RESEARCH

Original Research: Brief

Assessing Initial Validity and Reliability of

a Beverage Intake Questionnaire in
Hispanic Preschool-Aged Children
Karina R. Lora, PhD; Brenda Davy, PhD, RD; Valisa Hedrick, PhD, RD; Ann M. Ferris, PhD, RD; Michael P. Anderson, PhD;
Dorothy Wakefield, MS

ARTICLE INFORMATION ABSTRACT

Article history: Background Understanding the relationship between high-calorie beverage con-
Submitted 5 January 2016 sumption and weight gain requires an accurate report of dietary intake. A critical
Accepted 24 June 2016 need exists to develop and test the psychometrics of brief quantitative tools for
Available online 21 August 2016
minority pediatric populations.
Keywords: Objective To modify the adult beverage intake questionnaire (BEVQ-15) for
Validity Hispanic preschool-aged children (BEVQ-PS) and test its validity and testeretest
Reliability reliability in
Beverages
children aged 3 to 5 years.
Hispanic
Preschoolers Design Cross-sectional. The modified quantitative 12-beverage category questionnaire
assessed consumption of water, fruit juice, sweetened juice drinks, whole milk, reduced-
fat milk, low-fat milk, flavored milk, carbonated sweetened drinks, diet carbonated
2212-2672/Copyright ª 2016 by the Academy of drinks, sweet tea, tea with or without artificial sweetener, and sport drinks consumed
Nutrition and Dietetics.
http://dx.doi.org/10.1016/j.jand.2016.06.376 during the past month. Hispanic mothers (n 109) recruited ¼ from day-care centers
provided one 4-day food intake record (FIR) and completed two BEVQ-PS sur- veys
during a 2-week period for their preschool-aged child. Data collection was con- ducted
through one-on-one interviews in Spanish. Validity was assessed by comparing amounts
(in grams) and energy intