic groups. These interviews should focus on all the
kinds of food eaten and the ways in which foods are
prepared in that culture. Recipes and alternative names
of the same food should be collected and interviewers
should be familiarized with the results of these inter
views. Recipes and food names that are relatively uni
form should be included in the nutrient composition
data base. Even with these modifications, it may be
preferable to collect records and recalls in the field by
written records (not computer assisted) when special
ethnic foods are common. This would prevent the de
tail of food choice and preparation from being lost by
a priori coding.
Use of standard food lists for food frequency ques
tionnaires may be inappropriate for many individuals
with strong ethnic identification. Many members of
ethnic groups consume both foods common in the
mainstream culture and foods that are specific to their
own ethnic group. Development of the food list can
be accomplished either by modifying an existing food
list based on expert judgement of the diet of the target
population or, preferably, by examining the frequency
of reported foods in the population from a set of di
etary records or recalls. Food frequency questionnaires
for the Navajos and for Chinese Americans have been
developed using these approaches (134, 135).
C. Children
B, Ethnic Populations
Special modifications are needed in the content of
dietary assessment methods when the study popula
tion is composed of individuals with a strong sense of
ethnic identity (132). If the method requires an inter
view, interviewers of the same ethnic or cultural
background are preferable so that dietary information
can be communicated more effectively. If dietary in
formation is to be quantified into nutrient estimates,
examination of the nutrient composition data base is
necessary to ascertain the number of ethnic foods al
ready included and those to be added. It also is nec
essary to examine the recipes and assumptions under
lying the nutrient composition of certain ethnic foods.
Some very different foods may be called the same name
or similar foods may be called by different names (133).
For these reasons, it may be necessary to obtain de
tailed recipe information for all ethnic mixtures re
ported. For Hispanic subgroups, the continuing USDA
data base is a good starting point because foods re
ported in the Hispanic HANES have now been incor
porated. For Asian and Pacific Island subgroups, data
bases developed for the Hawaiian cancer studies in
clude many foods consumed by Hawaiian natives and
by Japanese, Chinese, and Polynesian groups (132).
The 24-hour dietary recall, food records, and food

frequency instruments all have been used to assess
children's diets, which are even more challenging than
assessing the diets of adults (136-141). Children tend
to have diets that are highly variable from day to day,
and their food habits can change rapidly. Younger
children are less able to recall, estimate, and cooperate
in usual dietary assessment procedures, so much in
formation by necessity has to be obtained by surrogate
reporters.
For preschool-aged children, information is ob
tained from surrogates, usually the primary caretaker(s), who may typically be a parent and an external
caregiver. If information can be obtained from only
one respondent, the reports likely are to be less com
plete. Even for periods when the caregiver and child
are together, foods tend to be underestimated (142).
A consensus recall method, in which the child and
parents combine to give responses on a 24-hour dietary
recall, has been shown to give more accurate infor
mation than a recall from either parent alone (143).
D. Elderly
Measuring diets among the elderly can present spe
cial problems (144, 145). Both recall and food fre-
about a subject's early life, and spouses or children

provide the best information about a subject's adult
life. When food frequency instruments are used, the
level of agreement between subject and surrogate re
ports of diet varies with the food and possibly with
other variables such as number of shared meals, in
terview situation, case status, and sex of the surrogate
reporter. Mean frequencies of use computed for in
dividual foods and food groups between surrogate re
porters and subject reporters tend to be similar, but
agreement is much lower when detailed categories of
frequency are compared. Several studies have shown
that agreement is better for alcoholic beverages, coffee,
and tea than for other foods.
Although subjects reporting themselves in the ex
tremes of the distribution seldom are reported by their
surrogates in the opposite extreme, many subjects who
report they are in an extreme are reported in the middle
of the distribution by surrogates (130). This may limit
the usefulness of surrogate information for analyses
at the individual level that rely on proper ranking.
Furthermore, there may be a substantial difference in
the quality of surrogate reports between spouses of
deceased subjects and spouses of surviving subjects
(131). For these reasons, use of surrogate respondents
should be minimized for obtaining dietary information
in analytical studies. When used, analyses excluding
the surrogate reports should be done to examine the
sensitivity of the reported associations to possible er
rors or biases in the surrogate reports.
quency techniques are inappropriate if memory is im

paired. Direct observation in institutional care facil
ities or shelf inventories for elders who live at home
can be useful. Even when memory is not impaired,
other factors can affect the assessment of diet among
the elderly. Because of the frequency of chronic illness
in this age group, often special diets (e.g., low sodium,
low fat, high fiber) have been recommended. Such rec
ommendations not only affect true dietary intake, but
also can bias reporting. When dentition is poor, the
interviewer should probe for foods that are prepared
or consumed in different ways. Elderly individuals also
are more likely to be taking multiple types of nutri
tional supplements, which present special problems
in dietary assessment (see Section V. H.) (146).
A. Estimation of Portion Size

Research has shown that individuals have difficulty
in estimating portion sizes of foods, both when ex
amining displayed foods and when reporting about
foods previously consumed (147, 148). In general,
U. S. consumers are poor at estimating the weights of
foods, and there is further confusion about the term
ounces, which is interpreted as indicating either vol
ume or weight. Furthermore, volume amounts of foods
may have limited meaning, as respondents appear to
be relatively insensitive to changes made in portion
size amounts shown in reference categories asked on
questionnaires (149). Portion sizes of foods that are
commonly bought and/or consumed in defined units
(e.g., bread by the slice, pieces of fruit, beverages in
cans or bottles) may be more easily reported than ir
regularly shaped foods (e.g., steak, lettuce).
Portion size aids are commonly used to help re
spondents estimate portion size. The National Health
and Nutrition Examination Surveys (NHANES) use
an extensive set of three-dimensional models; the Na
tionwide Food Consumption Surveys (NFCS) use
common household measures, such as cups and tea
spoons. In one study that compared these two ap
proaches among men, there was little difference in the
frequency of over- and underreporting (150). However,
those using the household measures had greater over
estimates than did those using the food models. Stud
ies indicate that accuracy of reporting using either
models or household measures can be improved with
training in that method (151), but the effects of train
ing deteriorate with time (152).
Two- and three-dimensional pictures have been de
veloped and used in 24-hour dietary recalls, diet re
cords, and food frequency questionnaires (see Section
VI. C.). One study, which examined the comparability
of portion size reports for the same foods using food

models and equivalent two-dimensional pictures of
those same models, found that although some respon
dents reported differently, no apparent bias in the di
rection of reporting was evident (153).
B. Mode of Administration
One way that the costs of collecting dietary infor
mation may be reduced is to administer the instrument
by telephone or by mail. Both telephone and mail sur
veys are less invasive than are face-to-face interviews.
The use of telephone surveys to collect dietary infor
mation has been reviewed recently (154). Telephone
surveys have higher response rates than do mail sur
veys (155) and have been used in a variety of public
health research settings (156). Interview by telephone
can be substantially less expensive than face-to-face
interviews, but cost comparisons vary with the re
search setting. The difficulty of reporting serving sizes
by telephone can be eased by mailing picture booklets
or other portion size estimation aids to the participants
before the telephone interview.
Research evaluating the quality of data from tele
phone interviews is limited. Several studies have found
substantial but imperfect agreement between dietary
data collected by telephone and dietary data estimated
by other methods, including face-to-face interviews
(157, 158), expected intakes (159), or observed intakes
(160). Recognition of the potential advantages of tele
phone interviewing led to its adoption in NHANES
III (phase I collected one in-person and two telephone
follow-up 24-hour recalls for respondents age 50 years
and older [161]) and in the Continuing Survey of Food
Intakes by Individuals (CSFII) conducted in 1985 and
1986. However, some segments of the population do
not have telephones, and some persons will not answer
their telephones under certain circumstances. There
fore, it is important to consider a dual sampling
scheme so potential respondents who do not have
telephones can be interviewed (156).
C. Multiple Days of Diet Information
When recalls or records are being used to estimate
usual intake of individuals to describe eating patterns
or to examine relationships between diet and disease,
more than 1 day of dietary information is usually
needed. Eating patterns vary between weekdays and
weekends and across seasons, so multiple observations
for individuals should include days in all parts of the
week and in all seasons of the year. Nonconsecutive
days are preferable to capture more of the variability
in an individual's diet, because eating behaviors on
consecutive days are correlated (162). The number of
days of information needed depends on which dietary
parameter is being estimated, the extent of variability
in the population, the research objectives, and the
V. SELECTED ISSUES IN DIETARY

ASSESSMENT METHODS
2255S
2256$
SUPPLEMENT
D. Choice of Nutrient Data Base

It is necessary to use a nutrient composition data
base when dietary data are to be converted to nutrient
intake data. Typically, such a data base includes the
description of the food, a food code, and the nutrient
composition per 100 grams of the food. The number
of foods and nutrients included varies with the data
base.
One of USDA's primary missions is to analyze the
nutrient composition of foods in the U. S. food supply,
accounting for various types of preparation (167). Re
visions of the Agriculture Handbook No. 8, Com
position of Foods . . . Raw, Processed, Prepared and
its electronic form, USDA Nutrient Data Base for
Standard Reference, include data on water, energy,
protein, total lipid, carbohydrate, total dietary fiber,
ash, calcium, iron, magnesium, phosphorus, potas
sium, sodium, zinc, copper, manganese, ascorbic acid,

thiamin, riboflavin, niacin, pantothenic acid, vitamin
B6, folacin, vitamin B12,vitamin A, eight saturated
fatty acids, four monounsaturated fatty acids seven
polyunsaturated fatty acids, cholesterol, phytosterol,
and 18 individual amino acids. Over 5,200 foods are
included in the latest release, which is published in 21
volumes. Printed copy of this material can be ordered
from the Superintendent of Documents, Government
Printing Office, Washington, DC 20402. Expanded and
revised data on nutrient content are released annually
as supplements (in print form) and update files (in ma
chine readable form). These data and other informa
tion about nutrient data from the USDA are also
available electronically through the Nutrient Data
Bank Bulletin Board (301-436-5635) and through In
ternet. Contact David B. Haytowitz, Agricultural
Research Service, USDA, 4700 River Road, Riverdale, MD 20737 (301-436-8491/Internet:
info12@info.umd.edu) for more information.4 Food and
nutrient information available electronically from
USDA and from others and directions for accessing
this information are listed in a free National Agricul
tural Library publication (168).
Research on nutrients and foods to improve current
estimates is ongoing, and high priority foods and nu
trients have been identified for analyses (169). Tables
of provisional values for selenium, vitamin D, and vi
tamin K and a publication on individual sugar contents
of foods are available from USDA, Agricultural Re
search Service, Room 314, 4700 River Road, Riverdale,
MD 20737.4 Data sets corresponding to these tables
also are available on the bulletin board. Analyses of
foods for individual carotenoid levels has led to the
availability of a data base for five carotenoids (170).
Dietary cholesterol values for eggs and some other
foods have been updated in the USDA data base from
results of new analytical methods (171). Dietary fiber
data are incomplete, but values are available on the
USDA data base for frequently consumed items.
Many other data bases are available in the United
States, but most are based fundamentally on the USDA
data base, often with added foods and specific brand
names. Estimates of nutrient intake from dietary re
calls and records are often affected by the nutrient
composition data base that is used to process the data
(172, 173). Differences are due to the number of food
items in the data base, the recency of nutrient data,
and the number of missing or imputed nutrient com
position values. Therefore, before choosing a nutrient
composition data base, a prime factor to consider is
the completeness and accuracy of the data for the nu
trients of interest. For some purposes, it may be useful
to choose a data base in which each nutrient value for
each food also contains a code for the quality of the
4 Before February 1995, at 6505 Belcrest Rd., Hyattsville,
20782 (301-436-8491).
MD
variability of the nutrient or food to be measured (163,

164). For most nutrients, as many as 7-14 independent
days of diet information may be necessary to charac
terize the individual's usual intake (162).
If the intent is only to generate a population distri
bution of a nutrient's intake (i.e., to separate withinperson variability from total observed variability to
estimate between-person variability), then only 2 days
of recalls are needed on a sample. Because multiple
days of dietary information are necessary to estimate
the distribution of usual diet in the population (e.g.,
the proportion of the population eating diets with
fewer than 30% of calories from fat), NCHS collected
three independent 24-hour recalls on a subsample of
older respondents in phase 1 of NHANES III (110).
USDA has also been collecting multiple days of dietary
intake data since 1977. Various statistical methods to
estimate the distribution of usual intakes from 2 or
more days of dietary information have been suggested.
One of these methods, developed by a National Acad
emy of Sciences subcommittee (33), has been improved
by researchers at Iowa State University in cooperation
with USDA (165), with computer software now being
developed.
Although studies using records or recalls often use
one or the other, a combined dietary recall and record
approach in which an initial interviewer-administered
24-hour recall is followed by self-administered 2-day
or 3-day records has been used by USDA in its 197778 and 1987-88 Nationwide Food Consumption Sur
veys and its Continuing Survey of Food Intakes by
Individuals 1989-91 (106) and by others in research
studies (166). The costs of collecting and processing
additional days of information include not only in
creased financial costs but also reduced response rates
as individuals tire of participating. All costs should
be carefully considered relative to the benefits of
collecting such information for the hypothesis of in
terest.
data: e.g., analytical value, calculated value, imputed

value, or missing. Investigators need to be aware that
a value of zero is assigned to missing values in some
data bases. The nutrient data base should also include
weight/volume equivalency information for each food
item. Many foods are reported in volumetric measures
(e.g., 1 cup) and must be converted to weight in grams.
The number of common mixtures (e.g., spaghetti with
sauce) available in the data base is another important
factor. If the study requires precision of nutrient es
timates, then procedures for calculating the nutrients
in various mixtures must be developed and incorpo
rated into nutrient composition calculations. Another
key consideration is how the data base is maintained
and supported. How often is the data base updated to
reflect new information? Is support available to assist
the user with questions?
Computerized data processing requires creating a

data file that includes a food code and an amount con
sumed for each food reported. Computer software
then links the nutrient composition of each food on
the separate nutrient composition data base file, con
verts the amount reported to multiples of 100 grams,
multiplies by that factor, stores that information, and
sums across all foods for each nutrient for each indi
vidual. Many computer packages have been developed
that include both a nutrient composition data base and
software to convert individual responses to specific
foods and, ultimately, to nutrients (174). These pack
ages are available for mainframe computers and for
IBM-compatible and Macintosh personal computer
systems. A relatively recent listing of food and nutri
tion microcomputer software programs is found in
Frank and Irving (175). More up-to-date information
can be found in the most recent edition of the Nutrient
Databank Directory (176). USDA's Food and Nutri
tion Information Center of the National Agricultural
Library maintains a Software Demonstration Center
of more than 200 software programs for IBM-com
patible, Macintosh, and Apple personal computers.
The programs cover dietary analysis, nutrition edu
cation, and other subjects. Although the Center does
not loan the programs, visitors can come to the Center
(address below) and preview the software. A complete
listing of the software programs available in the col
lection, Microcomputer Software Collection (177), is
updated electronically monthly and printed every De
cember. The information includes the publisher,
hardware used, price, and brief description of the soft
ware. The listing is available free from the Food and
Nutrition Information Center (10301 Baltimore Bou
levard, Room 304, Beltsville, MD 20705-2351; 301504-5719). The software list is also available in elec
tronic format on the Internet on the Food and Nutrition
Information Center gopher, the National Agricul
tural Library electronic bulletin board, or on floppy

disk.
Software should be chosen on the basis of the re
search needs, the level of detail necessary, the quality
of the nutrient composition data base, and the hard
ware and software requirements (174, 178). If precise
nutrient information is required, it is important that
the system is able to expand to incorporate informa
tion about newer foods in the marketplace and to in
tegrate detailed information about food preparation
(e.g., homemade stew) by processing recipe informa
tion. Sometimes the study purpose requires analysis
of dietary data to derive intake estimates not only for
nutrients, but for food groups (e.g., fruits and vege
tables), food components other than standard nutrients
(e.g., nitrites), or food characteristics (e.g., fried foods).
These additional requirements limit the choice of ac
ceptable software. Further guidance on how to choose
a software program suitable to these purposes can be
found in publications by the American School Food
Service Association (179), Christensen and Stearns
(180), and Brown and Associates (181).
Automation has been incorporated into national di
etary intake surveys to varying degrees. The system
used in NHANES III is the Dietary Data Collection
System, developed by NCHS in collaboration with the
University of Minnesota Nutrition Coordinating
Center. This system includes automated interviewing,
editing, and coding of dietary intake data. The Dietary
Data Collection System is copyright protected by the
Minnesota Nutrition Coordinating Center. (For more
information, contact Marilyn Buzzard, Ph.D., Nutri
tion Coordinating Center, 1300 South Second Street,
Suite 300, Minneapolis, MN 55454; 612-626-8645).
The use of the Dietary Data Collection System also
requires permission by NCHS. (Contact Margaret
McDowell, M.P.H., R.D., Division of Health Exami
nation Statistics, National Center for Health Statistics,
6525 Belcrest Road, Suite 900, Hyattsville, MD 20782;
301-436-7072).
NCHS will disseminate
the
NHANES III Dietary Interviewer's Manual, data ed
iting guidelines, and a recipe workshop report to per
sons who request such information.
The automated food coding system used for the
USDA Continuing Survey of Food Intakes by Individ
uals (CSFII)is the SURVEYNET, developed by USDA/
ARS and the University of Texas-Houston School of
Public Health. For the CSFII 1994-96, food intake in
formation is collected on paper forms and then coded
using SURVEY NET. SURVEY NET is a network di
etary coding system that provides on-line coding, rec
ipe modification and development, data editing and
management, and nutrient analysis of dietary data
with multiple user access to manage the survey activ
ities. (For more information, contact R. Sue McPherson, Ph.D., University of Texas-Houston, School
of Public Health, 1200 Hermann Pressler Drive,
Houston, TX 77225; 713-792-4660). The CSFII
E. Choice of Computer Software
2257S
2258S
SUPPLEMENT
1994-96 interviewer manual and food instruction

booklet used by the interviewers to probe for extensive
detail on types and quantities of foods consumed are
available from the Agricultural Research Service (con
tact Patricia Guenther, Ph.D., R.D., Beltsville Human
Nutrition Research Center, Agricultural Research
Service, USDA, Riverdale, MD 20737; 301-7348485).5
Various diet history and food frequency instru
ments also have been automated. The user of these
software packages should be aware of the source of
information in the nutrient database and the assump
tions about the nutrient content of each food item
listed in the questionnaire. These are described in Sec
tion VI for specific instruments.
F. Measuring Knowledge, Attitudes,
about Diet
and Beliefs
5 Before February 1995 at 6505 Belcrest Rd., Hyattsville,

20782(301-436-5618).
MD
G. Cognitive Research Related to Dietary

Assessment
Nearly all studies using dietary information about
subjects rely on the subjects' own reports of their diets.
Because memory of these events is based on cognitive
processes, it is important to understand and to take
advantage of what is known about how respondents
remember dietary information and how that infor
mation is retrieved and reported to the investigator.
The implications of such cognitive processes for di
etary assessment have been researched and discussed
by several investigators (78, 86, 149, 186-189).
There is an important distinction between episodic
memory and generic memory. Episodic memory relies
on particular memories about episodes of eating and
drinking, whereas generic memory relies on general
knowledge about the respondent's typical diet. A 24hour recall relies primarily on episodic memory of all
actual events in the very recent past, whereas a food
frequency questionnaire in which the respondent is
asked to report the usual frequency of eating a food
over the previous year relies primarily on generic
memory. As the time between the behavior and the
report increases, respondents may rely more on generic
memory and less on episodic memory (187).
What can the investigator do to enhance retrieval
and improve reporting of diet? Research indicates that
the amount of dietary information retrieved from
memory can be enhanced by the context in which the
instrument is administered and by use of specific
Although knowledge is not behavior, knowledge

can be an important determinant of dietary behavior.
Many dietary interventions that include an educa
tional component can be assessed in part by their ef
fects on knowledge (182). Measuring attitudes, beliefs,
and knowledge can be helpful in understanding how
to enhance the sequence of events leading to dietary
change in the population. Knowledge, attitudes, and
beliefs about diet can be seen as barriers to behavior
change, as factors to be changed in the process leading
to behavior change, and as enhancers of nutrition in
tervention messages. In the National 5 A Day Survey,
for instance, a strong correlation was noted between
knowledge of the recommended daily number of serv
ings of fruits and vegetables and reported intake (sub
mitted for publication, Susan M. Krebs-Smith). Section
VI includes some questions on diet knowledge, atti
tudes, and beliefs used in the USDA Diet and Health
Knowledge Survey, the 1992 National Health Inter
view Survey (183), and other studies (68, 73).
There has been little standardization in the mea
surement of knowledge, attitudes, and beliefs about
diet. In many cases, standardized questions may not
be needed to best accomplish the purpose. For instance,
a health professional wishing to promote the con
sumption of low-fat dairy products among Hispanics
served by his or her clinic may already have a good
idea about that population's set of knowledge, atti
tudes, and beliefs. A reasonable way to develop and
refine a set of questions is to convene a focus group
of 5-10 people who discuss their knowledge, attitudes,
and beliefs in a nonthreatening and nonjudgemental
way. Questions developed to target the prevalent sit
uation in that population should be tested for clarity
before being included in a survey.
Several models have been proposed to explain how

and why individuals change their health behaviors, and
these models are now serving as the basis for the de
velopment of questions for dietary knowledge and at
titudes (182). At this point there is no consensus on
which particular questions and which particular way
to score the questions are optimal for these various
models. The Stages of Change Model for behavior
change holds that there is a sequence of change that
involves beliefs, attitudes, and knowledge, culminat
ing in measurable change (95, 184). This behavioral
model has been used extensively to explain smoking
cessation, and may be applicable equally for the se
quence of events that must progress to meaningful,
permanent dietary changes necessary to reduce chronic
disease risk. In brief, this model regards people as al
ways traversing through phases of preconception,
conception, preparation, action, and maintenance of
a behavioral change. The factors that affect movement
forward through these stages of change differ for the
different stages. Nutrition education is now beginning
to make use of the stages of change model to assess
the factors that can lead to successful interventions
(96, 185). Section VI includes some illustrative ques
tions used to assess placement in a stages of change
framework (96).
2259S
H. Assessment
of Nutritional Supplements
It is often important or useful in dietary assessments

to assess the intake of nutritional supplements, such
as vitamin and mineral pills. Use of supplements in
the United States has been assessed in the 1980 Vi
tamin and Mineral Supplement Intake Survey, the
1986 National Health Interview Survey on Vitamin
and Mineral Supplements, and in the 1992 National
Health Interview Survey on Cancer Epidemiology.
Recent data from the 1992 National Health Interview
Survey indicate that 46% of the U. S. adult population
report use of nutritional supplements in the past year,
and approximately 24% of the population report reg
ular daily use. Supplement intake can be assessed for
the past 24 hours or for several days by including sup
plements in 24-hour dietary recalls or food records.
Alternatively, the research question may require as
sessment of usual supplement use over a longer period
of time. This requires supplement questions of the
food frequency type.
Of primary interest is the type of supplement taken.
There are hundreds of different products available both
over-the-counter and by prescription. Although it is
possible to ask respondents to report which supple
ments they take in an open-ended manner, this infor
mation is difficult to code. An alternative approach is
to ask close-ended questions about specific types that
are of interest. Additional parameters need to be as
sessed for each brand of supplement taken: the amount
per pill, the frequency of use, and the duration of use.

A particular complexity in assessing supplement use
is that many individuals take supplements inconsis
tently, in patterns which are hard to characterize (e.g.,
frequently for a while until they feel better or the bot
tle runs out, then not at all for a while, then irregu
larly). In many studies subjects are asked to have
available all medications they take, including vitamins,
to better account for the types and amounts taken.
It is advisable to pretest the specific questions on
supplement use in the population to be studied. Several
examples of questions on supplement use are found
in Section VI. N.
/. Biological Correlates of Nutrient Intake
Because all dietary assessment methods have limi
tations, many investigators have searched for useful
biological markers of usual dietary intake (190). Lab
oratory analyses of blood, urine, adipose tissue, stools,
nails, and hair have yielded only a few biological
markers that may be of some limited usefulness for
assessing usual diet. The major problem with most
biomarkers studied is that in well-fed populations
there are many determinants of nutrient concentra
tions in biological tissues apart from dietary intake.
Biomarkers have been used mostly for studies of
the validation of dietary reports. Some investigators
also have used biomarkers to examine the relationship
between blood nutrient levels and subsequent disease
risk in cohort studies. Biomarkers also can be used as
an adjunct measure of dietary change in intervention
trials. The potential problem of biased diet reports,
especially in the context of dietary interventions, can
be solved only by objective measures, such as biomarker changes, that are not biased by errors in re
porting. Even though the correlations between, for in
stance, blood carotene levels and the intake of fruits
and vegetables might be imperfect, it is clear from
feeding studies that increasing intakes of fruits and
vegetables increases blood levels of these nutrients.
Thus, a greater mean increase in blood levels among
individuals in an intervention group than among con
trols would be a useful unbiased indicator of inter
vention success.
J. Determination
of Sample
Size
Much has been written about the computation of

sample sizes needed in research studies (191-193). The
statistical answer to the question of how many subjects
are needed is often difficult to understand, but the
nonstatistical answer is easyit depends on why the
study is being done. If an assessment process is being
piloted, then 10 or 20 subjects are plenty. If the pur
pose of the study is to gather data to give a rough idea
of the dietary intake of a group being served, then 30
or 40 may be enough. If a specific hypothesis is being
memory cues and probes. For example, on a 24-hour

dietary recall, foods that were not reported initially
by the respondent can be recovered by interviewer
probes. The effectiveness of these probes is well es
tablished and is therefore part of the interviewing
protocols in the NHANES and CSFII dietary surveys
(see Section VI. B.). Probes can be useful in improving
generic memory too, when subjects are asked to report
their usual diets from periods in the past. Such probes
can feature questions about past living situations and
related eating habits.
Social scientists have long known that the way in
which questions are asked affects responses. Certain
characteristics of the interviewing situation may affect
reporting according to social desirability for foods seen
as "good" or "bad." For example, the presence of other
family members during the dietary interview probably
enhances biases related to social desirability, especially
for certain foods like alcoholic beverages. An interview
in a health setting such as a clinic also may enhance
biases related to social desirability for foods tied to
compliance with dietary recommendations previously
made for health reasons. In all instances, interviewers
should be trained to refrain from either positive or
negative feedback about good or bad dietary habits
and should repeatedly encourage subjects to accurately
report all foods.
2260S
SUPPLEMENT
K. Validation/Calibration
Studies
It is important and desirable that any new dietary

assessment method be validated or calibrated against
other more established methods (195). The purpose
of such studies is to understand better how the method
works in the particular research setting and to use that
information for better interpretation of results from
the overall study. For example, if a new food frequency
questionnaire or brief assessment questionnaire is to
be used in the main study, results of that questionnaire
should be compared with results from another more
rigorous dietary assessment method, for example, 24hour dietary recalls or a more detailed food frequency
questionnaire, conducted on the same individuals.
The kind of information derived from validation

and calibration studies is different than information
derived from focus groups or pretests of study pro
cedures. Focus groups often give very valuable infor
mation about cultural understandings of foods and
food-related questions, which guide the investigator
in designing the study methods. Pretests of study pro
cedures probably are beneficial in any new research
project, even when established methods are being used,
because the feasibility of methods in the particular
research setting is being evaluated. Validation studies,
in contrast, yield information about how well the new
method is measuring what it is intended to measure,
and calibration studies use the same information to
compare (calibrate) how one method of dietary as
sessment compares with a reference method.
Validation studies are hard to design because of the
difficulty and expense in collecting independent di
etary information. Some researchers have used obser
vational techniques to establish true dietary intake
(141, 142, 196). Others have used laboratory measures,
such as the 24-hour urine collection to measure protein
intake and the doubly labeled water technique to mea
sure energy expenditure (197). However, the high cost
of this latter technique makes it impractical for most
studies. The overall validity of energy intake estimates
from the dietary assessment can be checked roughly
by comparing weight data to reported energy intakes
in conjunction with use of equations to estimate basal
metabolic rate (197).
Because they are relatively expensive to conduct,
calibration studies are done on small samples com
pared with the size of the main study. However, the
sample should be large enough to estimate the rela
tionship between the study instrument and a reference
method with reasonable precision. Increasing the
numbers of individuals sampled and decreasing the
number of repeat measures per individual (e.g., two
nonconsecutive 24-hour recalls on 100 people rather
than four recalls on 50 people) can often help to in
crease precision without extra cost (163). To the extent
possible, the sample should be chosen randomly, per
haps within strata, defined by either dietary or other
variables.
The resulting statistics that quantify the relation
ship between the new method and the reference
method can be used for a variety of purposes. Because
the reference method itself is usually imperfect, mea
sures such as correlation coefficients may underesti
mate the level of agreement with the actual usual in
take. This phenomenon, referred to as "attenuation
bias," can be estimated and the measure of agreement
can be "corrected" to more nearly reflect the corre
lation between the diet measure and true diet (89).
This information also gives guidance as to the sample
size required, as the less precise the diet measure, the
more individuals will be needed to attain the desired
power (48). The estimated regression relationship be-
tested, for example, about dietary differences between

two groups or about the relationship between diet and
disease risk, then hundreds or thousands of subjects
may be needed.
The factors to consider in hypothesis-testing studies
are how strong the true association is thought to be
and how certain the investigator wants to be to see an
association, if one is truly there. If the association is
thought to be very weak, and if missing an association
that is truly there is to be avoided at all costs, a huge
sample will be needed. If the association is truly weak
(e.g., dietary fats and breast cancer), then the study
will need to be very large to have enough power to
demonstrate the association. If, on the other hand, the
association is truly strong (e.g., smoking and lung can
cer), then the study can be fairly small yet still pow
erful enough to show the association.
Often the purpose of dietary assessment is not to
test a specific hypothesis but to describe the diet of a
population. For dietary survey purposes, the only
question in determining the sample size is how precise
the investigator wants to be in estimating the average
dietary intake of the population by the measures of
the sample. One can expect the average intake of a
sample of only 20 people to be much farther from the
true average of the population of a city than would be
the average of a sample of 200. The variability of diet
in the population also affects the needed sample size.
The more varied the diet in the population, the larger
the sample size needed to reach the same level of con
fidence in the estimate of the population average in
take. For example, fewer interviews are needed to es
timate the average diet of monks in a monastery than
are needed to estimate the average diet of workers in
a factory because the monks are likely to have a more
homogeneous diet than are the factory workers.
In summary, there are many sources of information
about sample size (191-193), and computer software
also is available to assist in determining sample size
(194). Most importantly, it's always a good idea to
consult with a statistician before conducting the study
to make sure that the sample size is reasonable.
tween the new method and the reference method also

can be used to adjust the relationships between diet
and outcome as assessed in the larger study (89). For
example, the mean amounts of foods or nutrients and
their distributions, as estimated by a brief method,
can be adjusted according to the calibration study re
sults. Methods have been described to then adjust es
timates of relationships measured in studies (e.g., rel
ative risk estimates for disease relative to low nutrient
intake) (198). All of these adjustments require the
strong assumption that the reference method is
unbiased, which in many cases may not hold true
(21,22).
L. Energy Adjustment
VI. EXAMPLES OF DIETARY

ASSESSMENT TOOLS
This section includes examples of the many dietary
assessment tools that have been used. In most cases
only enough of the tool is reproduced to show the for
mat of the instrument, and the type size for many in
struments has been reduced. This is not intended to
be an exhaustive listing of all dietary assessment in
struments nor is inclusion in this set of examples an
implied endorsement of any particular instrument.
Readers who are interested in using or adapting these
dietary assessment tools should contact the resource
people listed with each tool. We have attempted to
include a diversity of tools designed to assess dietary
behaviors, knowledge, attitudes, and beliefs. We chose
these examples from instruments with the following
characteristics: [1] currently used in national surveys,
[2] used in the past in important studies, and/or [3]
designed to assess the diet of special populations.
A. Food Record
The form used to record foods and beverages con
sumed must be designed carefully to assist the re
spondent in easy but complete recording. Shown here
are two examples of different formats. Figure 1 shows
a portion of the record form used by USDA in many
clinical research studies in the Beltsville Human Nu
trition Research Center of the USDA's Agricultural
Research Service (206). Figure 2 shows a portion of
the record form used by researchers at the Robert Koch
Institute in Berlin, Germany and at the University of
North Carolina School of Public Health. This latter
form is also an example of assessment of physical
activity.
An instruction booklet for the subjects' use during
the food recording period is essential. Figure 3 pro
vides an example page from a food instruction booklet
used in the USDA Beltsville studies.
Resource:
Priscilla Steele, L.D., R.D., M.S.
Research Dietitian
Beltsville Human Nutrition Research Center
Agricultural Research Service
U. S. Department of Agriculture
10300 Baltimore Avenue
Room 326, Building 308, BARC-East
Beltsville, MD 20705
(301)504-8411
Many researchers have suggested that when rela

tionships between nutrient intakes and diseases are
analyzed, nutrient intake should be adjusted for total
energy intake. The rationale for this recommendation
involves considering biological mechanisms, statistical
confounding, and imprecision of measurements of
nutrient intake. Biological mechanisms of the etiological relationship may present a compelling reason for
the use of energy adjustment. Unfortunately, however,
our understanding of these basic biological processes
for many disease processes is limited.
In the absence of clear biological reasons to adjust
for caloric intake, the potential for confounding is the
most commonly cited reason for energy adjustment.
Confounding occurs if energy intake is related both
to the nutrient of interest and the outcome variable.
Relationships between energy intake and various out
come variables may be unknown. However, total en
ergy intake is related to many other dietary patterns,
e.g., macronutrient intakes, meat intake, total grams
of food (which might reflect exposure to contamina
tion), and the intake of fiber, fruits, and vegetables.
Because energy is derived from many nutrients, the
adjustment of energy can camouflage a true nutrient
effect (199). This potential for overadjustment maybe
important particularly for macronutrients, such as di
etary fat.
Several statistical methods for incorporating energy
and other nutrients in the same model have been pro
posed (8, 200, 201). These models have been reviewed
and evaluated using fat as an example (202, 203). Each
approach is appropriate for addressing a different study
question (203-205). Interpretation of each of the
models requires assumptions about the relative im
portance of other variables. Clearly, more research is
needed in our understanding of when energy adjust
ment procedures should be used and which procedures
are optimal for particular questions of interest.
2261S
2262S
SUPPLEMENT
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7 Day
Day 1
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2263S
Berlin, Germany
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Hr.
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track
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other
Min .
sleep
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car driving
light walking
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Food
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Bra.
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2264S
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2265S
Resources:
Patricia Guenther, Ph.D., R. D.
Nutritionist
After Feb. 1, 1995:
4700 River Road
Riverdale MD 20737
(301)-734-8485
Before Feb. 1, 1995:
6505 Belcrest Road
Hyattsville, MD 20782
(301)436-5618
B. 24-Hour Dietary Recall
Margaret McDowell, MPH, R. D.

Health Statistician
Division of Health Examination
Statistics
National Center for Health Statistics
U. S. Department for Health and Human Services
6525 Belcrest Road, Suite 900
(301)436-7072
mxm7@nch09a.em.cdc.gov
FIGURE 4 24-Hour Dietary Recall Form (Excerpt), Food Intake Analysis System: University of Texas-Houston,
School of Public Health
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Interviewer-administered
24-hour dietary recalls
have been used in many settings by many different
practitioners and have been recorded on a variety of
forms. An example of a paper format, developed by
investigators at the University of Texas-Houston
School of Public Health, is shown in Figure 4. The
format used in the USDA Continuing Survey of Food
Intakes by Individuals (CSFII), 1994, is shown in
Figure 5.
The level of detail needed to adequately describe
the foods eaten in any 24-hour recall should be spec
ified for the interviewer so that information is ob
tained and recorded consistently and thoroughly.
These probes need to be modified as the foods offered
in the marketplace change. Interviewers for USDA's
surveys use a food instruction booklet (207); an excerpt
from the 1994 version is shown in Figure 6. Although
interviewers in NCHS's NHANES III nearly always
use the automated interviewing and coding system,
abbreviated instructions for interviews recorded on
paper are available; an excerpt is found in Figure
7(31).
2266S
SUPPLEMENT
FIGURE 5 24-Hour Dietary Recall, Individual Intake Form (Excerpt), Continuing Survey of Food Intakes by
Individuals 1994: USDA
INDIVIDUAL
INTAKE FORM
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Obtained(HAND
EwMHorn.YES
CARD 13)0*E.l.nAIVES
1 (07)
2VES
HO
2YES
NO
1 (07)
2VES
NO
2YES
NO
1 (07)
2VES
NO
2YES
NO
1 (O7)
2YES
NO
2YES
NO
1 (O7)
2YES
NO
NO
REVIEW:
1 (O7)
..2O
NO
1
2
Now let's see If I have everything. I'd like you to try to remember anything else (you/NAME)
ate or drank yesterday, that you haven't already tokj me about. Including anything
(you/he/she) ate or drank whle preparing a meal or whle waking to eat
HAND
CARD
II
I'd like you to taNnw everything (you ' NAME) had to eat and drink an day yesterday
a.
(DAY), from midnight to midnight. Include everything (you/NAME) ate and drank at
home and away - even snacks coffee, and alcoholic beverage. (DO NOT
INTERRUPT RESPONDENT. USE HANDCAHD II IF NECESSARY|
At (EARLIEST TIME) (you/NAME) had (FOODS) for (EARLIEST OCCASION).. .

Did (you/he/she) have anything to eat or drink before that, starting at midnight?
Next, at (TiMEi (you/he/she) had (FOODS) tor (OCCASION). .

Did (you/he/she) have anything to eat or drink between (LAST OCCASION) at (LAST TIME) and
(THIS OCCASION) at (THIS TIME)?
[REPEAT b FOR EACH OCCASION]
c.
Did (you/he/she)
[IF INFANT OR CHILD SP ] I'd like you to tel me everything (NAME) had to eat and drink all day
yesterday. (DAY), from midnight to midnight Include everything (he/she) ate and drank at home
and away. Including snacks and drinks (and bottles or breast mlk).
have anything to eat or drink yesterday after (LAST TIME) but before midnight?
[WHEN RESPONDENT STOPS. ASK: Anything else?]
Now let's go back to the beginning of the day and find out where (you/NAME). or other people who live
Now I'm going to ask you specific questions about the foods and beverages we just listed. When
you remember anything else you ate or drank as we go along, please tell me
begin to (eat/drink)
the (FOOD)?
here, obtained the food (you/he/she) ale and where (you/he/she) ate It
7.
2.
About what time did (you/NAME)

RECORDED ON QUICK LIST]
3.
Looking at this card, please teme what (you/NAME) would etti this occasion? [OR CONFIRM
IF RECORDED ON QUICK LIST]
(Looking at this card) Where did (you/he/she)

FOR THIS FOOD)?
[OR CONFIRM IF
HAND
CARD
01 STORE.SUCH AS
SUPERMARKET. GROCERY STORE.
OR WAREHOUSE, CONVENIENCE
STORE. DRUG STORE. OR
13
09
SOUP KITCHEN. SHELTER. FOOD PANTRY
10
11
12
MEALS ON WHEELS
OTHER COMMUNITY FOOD PROGRAM
GROWN OR CAUGHT BY YOU OR SOMEONE
YOU KNOW
GAS STATION
SPECIALTY STORE SUCH AS BAKERY,
01
BREAKFAST
02
BRUNCH
03
LUNCH
04
05
06
DINNER
SUPPER
FOOD AND/OR BEVERAGE BREAK
OEU. SEAFOOD,
IF FISH OR SEAFOOD.
ETHNIC FOOD.
HEALTH FOOD
COMMISSARY
PRODUCE STAND OR FARMER'S
SNACK
ALCOHOLIC BEVERAGE
OTHER BEVERAGE
07
08
obtain this (FOOD/MOST OF THE INGREDIENTS
FEEDING (INFANT ONLY)

OTHER (SPECIFY)
02
MARKET
RESTAURANT WITH WAITER/WAITRESS
03
SERVICE
FAST FOOD PLACE, PIZZA PLACE
04
05
BAR, TAVERN. LOUNGE

SCHOOL CAFETERIA
13
72
73
74
Tba ocean, or
A bay. sound, or tujtfy?
DON'T KNOW BODY OF WATER
14
15
16
IT
96
BOXI
lak.pond, or river
ELSE/GIFT
MAIL ORDER PURCHASE

COMMON COFFEE POT OR
SNACK TRAY
RESIDENTIAL DINING FACILITY
OTHER (SPECIFY)
DON'T KNOW
Did (you/NAME) (eat/drink) this (FOOD) at your home?

IF YES. GO BACK TO O7 FOR NEXT FOOD
IF NO, GO TO O9
SEE FIB COLUMN Q4 FOR FOOD PROBES

(SEE FIB COLUMN Q5 FOR AMOUNT SPECIFICATIONS.]
(you/NAME) actually (eat/drink)?
Freshwater
SOME OTHER PLACE (PLEASE DESCRIBE)
06 OTHER CAFETERIA
07 VENDING MACHINE
OB CHILD CARE CENTER, FAMILY DAY
CARE HOME. ADULT DAY CARE
TRANSFER QUICK UST FOOD TO GRID. CHECK OFF FOOD IN QUICK

UST AS IT IS TRANSFERRED
How much of this (FOOD| did
[ASK IF NOT OBVIOUS:)

Did (you/NAME) have (NEXT QUICK UST ITEM) with your
(OCCASION) at (TIME) or was that at another time?
(IF SAME OCCASION, GO BACK TO BOX 1 IF ANOTHER TIME. GO BACK TO Q2 ]
9.
ASK: Did it com from a..
71
SOMEONE
Before (you/NAME) (ate/drank) this particular (FOOD), was it ever at your home?
REPEAT 07-9 FOR EACH FOOD
AM
PM
TIME STARTED
2YES
NO
2267S
FIGURE 6 Food Instruction Booklet for Conducting

Food Intakes by Individuals 1994: USDA
a 24-Hour Dietary Recall (Excerpt), Continuing
Survey of
CEREALS, PASTA, RICE

04.
Food/Drink
Category
RMdy-to-Eat
Cereal
Description of Food/Drink
BRAND: What was the brand name? (Was it Kellogg's
Com Rakes, Honey Nut Cheerios, Special K, Rice
rispies...?)
ADDITIONS: Did you add anything to the cereal?
RECORD EACH ADDITION ON A SEPARATE UNE IN THE
FOOD/DRINK COLUMN. ASK O4 AND 05 FOR EACH ADDITION.
IF VOLUME: How much?

(Tsp, Tbsp, Cup)
IF WEIGHT: What was the

weight of Individual box and
portion eaten?
(Example: 1/2 of 1 WO)
IF BISCUITS: How many?
What shape were the
biscuits?
(Example: 10 spoon size;
2 ree biscuits)
SNACKS
CM.
Food/Drink
Category
Chip,
Puffs,
Twists,
Potato sticks
Description of Food/Drink
KIND: What kind were they? (Werethey potato chips,
com chips, com puffs, tortila chips...?)
IF POTATO CHIPS: Were they regular or ruffled?
Were they thick cut?
TYPE: Were they regular, unsalted, lowfat...?
BRAND: What was the brand name?
05.
How much of this (FOOD)
did you actually (eat/drink)?
IF NUMBER: How many?
(Cup)
package weight and portion
eaten?
(Example: 1/2 of 3/4 WO
package)
ADDITIONS: Did you add anything to the (FOOD)?

RECORO EACH ADDITION ON A SEPARATE UNE IN THE
FOOD/DRINK COLUMN. ASK CMAND OS FOR EACH ADDITION
Examples: Dip, see below

Salsa, page 65
Crackers
KIND: What kind were they? (Werethey saltines,

graham crackers, animal crackers, peanut butter
sandwich crackers, rice cakes, melba toast...?)
IF NUMBER: How many and

what was the shape?
(ree, sq, wedge)
TYPE: Were they regular, low sodium, lowfat...?

package weight and portion
eaten?
(Example: 1/4 of 12 WO
box)
BRAND: What was the brand name?

ADDITIONS: Did you add anything to the crackers?
RECORD EACH ADDITION ON A SEPARATE UNE IN THE
FOOD/DRINK COLUMN. ASK O4 AND OS FOR EACH ADDITION.
Examples: Dip, see below

Cheese, page 23
Peanut butter, page 69

(Cup)
Examples: Milk, page 6

Sugar or sugar substitute, page 20
Fruit,page 31
05.
How much of this (FOOD)
did you actually (eat/drink)?
2268S
SUPPLEMENT
FIGURE 7 Abbreviated Interviewer Probes for Conducting a 24-Hour Dietary Recall (Excerpt), National Health
and Nutrition Examination Survey III: NCHS
GUIDEITEMGRAIN
PROBING
PROBESFat
Kind: Melba, animal, graham

Type:
unsaltedKind:
Low sodium,
Com, white or WW flour
Prep:
plainKind:
Fried*,
White, whole wheat*, buckwheat
Type: W/fruit,
w/nutsBrand:
RTECooked
Deli meat
CheeseSpreads
(specify)Fat
CheeseSyrup
(specify)Milk
Butter/Margarine
Sugar
Whipped
ToppingMilk/cream
Include generic
Kind: Wheat flake, puffed corn
Type: Pre-sweetened,
plainKind:
Oatmeal, grits, cream of wheat
Type: Instant, quick cooking, regular
Prep:
w/saltBrand
W/milk*. or water,
Granlax/N/X/X/^SPECIFICATIONKind:
Prep: Scratch*orcommercial
Scratch:W/coconut,w/nuts
x/X/X/X/X/X/X/X/X/INGREDIENT
W/fruit
SweetenerButter/margarine/X/v^^
(% fat)
(specify)'X/X/XyADDITIONSSauce
Fat
PRODUCTSPasta/RiceBreadRollsBiscuitsMuffinsCrackersTortillasPancakes/WafflesCereal
Macaroni, noodle, rice
(specify)Fat Meat
Type: Egg noodle, brown rice, white rice;
Cheese
instant, regular, converted
ButterMargarineSpreads
Prep:
waterKind:
Salt added to
French, Italian, white, WW
Type: Diet, low sodium, high fiber,
JellySpreads
bakery, scratch
Prep:
untoastedKind:
Toasted,
White, whole wheat, hoagie
Type: Diet; high fiber
JellySpreads
Prep:
commercialKind:
Scratch, mix,
(specify)Fat
Baking powder, whole wheat
Prep:
scratch*Kind:
Mix. refrieerated dough,
JellySpreads
Bran, corn, wheat
(specify)Fat
Type: W/fruit, w/nuts, plain
JellySpreads
Prep:
scratchBrand
Mix. commercial,
2269S
C. Serving Size Pictures

A variety of aids have been used to help respondents
report portion sizes. Figure 8 shows examples of twodimensional pictures developed for the Food Intake
Analysis System by the University of Texas-Houston
School of Public Health. These pictures (reduced here)
are calibrated to indicate specific quantities.
Resource:
R. Sue McPherson, Ph.D.
Assistant Professor of Epidemiology and Nutrition
University of Texas-Houston
School of Public Health
1200 Hermann Pressler Drive
Houston, TX 77225
(713)792-5332
FIGURE 8 Two-Dimensional Food Model Pictures (Excerpt), Food Intake Analysis System, University of TexasHouston, School of Public Health
2270S
SUPPLEMENT
D. Computer Assisted Interview Diet History

Program, Robert Koch Institute, Berlin, Germany
This diet history program, developed at the World
Health Organization Collaborating Center on Nutri
tional Epidemiology in Berlin, is an example of a fully
automated diet history tool. The basic method applied
is a meal-based diet history, with a short cross-check
set of food frequency questions prompted at the end
of the interview. The program is a complex decision
tree, with extensive branching to collect detailed in
formation on thousands of individual foods eaten in
dozens of preparation forms. The program consists of
170 different screens, a subset of which is presented
to the subject, depending upon their prior responses.
If a respondent eats foods not prompted by the inter
view directly, there is a function key entitled "food
list" that calls up a 12,000 food item data base, with
FIGURE 9 Results of Automated
Resource:
Lenore Kohlmeier, Ph.D.
Professor
Department of Nutrition and Epidemiology
CB# 7400, 2105e McGavran-Greenberg
Hall
University of North Carolina
Chapel Hill, NC 27599-7400
(919)966-7450
lkohlmeier@sphvax.sph.unc.edu
Diet History System (Excerpt), Robert Koch Institute,
Berlin, Germany
Now we would like to show you which foods are the main sources of important nutrients in your
personal
diet:Energy
(kcal)
BeerVanilla
Yogurt
dishesPizzaFat
Chicken and chicken
(g)PeanutButterPalm
OilChicken
dishesPotato
and chicken
Chips
/^^^N^^^X^^âbsolute271253
ofsupply1110
144143absolute2114987^^X^-^^^V%
66%
supply1612876^^^^V/\
of
various preparation forms, from which the subject can

select the desired food or product. At the conclusion
of the Diet History Program, the respondent is given

a seven-page printout displaying information on nu
trient intake, major food sources of nutrients, and how
nutrient intakes compare with recommended
levels
(Figure 9).
This automated Diet History Program, which is
loaded on a portable laptop computer, has been tested
in over 2,000 individuals from epidemiological
sur
veys and case-control studies in Europe (208). The
program was found to be feasible logistically when
conducted centrally, in homes, or in hospitals.
2271S
E. The CARDIA Diet History
FIGURE
10 CARDIA
Dietary
History
Resource:
Joan E. Hilner, M.P.H., M.A., R.D.
Deputy Director of Operations
CARDIA Coordinating Center
University of Alabama at Birmingham
Medical Towers Building, Room 504
1717 11th Avenue South
Birmingham, AL 35294
(205) 934-0786
(Excerpt)FORM
6
PAGE 19 OF
681NCC
GRAINS/CEREALS CONTINUED
Size
AmountFr.qUnitPrep
DescriptionCommentsServing
CodeyHem
22. Q.
Q.
Q.
Q.
Do you usually eat hot or cold cereal?

How much do you usually have?
What kind do you usually have?
How often?
(1) NO
(2) YES
CP
cereals:Regular:OatmealFarina/Cream
61143611356367063690617476110162180/\/\,^/Hot
WheatInstant:Oatmeal,
of
plainOatmeal,
flavoredCream
wheatCorn of
gritsCold
Cereals:Unknown
typeBrand/type:\/\^/\/\/\/\/\/\^/X^yX^/CPCPPKTPKTPKTCPCPN^^\/^^.^/^^/^^/\/\/\/^
CodeFat Code
An example of a food-specific dietary history is the

tool developed for the Coronary Artery Risk Devel
opment in Young Adults (CARDIA) prospective study
(77), funded by the National Heart, Lung, and Blood
Institute (NHLBI). The approach was based on the
Burke diet history (75) and earlier diet history instru
ments used in the Chicago Western Electric Study
(209). Administration of the questionnaire requires
intensive training of nutritionist interviewers. The
instrument, which requires approximately 45 minutes
to complete, consists of questions about general di
etary practices; a comprehensive, quantitative food
frequency questionnaire of usual intake for approxi
mately 300 foods, referencing the past month; and
questions about dietary behaviors and attitudes. Por
tion sizes are asked for most foods. Food models, mea
suring cups and spoons, and rulers are used to help
respondents report portion sizes. Because detailed fat
consumption estimates were deemed important, ad
ditional information about fat used in preparation (i.e.,
type of fat, preparation method) is recorded for some
foods. An excerpt of the form is shown in Figure 10.
The food list was developed using several sources
including core foods consumed in the Western Electric
Study, foods consumed by NHANES II respondents,

the food table developed for the Multiple Risk Factor
Intervention Trial and the Lipid Research Clinics
studies, and suggestions about regional food use from
registered dietitians. Nutrient analyses are conducted
at the CARDIA Coordinating Center using Tape 20
from the University of Minnesota's Nutrition Coor
dinating Center. The questionnaire has been examined
for reliability and validity in 128 individuals aged 18
to 35 and varying by gender and race (210). The in
strument also has been computerized, and special
quality control procedures have been developed that
incorporate listening to an audiotape of the interview
while visually reviewing recorded data (211). Any use
of the instrument requires prior approval by the CAR
DIA Steering Committee and NHLBI.
2272S
SUPPLEMENT
Questionnaires developed at the Cancer Research

Center of Hawaii are examples of tools that assess eat
ing patterns of specific ethnic groups. Because the
population is heterogeneous, the questionnaires have
included foods used by Hawaiian, Japanese, Chinese,
Filipino, and Caucasian ethnic groups. Both frequen
cies and quantities for each food item are obtained.
Colored photographs of three portion sizes on dinner
plates (referred to as A, B, or C rather than small, me
dium, or large) are used for estimating amounts.
The food list was derived from analysis of 3-day mea
sured food records from representative samples of men
and women of the five major ethnic groups of Hawaii.
The major sources of energy and nutrient intake of each
ethnic group were included (212, 213). These same data
were used to establish the three modes of usual portion
sizes. The interviewer-administered questionnaire has
been tested for validity and reproducibility among the
ethnic groups of Hawaii (214, 215).
FIGURE 11 Diet Questionnaire for the Hawaii and Los Angeles Cohort Study (Excerpt)
YEARNever
SOUP, RAMEN
JOOKCream
AND
USE DURING LAST

3timesa
to
3timesa
to
6timesaweek0oooo^
to
orhardly
monthOoooox\
week0OOoo~\
monthOoooo\.
everOoooo/\
weekOoooo\
day0Ooo0.
day0oooo\
a
ONEO
54 cup or less OR
O Small bowl (about 1 cup)
ORO
more)CHOOSE
Large bowl (2 cups or
Soup or
ChowderDried
Pea(Legume)
Bean or
Soup (such as
splitpea)Tomato
Portuguese bean,
ONEO
54 cup or less OR
ORO
more)CHOOSE
or Vegetable
Soup (may include
meat,
fish)Miso
poultry,
ONEO
54 cup or less OR
O Small bowl (about 1 cup) OR
O Large bowl (2 cups or
more)CHOOSE
SoupBroth
ONEO
54 cup or less OR
ORO
more)CHOOSE
orRice with Noodles

(such as beef
noodle,
rice.won chicken
tun mein)
^
USUAL
or
SIZECHOOSE
SERVING
moretimes
/\
/\
/\
/\
ONEO
'/' cup or less OR
ORO
Large bowl (2 cups or more)
/\AVERAGE
x\Onceax\
s\ /2
/2 >\. >Oncea
X\
Xs4
s\
/*Oncea
/\ /2 /\
/\/\/\/\/\/\/\/x\YOUR
Another questionnaire was developed recently to

assess the diets of five ethnic groups (Hispanics, Af
rican-Americans, Japanese, Hawaiians, and Cauca
sians) for a multiethnic cohort study in Los Angeles
and Hawaii, conducted by investigators at the Uni
versity of Hawaii, the University of Southern Cali
fornia, and the Salk Institute. This format includes
eight frequency categories for foods and nine fre
quency categories for beverages. Photographs of three
portion sizes are printed on the self-administered
mailed questionnaire. A portion of a page of the ques
tionnaire is shown in Figure 11. The complete list of
192 items included in the questionnaire appears in
Figure 12.
Resource:
Jean H. Hankin, Dr.P.H., R.D.
Nutrition Researcher
Cancer Research Center of Hawaii
University of Hawaii
1236 Lauhala Street
Honolulu, HI 96813
(808)586-2987
F. university of Hawaii Questionnaires
2273S
FIGURE 12 Food List for the Diet Questionnaire for the Hawaii and Los Angeles Cohort Study (Complete)
MEATS (NOT PART OF MIXED DISHES)Beef Steak

or Roast, Veal or Lamb (includes beef teriyaki, chile col
orado and carne asada); Shortribs; Corned Beef (fresh or
canned); Corned Beef Hash; Pork Chops or Roasts, Kalua
Pig, or Carnitas (includes chile verde); Ham (includes
baked, fried, or sandwich); Ham Hocks or Pig's Feet;
Spareribs; Liver; Chicken or Turkey Wings
POULTRY
AND FISH (NOT PART OF MIXED
DISHES)Fried Chicken (includes fried chicken sand
wich, nuggets); Roasted, Baked, Grilled or Stewed
Chicken (includes grilled chicken sandwich); Turkey (in
cludes roast, ground, deli-style, or sandwich); Fried
Shrimp or Other Shellfish (includes tempura, fried cala
mari or squid); Cooked, Canned, or Raw Shellfish (such
as crab, squid, shrimp); Fried Fish (includes pan-fried fish,
frozen fish sticks, fried fish sandwich); Baked, Broiled,
Boiled or Raw Fish (such as red snapper, salmon, sashimi);
Canned Tunafish (plain, salad, or sandwich); Other
Canned Fish (such as salmon, mackerel, sardines); Salted
and Dried Fish (such as ike, cuttlefish, iriko)
PROCESSED MEATS AND MEXICAN DISHESBa
con (includes Canadian bacon); Regular Hot Dogs (beef
or pork); Chicken or Turkey Hot Dogs or Luncheon
Meats; Spam, Bologna, Salami, Pastrami or Other Lun
cheon Meats; Sausage (such as pork, beef, chorizo, Polish,
Vienna, Portuguese, hot links); Tacos, Tostadas, Sopes,
or Taco Salad (with beef or pork); Tacos, Tostadas, Sopes,
or Taco Salad (with chicken); Meat Burritos (includes beef
and bean and other combinations); Vegetables or Bean
Burritos, Tacos, or Tostadas (no meat); Enchiladas with
Chicken; Enchiladas with Beef; Enchiladas with Cheese,

Quesadillas, or Nachos with Cheese,- Tamales; Chili Rel
lenos
RICE, POTATOES, TARO, AND POIWhite Rice (in
cludes musubi); Sushi or Barazushi; Brown or Wild Rice;
Mexican or Spanish Rice; Fried Rice; French-Fried, HashBrowned or other Fried Potatoes; Mashed, Scalloped or
Au Gratin Potatoes; Baked or Boiled White Potatoes; Yel
low-Orange Sweet Potatoes or Yams; White or Purple
Sweet Potatoes; Taro; Poi
SALAD ITEMS, EGGS, AND OTHER NON-MEAT
ITEMSLight Green Lettuce or Tossed Salad (such as
iceberg or head lettuce); Dark Green Lettuce (such as ro
maine, red, butter, manoa, endive),- Tomatoes
Coleslaw; Regular Salad Dressings or Mayonnaise Added
to Salads; Low-Calorie or Diet Dressings Added to Salads;
Eggs, Cooked or Raw (includes egg salad); Egg Substitute;
Tofu (soybean curd); Vegetarian Meat Loaf, Meatballs or
Patties
RAW OR COOKED VEGETABLES (NOT IN SOUPS
OR MIXED DISHES) -Broccoli (raw or cooked),- Cabbage
(such as head, Chinese or Napa cabbage, Brussels sprouts);
Dark Leafy Greens (such as spinach, collard, mustard or
turnip greens, bok choy, watercress, chard); Green Beans
or Peas; Other Green Vegetables (such as zucchini, celery,
asparagus, green pepper, okra); Cauliflower; Carrots (raw
or cooked); Corn (fresh, frozen, or canned); Pumpkin or
Yellow-Orange Winter Squash; Other Vegetables (such as
white or summer squash, beets, eggplant)
DRIED
BEANS (NOT IN SOUPS OR MIXED
DISHES)Refried Beans (not in burritos or tostadas);
Baked Beans or Pork and Beans; Boiled Dried Beans or
Peas (such as red, lima, pinto or soy beans, black-eyed
peas, frijoles de la olla)
FRUITS AND JUICESOranges; Tangerines or Man
darin Oranges; Grapefruit or Pomelo; Papaya; Pineapple
(fresh or canned); Peaches (fresh, canned, or dried); Apri
cots (fresh, canned, or dried); Pears (fresh, canned, or
dried); Apples and Applesauce; Bananas; Cantaloupe (in
season); Watermelon (in season); Mangoes (in season);
Avocados and Guacamole; Any Other Fruit (fresh, canned,
or dried); Orange or Grapefruit Juice (not orange drinks
or orange soda); Tomato or V-8 Juice; Other Fruit Juices
or Fruit Drinks
BREAD ITEMSWhite
Bread (includes sandwich,
French, sourdough, pan dulce, Portuguese sweet bread);
Whole Wheat or Rye Bread (includes pumpernickel, whole
wheat pita bread); Other Bread (such as mixed grain, oat
bran, raisin bread); Rolls, Buns, Biscuits, or Flour Tortillas
(includes bagels, English muffins); Corn Tortillas, Corn
Muffins, or Cornbread (includes cornbread stuffing); Bran,
Blueberry or Other Muffins, Banana or Mango Bread;
Sweet Rolls, Croissants, Doughnuts, Danish Pastry, or
Coffee Cake; Pancakes, Waffles, or French Toast; Mar
garine Added to Bread Items; Butter Added to Bread
Items; Peanut Butter Added to Bread Items; Jam or Jelly
Added to Bread Items; Mayonnaise in Sandwiches
SOUPS, KAMEN, AND JOOKCream Soup or Chow

der; Dried Bean or Pea (Legume) Soup (such as Portuguese
bean, split pea); Tomato or Vegetable Soup (may include
meat, poultry, or fish); Miso Soup; Broth with Noodles
or Rice (such as beef noodle, chicken rice, won tun mein);
Mexican Meat Soup or Stew (such as menudo, albndigas,
cocido, pozole); Ramen or Saimin (Oriental noodles with
broth); Jook (rice gruelmay include meat, poultry, fish,
or vegetables)
NOODLES, SPAGHETTI, AND MIXED DISHES
Chow Mein, Chow Fun, or Yakisoba (Oriental fried noo
dles); Spaghetti, Ravioli, Lasagna, or Other Pasta with
Tomato Sauce,- Macaroni and Cheese or Other Pasta and
Cheese Casseroles; Macaroni or Potato Salad (with may
onnaise); Pasta or Somen Salad; Noodle Casseroles (with
tuna, chicken or turkey); Pasta with Cream Sauce (such
as linguine with clam sauce, beef stroganoff); Arroz Con
Polio (rice with chicken); Stew, Curry, Pot Pie, or Empanada (with beef or lamb); Stew, Curry, Pot Pie, or Empanada (with chicken or turkey)
MIXED DISHESStir-Fried Beef or Pork and Vegeta
bles, or Fajitas (such as beef broccoli, pork to fu, chop suey,
sukiyaki); Stir-Fried Chicken and Vegetables, or Fajitas
(such as sukiyaki, nishime, chicken long rice); Stir-Fried
Shrimp or Fish and Vegetables; Stir-Fried Vegetables (no
meat); Pork and Greens or Laulaus,- Chili; Hamburgers
(on a bun); Cheeseburgers (on a bun); Meat Loaf, Meat
balls, or Patties (not fast-food hamburgers); Pizza
2274S
SUPPLEMENT
FIGURE 12 (Continued] Food List for the Diet Questionnaire for the Hawaii and Los Angeles Cohort Study
(Complete)
ALCOHOLIC AND OTHER BEVERAGESRegular or
Draft Beer; Light Beer; White or Pink Wine (includes
champagne and sake); Red Wine; Hard Liquor (such as
bourbon, scotch, gin, vodka, tequila, rum, cocktails); Reg
ular Sodas (such as Coca-Cola, Pepsi, 7-Up); Diet Sodas
(such as Diet Coke, Diet Pepsi, Diet 7-Up); Cappuccino
1 cup or mug (includes cafau lait, cafflatte, cafcon
leche); Regular Coffee1 cup or mug (brewed or instant);
Decaffeinated ("Decaf") Coffee1 cup or mug (brewed
or instant); Black Tea -1 cup or glass (such as Lipton's,
oolong, iced tea); Green, Herbal, or Other Tea1 cup;
Fortified Diet Beverages 1 glass or can (such as Slimfast)
HOW OFTEN DID YOU EAT THE FOLLOWING
ITEMS?Western Pickles or Relish (such as dill or sweet
pickles); Olives; Salsa or Hot Chili Peppers (red or green);
Garlic; Onions; Oriental Salted or Pickled Vegetables
(such as salted cabbage or leafy greens, takuwan, kim
chee); Seaweed (fresh or dried) (such as ogo limu, furikake); Gravy on meat, potatoes, rice
HOW OFTEN DID YOU ADD THE FOLLOWING
ITEMS TO YOUR FOODS AT THE TABLE . . .
Salt; Shoyu (Soy Sauce) or Teriyaki Sauce; Mustard; Catsup; Sour Cream
HOW OFTEN DID YOU EAT YOUR MEAT, POUL
TRY, OR FISH PREPARED IN THE FOLLOWING
WAYS . . . Charcoal-broiled; Oven-broiled; Fried;
Barbecued
HOW OFTEN DID YOU EAT MEAT, CHICKEN, OR
FISH COOKED WITH . . . Vegetable Oil; Salt Pork,
Lard, or Bacon Fat; Vegetable Shortening (such as Crisco);
Margarine; Butter; Vegetable spray, water, or non-stick
pan
BREAKFAST CEREALS, MILK, AND CHEESE

Highly Fortified Cereals (such as Product 19, Total,
Most); Bran or High Fiber Cereals; Other Cold Ce
reals (such as corn flakes, Cheerios, granla);
Cooked Cereals (such as oatmeal, cream of wheat,
corn grits); Whole Milk (as beverage or added to
cereal); Lowfat Milk (1% or 2%) (as beverage or
added to cerealincludes lactaid and acidophilus
milk); Nonfat or Skim Milk or Buttermilk (as bev
erage or added to cereal); Yogurt (includes lowfat
and nonfat); Chocolate Milk, Cocoa, or Ovaltine;
Milkshakes or Malts; Cottage Cheese (includes
farmer's and ricotta cheese); Lowfat Cheese (such
as lowfat American, lowfat Swiss, mozzarella);
Other Cheese (such as American, cheddar, cream
cheese)
DESSERTS AND SNACKSIce Cream; Ice Milk,
Frozen Yogurt, or Sherbet; Cookies, Brownies, or
Fruit Bars; Cake; Apple or Other Fruit Pies, Tarts,
Cobblers, or Turnovers; Pumpkin, Sweet Potato, or
Carrot Pies; Cream or Custard Pies, Eclairs, or
Cream Puffs; Puddings or Custards (includes flan);
Chocolate Candy; Dim Sum, such as Bao or Manapua (Chinese bun with meat and vegetables); Other
Dim Sum (such as pork hash, gau gee, fried won
ton, eggroll); Crackers and Pretzels (such as soda,
graham, Japanese rice crackers, wheat thins);
Peanuts or Other Nuts; Potato, Corn, Tortilla
or Other Chips, or Chicharrones (pork rinds); Pop
corn;
G. Health Habits and History Questionnaire

("Block Questionnaire")
Validation/calibration
studies of the 100-item
questionnaire have been reported for middle-aged and
older women in the pilot of the Women's Health Trial
(52), elderly women in San Francisco (calcium only)
(43), middle-aged and older men in the Gerontology
Research Center study (for past diet) (44), a hetero
geneous group of Michigan adults (55), residents of
Beaver Dam, Wisconsin (53), and a low-income black
clinic population (222). The 100-item questionnaire
has been modified by other researchers for other pop
ulations. The 60-item questionnaire has not been di
rectly validated or calibrated. However, responses for
the 60 items taken from the full questionnaire and
multiple dietary records have been compared (218),
and adjustment factors to estimate nutrient intake
with 100 items using only the 60 items have been cal
culated (223).
The 100-item questionnaire is available in both
code-and-key and scannable versions and as a com
puter-assisted interview,- the 60-item questionnaire is
available in a code-and-key format and computer-as
sisted interview.
Resources:
Gladys Block, Ph.D.
Professor of Epidemiology and Public Health
Nutrition
University of California
419 Warren Hall
Berkeley, CA 94720
(510)643-7896
gblock@uclink2 .berkeley. edu
Anne M. Hartman, M. S.
Health Statistician
National Cancer Institute
Division of Cancer Prevention and Control
Applied Research Branch
EPN, Room 313
6130 Executive Boulevard MSC 7344
(301)496-8500
hartmana@dcpcepn.nci.nih.gov
The Health Habits and History Questionnaire

(HHHQ), developed at the National Cancer Institute
under the direction of Gladys Block et al. (45), is an
example of a food frequency instrument that uses na
tional data as the basis for its development. Both codeand-key and computer-scannable (see Figure 13) ver
sions of the HHHQ are available. The format of the
code-and-key version asks frequency information in
an open-ended manner; the computer-scannable ver
sion includes nine frequency categories. Portion size
(small, medium, or large) for each food item is asked
separately. Seasonal use of some foods is asked as sep
arate food items. These versions have slight differences
in food lists, wording of the food items, and order of
food items asked.
The 100-item questionnaire was based on 24-hour
dietary recall data collected on adults in NHANES II,
so that the major food sources of energy and 17 nu
trients and usual portion sizes of those foods could be
included (216, 217). A 60-item questionnaire, which
is a subset of the 100 items most predictive of the
same nutrients (218), also is available. Slightly modi
fied versions of the 60-item questionnaire were used
in the 1987 (219) and 1992 (183) rounds of the Na
tional Health Interview Survey. A complete list of
foods included in these various versions of the ques
tionnaire is given in Figure 14. The ordering of the
items listed is that of the scannable HHHQ. Ordering
for the other HHHQ questionnaires varies.
Beyond the food frequency list, additional questions
(e.g., specific cereal brand, consumption of meat fat,
and the skin on chicken) allow further specificity of
nutrient estimates for the individual. The HHHQ is
designed to be analyzed using special software (220,
221) that allows flexibility in the foods asked and the
nutrients assessed. Foods on the questionnaire can be
added, deleted, or rearranged. Nutrients can be added
to the data base or existing values can be modified.
2275S
2276S
SUPPLEMENT
FIGURE 13 Health Habits and History Questionnaire (HHHQ) (Excerpts)

Code-and-key version
OFFICE USE
Serving(1)
JUICESEXAMPLE FRUITS &
pearsApples,- Apples, applesauce,
pearsBananasPeaches,
applesauce,
cup(1)
or Vi
cup1
or '/2
year)Peaches,
apricots (canned, frozen or dried, whole
season)Cantaloupe
apricots, nectarines (fresh, in
(in season)Medium
medium(1)
cup1
or Vi
medium'/4
mediumYour
Serving
SizeSM/L
>,SHoi-uI4.voit1en?1~?%.Il
11
15
19
23
27
MUCHNEVER
SIZESMLFRUITS
TYPE
OF FOODHOW
OFTEN
HOW
OR LESS
SERVING
PER
PER
PER
PER
PER
THAN ONCE
SERVINGYOUR
WEEK1PER
WEEK2 WEEK3-4
WEEK5-6PER
DAY2+ DAYMEDIUM
MON2-3 MON1PER
PER MONTH1
JUICESEXAMPLE:
AND
etc.Apples, Apples,
medium
or
cup1
1/2
pearsBananasPeaches,
applesauce,
medium
or
cup1
1/2
medium1
apricots(fresh
or
cannedCantaloupe
season)Cantaloupe
(in
medium
or 1/2
cup1/4
medium1/4medium
(rest of year)
/\ /\
/\
/\
S\/\/\/\/\/*-0OO00O
v^1 ^\/\Ô00oo0^v000oo^Ôo000o
^^
X/N/VOooo00s/s00oo00/v0oooox/\O00ooox/v0000o0"ÔOOOOOX/^v0ooo0o/v0OOo0o
Scannable version
2277S
FIGURE 14 Food List for the Health Habits and History Questionnaire (HHHQ) (Complete
Code-and-Key
Foods included in HHHQ
X
X
X
Long
Short
XX
X
X
X
X
X
X
XX
X
X
X
X
XX
X
X
X
X
X
X
X
X
X
BREAKFAST FOODS
High fiber, bran or granla
cereals, shredded wheat
Highly fortified cereals, such as
Total, Just Right or Product 19
Special K, Total
Product 19, Total, or Most
Other cold cereals, such as corn
flakes, Rice Krispies
Cooked cereals, or grits
Cooked cereal
Milk on cereal
Sugar added to cereal
Eggs
Bacon
Sausage
XX
X
X
X
X
X
X
X
X
X
X
X
XX
XX
XX
VEGETABLES
String beans, green beans
Peas
Chili with beans
Other beans such as baked beans,
pintos, kidney, limas, and
lentils
Other beans such as baked beans,
pintos, kidney beans, limas
Beans such as baked beans,
pintos, kidney, limas, or in chili
X
X
X
VEGETABLES (Continued)
Corn
Winter squash/baked squash
Tomatoes, tomato juice
Red chili sauce, taco sauce, salsa
picante
Red chilies, crushed, saucesexclude picante, taco sauce
Broccoli
Cauliflower or brussels sprouts
Spinach (raw)
Spinach (cooked)
Spinach
Mustard greens, turnip greens,
collards
Cole slaw, cabbage, sauerkraut
Carrots, or mixed vegetables
containing carrots
Carrots, or peas and carrots
Mixed vegetables
Green salad
Regular salad dressing &
mayonnaise, including on
sandwiches or on potato salad,
etc.
French fries and fried potatoes
Sweet potatoes, yams
Other potatoes, including boiled,
baked, mashed & potato salad
Other potatoes, including boiled,
baked, potato salad
Other potatoes, incl. boiled,
baked, potato salad, mashed
Rice
Any other vegetable, including
cooked onions, summer squash
Most frequent other vegetable?
Butter, margarine or other fat
added to veg., potatoes, etc.
Butter, margarine or other fat
added to vegetables
Scannable
X
X
X
Long
Short
X
X
XX
X
X
XXX
X
X
X
X
X
X
X
X
X
XX
XX
X
X
XX
X
X
X
XX
XX
X
X
X
X
XX
X
X
X
X
BEEF, FISH, POULTRY,

LUNCH ITEMS
XX
X
X
X
X
X
X
Hamburgers, cheeseburgers,
meatloaf, beef burritos, tacos
Hamburgers, cheeseburgers,
meatloaf
Beef (steaks, roasts, etc.,
including sandwiches)
Beefsteaks, roasts
Beef stew or pot pie with carrots
or other vegetables
Liver, including chicken livers
Pork, including chops, roasts
Fried chicken
Chicken or turkey (roasted,
stewed or broiled, including on
sandwiches)
Chicken or turkey, roasted,
stewed or broiled
Fried fish or fish sandwich
Tuna, tuna salad, tuna casserole
X
X
X
X
X
X
XX
XX
XX
XX
X
X
X
XX
X
FRUITS AND JUICES

Apples, applesauce, pears
Bananas
Peaches, apricots (fresh or canned]
Peaches, apricots (canned, frozen
or dried, whole year]
Peaches, apricots, nectarines
(fresh, in season)
Cantaloupe (in season)
Cantaloupe (rest of year)
Cantaloupe (out of season)
Watermelon (in season)
Strawberries (in season)
Strawberries (frozen or canned,
whole year)
Strawberries (fresh, in season)
Oranges
Orange juice
Grapefruit
Grapefruit, grapefruit juice
Orange juice or grapefruit juice
Fruit drinks with added vitamin
C, such as Hi-C
Tang, Start breakfast drinks
Other fruit juices, fortified fruit
drinks
Any other fruit, including berries,
fruit cocktail, grapes
Any other fruit, including berries,
fruit cocktail
Most frequent other fruit or
juice?
Scannable
Code-and-Key
2278S
SUPPLEMENT
FIGURE 14 [Continued] Food List for the Health Habits and History Questionnaire (HHHQ) (Complete)
Code-and-Key
Scannable
Long
Short
BEEF, FISH, POULTRY,

LUNCH ITEMS (Continued)
Scannable
Long
X
X
X
X
Short
DAIRY PRODUCTS
Cottage cheese
Other cheeses and cheese spreads
Cheeses and cheese spreads, not
including cottage
Flavored yogurt, frozen yogurt
Flavored yogurt
X
X
X
XX
X
X
XX
X
Ice cream
Doughnuts,
X
X
X
X
X
XX
X
X
X
X
X
X
X
X
X
XX
X
X
X
X
XX
XX
XX
X
X
X
X
SWEETS
BREADS, SNACKS, SPREADS

Biscuits, muffins (including fast
foods)
White bread (including
sandwiches, bagels, burger rolls,
French or Italian bread)
White bread, rolls, crackers,
(including sandwiches)
White bread (including
sandwiches), bagels, etc.,
crackers
Dark bread, such as wheat, rye,
pumpernickel, (including
sandwiches)
Dark bread, incl. whole wheat,
rye, pumpernickel
Corn bread, corn muffins, corn
tortillas
Salty snacks, such as potato chips,
corn chips, popcorn
Salty snacks (such as chips,
popcorn)
Peanuts, peanut butter
Margarine on bread or rolls
Butter on bread or rolls
Salad dressing, mayonnaise
(including on sandwiches)
Gravies made with meat
drippings, or white sauce
X
X
XX
XX
Pumpkin pie, sweet potato pie
Other pies
Pies
Chocolate candy
Other candy, jelly, honey, brown
sugar
XX
cookies, cake, pastry
BEVERAGES
Whole milk and beverages with
whole milk (not incl. on cereal)
Whole milk and beverages with
whole milk
2% milk and beverages with 2%
milk (not including on cereal)
2% milk and beverages with 2%
milk
Skim milk, 1% milk or butter
milk (not including on cereal)
Skim milk, 1% milk or buttermilk
Regular soft drinks (not diet soda)
Regular soft drinks
Regular soft drinks (not diet)
Diet soft drinks
Beer
Wine or wine coolers
Wine
Liquor
Coffee, regular or decaf
Decaffeinated coffee
Coffee, not decaffeinated
Tea (hot or iced)
Lemon in tea
Non-dairy creamer in coffee or
tea
Cream (real) or Half-and-Half in
coffee or tea
Cream (real) in coffee or tea
Milk in coffee or tea
Milk or cream in coffee or tea
Sugar in coffee or tea
Sugar in coffee or tea, or on cereal
Artificial sweetener in coffee or tea
Glasses of water
X
X
X
X
X
X
X
X
X
X
XX
X
X
X
XX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Oysters
Shell fish (shrimp, crab, lobster,
etc.)
Shell fish (shrimp, lobster, crab,
oysters, etc.)
Other fish (broiled or baked)
Spaghetti, lasagna, other pasta
with tomato sauce
Pizza
Mixed dishes with cheese (such as
macaroni and cheese)
Liverwurst
Hot dogs
Ham, bologna, salami and other
lunch meats
Ham, lunch meats
Vegetable and tomato soups,
including vegetable beef,
minestrone
Vegetable soup, vegetable beef,
minestrone, tomato soup
Other soups
Code-and-Key
H. Fred Hutchinson Cancer Research Center

Food Frequency Questionnaire
The questionnaire
developed by Kristal and col
leagues at the Fred Hutchinson Cancer Research Cen
ter in Seattle, Washington is an example of a food fre
quency instrument that links answers from an exten
sive list of food questions to specific food frequency
items to derive more precise nutrient estimates for
those items. Researchers revised the machine-readable
version of the HHHQ and developed a software system
to process the questionnaire. The format used is sim
ilar to the HHHQ, with nine frequency categories and
a small, medium, or large portion size. The food list,
composed of 98 foods, differs somewhat from that of
the Health Habits and History Questionnaire (Figure
15). In addition, 15 behavioral questions are asked be
fore the food list (Figure 16).
The nutrient data base values come from the Min

nesota Nutrition Data System (NDS), Version 2.6.
Answers to the behavioral questions are used directly
in the program to choose more appropriate nutrient
composition values for certain foods in the food list.
This system is currently being used in studies at the
Fred Hutchinson Cancer Research Center and by other
users. The Center will provide forms, process, and an
alyze the resulting data for a fee.
Resource:
Alan R. Kristal, Dr.P.H.
Cancer Prevention Research Unit
Fred Hutchinson Cancer Research Center
1124 Columbia Street MP 702
Seattle, WA 98104
(206)667-4686
akristal@cclink.fhcrc.org
VEGETABLESString beans, green beans; Peas; Beans

such as baked beans, pinto, kidney, lima beans, lentils;
Avocado or guacamole; Corn,- Tomatoes, fresh or juice;
Tomatoes cooked, tomato sauce, salsa,- Broccoli; Cooked
greens (spinach, mustard greens, turnip greens, collards,
etc.; Carrots, including in mixed dishes; Summer squash,
such as zucchini; Winter squash such as acorn, butternut;
Coleslaw; Cabbage, sauerkraut, brussel sprouts; Cauli
flower; Onions, leeks, including in cooking; Lettuce, plain
lettuce salad; Mixed lettuce salad with vegetables, such
as carrots, tomatoes, etc.; Salad dressing, such as Italian,
1000 Island, French, etc.; French fries, fried potatoes;
Sweet potatoes, yarns; Other potatoes, (boiled, baked,
mashed); Potato, macaroni, or pasta salads made with
mayonnaise or oil; Rice, noodles or other grain (as a side
dish); Butter, margarine, sour cream or other fat added to
vegetables, potatoes, rice, or noodles
MEAT, FISH, MAIN DISHES, LUNCH ITEMS
Ground beef including hamburgers, meatloaf, tacos, etc.;
Beef, pork or lamb as a main dish, such as steak, roast or
ham; Stew, pot pie or casserole with meat or chicken;
Chili with meat and beans; Liver, including chicken liver
and other organ meats; Fried chicken; Chicken or turkey
(roasted, stewed or broiled); Gravies made with meat
drippings, or white sauce; Fried fish, fish sandwich, fried
shellfish (shrimp, oysters); Shellfish, not fried, such as
shrimp, lobster, crab, oysters, etc.); Tuna, tuna salad or
tuna casserole; Other fish (broiled or baked); Macaroni
(Complete)
and cheese, lasagna or pasta with a cream sauce; Spaghetti

or other pasta with meat sauce; Spaghetti or other pasta
with tomato sauce (and no meat); Pizza-, Lunch meats,
such as ham, turkey or special lean lunch meats; Other
lunch meats, including roast beef, bologna and salami;
Hot dogs, sausage (not including breakfast sausage);
Cream soups, such as chowders, potato, etc.; Bean soups,
such as pea, lentil, black bean, minestrone, etc.; Vegetable
soups; Other soups, such as chicken noodle
BREADS,
SNACKS,
SPREADSBiscuits,
muffins,White breads, sandwich bread, bagels, rolls, pita bread;
Dark breads, sandwich bread, bagels, rolls; Crackers, such
as saltines, Ritz, etc.; Corn bread, corn muffins; Tortillas,
all types; Snack chips (potato chips, corn chips, cheese
crackers, tortilla chips); Popcorn; Peanut butter, peanuts,
other nuts and seeds; Butter or margarine on bread; May
onnaise and mayonnaise type spreads, on sandwiches and
in salads
BREAKFAST FOODSCereals, cold or cooked; Milk
on cereal; Pancakes or waffles; Eggs; Bacon; Breakfast
sausage
DAIRY PRODUCTSCottage
cheese, regular or lowfat; Low-fat or part-skim cheeses, such as lite-line, etc.,
including in cooking; Regular cheeses or cheese spreads,
including in cooking; Yogurt, all types (not frozen)
SWEETSIce cream, milkshake; Pudding, custard, flan;
Low-fat frozen desserts, such as frozen yogurt, sherbet,
ice milk, etc.; Jello, all flavors; Doughnuts, cakes, pastries;
Cookies; Pies; Chocolate candy, candy bars; Hard candy,
jam, jelly, honey, syrup
BEVERAGESMilk (not including on cereal) and bev
erages with milk (such as hot chocolate); Regular soft
drinks, soda pop (not diet), Kool Aid; Beer; Wine; Liquor,
mixed drinks; Coffee or tea (all types); Cream, milk or
non-dairy creamer in tea or coffee; Sugar in coffee or tea
or on cereal
FIGURE IS Food List of the Fred Hutchinson Cancer Research Center Food Frequency Questionnaire
FRUITS
AND
JUICESApples,
pears; Bananas;
Peaches, nectarines or plums (fresh or canned); Cantal
oupe (in season); Other melon, watermelon, honeydew,
etc. (in season); Apricots (fresh, canned, dried); Other
dried fruit, raisins, prunes, etc.; Oranges, grapefruit or
tangerines (not juice); Strawberries (in season); Any other
fruit (fruit cocktail, berries, applesauce, grapes, pineapple,
etc.); Orange juice, grapefruit juice, or Vitamin C enriched
fruit drinks; Other fruit juices, fruit drinks
2279S
2280S
SUPPLEMENT
FIGURE lBehavioral Questions (Complete), Fred Hutchinson Cancer Research Center Food Frequency Ques
tionnaire
When you drank milk or milk beverages, was it usually . . .

Whole milk
2% milk
1% milk or buttermilk
Nonfat/skim milk
When you used milk or cream on cereal, was it usually . . .
Cream or half and half
Whole milk
2% milk
1% milk
Nonfat/skim milk
Non dairy creamer
Milk, do not know kind
When you used milk or cream in coffee or tea, what types
did you usually use?
Cream or half and half
Whole milk
2% milk
Nonfat/skim milk
Non dairy creamer
Milk, do not know kind
What type of popcorn did you usually eat?
Popped in oil, pre-popped, or at movies
Regular microwave
Air-popped or special "lite" microwave
When you ate popcorn, how often did you add butter or
margarine?
Almost always
Often
Sometimes
Rarely
Never
When you ate tuna was it usually
Water-packed
Oil-packed
Either one
Don't know
When you ate tuna how was it usually prepared?

Tuna, plain
Tuna salad with mayonnaise
Tuna noodle casserole
When you ate breakfast cereals, what type did you usually
eat?
Granlatype cereals
High-fiber or bran cereals, such as FiberOne, Raisin Bran
Whole grain cereals such as Cheerios, Shredded Wheat
Fortified cereals such as Total, Product 19
Cookded cereals such as Oatmeal, Cream of Wheat
Other cereals such as Corn Flakes, Frosted Flakes
When you ate cookes, how often were they graham crackers,
vanilla wafers, fig bars, or special lowfat or no fat cookeis?
Almost always
Often
Sometimes
Rarely
Never
When you ate cakes or other pastries, how often were they
angel food cakes, sponge cakes, or special low fat or no fat
cakes or pastries?
Almost always
Often
Sometimes
Rarely
Never
Which of the following did you usually use in cooking?
Margarine
Butter
Oil (vegetable, olive, safflower, cala)
Shortening (Crisco) or lard
Non-stick spray (Pam) or no fat
Don't know
Which of the following
and potatoes?
Margarine
did you usually add to vegetables
Butter
Low calorie margarine
Sour cream
Low-fat sour cream
Didn't add fat
Don't know
What kinds of spreads did ou usually use on breads and rolls?
Margarine
Butter
Low calorie margarine
Didn't use spreads
Don't know
What type of salad dressing did you usually use?
Regular
Low-fat (diet)
Fat-free (no oil)
Didn't use salad dressing
What type of mayonnaise did you usually use?
Regular
Low-fat (diet)
Fat-free
Didn't use mayonnaise
When you ate chicken, how often did you eat the skin?
Almost always
Often
Sometimes
Rarely
Never
Did you usually choose . . .
Light meat
Dark meat
Both
When you ate beef, pork or lamb, how often did you eat the
fat?
Almost always
Often
Sometimes
Rarely
Never
When you ate ground meat or hamburger, was it usually . . .
Regular
Lean
Extra lean
Ground turkey
Don't know
/. Modifications of the Health Habits and

History Questionnaire (HHHQ)
Institute's version developed by Kristal et al. (224).

Hispanic foods were identified primarily through
analysis of data from NCHS's Hispanic Health and
Nutrition Examination Survey. The modified ques
tionnaire contains 118 food items. The Tufts ques
tionnaire also asks the respondent to record portion
size of each food in an open-ended manner, rather than
by checking the appropriate small, medium, and large
categories. Although frequency response data can be
optically scanned, portion size information must be
entered manually. The Tufts questionnaire has been
pretested and currently is being validated and used to
assess the usual intakes of Hispanic elderly and nonHispanic neighborhood controls in the Boston area.
Resources:
Julie A. Mares-Perlman, Ph.D.
Assistant Professor
Department of Ophthalmology and Visual Sciences
University of Wisconsin at Madison Medical School
610 N. Walnut Street-405 WARF
Madison, WI 53705-2397
(608) 262-8044
maresp@epi.ophth.wisc.edu
Katherine Tucker, Ph.D.
Epidemiology Program
USDA Human Nutrition Research
Center on Aging at Tufts University
711 Washington Street
Boston, MA 02111
(617)556-3351
tucker@hnrc.tufts.edu
Several investigators have modified the HHHQ for

use in particular populations. Here we present two
examples of how the HHHQ was adapted for a par
ticular study purpose.
One modification of the 100-item code-and-key
version of the HHHQ currently is being used in the
University of Wisconsin's Nutritional Factors in Eye
Disease Study of Beaver Dam, Wisconsin. It was de
signed to include more recent low-fat and other mod
ified foods available in the marketplace (see Figure
17). The modified questionnaire, designed for admin
istration by an interviewer, contains 125 food items.
Added food items were identified from previous di
etary intake data in the study population collected be
tween 1988 and 1991, including food records and the
open-ended section of the HHHQ; from the 1991 Na
tional Eating Trend Survey (a national consumer sur
vey using 14-day household diet records); and from
detailed reports about fat-modified foods eaten from
a subset of consumers of such foods in 1993. The new
questionnaire was pilot tested in an adjacent com
munity. Results of a validation study in Beaver Dam
are expected in 1995.
Another modification of the 100-item HHHQ, de
veloped for the Tufts Elderly Health and Nutrition
Study, changes the foods appearing on the code-andkey version of the HHHQ to include fat-modified
foods and foods frequently consumed by Hispanics
(see Figure 18). Some modifications of the food list
were taken from the Fred Hutchinson Cancer Research
2281S
2282S
SUPPLEMENT
FIGURE 17 Foods Added to the Health Habits and History Questionnaire in the Beaver Dam Eye Study: Uni
versity of Wisconsin
FIGURE 18 Foods Added to the Health Habits and History Questionnaire in the Tufts Elderly Health and
Nutrition Study: USDA Human Nutrition Research Center on Aging at Tufts University
* Mangoes
* Non-fortified fruit drinks
* Avocado, raw
Diet salad dressing & mayonnaise
Butter, margarine or other fat added to potatoes
Rice with meat (pork, beef)
Rice with chicken
Rice with pigeon peas
Rice with beans
Root crops (including tannier, cassava)
Green plantains: boiled/baked
Green plantains: fried
Ripe plantains: boiled/baked
Ripe plantains: fried
Meat pies, eggrolls, fritters
Homemade soups with meat/chicken
Potato chips, corn chips
Popcorn
Low fat cottage cheese or low-fat cheeses
Flavored yogurt
Plain yogurt
Sherbet or jello
Frozen yogurt, ice milk
* Pudding, custard, cheesecake
* Whole milk in coffee or tea
* 2% milk in coffee or tea
* Skim or 1% milk in coffee or tea
* Added by Tufts; others added by Fred Hutchinson Cancer Research Center.
Orange or grapefruit juice with added calcium

Fat-free salad dressing
Low/reduced fat salad dressing
Fat-free mayonnaise
Low/reduced fat mayonnaise
Light/diet margarine or other fat on vegetables, potatoes, etc.
Low/reduced fat frozen or prepackaged dinner
Reduced fat hot dogs or chicken or turkey hot dogs
Low/reduced fat ham or lunchmeat
Low/reduced fat muffins, biscuits
Fat-free bread, crackers, bagels, etc.
Low/reduced fat salty snacks
Light/diet margarine on bread or rolls
Only egg whites or egg substitute
Low/reduced fat bacon (lean) or turkey bacon
Low/reduced fat sausage (lean) or turkey sausage
Fat-free ice cream, frozen yogurt, ice milk
Low/reduced fat ice cream/frozen yogurt/ice milk
Fat-free and low/reduced fat cookies, cakes
Fat-free cottage cheese
Low/reduced fat cottage cheese
Fat-free "other" cheese/chs spreads (incl crm chs)
Low/reduced fat "other" cheeses/chs spreads (incl crm chs)
Fat-free yogurt
Low/reduced fat yogurt
Z283S
J. university
of Arizona Questionnaires
Resource:
Douglas L. Taren, Ph.D.
Associate Professor
University of Arizona Health Sciences Center
Department of Family and Community Medicine
Tucson, AZ 85724
(602) 626-7863
nutrisec@arizrvax.ccit.arizona.edu
FIGURE 19 Southwestern Food Frequency Questionnaire (1994) (Excerpt): University of Arizona
TANSEGUIDO
ENPROMEDIO,
QUE
ONUNCAly>GUISADOS
Sizes
LOSSlfTIIFNTFS
COME
IMPIMTOTOn
AI
youeat
the average, how often do
the following foods?PORCINPortion m
ALDU(lorilima.
PORSEMANA(4
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PORSEMANA(1
ALMESaorJlima.
lot
ormoraI
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-e*k>VEZ
1MASVECESALDIAO
1 lim.
MtMVEZ
SOPASSide,
Y
SoupsFRIJOLES
Mixed Dishes, and
BeansFRIJOLES
REFRITOS.
Retried
CHARROSBAYOS,
DE LA OLLA,
ALUBIAS.Baked
NEGROS, PINTOS.
"Charro-Style"Beans,
/ Cooked Beans,
BeansARROZ
Black, Pinto, and Kidney
LAMEXICANA.
BLANCO O A
RiceSOPAS
Plain or Mexican
(SINQUESO
DE PASTA / FIDEO
Soup,Pastas
Y SIN CARNE). Noodle
MeatPAPAS
without Cheese or
PAPASAFRITAS, PAPITASO, O
andFried
LA FRANCESA. French Fries
PotatoesPAPAS
HORNO,PURE
HERVIDAS, AL
PAPAS.Other
DE PAPA, OTRAS
Baked,Mashed
Potato, including Boiled,
\/\/\/\/\/\/\/\/\/\AA/\/\/dddddd\/\/\/\/^vyvxsSSSSSS/\
/\/\
/\/\
/\S\/\
Several food frequency questionnaires have been

developed at the University of Arizona Health Sciences
Center to assess the diets of a variety of cultural
groups, including Hispanics and Native Americans.
The earliest of these instruments, the Arizona Food
Frequency Questionnaire, is an adaptation of the
computer-scannable HHHQ. The food list, composed
of about 115 foods and beverages, is modified to im
prove assessment of high fiber cereals and Southwest
ern foods.
A more recent food frequency questionnaire, the
Southwestern Food Frequency Questionnaire, includes
foods common to the Southwestern United States; it
is presented in Spanish with English translation. The
food list was developed using focus groups and key
informants and then pilot tested. Although frequency
and portion size are asked, the format and categories
differ from other tools (see Figure 19}.The complete
adult questionnaire includes a list of about 160 foods
(see Figure 20). Shorter questionnaires also have been
developed: for children (excluding primarily adult
foods) and for both adults and children (subsets of both

the adult form and the children form). All four versions
of the questionnaire are available in machine-readable
format.
All versions of the Southwestern Food Frequency
Questionnaire are currently being validated in His
panic and non-Hispanic adults and children by com
parison with multiple 24-hour recalls. The original in
strument has been used in a variety of studies, includ
ing community assessments by the Arizona Office of
Nutrition and the University of California San Diego
Por La Vida Study. The questionnaire is copyright
protected by the University of Arizona.
2284S
FIGURE
Arizona
SUPPLEMENT
20 Food List of the Southwestern
Food Frequency Questionnaire
CEREALSOatmeal or Other Cooked Cereals; How of

ten do you eat cold cereals? Which cereals do you usually
eat? Do you add sugar to cereal?
VEGETABLESZucchini; Winter Squash, Baked Squash;
Corn; Carrots; Sweet Ptalos, Yams; String Beans; Peas;
Cauliflower or Brussels Sprouts; Cooked Spinach; Mus
tard Greens, Turnip Greens, Collards; Mixed Vegetables
containing Carrots, canned or frozen,- Butter or Margarine
on Vegetables; Chiles: Jalapeno, Serrano, etc., including
Bell Peppers; Avocado, Guacamole; Cactus Leaves; Cole
University
of
Slaw; Cabbage, Sauerkraut; Broccoli; Raw Spinach, Wa

tercress; Lettuce; Raw Tomato; Hicama; Cucumber; On
ion; Garlic; Cilantro
FRUITSOranges, Tangerines; Limes and Lime Juice;
Bananas,- Apples, Pears, Guavas; Mangoes in Season; Fresh
Peaches, Apricots, Nectarines in Season; Canned or Frozen
Peaches, Apricots; Watermelon in Season; Cantaloupe in
Season; Fresh Strawberries in Season; Frozen Strawberries;
Grapes; Raisins, Prunes, Figs,- Fresh Plums; Grapefruit
TORTILLASFlour
Tortillas (excluding use in mixed
and side dishes); Corn Tortillas (excluding use in mixed
and side dishes)
BREADSWhite Bread, Rolls, Crackers, Mexican Bread;
Whole Wheat Bread/Rolls; Corn Bread; Bran Muffin;
Pancakes and Waffles; Butter, Margarine, or Sour Cream
on Breads, Pancakes, or Tortillas; Sweet Bread
SWEETSIce Cream; Sherbert; Custard of Pudding; Rice
Pudding with Raisins; Doughnuts;
Cookies; Cake;
Pumpkin Pie, Sweet Potato Pie; Pastries; Turnovers, Coyotas; Chocolate Candy; Other Candy, Jelly, Honey, Mo
lasses
SALTY SNACKS AND SPEADSPopcorn,- Butter or
Margarine on Popcorn; Chips, all types; Pork Rinds,Shelled Nuts, including Peanuts; Peanut Butter; Salad
Dressing, Mayonnaise on Salads or Sandwiches; Gravies
made with Meat Drippings or White Sauce
BEVERAGESWater; Orange Juice; Lemonade; RiceBased Tea of Hibiscus Flowers; Grapefruit Juice,- Grape
Juice; Tomato Juice; Tang, Start Breakfast Drinks, Juice
Drinks; Regular Soft Drinks; Diet Soft Drinks; Beer; Liq
uor/Alcohol; Wine; Regular Coffee; Decaffeinated Coffee;
Herbal Tea; Tea, Hot or Iced
To your coffee or tea, do you add:
Non-Dairy Creamer?
Milk?
or Real Cream?
To your coffee or tea, do you add:
Sugar?
Diet Sugar or Artificial Sweetener?
Whole Milk and Beverages with Whole Milk (excluding
milk in cereals); Skim Milk, 1% Milk or Buttermilk, Re
constituted Milk (excluding milk in cereals),- 2% Milk and
Beverages with 2% Milk (excluding milk in cereals); Con
densed Milk; Evaporated Milk
SIDE, MIXED DISHES, AND SOUPSRefried Beans;

Baked/Cooked Beans, "Charro-Style" Beans, Black, Pinto,
and Kidney Beans; Plain or Mexican Rice; Noodle Soup,
Pastas without Cheese or Meat; Lentils, Garbanzo Beans
(Cooked, in Soups, etc.); French Fries and Fried Potatoes;
Other Potatoes, including Boiled, Baked, Mashed; Red or
Green Mole, with Chicken, Pork, Goat, or Lamb; Chile
with Meat; Zucchini with Cheese; Chiles Rellenos with
Cheese or Meat and Potato Dish; Meat Tamales; Green
Corn Tamales,- Flour or Corn Quesadillas; Chimichangas;
Soft Tacos; Tostadas; Burritos; Enchiladas, Chilaquiles,
Pastel Azteca; Crispy Tacos; Mexican Sauce, Taco Sauce,
Other; Pozole, Menudo, Gallina Pinta; Cazuela Soup,
Meatball Soup; Tortilla Soup; Cheese Soup; Vegetable
Soup, Vegetable Beef, Cocido, Minestrone, Tomato Soup,
and Soups with Carrots; Other Soups; Spaghetti, Lasagna,
Other Pasta with Tomato Sauce; Pizza; Mixed Dishes with
Cheese, like Macaroni and Cheese
MEATS AND EGGSEggs; Bacon; Mexican Sausage,Sausage; Hot Dogs; Hamburgers, Cheeseburgers, Meat
Loaf, Veal Dishes; Ham, Lunch Meats, Spam; Beef-Steaks,
Roasts, Carne Asada; Beef Stew or Pot Pie with Carrots
and Other Vegetables; Beef with Chile ("Sonoran-Style"),
Pork or Veal with Chile, Birria; Machaca; Liver: Beef,
Chicken, Veal
MEATS, POULTRY, AND FISHPork, including Carnitas Chops, Roasts, Fried; Fried Chicken; Chicken or
Turkey: Baked, Stewed, or Broiled; Fried Fish or Fish
Sandwich; Tuna Fish, Tuna Salad, Tuna Casserole; Shell
Fish: Shrimp, Lobster, Crab, Oysters, etc.; Ceviche, Pic
kled Herring; Other Fish: Broiled, Baked, etc.
DAIRY PRODUCTSFresh
Cheese; Yogurt; Cottage
Cheese; Other Cheeses and Cheese Spreads; Creams (Sour,
Semi-Sweet, Sweet, etc.)
(1994) (Complete):
2285S
K. Harvard University Food Frequency

Questionnaire ("Willett Questionnaire")
Resource:
Laura Sampson, R.D., M.S.
Research Dietitian
Department of Nutrition
Harvard School of Public Health
665 Huntington Avenue
Boston, MA 02115
(617)432-4563
FIGURE 21 Harvard Food Frequency Questionnaire (Excerpt)
3. For each food listed, fill in the circle indicating

how often on average
.
you have used the amount
ijring the past year.
specified durin
AVERAGE USE LAST YEAR
DAIRY FOODS
Skim or low fat milk (8 02. glass)
Whole milk (8 oz. glass)
Cream, e.g. coffee, whipped
(Tbs)
Sour cream (Tbs)

Non-dairy coffee whitener (tsp.)
Several versions of a food frequency questionnaire

have been developed for use in studies at Harvard
University by Walter Willett and colleagues (8). The
general format for the questionnaire includes nine
frequency categories (see Figure 21). Portion size is
asked as part of the food item rather than as a separate
item. Respondents are asked to average seasonal use
of foods over the entire year. Both code-and-key and
computer-scannable versions are available.
The food lists were based on food records collected
from pilot participants in several different studies. The
most recent version, developed for use in the Health
Professionals Followup Study (40), includes 131 food
items. Figure 22 lists the foods included in versions
available now. Wording differs on some items and is
indicated in the listing. The order of the foods pre
sented is that of the general form for adults. Food orderings differ on the other forms.
The questionnaire has been modified by Harvard
researchers and others for their specific populations
and purposes. In a study of Hispanic children in New
York City, researchers modified the portion size of
foods listed to better reflect more typical portion sizes

for children (225). Numerous validation/calibration
studies of various food frequency questionnaires have
been reported for female nurses (51, 56, 226), male
health professionals (40, 57), low-income pregnant
women (227), and children (225).
A more recent food questionnaire for children uses
an entirely different format (see Figure 23). Although
portion size is generally incorporated into the food
item questions, it is omitted from other items. Other
questions, such as type of milk usually drunk, are in
terspersed throughout the questionnaire. Frequency
categories are tailored to the particular food item,
varying from four to seven categories, and seasonal
variation in consumption is not asked. A complete list
of the 131 items included is found in Figure 24.
2286S
SUPPLEMENT
FIGURE 22 Food List of the Harvard Food Frequency Questionnaires
(Complete)
Adults
Foods included:
Harvard FFQ's
General
Adults
Short
Children
DAIRY FOODS
FRUITS
Raisins or grapes
Prunes
Bananas
Cantaloupe
Watermelon
Fresh apples or pears
Apple juice or cider
Oranges
Orange juice
Orange juice or grapefruit juice
Grapefruit
Grapefruit juice
Other fruit juices
Strawberries, fresh, frozen or
canned
Blueberries, fresh, frozen or canned
Peaches, apricots or plums
Other fruits, fresh, frozen, or
canned
VEGETABLES
Tomatoes
Tomato juice
Tomatoes or tomato juice
Tomato sauce, e.g. spaghetti sauce
Red chili sauce
Tofu or soybeans
String beans
Broccoli
Cabbage or cole slaw
Cauliflower
Brussels sprouts
Cabbage, cauliflower, or Brussels
sprouts
Carrots, raw
Carrots, cooked
Carrots
Corn
Peas, or lima beans
Mixed vegetables
Beans or lentils, baked or dried
XXX
XXX
X
X
X
X
XXX
X
X
X
X
XXX
XXX
X
XXX
XXX
XXX
X
X
XXX
X
X
XXX
X
XXX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XXX
X
X
VEGETABLES (Continued)
Yellow (winter) squash
Eggplant, zucchini or other
summer squash
Yams or sweet potatoes
Spinach, cooked
Spinach, raw as in salad
Kale, mustard or chard greens
Spinach or collard greens, cooked
Iceberg or head lettuce
Romaine or leaf lettuce
Celery
Beets
Alfalfa sprouts
Garlic, fresh or powdered
EGGS, MEAT, ETC.
Eggs
Chicken or turkey, with skin
Chicken or turkey, without skin
Bacon
Hot dogs
Processed meats, e.g. sausage,
salami, bologna, etc.
Liver
Hamburger
Beef, pork, or lamb as a sandwich
or mixed dish, e.g. stew,
casserole, lasagne, etc.
Beef, pork, or lamb as a main dish,
e.g. steak, roast, ham, etc.
Canned tuna fish
Dark meat fish, e.g. mackerel,
General
Short
Children
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
salmon, sardines, bluefish,
swordfish
Other fish
Shrimp, lobster, scallops as a main
dish
Fish
X
X
BREADS, CEREALS, STARCHES

X
X
X
X
X
X
X
X
XXX
XXX
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
XXX
XXX
X
XXX
Cold breakfast cereal

Cooked oatmeal
Other cooked breakfast cereal
Cooked breakfast cereal, e.g.
oatmeal
White bread, including pita bread
White bread
Dark bread
Dark bread, including wheat pita
bread
English muffins, bagels, or rolls
Muffins or biscuits
Brown rice
White rice
Pasta, e.g. spaghetti, noodles, etc.
Rice or Pasta, e.g. spaghetti,
noodles, etc.
Other grains, e.g. bulgar, kasha,
couscous, etc.
Pancakes or waffles
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Skim or low fat milk

Whole milk
Cream, e.g. coffee, whipped
Sour cream
Non-dairy coffee whitener
Sherbet or ice milk
Ice cream
Ice cream sundae
Yogurt
Cottage or ricotta cheese
Cream cheese
Other cheese, e.g. American, cheddar,
etc., plain or as part of a dish
Margarine, added to food or bread;
exclude use in cooking
Butter, added to food or bread;
exclude use in cooking
Foods included:
Harvard FFQ's
2287S
FIGURE 22 [Continued} Food List of the Harvard Food Frequency Questionnaires (Complete)
Adults
Foods included:
Harvard FFQ's
General
Adults
Short
Children
BREADS, CEREALS, STARCHES
(Continued)
French fried potatoes
Potatoes, baked, boiled or mashed
Potato chips or corn chips
Potato chips
Corn chips, e.g. Fritos, Doritos
Crackers, Triscuits, Wheat Thins
Pizza
General
Short
Children
SWEETS, BAKED GOODS,

MISCELLANEOUS
XXX
XXX
X
X
X
X
X
X
X
X
BEVERAGES
X
X
X
X
XXX
X
X
X
X
X
X
X
X
X
X
X
X
X
Chocolate, e.g. Hershey's, M & M's

Candy bars, e.g. Snickers, Milky
Way, Reeses
Chocolate
Chocolate pieces (e.g. Hershey bar,
Kisses, M &.M's)
Other candy bars (e.g. Snickers,
Milky Way, Mars)
Candy without chocolate
Cookies, home baked
Cookies, ready made
Cookies
Brownies
Doughnuts
Cake, home baked
Cake, ready made
Cake
Sweet roll, coffee cake or other
pastry, home baked
Sweet roll, coffee cake or other
pastry, ready made
Pie, homemade
Pie, ready made
Jams, jellies, preserves, syrup, or
honey
Onion rings, french fried
Peanut butter
Popcorn
Nuts
Bran, added to food
Wheat germ
Chowder or cream soup
Oil and vinegar dressing, e.g.
Italian
Mayonnaise or other creamy salad
dressing
Mustard, dry or prepared
Pepper
Salt
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Low calorie cola, e.g. Tab with

caffeine
Low calorie caffeine-free cola, e.g.
Pepsi Free
Other low calorie carbonated
beverage, e.g. Fresca, Diet 7-Up,
diet ginger ale
Low calorie carbonated beverage,
e.g. Diet Coke
Coke, Pepsi, or other cola with
sugar
Caffeine Free Coke, Pepsi, or other
cola with sugar
Other carbonated beverage with
sugar, e.g. 7-Up, ginger ale
Carbonated beverage with sugar,
e.g. Coke, Pepsi
Hawaiian Punch, lemonade, or
other non-carbonated fruit
drinks
Milk shake or frappe
Decaffeinated coffee
Coffee
Coffee, not decaffeinated
Tea, not herbal teas
Beer
Red wine
White wine
Wine
Liquour, e.g. whiskey, gin, etc.
Foods included:
Harvard FFQ's
2288S
SUPPLEMENT
FIGURE 23 Harvard Eating Survey for Children (Excerpt)
DIETARY
INTAKE
Estimate how often you eat the following foods:
Example 1 If you drink one can of diet soda 2 3 times per week, then your answer should look
like this:
El. Diet soda

(1 can or glass)
0 Never
01 - 3 cans per month
01 can per week
2-6 cans per week
01 can per day
O 2 or more cans per day
27. What TYPE of milk do

you usually drink?
O Whole milk
O 2% milk
01% milk
O Skim/nonfat milk
O Don't know
0 Don't drink milk
28. Milk (glass or with cereal)

0 Never
01 glass per week or less
0 2 - 6 glasses per week
01 glass per day
O 2 - 3 glasses per day
O 4+ glasses per day
29. Chocolate milk (glass)

Never
1 - 3 glasses per month
O 1 glass per week
0 2 - 6 glasses per week
01 - 2 glasses per day
O 3 or more glasses per day
DAIRY
PRODUCTS
2289S
FIGURI! 24 Food List of the Harvard Eating Survey for Children (Complete)
BEVERAGESDiet
soda; Sodanot diet; Hawaiian
Punch, lemonade, Koolaid or other non-carbonated fruit
drink; Iced tea -sweetened; Tea; Coffeenot decaf.; Beer;
Wine or wine coolers; Liquor, like vodka or rum
DAIRY PRODUCTSWhat
TYPE of milk do you usu
ally drink? Milk (glass or with cereal); Chocolate milk;
Instant Breakfast Drink; Whipped cream; YogurtNot
frozen; Cottage or ricotta cheese; Cheese; Cream cheese;
What TYPE of yogurt, cottage cheese en dairy products
(besides milk) do you use mostly? ButterNOT margar
ine; MargarineNOT butter; What FORM and BRAND
of margarine does your family usually use? What TYPE
of oil does your family use at home?
MISCELLANEOUS
FOODSBrown gravy; Ketchup;
Clear soup (with rice, noodles, vegetables); Cream (milk)
soups or chowder; Mayonnaise; Low calorie salad dress
ing; Salad dressing (not low calorie); Salsa; How much fat
on your beef, pork, or lamb do you eat? Do you eat the
skin of the chicken or turkey?
Please list any other important foods that you usually eat
at least once per week that are not listed (for example,
coconut, hummus, falafel, eggrolls, chili, plantains, man
goes, etc . . .)
MAIN DISHESCheeseburger;
Hamburger; Pizza, Tacos/burritos;
Which taco filling do you usually have?
Chicken nuggets; Hot dogs; Peanut butter sandwich (plain
or with jelly, fluff, etc.); Chicken or turkey sandwich;
Roast beef or ham sandwich; Salami, bologna, or other
deli meat sandwich; Tuna sandwich; Chicken or turkey
as main dish; Fish sticks, fish cakes or ash sandwich; Fresh
fish as main dish; Beef (steak, roast) or lamb as main dish;
Pork or ham as main dish; Meatballs or meatloaf ; Lasagna/
baked ziti; Macaroni and cheese; Spaghetti with tomato
sauce; Eggs; Liver: beef, calf, or pork; Shrimp, lobster,
scallops
BREADS &. CEREALSCold breakfast cereal; Hot

breakfast cereal, like oatmeal, grits; White bread, pita
bread, or toast; Dark bread; English muffins or bagels;
Muffin,- Cornbread; Biscuit/roll; Rice; Noodles, pasta;
Tortillano filling; Other grains, like kasha, couscous,
bulgar; Pancakes or waffles; French fries,- Potatoes
baked, boiled, mashed
FRUITS & VEGETABLESRaisins;
Grapes; Bananas;
Cantaloupe, melons; Apples or applesauce; Pears; Or
anges, grapefruit; Strawberries; Peaches, plums, apricots;
Orange juice; Apple juice and other fruit juices; Tomatoes;
Tomato/spaghetti
sauce; Tofu; String beans; Broccoli;
Beets; Corn; Peas or lima beans; Mixed vegetables; Spin
ach; Greens/kale; Green/red peppers; Yams/sweet pota
toes; Zucchini, summer squash, eggplant; Carrots, cooked;
Carrots, raw; Celery,- Lettuce/tossed salad; Coleslaw; Po
tato salad; Beans/lentils/soybeans
SNACK FOODS/DESSERTS[Fill
in the number of
snacks (food or drinks) eaten on school days and week
ends/vacation
days.] Potato chips; Corn chips/Doritos;
Nachos with cheese; Popcorn; Pretzels; Peanuts, nuts; Fun
fruit; Graham crackers; Crackers, like saltines, or wheat
thins; PoptartS; Cake; Snack cakes, Twinkies; Danish,
sweetrolls, pastry; DonutS; Cookies; Brownies; Pie;
Chocolate, like Hershey's or M & M's; Other candy bars
(Milky Way, Snickers); Other candy without chocolate
(mints, Lifesavers); Jello; Pudding; Frozen yogurt; Ice
cream; Milkshake or frappe; Popsicles
2290S
SUPPLEMENT
L. National Health and Nutrition Examination

Survey (NHANES) Food Frequency
Questionnaires, National Center
for Health Statistics
study participants ages 12 and older (111, 112). The

respondents are asked to report usual diet in the past
month by indicating how often each food is eaten per
day, per week, per month, or not at all (see Figure 25).
The food list was based on previous NHANES food
frequency questionnaires and analyses of NHANES II
and HHANES (228). See Figure 26 for a complete list
ing of the 61 items included on the NHANES III food
frequency.
Resource:
Ronette R. Briefel, Dr.P.H., R.D.
Coordinator for Nutrition Monitoring and Related
Research
National Center for Health Statistics
6525 Belcrest Road, Room 1000
(301)436-3473
rrbl@nch09a.em.cdc.gov
FIGURE 25 National Health and Nutrition Examination Survey III Food Frequency Questionnaire (Excerpt):
NCHS
FOOD YEARS)HAND
FREQUENCY
(AGES 17+
HAO-5.certain
CARO
foods. When answering think about your usual

diet over the past month. Tell me how often you usually
ate or drank these foods per day, per week, per month,
all.N1. or not at
DK^
per 1 Day
Q D
2Week
Q] W
3Month
Q M
or
4Never
Q] N
2Dw
3DM
4DN
2QW
3QM
or
4 Q] N
or
4QN
9Q
DK
MILK
PRODUCTSRrst
AND MILK
ar* milk and milk products.
cooking.a.
use in
Do not include their
How often did you have chocolate milk and hot

cocoa?b.
How often did you have milk to drink or on cereal?
Do not count small amounts of milk added to
tea.c.coffee or
CHECK ITEM.
ANONIb.d.
REFER TO RESPONSES IN N1a
9DDK_pw1DD
9QOK1
1QO
-NEVER" IN BOTH N1a AND N1b (Nie)
OTHER01
2 H
What type of milk was it? Was it usually whole,
2%,
type?IF
1%. skim, nonfat, or some other
SP CANNOT PROVIDE USUAL TYPE, MARK ALL
APPLY.e.
THAT
Yogurt and frozen yogurtTimes
O]
whole/regular
02 Q
2%/lowtat
03 O]
1%
04 Q
skim/nonfat
05 Q]
buttermilk
06 Q
evaporated
07 Q
other
99 Q
DKperlQD
08specify
2QW
SQW
9^]DK
Food frequency questionnaires have been admin

istered in the NHANES I (1971-1975), NHANES II
(1976-1980), Hispanic HANES (1982-1984), and
NHANES III (1988-1994) (112). Questionnaires used
in NHANES I, II, and Hispanic HANES (HHANES)
were similar; information was asked for relatively few
food groups. HHANES included a few additional foods
typically consumed by Hispanics, and includes English
and Spanish versions (113).
We include the food frequency questionnaire used
in NHANES III as an example of an instrument used
in a current national study. As in previous NHANES
studies, the food frequency questionnaire used in the
NHANES III study is interviewer-administered to
22.91$
FIGURE 26 Food List of the National Health and Nutrition Examination Survey III Food Frequency Question
naire (Complete): NCHS
MILK AND MILK PRODUCTSChocolate
milk and
hot cocoa; Milk to drink or on cereal; What type of milk?
Yogurt and frozen yogurt; Ice cream, ice milk, and milk
shakes; Cheese, all types including American, Swiss,
cheddar, and cottage cheese; Pizza, calzone, and lasagna;
Cheese dishes such as macaroni and cheese, cheese nachos,
cheese enchiladas, and quesadillas
BEANS, NUTS, CEREALS, AND GRAIN PROD

UCTSBeans, lentils, and (chickpeas/garbanzos).
In
clude kidney, pinto, refried, black, and baked beans; Pea
nuts, peanut butter, other types of nuts, and seeds; AllBran, All-Bran Extra Fiber, 100% Brand, and Fiber One;
Total, Product 19, Most, and Just Right; All other coldcereals like corn flakes, Cheerios, Rice Krispies, and presweetened cereals; Cooked, hot cereals like oatmeal,
cream of wheat, cream of rice, and grits; White bread,
rolls, bagels, biscuits, English muffins, and crackers. In
clude those used for sandwiches; Dark breads and rolls,
including whole wheat, rye, and pumpernickel;
Corn
bread, corn muffins, and corn tortillas; Flour tortillas;
Rice; Salted snacks such as potato chips, taco chips, corn
chips, and salted pretzels and popcorn
DESSERTS,
SWEETS, AND BEVERAGESCakes,
cookies, brownies, pies, doughnuts, and pastries; Choc
olate candy and fudge; Hi-C, Tang, Hawaiian Punch,
Koolaid, and other drinks with added vitamin C; Diet
colas, diet sodas, and diet drinks such as Crystal Light;
Regular colas and sodas, not diet; Regular coffee with caf
feine; Regular tea with caffeine; Beer and lite beer; Wine,
wine coolers, sangria, and champagne; Hard liquor such
as tequila, gin, vodka, scotch, rum, whiskey and liqueurs
either alone or mixed
FATS (Added after preparation)Margarine;
Butter; Oil
and vinegar, mayonnaise and salad dressings such as Ital
ian and Thousand Island, including those added to salads
and sandwiches
MAIN
DISHES, MEAT, FISH, CHICKEN,
AND
EGGSStew or soup containing vegetables, including
minestrone, tomato, and split pea; Spaghetti and pasta
with tomato sauce; Bacon, sausage (chorizo) and luncheon
meats such as hot dogs, salami, and bologna; Liver and
other organ meats such as heart, kidney, tongue, and tripe
(menudo); Beef, including hamburger, steaks, roast beef,
and meatloaf; Pork and ham, including roast pork, pork
chops, and spare ribs; Shrimp, clams, oysters, crab, and
lobster; Fish including fillets, fish sticks, fish sandwiches,
and tuna fish; Chicken, all types, including baked, fried,
chicken nuggets, and chicken salad. Include turkey; Eggs
including scrambled, fried, omelettes, hard-boiled eggs,
and egg salad
FRUITS AND FRUIT JUICESOrange juice, grape
fruit juice and tangerine juice; Other fruit juices such as
grape juice, apple juice, cranberry juice, and fruit nectars;
Citrus fruits including oranges, grapefruits, and tanger
ines; Melons including cantaloupe, honeydew, and wa
termelon; Peaches, nectarines, apricots, guava, mango,
and papaya; Any other fruits, such as apples, bananas,
pears, berries, cherries, grapes, plums, and strawberries
(include plantains)
VEGETABLESCarrots
and vegetable mixtures con
taining carrots; Broccoli; Brussels sprouts and cauliflower;
White potatoes, including baked, mashed, boiled, frenchfries, and potato salad; Sweet potatoes, yams, and orange
squash including acorn, butternut, hubbard, and pump
kin; Tomatoes including fresh and stewed tomatoes, to
mato juice, and salsa; Spinach, greens, collards, and kale;

Tossed salad; Cabbage, cole slaw, and sauerkraut; Hot
red chili peppers (do not count ground red chili peppers);
Peppers including green, red, and yellow peppers; Any
other vegetables such as green beans, corn, peas, mush
rooms, and zucchini
2292S
SUPPLEMENT
M. Navajo Health and Nutrition Survey

The Navajo Health and Nutrition Survey is an ad
aptation of the NHANES III food frequency question
naire in which foods were added that are eaten fre
quently by Navajos. The survey was designed and
conducted by the Navajo Area Indian Health Service
to study the dietary intake and health status of Navajos
aged 12 years and older living within the eight Service
Units on the Navajo Reservation (134). Both the 72item food frequency questionnaire, adapted from
NHANES III, and a 24-hour recall were administered
by interview. Figure 27 lists the differences between

the foods included on the Navajo Health and Nutrition
Survey and the NHANES III food frequency ques
tionnaires.
Resource:
Linda L. White, R.D.
Service Unit Director
Kayenta Service Unit
Indian Health Service
P. O. Box 368
Kayenta, AZ 86033
(602) 697-6102
FIGURE 27 Differences in Food List between National Health and Nutrition Examination Survey III and
Navajo HANES
Navajo HANES
Cheese, all types including American, Swiss, cheddar, and cottage

cheese
Pizza, calzone, and lasagna
Cheese dishes such as macaroni and cheese, cheese nachos, cheese
enchiladas, and quesadillas
Bacon, sausage (chorizo) and luncheon meats such as hot dogs,
salami, and bologna
Cheese, all types including American, Commodity, Swiss,

cheddar, and cottage cheese
Pizza and lasagna
Cheese dishes such as macaroni and cheese, cheese nachos, cheese
enchiladas
Bacon, sausage and luncheon meat such as hot dogs, salami,
bologna, and vienna sausage
Spam and commodity lunch meat
Shrimp, clams, oysters, crab, and lobster
Melons including cantaloupe,
honeydew, and watermelon
Peaches, nectarines, apricots, guava, mango and papaya

Any other fruits, such as apples, bananas, pears, berries, cherries,
grapes, plums, strawberries (include plantain)
Sweet potatoes, yams, and orange squash including acorn,
butternut, hubbard, and pumpkin
Cabbage, cole slaw, and sauerkraut
Beans, lentils, and (chickpeas/garbanzos).

refried, black, and baked beans.
Include kidney, pinto,
Dark breads and rolls, including whole wheat, rye, and

pumpernickel
Flour tortillas
Hi-C, Tang, Hawaiian Punch, Koolaid, and other drinks with

added vitamin C
Mutton, including mutton ribs, mutton stew (Mutton and

potatoes/Navajo dumplings only)
Navajo tacos
Melons including cantaloupe, honeydew, watermelon, Navajo
melon, and casabas
Peaches, nectarines, apricots, and kiwi fruit
Any other fruits, such as apples, bananas, pears, berries, cherries,
grapes, plums, and strawberries
Sweet potatoes, yams, and orange squash including acorn,
butternut, hubbard, pumpkin, and yellow squash
Cabbage and cole slaw
Indian corn
Any other vegetables
Beans and lentils. Include kidney, pinto, refried, black and baked
beans, and pork and beans.
Blue corn mush with ash
Blue corn mush without ash
Dark breads and rolls, including whole wheat
Flour tortillas, includes Navajo and Mexican
Blue corn bread, kneel down bread, and blue corn pancakes
Fry bread
Navajo cake
Hi-C, Tang, Hawaiian Punch, Koolaid, Gatorade, and other
drinks with added vitamin C
Gravy and/or drippings
NHANES III
N. Nutritional Supplement
2293S
and History Questionnaire (see Section VI. G.); it asks

about use in the past year and can be self-administered.
Figure 30 is taken from the NHANES III (111) (see
Section VI. L.); it asks about use in the past month
and is interviewer administered.
Resources:
Contact the resource person listed under the descrip
tion of each tool.
Questionnaires
There are many ways of asking questions about nu

tritional supplements. We include three to illustrate
this variety of approaches. Figure 28 is taken from the
Harvard food frequency questionnaires (see Section
VI. K.); it asks about current use and can be self-ad
ministered. Figure 29 is taken from the Health Habits
FIGURE 28 Harvard Food Frequency Questionnaire Questions to Assess Current Use of Supplements (Complete
Section)
1. Do you currently take multiple vitamins? (Please report individual vitamins under question 2.)
O No
6'9I1
O Yes
* If yes, a) How many do you take
O 2 or less
Q
moreb)
O 3-5
O 10 or
What specific brand do
you usually use?
type2. 1
vitaminsa)
Not counting
multiple
No
monthsb)
O Yes' seasonal only

O Yes. rnost
do you take
preparations:I
any of the following
How
many QO-lyr.
0^What
years?010.
dose _> O Less than
wknow!
per day?
W 8.000 IU
Vitamin
C?O
No
monthsc)
O Yes' seasonal only

O Yes, most
Vitamin
id) O No
B,,?
O Yes * lf ves-
Vitamin
E?O
iê) No
O Yes If ves,
knowHow
1O
1î)
(~\ 8.000 to
W 12.000 III
fV3000to
W 22.000 IU
How
many QO-lyr.
0^What
O2'4
O 5'9 Vs010+yrs.
dose O
Less than
per day?
^400mg
O400 to
w 700 mg
O 75to
w 1250 mg.
O 130m
w or more
ODon''
w
>Q "1 Vr
O 2-4 yrs
O 5-9
O Less
to10 than
mg.
O 10 to
39 mg
O 40
79
O
knowO
10+ yrs
80
Don'tor
mg
more
O
O
know_
Don't
O
O Don''
dose per day?

mgHow
O yes If yes.
irSA""1
OYes
H ves.
Are there other supple

ments that you take on
a regular basis? Please
mark if yes:,
>QO-1yr.
O2'4
Vs-
vs
O 5'9
yrs.
f~)23.OOOIU
w or more
knowO
O
10+ yrs.
600 IU
know_.
or more
dose par day?
>O Less
to100than
IU
O 10to
250 IU
O 30
500
many years?
knowWhat
dose per day?
knowHow
>Q "1 Vr
>Q Less than
80 meg.
O 2-4 yrs
O 80 to
130 meg.
Q 5-9 yrsDon't (J 10+ yrs

O 14to
O 260 meg
250 meg.
or more
Q 2-4 yrs
Q 5-9
yrs.What
many years?
I^g)Zinc?O
No
O Yes If yes.
1ON
Q 5-9 yrs.
1 yrsWhat
many years?
IUHow
1h)Calcium?
No
Q 2-4 yrs.
YrsWhat
many years?
Selenium?O
I-Vf)kon?
No
O Yes If ves.
Specify exact brand and
tQO-1
yr.
knowO
(J
10+ yrs.
401
ODon''or
mg.
know_.
more
dose per day?

mgHow
>OLesstnan
51 mg.
O51 to
200 mg.
O201to
400
yrs.What
many years?
>QO-1 yr.
Q 2-4 yrs
0^-9
mgHowdose per day?
O 25
Lessmg
than
O
to
w 25
74 mg
Q
w 75
100to
knowO
O
10+ yrs
ODon''or
101 mg
more
many years?
knowWhat
dose par day?
knowO
>QO"1 V
>OLesstnan
400 mg
O 2-4 yrs.
O400to
900 mg
O 5-9 yrs._
O901to
1300 mg.
O 10+ VS.
O1301m9
or more
Folie acid
O odllver
CaroteneQB-Complex
n
Vitamin D
'
Vitamins
OP111^3-3,
Fatty-acids
O lodine
H Coooer
O Beta"
QSrewer's
YeastO
O Magnesium
O Do"'1
._ Don't
O
Q Don''
_ Don't
O
._ Don't
O
know_
Don't
O
O00"'1
Other (please specify):

ii
Vitamin
A?O
>
2294S
SUPPLEMENT
FIGURI! 29 Health Habits and History Questionnaire Questions to Assess Use of Supplements in Past Year
(Complete Section)
9. During
minerals?O
the past year have you taken any vitamins or
No
O Yes, fairly regularly i
IF YES, what do you take fairly regularly?
<+NUMBER
TABLETSVITAMIN
O Yes, but not regularly
OF
YEARS?LESSTHAN1
HOW MANY
TYPEMultiple
YR0OOOO001-2YEARS0OOOoo03-5YEARS0OOOo006-9YEARSOOOOo0010+YEARSOOooooo10.
VitaminsStress-tabs
typeTherapeutic,
typeOne-a-dayTheragran
typeOther
IfC:How
you take Vitamin E or Vitamin
knowHow
many units per Vitamin E tablet?
know11. many milligrams per Vitamin C tablet?
O 100
O 100
Donutrients?O
you regularly take pills containing any of these
Beta-caroteneO
No or don't know
O Iron
O
Zinc
O Selenium
O 200
O 250
O 400
O 500
O 1000
O 1000
O Don't
O Don't
VitaminsVitamin
AVitamin
ECalcium
TurnsVitamin
or
CNONEOO00OOO1-3PERWEEKOO00ooo4-6PERWEEKOoo0ooo1PERDAY0oo00oo2PERDAY0OOO0o03PERDAY0
2295S
FIGURE 30 Questions to Assess Use of Supplements in Past Month: National Health and Nutrition Examination
Survey III: NCHS
VITAMINS
X8.X3.
AND MINERALS:
RECORD LABEL INFORMATION AND ASK X6 -
#1NAME:1
02NAME:1
ENTER COMPLETE MAME OF VTTAMIN/

MINERAL FROM LABEL OR PROBE
RESPONDENT.X4.
ITEM.X5.CHECK
(X5)2
Q
CONTAINER SEEN
CONTAINER NOT SEEN.

PRODUCT NAME FURNISHED
BY RESPONDENT
(X6)3
Q
(X5)2
Q
CONTAINER SEEN
CONTAINER NOT SEEN.

PRODUCT NAME FURNISHED
BY RESPONDENT
(X6)3
PRODUCT NAME NOT ON

CONTAINER
(X6)namecity
PRODUCT NAME NOT ON

CONTAINER
(X6)amacity
STATE).X6.
statetimes
statetimes_____
How often did you take/use (PRODUCT! in
month?X7.
the past
Q
2 Q
Pr
number999
dy2
D
day
Q]
week
3 Q
month4
3month4
Q
number999
Q] other 5
specify01
Q
other 5
specify01
DKnumberi
Q
DKnumber1
Q
it?X8.
How much (PRODUCT did you take/use

each time you took
Q] capsule,
tablets/pills02
teaspoons03
Q
Q] capsules,
tablets/pills02
teaspoons03
r~\
tablespoons04
Q
tablespoons04
Q
Q
fluid ounces/
ounce05
Q
fluid ounces/
ounces05
drops/dropper*06
Q
drops/droppers06
Q
Q
packets/packs/
paks/packages07
Q
packets/packs/
paks/packages07
ml.08
Q
ml.08Q
wafers09
\~\
wafers09
n
O
other 10
specify666
specify666
amounts999
n
variable
amounts999
Q] variable
DKnumber1
Q
DKnumber1
Q
For how long have you been taking/using this

type of product?PRODUCT
Q] less than one

month2
Q
years999
Q
week
3 Q
DKPRODUCT
other 10
Q
less than one
month2
months3
Q
months
y999 D
Q
DK
ENTER MANUFACTURER'S OR DISTRIBU

TOR'S NAME AND ADDRESS (CITY AND
2296S
SUPPLEMENT
O. Block Screening Questionnaires

Brief food frequency questionnaires designed for
screening purposes were developed by Block and col
leagues from analyses of NHANES II data on the rel
ative contribution of food groups to fat, fruit and veg
etable, and calcium intake of the U. S. population (43,
217, 229). The food items included in these screening
tools are a subset of those found in the 100-item
Health Habits and History Questionnaire (see Section
VI. G.). These shortened questionnaires use the codeand-key format and are analyzed using the computer
software described in Section VI. G.
Block's most recent screener, shown in Figure 31,
combines the fat and plant food dimensions in a 24item questionnaire, includes an updated food list, and
uses a self-scoring format. Scoring algorithms for both
dimensions are shown in Figure 32. Estimates of fat

intake from an earlier version of the fat screener have
been compared with multiple diet records (61). Cor
relations between multiple records and the self-scoring
version were 0.65 for grams of fat and 0.40 for per
centage energy from carbohydrate (submitted for pub
lication, Alice Dowdy).
Resource:
Gladys Block, Ph.D.
Professor of Epidemiology and Public Health Nutri
tion
University of California
419 Warren Hall
Berkeley, CA 94720
(510)643-7896
gblock@uclink2.berkeley.edu
2297S
FIGURE 31 Block Screening Questionnaire for Fat and Fruit/Vegetable/Fiber Intake (Complete)
Food Questionnaire
Thinh about your eating habits over the past year or so. About how often do you eat each
of the following foods? Mark an V in one box for each food
ScoreOrange
Hamburgers or cheesburgers
Beef, such as steaks, roasts
Fried chicken
Hot dogs, franks
Cold cuts, lunch meats, ham, etc.
Salad dressings, mayo (not diet)
Margarine or butter
Eggs
Bacon or sausage
Cheese or cheese spread
French fries
Potato chips, com chips, popcorn
creamDouahnuts.
Ice
pastries, cake,
cookies(0)
W
5* times
per
oa a
a
D
a
a
a
Q
a
aGa a
a
a
a
a
a
a
a
a
Q
a
a
a
a
Q
a
o
o
a
o
a
a
aa a
o
a
a
a
a
a
a
aoQaa(2)
a
a
a
a
Q
Q
a
a,
a. - a
a
a
a
a
o
ao2-3 aMeat/Snacks
a
a
Score
than
once per
WEEKa
aa
juiceNot
counting juice, about how
often
fruit?Green
do you eat any
salad
PotatoesBeans,
such as baked beans,
chiliAbout
pintos,
kidney beans or in
how often do you eat any
other
vegetables?High-fiber
cerealDark or bran
bread, such as whole
wheat,
ryeWhite
bread, includine french,
Italian, biscuits, muffins(0)Less
About 1
time per
WEEK
daya
(2)
2-3 times
per
WEEK
(3)
4-6 times
per
WEEK
=Points
(4)
Every
aa a
a
Qa a
a
o
o
o
a
aaa aa
a
a
o
aa a
Q
aa o
a
a
aa(1) aa a
aFruit/Vegetable/Fiber
a
a
ao
Score
=PointsScore
Whole milk
(3)
times 1-2 times 3-4 times
Less than
once per
per
per
per
MONTHa MONTHaWEEK
WEEKa WEEK
2298S
SUPPLEMENT
FIGURE 32 Scoring for Block Screening Questionnaire for Fat and Fruit/Vegetable/Fiber Intake
To score:
For each food, write the number that is at the top of the column you checked, in the box
at the far right. Add up the numbers in the boxes to get your total scores for Meat/Snacks
and Fruit/Vegetable/Fiber.
For Meat/Snacks
Score:
If Your Score Is:

more
than
Your diet is high in fat. There are many ways you can make your eating
27
pattern lower in fat. You should look at your highest scores above to find
areas in which to begin.
25-27
Your diet is quite high in fat. To make your eating pattern lower in fat,
you may want to begin in the areas where you scored highest.
22-24
You are generally eating a typical American diet, which could be lower
in fat.
18-21
You are making better low fat food choices.
For Fruit/Vegetable/Fiber
Score:
If Your Score Is:

30 or more
You're doing very well! This is the desirable score on this screener.
20 to 29
You should include more fruits, vegetables and whole ins.
less than 20
Your diet is probably low in important nutrients. You should find ways
to increase the fruits and vegetables and other fiber rich foods you eat
every day.
17 or less
You are making the best low fat food choices. Keep up the great work!
If you scored 17 or less, you're doing well! This is the desirable score on this screener.
99S
P. The Nutrition Screening Initiative Determine

Your Nutritional Health Checklist
Resource:
Nutrition Screening Initiative
2626 Pennsylvania Avenue NW
Washington, DC 20037
(202)625-1662
FIGURE 33 The Determine Your Nutritional Health Checklist: The Nutrition Screening Initiative
The Warning Signs of poor nutritional
health are often overlooked. Use this
checklist to find out if you or someone you
know is at nutritional risk.
Read the statements below. Circle the number in the
yes column for those that apply to you or someone
you know. For each yes answer, score the number in
the box. Total your nutritional score.
DETERMINE
YOUR
NUTRITIONAL
HEALTH
YES
I have an illness or condition that made me change the kind and/or amount of food I eat
I eat fewer than 2 meals per day.

I eat few fruits or vegetables, or milk products.
I have 3 or more drinks of beer, liquor or wine almost every day.
1 have tooth or mouth problems that make it hard for me to eat.
I don't always have enough money to buy the food I need.
I eat alone most of the time.
I take 3 or more different prescribed or over-the-counter
drugs a day.
Without wanting to, I have lost or gained 10 pounds in the last 6 months.
I am not always physically able to shop, cook and/or feed myself.
TOTAL
Total Your Nutritional Score. If it's 0-2
Good! Recheck your nutritional score in 6

months.
3-5
You are at moderata nutritional risk.

See what can be done to improve your eating
habits and lifestyle. Your office on aging,
senior nutrition program, senior citizens
center or health department can help.
Recheck your nutritional score in 3 months.
6 or more You are at high nutritional risk. Bring

this checklist the next time you see your
doctor, dietitian or other qualified health or
social service professional. Talk with them
about any problems you may have. Ask
for help to improve your nutritional health.
Ttir se materials developed anil

distributed by the Nutrition Screening
Initiative, a project of:
AMERICAN ACADEMY
OF FAMILY PHYSICIANS
ft
Ei*,
THE AMERICAN
DIETETIC ASSOCIATION
MC
QrA
NATIONAL COUNCIL
ON THE AGING. INC.
Remember that warning signs

suggest risk, but do not represent
diagnosis of any condition. Turn the
page to learn more about the
Warning Signs of poor nutritional
health.
Reprinted with permission by the Nutrition Screening Initiative, a project of the American Academy of Family Physicians,
the American Dietetic Association and the National Council on the Aging, Inc., and funded in part by a grant from Ross
Laboratories, a division of Abbott Laboratories.
The Nutrition Screening Initiative, a project of the

American Dietetic Association, the American Acad
emy of Family Physicians, and the National Council
on the Aging, is a nationwide effort to increase aware
ness of potential nutritional problems in the elderly
(99). We include the Nutrition Screening Initiative's
Determine Your Nutritional Health Checklist (Figure
33) as an example of a tool developed to measure in
dicators of inadequate dietary intake and nutrient de
privation and not overconsumption of dietary lipids
or other components. Clearly, the Checklist includes
many nondietary factors related to nutrition. The
Checklist can be self-administered and self-scored or
administered by family members or other nonhealth
caregivers. A high nutritional risk score indicates that
further screening by a health or social service profes
sional (Level 1 Screen) and possibly laboratory work

(Level 2 Screen) may be indicated.
The questions on the Checklist were selected be
cause of published associations found between these
factors and nutritional status of older individuals. Po
tential questions were reviewed and improved in focus
groups of older Americans. The ability of the Deter
mine Checklist to predict nutrition-related problems
among older individuals was examined in retrospective
simulations and in a field study (98, 230). The Check
list may be duplicated freely. Copies of the Checklist,
the Level 1 and 2 Screens, and other publications on
nutrition screening and interventions are available
from the address listed below.
2300S
SUPPLEMENT
Q. Food Habits and Eating Patterns

Questionnaires, Kristal et al., Fred Hutchinson
Cancer Research Center
A Food Habits Questionnaire, developed by Kristal
and colleagues at the Fred Hutchinson Cancer Re
search Center in Seattle, Washington (73), is an ex
ample of a tool that aims to measure fat-related dietary
behaviors for the purpose of nutrition intervention
research. The original questionnaire, composed of 20
items and five response categories (Usually or Always;
Often; Sometimes; Rarely or Never,- Not Applicable),
has been validated in a small group of women aged 45
to 59 years (73). It subsequently was validated and
used to measure maintenance of low-fat dietary pat
terns in a group of almost 900 participants in the
Women's Health Trial (231). A revised version of that
Resource:
Seattle, WA 98104
(206)667-4686
akristal@cclink.
Fred Hutchinson
fhere, org
Cancer Research Center (Excerpt)
QUESTIONNAIRETheseEATING PATTERNS
|MEAT.
questions are about the way you ate over the past 3 months. Please circle your response.
MAININFISH AND
MONTHS1.2.N/Did
THE PAST 3
orWhen
orNever44444
Sometimes2
fish?No
you cat
-Ô
Yes
(answerboth)*Did
Li
fish:you ate
poached?
how often was it broiled, baked or
fried?When
how often was it
32
32
chicken?No
you eat
>D Yes
chicken:
you ate
how often was it broiled, or
O (answerall baked?
fried?
how often was it
three)*v^^vvx/x-DISHESUsually
how often did you take off the skin?
-X/V^v^N/V^V^^v/N/VAlways11111WOften
32
32
3N/N/VN/*Rarely
V^^
FIGURE 34 Kristal Eating Patterns Questionnaire:
tool is now being used in a feasibility study of about

2,100 individuals from minority populations.
The most recent version, "Eating Patterns Ques
tionnaire," is composed of 26 items with the same
five response categories (Figure 34). The reference
time period is the last 3 months. Items from this ver
sion were used and validated in about 1,900 partici
pants in a nutrition intervention study (100). The
items asked are listed in Figure 35.
2301S
FIGURE 35 List of Items in Kristal Eating Patterns Questionnaire (Complete): Fred Hutchinson Cancer Research
Institute
When you ate fish:
how often was it broiled, baked or poached?
how often was it fried?
When you ate boiled or baked potatoes:

how often did you eat them without butter, margarine,
or sour cream?
When you ate chicken:

how often was it broiled, or baked?
how often was it fried?
how often did you take off the skin?
When you ate rice:

how often did you eat brown instead of white rice?
When you ate spaghetti or noodles:

how often did you eat them plain or with a tomato
sauce without meat?
how often did you eat whole-wheat types?
When you ate red meat:
how often did you trim all the visible fat?
When you ate bread, rolls, muffins, or crackers:

how often did you eat them without butter or mar
garine?
how often were they whole grain types (whole-wheat,
pumpernickle, rye)?
When you ate cereal:
how often did you eat Fruit 'N Fiber, a bran cereal
(raisin bran) or other special high-fiber cereal?
how often did you add bran?
When you had milk:
how often was it very low fat (1%) or nonfat,
milk?
When you ate cheese:
how often was it specially-made,
skim
low fat (diet) cheese?
When you ate frozen desserts:

how often were they ice milk, nonfat ice cream (such
as Simple Pleasures), frozen yogurt, or sherbet?
When you ate cooked vegetables:
how often did you add butter, margarine,
bacon fat?
how often were they fried?
salt pork, or
When you ate potatoes:

how often were they fried (french fries, hash browns,
etc.)?
At dinner (or your main meal):

how often did you have no meat, fish, eggs or cheese?
At dinner (or your main meal):
how often did you eat two or more vegetables
potatoes or salad)?
(not
When you ate lunch:

how often did you have one or more vegetables
including potatoes or salad)?
(not
When you ate breakfast:

how often did you eat fresh fruit (not juice)?
how often did you eat hot or cold cereal?
When you ate dessert:
how often did you put cream or whipped cream on
top?
how often did you eat only fruit for dessert?
When you ate snacks:
how often did you eat raw vegetables?
how often did you eat fresh fruit?
When you sauteed or pan fried foods:
how often did you use Pam or other non-stick
instead of oil, margarine, or butter?
spray
When you made casseroles or mixed dishes:

how often did you add bran?
When you cook red meat (beef, pork, lamb):
how often did you trim all the fat before cooking?
When you used mayonnaise or mayonnaise-type dressing:
how often did you use low fat or nonfat types?
When you baked cookies, cakes or pies:
how often did you change the recipe to use less butter,
margarine or oil?
When you ate ground beef:

how often did you choose extra lean (very low fat)
ground beef?
When you ate green salads:

how often did you use no dressing?
how often did you use low calorie, diet dressing?
2302S
SUPPLEMENT
R. Food Behavior Checklist, Kristal et al.,

The Food Behavior Checklist, developed by Kristal
et al. (68), is an example of a tool to assess food use
related to adopting lower-fat and higher-fiber diets.
The tool is a simplification of the 24-hour dietary re
call, asking whether a particular food was consumed
(yes/no) in the previous day (see Figure 36). It is
designed to characterize group (not individual) in

take.
Resource:
Seattle, WA 98104
(206)667-4686
akristal@cclink.fhcrc.org
FIGURE 36 Kristal Food Behavior Checklist: Fred Hutchinson Cancer Research Institute
Food Items Included in Food Behavior Checklist
One or more servings of fresh fruit

Green salad
Vegetable, other than salad, at lunch
Vegetable, other than salad, at dinner
Butter, margarine, or creamy sauce on cooked vegetables
Dark bread, including whole wheat, rye, or pumpernickel
Whole grain or bran muffins
Butter or margarine on bread
Deep-friend food like french fried potatoes, fried chicken or fish, tacos, egg rolls, or
dim-sum
Hot dog, salami, bologna, or other luncheon meat
Hamburger, meat loaf, tacos or other dish with ground beef
Cake, pie, custard, tart of cookies
Ice cream
Reprinted
with permission
from Kristal et al. (68).
Cereal (hot or cold)

a. If yes, was it a high fiber cereal?
a. If yes, was it any of the following? Any bran cereal, Raisin Bran, Wheatena,
Shredded Wheat, Oatbran, Oatmeal or Fruit n Fiber?
Breakfast or snack pastry such as donuts, croissants, danish, coffee cake, or sweet
rolles, pan dulce or custard tarts
Bacon, sausage, or chorizo
Milk, including milk on cereal, chocolate milk, or cafe con leche
a. If yes, was it
regular or whole milk?
low-fat or 2% milk?
skim, 1% or non-fat milk?
DIETARY ASSESSMENT
S. Young Children's Diet Assessment

Questionnaire, Dennison, et al., Mary Imogene
Bassett Hospital Research Institute
The Young Children's Diet Assessment Question
naire is an example of a modification of an existing
questionnaire for use in a special group. The Food
Habits Questionnaire developed by Kristal et al. (see
Section VI. Q.) was modified by Dennison and col
leagues for use with parents of young children. Its
purpose is to screen and identify children with high
or low dietary intakes of saturated fat and cholesterol.
MANUAL
2303S
The final questionnaire, shown in Figure 37, is com

posed of 16 questions with six response categories.
This questionnaire has been validated in a small sam
ple of 2-year-old children in upstate New York (2,32).
Further validation of the questionnaire is underway.
Resource:
Barbara A. Dennison, M.D.
Research Institute
Mary Imogene Bassett Hospital
Cooperstown, NY 13326-1394
(607)547-3742
FIGURE 37 Dennison Diet Assessment Questionnaire for Young Children (Complete)

QUESTIONNAIRETTie YOUNG CHILDREN'S DIET ASSESSMENT
following statements have to do with vour child's food habits during themonth.MMri
past
month,how
serving chicken to your child, in the past
+Inoften did you remove the skin?
yourchild:a.
the past month, how often did you serve
ground
ordinner?
beef or hamburgers for lunch
*+b.
*c.
hot dogs for lunch or dinner?
*In
candy for a snack or dessert?
yourchild:a.
the past month, how often did you give
+b.2% milk?
c.
very low-fat (1%) or non-fat milk?
+d.part skim milk or reduced fat cheese?
ice
ofIcecream?
milk, frozen yogurt or sherbet Instead
In
you:a,
the past month, how often did
put
cookedvegetables?
butter or margarine on your child's
*b.
serve
dishoryour child trench fries as a side
*c. snack?
grill
ormargarine?
your child's sandwich in butter
UwriV1.2.3.4.5..6.*+When
Nmr1111111111111111NoiApptabto9999999999999
*d.
serve
atdinner?
your child two or more vegetables
In
you:a.
the past month, how often did
give
chipsas
your child potato, com, or taco
*+b. a snack or side dish?
give
sandwichrather
your child a peanut butter
+c.
than a meat sandwich?
+In
serve your child margarine Instead of butter?
didyou
the past month, for breakfast, how often
*+Reverse
serve eggs?
scoringQuestion
question before
scoreQuestion
contributes to the dietary cholesterol
contributes to the saturated fatty acid Intake scoreS86SS6668S8SS88S4444444444444444Otan3333333333333333lonwifnM222222222222
2304S
SUPPLEMENT
T. Behavioral Risk Factor Surveillance System

Dietary Modules, Centers for Disease Control
and Prevention
Resource:
Tim Byers, M.D., M.P.H.
Chief, Chronic Disease Prevention Branch
Division of Nutrition
National Center for Chronic Disease Prevention and
Health Promotion
4770 Buford Highway, NE
Mail Stop K-26
Atlanta, GA 30341-3724
(404)488-4260
txb5@ccddnl .em.cdc.gov
FIGURE 38 Question Format and Complete Food List of the Behavioral Risk Factor Surveillance System
Dietary Modules: Centers for Disease Control and Prevention
Question
Format
How often do you eat hot dogs or lunch meats such as ham or other cold cuts?
Don't know/Not sure
Per Day
Per Week
Refused
Per Month
Per Year
Never
Complete
List of Foods Included
in the Dietary Modules
DIETARY FAT
Hot dogs or lunch meats such as ham or other cold cuts
Bacon or sausage
Pork other than ham, bacon, or sausage
Hamburgers, cheeseburgers or meatloaf
Beef other than hamburger, cheeseburger, or meatloaf
Fried chicken
French fries or fried potatoes
Cheese or cheese spreads, not including cottage cheese
Doughnuts, cookies, cake, pastry, or pies
Snacks, such as chips or popcorn
Add butter or margarine to bread, rolls, or vegetables
Eggs
Classes of whole milk (include drinks made with whole milk or milk on cereal; do
not include lowfat milk, such as skim milk or 2% milk)
FRUITS AND VEGETABLES
Fruit juices such as orange, grapefruit, or tomato
Fruit (not counting juice)
Green salad
Potatoes (not including french fries, fried potatoes or potato chips)
Carrots
Servings of vegetables (not counting carrots, potatoes or salad)
The purpose of the Behavioral Risk Factor Surveil

lance System (BRFFS)is to provide state-specific esti
mates of health behaviors relating to leading causes of
death among U. S. adults. Telephone interviews are
administered by departments of health in each partic
ipating state using random-digit dialing techniques.
We include the two dietary modules as examples of
brief dietary instruments used currently in a national
study. These modules were developed as a collabora
tive effort between Centers for Disease Control and
Prevention (CDC) and National Cancer Institute (NCI)
and other consultants to estimate the usual dietary
intake of fat, fruits, and vegetables. The questions
were adapted from the 1987 National Health Inter
view Survey (HIS) Cancer Risk Factor Supplement Ep
idemiology Study (219) and are similar to the Block
fat screener items (61), adapted for use in telephone
surveys. The format for the questions and the complete
list of foods included in the dietary fat and fruits and

vegetables modules are shown in Figure 38.
Both modules have been evaluated in five demographically diverse populations by comparing esti
mates with those from more extensive dietary assess
ments (65). State-specific BRFSS diet findings can be
obtained from the BRFSS coordinator in each state's
health department. Other details of the survey method
can be obtained from CDC.
DIETARY ASSESSMENT
(I. 5 A Day for Better Health

Another example of a short assessment instrument
currently being used in studies throughout the nation
is the set of questions developed by grantees for the
NCI 5 A Day for Better Health effort. These questions,
shown in Figure 39, are designed to provide an indi
cator of the average number of servings of fruits and
vegetables consumed per day and will be used at all
sites for the 5 A Day grantees. The questions can be
administered by interviewer or by self, by telephone
or in person. The time frame is the past month. Fre
quency information is asked for five foods using 10
frequency categories. Portion size is not asked. Also
included are summary questions asking how many
servings of broad food groups were eaten. Validation
studies for these questions are planned in individual
5 A Day research projects.
MANUAL
2305S
Resources:
Gloria Stables, M.S.
Nutritionist
EPN, Room 330
(301)496-8520
stablesg@dcpcepn.nci.nih.gov
Amy F. Subar, Ph.D.
Nutritionist
EPN, Room 313
(301)496-8500
sfd@nihcu
Both at:
The next seven questionsprovidea simpleway to how many servingsof fruits and vegetablesyou normallyeat. Pleaseput an
"X" in the box showing how often you ate or drank each of these itemsof food in the past month.
month?Never0OOO01
how often did you eat or drink these foods in the past
Food
item100%
-3
-2times
or
times times time
times more
times
per
per
per
per
per
times
per
per
per
per
month0OOOo1
week00OOO3-4
weekOOOO05-6
weekOOOOO1
day0Oo002times
dayOOO003times
dayOOOO04
dayOOOOO5
dayO0OOo
Orange
juice or
grapefruit
juiceOther
100% fruit
juices, not
counting fruit
drinksGreen
salad (with
or without other
vegetables)French
fries or
fried
potatoesBaked,
boiled or
mashed potatoesAbout
month?NeverOO1
how many servings of these foods did you eat in the past
-2
6
per
per
per
per
or
per
per
per
dayOO2 dayOO3 dayOo4 dayOO5 more
monthOo1
weekOO3-4
weekOO5week0o1
per
dayOO
3per
-
itemAbout
Food
how many
servings of vegetables
did you eat NOT
counting salad or
potatoes?About
how many
servings of fruit did
you eat NOT counting
juices?About
FIGURE 39 Core Questions to be Asked by All Sites to Assess Intake of Fruits and Vegetables: 5 A Day Grantees
2306$
V. Stages of Change Questions

Various sets of questions and algorithms for clas
sification have been developed to assess individuals'
placement in a stages of change model. Figure 40, re
printed from Glanz et al. (96), lists a classification al
gorithm, concepts, and items that measure the con
cepts. Stage of change, as assessed by these questions
in the baseline survey of the NCI-supported Working
Well Trial, were associated with fat and fiber intakes
(measured by an 88-item food frequency question
naire), as predicted.
A different set of questions has been developed by
5 A Day grantees (see previous section) to assess stages
of change with regard to fruit and vegetable intakes
for adults (Figure 41). These questions will be used in
individual sites and validated in some sites.
Resources:
Karen Glanz, Ph.D., M. P. H.
Professor
Cancer Research Center of Hawaii
University of Hawaii
1236 Lauhala Street
Honolulu, HI 96813
(808) 586-3076
kglanz@uhunix.uhcc.hawaii.edu
Jerianne Heimendinger, Ph.D.

Program Director
5 A Day for Better Health
EPN, Room 330
6130 Executive Blvd. MSC 7344
(301)496-8520
heimendj@dcpcepn.nci.nih.gov
2307S

FIGURE 40 "Stages of Dietary Change: Algorithm
CLASSIFICATION
and Items"
ALGORITHM FOR STAGES OF DIETARY CHANGE

(Fat/Fiber)
Stage"
Item(s) Used
Definition
MAINTENANCE
Healthy1" diet for a 6 months
Self-rated diet
ACTION
Healthy diet for < 6 months or tried to change with some

success in the last 6 months
Self-rated diet
Reported changes: attempts,
success
PREPARATION
Tried to make healthy diet changes in last 6 months but

not successful, OR
Self-rated diet
success
Behavioral intentions to change diet
Definitely plan to change

Maybe/probably plan to change diet in the next 6
months; and no attempts to change in the last 6
months
Self-rated diet
success
PRECONTEMPLATION
No plans to change diet in diet in the next 6 months; and

no attempts to change in the last 6 months
Self-rated diet
success
' Assignment
to stage was done sequentially,
beginning with Maintenance.
Once an individual was assigned to a stage, the
remaining response codes were not processed.

* Healthy diet = Low/very low fat, or high/very high fiber
Concept Item
SELF-RATED DIET
How high in fat is your overall diet?
(If LOW or VERY LOW):
For how long have you followed a diet that is low in fat?
How high in fiber is your overall diet?
(If HIGH or VERY HIGH):
For how long have you followed a diet that is high in fiber?
Response Options
1 to 5; 1 = very high to
5 = very low
1 to 4; 1 =< 1 month to
4 = aone year
1 to 5; 1 = very high to
5 = very low
1 to 4; 1 = <1 month to
4 = sonyear
BEHAVIORAL INTENTIONS TO CHANGE DIET

[This section introduced by: "The following questions ask about changes you may have
made, or may make, in the way you eat."]
Over the next six months, do you plan to cut down on fats?
Over the next six months, do you plan to eat more fruits and vegetables?
REPORTED EATING HABITS CHANGES: ATTEMPTS, SUCCESS
Have you tried to make any changes to lower the fat in your diet in the past six months?
(If YES:) How successful were you in making those changes?
Have you tried to make any changes to increase the fiber in your diet in the past six
months?
(If YES:) How successful were you in making those changes?
Reprinted by permission
from Glanz et al. (96).
1 to 5,
to
1 to 5,
to
1 = definitely
5 = definitely
1 = definitely
5 = definitely
yes
no
yes
no
Yes/No
1 to 5, 1 = extremely
successful, 5 = not
successful
Yes/No
1 to 5, 1 = extremely
successful, 5 = not
successful
CONTEMPLATION
2308S
SUPPLEMENT
FIGURE 41 Stages of Change Questions for Adults: 5 A Day Grantees

1. How many servings of fruit and vegetables do you eat each day?
0 1-2 3-4 5-6 7-8 9-10 11 or more
2. About how long have you been eating this number of daily servings of fruit and
vegetables?
less than one month 1-3 months 4-6 months longer than 6 months
* Individual sites may choose an alternative cutpoint for number of daily servings
used to classify individuals in action or maintenance.
3. Are you seriously thinking about eating more servings of fruits and vegetables
starting sometime in the next six months?
yes (go to question 4) no (skip question 4)
4. Are you planning to eat more servings of fruits and vegetables during the next
month?
yes no
Algorithm for assigning stage of change:
If answer to Ql is 5 or greater*, and answer to Q2 is greater than 6 months:
stage=MAINTENANCE.
If answer to Ql is 5 or greater*, and answer to Q2 is 6 months or less: stage=ACTION.
If answer to Ql is less than 5, answer to Q3 is "yes," and answer to Q4 is "yes:"
stage=PREP ARATION.
If answer to Ql is less than 5, answer to Q3 is "yes," and answer to Q4 is "no:"
stage=CONTEMPLATION.
If answer to Ql is less than 5, and answer to Q3 is "no:"
stage=PRECONTEMPLATION.
DIETARY ASSESSMENT
2309$
of nutrients, and behaviors affecting fat and fiber con

sumption. Many of the behavior questions were
adapted from those developed by Kristal, et al. The
1994-96 version includes an expanded list of ques
tions on use of food labels and attitudes toward using
them. The 1989-91 versions include questions related
to food safety that are not included on the 1994-96
version. Sample DHKS questions are shown in Figure
42. Some findings from the 1989 DHKS have been
published (233, 234). A report summarizing the ag
gregated findings for 1989-1991 is in preparation.
Resource:
Linda Cleveland, M. S., R. D.
Nutritionist
Before Feb. 1, 1995:
6505 Belcrest Road, Room 364
(301)436-3543
After Feb. 1, 1995:
4700 River Rd.
Riverdale, MD 20737
(301)436-8457
FIGURE 42 Diet and Health Knowledge Survey 1994-96 (Excerpts): USDA

How many servings from the (FOOD GROUP) would you say a
person of your age and sex should eat each day for good health?
Fruit Group
Vegetable Group
Milk, Yogurt, and Cheese Group?
Bread, Cereal, Rice, and Pasta Group?
Meat, Poultry, Fish, Dry Beans, and Eggs Group?
Tell me if you strongly agree, somewhat agree, somewhat dis
agree, or strongly disagree with the statement:
Choosing a healthy diet is just a matter of knowing what
foods are good and what foods are bad.
Eating a variety of foods each day probably gives you all the
vitamins and minerals you need.
Some people are born to be fat and some thin; there is not
much you can do to change this.
Starchy foods, like bread, potatoes, and rice, make people fat.
There are so many recommendations about healthy ways to
eat, it's hard to know what to believe.
What you eat can make a big difference in your chance of
getting a disease, like heart disease or cancer.
The things I eat and drink now are healthy so there is no
reason for me to make changes.
Compared to what is healthy, do you think your diet is too low,
too high, or about right in (STATEMENT):
Calories?
Calcium?
Iron?
Vitamin C?
Protein?
Fat?
Saturated fat?
Cholesterol?
Salt or sodium?
Fiber?
Sugar and sweets?
To you personally, is it very important, somewhat important,
not too important, or not at all important to (STATEMENT):
Use salt or sodium only in moderation?
Choose a diet low in saturated fat?
Choose a diet with plenty of fruits and vegetables?

Use sugars only in moderation?
Choose a diet with adequate fiber?
Eat a variety of foods?
Maintain a healthy weight?
Choose a diet low in fat?
Choose a diet low in cholesterol?
Choose a diet with plenty of breads, cereals, rice, and pasta?
Eat at least two servings of dairy products daily?
Based on your knowledge, which has more saturated fat:
Liver, or T-bone steak?
Butter, or Margarine?
Egg white, or Egg yolk?
Skim milk, or Whole milk?
Which has more fat :
Regular hamburger, or Ground round?
Loin pork chops, or Pork spare ribs?
Hot dogs, or Ham?
Peanuts, or Popcorn?
Yogurt, or Sour cream?
Porterhouse steak, or Round steak?
Which kind of fat is more likely to be a liquid rather than a solid:
Saturated fats, Polyunsaturated fats, or Are they equally likely
to be liquids?
If a food has no cholesterol is it also: Low in saturated fat, High in
saturated fat, or Could it be either high or low in saturated fat?
Is cholesterol found in: Vegetables and vegetable oils, Animal
products like meat and dairy products, or All foods containing
fat or oil?
When you buy food, how important is (FACTOR)very im
portant, somewhat important, not too important, or not at all
important?
How safe the food is to eat?
Nutrition?
Price?
How well the food keeps?
How easy the food is to prepare?
Taste?
W. Diet and Health Knowledge Survey, (JSDA

We include questions from USDA's Diet and Health
Knowledge Survey (DHKS) as an example of knowl
edge and attitude questions currently being asked in
a national survey. This survey, initiated in 1989, pro
vides data on people's attitudes about the Dietary
Guidelines for Americans and their knowledge and
behaviors related to implementing the Guidelines. The
DHKS is administered by telephone after collection
of food intake data in the Continuing Survey of Food
Intakes by Individuals (CSFII). Thus, data on dietary
knowledge and attitudes can be linked to data on food
and nutrient intake for the same individual. Respon
dents in the 1989, 1990, and 1991 DHKS were main
meal planners/preparers in U. S. households. In 1994,
1995, and 1996, the sample is composed of adults 20
years and older, regardless of meal planner/preparer
status.
There have been some changes in the DHKS ques
tionnaire over the years, but many of the questions
remain the same. The 1994-96 DHKS questionnaire
assesses self-perceptions of relative nutrient intake,
perceived importance of following dietary guidance,
awareness of diet-health relationships, use of food la
bels, knowledge about food guidance and food sources
MANUAL
2310S
SUPPLEMENT
X. Knowledge, Attitudes, and Belief Questions

in the 1992 National Health Interview Survey
are found in Figure 43. Results of analyses of these

data for the 1992 NHIS will be available soon.
We include some questions used in the Epidemiol

ogy Supplement of the 1992 National Health Inter
view Survey (NHIS) as a further example of food
knowledge questions administered to a national sam
ple. These questions were developed through cognitive
testing in focus groups and pilot studies. The 1992
NHIS included interviews with 24,040 individuals,
representative of the United States; the Epidemiology
Supplement was administered to a half-sample of
about 12,005 individuals (183). The questions asked
Resource:
Amy F. Subar, Ph.D.
Nutritionist
EPN, Room 313
(301)496-8500
sfd@nihcu
FIGURE 43 Questions on Food Knowledge (Complete): National Health Interview Survey, 1992
1. Please tell me if you agree or disagree with the following statements, or if you have no opinion
a. There are plenty of healthy foods that taste good.
b. It is easy to eat a healthy diet.
c. In general, healthy foods cost more than other kinds of foods.
d. There is a lot of conflicting advice on healthy ways to eat.
2. Do you get encouragement from your family or friends to eat more healthy food?
3. I am going to read two statements. Please tell me which you agree with MOST.
A. What people eat or drink has little effect on whether they will develop major diseases. OR
B. By eating the right kinds of foods, people can reduce their chances of developing major diseases.
4. In your opinion, what major diseases may be related to what people eat and drink?
Cancer
Heart disease
Obesity/overweight
Diabetes
Hypertension or high blood pressure
Ulcers/other digestive problems (not cancer)
Other disease(s)
5. [If cancer not mentioned] Do you think cancer may be related to what people eat and drink?
6. [If "yes") Which of these would be helpful if a person wanted to reduce his or her chances of getting certain kinds
of cancer?
Eating more fiber
Eating less sugar
Avoiding foods with additives
Eating less fat
Eating less salt
Eating more fruit and vegetables
Taking vitamins
None of these changes would be helpful
7. Some foods contain fiber. Have you heard of fiber?
8. [If "yes"] I am going to read a list of foods two at a time. For each food pair, please tell me which one you think
contains more FIBER. If you are not sure which food contains more fiber, let me know.
a. First, 1 bowl of shredded wheat OR 1 bowl of corn flakes?
b. 1 cup of iceberg lettuce OR 1 cup of carrots?
c. 1 cup of spaghetti with meatballs OR 1 cup of chili with beans?
9. Now I am going to read another list of foods two at a time. For each food pair please tell me which one you think
contains more FAT. If you're not sure which one contains more fat, let me know.
a. First, regular potato chips OR pretzels?
b. 1 glass of cola OR a glass of whole milk?
c. 1 small bran muffin OR 1 slice of whole wheat bread?
10. How many servings of fruits and vegetables do you think a person should eat EACH DAY for good health?
11. How often do you or the person who shops for your food buy items that are labelled "low fat" or "non-fat"
would you say often, sometimes, rarely, or never?
ACKNOWLEDGMENTS
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(1989) Westat,
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The authors would like to acknowledge the follow

ing individuals for their helpful comments on earlier
drafts of the manual: Carol Ballew, Ronette R. Briefel,
Bethene Ervin, Sandy Facinoli, Katherine Piegai, Laur
ence Freedman, Patricia Guenther, Anne M. Hartman,
Jean Hankin, Alan Kristal, Larry Kessler, Susan M.
Krebs-Smith, Sarah Kuester, Frances A. Larkin, Betty
Perloff, Nancy Potischman, Christopher Sempos, Mary
K. Serdula, Amy F. Subar, Walter Willett, Jacqueline
Wright, and Regina Ziegler.
We also acknowledge the many individuals who
provided information: Gladys Block, I. Marilyn Buz
zard, Linda Cleveland, Barbara Dennison, Sandy Fa
cinoli, Karen Glanz, Patricia Guenther, Mary Hama,
Jean Hankin, David B. Haytowitz, Jerianne Heimendinger, Maureen Harris, Catherine Loria, Julie MaresPerlman, Heather McCreath, Margaret McDowell,
Sharon Mickle, Laura Sampson, Priscilla Steele, Amy
F. Subar, Douglas Taren, and Katherine Tucker. Susana
Rosales, Ellen Kish, and Julie Couch are gratefully ac
knowledged for their assistance in manuscript prep
aration. We also thank Gloria C. Rasband, Neha Shirgaonkar and Josh Udler for bibliographical assistance.
2311S
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MANUAL

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Supplement

Dietary Assessment Resource Manual1

II. DIETARY ASSESSMENT

Five families of assessment methods are reviewed

$3.00 1994 American Institute of Nutrition.

to The Journal of Nutrition.

editor for this publication was Lenore Kohlmeier, School of Public

J. Nutr. 124: 2245S-2317S,

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This manual is intended to serve as a resource for

are usually unsatisfactory because of respondent fa

increases and becomes more burdensome to complete

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ment methods are compared. By recording foods as

DIETARY ASSESSMENT MANUAL

used: NHANES: National Health and Nutrition

Examination Survey; NCHS: National Center for Health Statistics;

24-hour recall to characterize an individual's usual

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the study period, and the use of a computerized data

naires without the additional respondent burden of

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Strengths. The food frequency approach is de

DIETARY ASSESSMENT MANUAL

tions between the methods for most foods and nu

takes of dietary fat using 13 questions and fruits and

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Several brief dietary assessment methods have been

III. DIETARY ASSESSMENT

The primary research question must be clearly

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The term "diet history" is used in many ways. In

nutrient intake (e.g., frying vs. baking), as well as ex

DIETARY ASSESSMENT MANUAL

What time period is of interest?

B. Case-Control (Retrospective) Studies

populations by asking participants from past dietary

C. Cohort (Prospective) Studies

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One of the most common types of studies is the

diet is measured repeatedly over the years, repeated

Accurate measurement of intake is not always re

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Measurement of the dietary changes resulting from

E. Dietary Screening in Clinical Settings

DIETARY ASSESSMENT MANUAL

of recent major dietary intake surveys conducted

in the United States

Nationwide Food Consumption Survey

and guide policy. The components of nutritional sur

The type of information required for a surveillance

IV. DIETARY ASSESSMENT

To examine the suitability of the initial data base,

The 24-hour dietary recall, food records, and food

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about a subject's early life, and spouses or children

DIETARY ASSESSMENT MANUAL

quency techniques are inappropriate if memory is im

A. Estimation of Portion Size

of portion size reports for the same foods using food

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V. SELECTED ISSUES IN DIETARY

D. Choice of Nutrient Data Base

sium, sodium, zinc, copper, manganese, ascorbic acid,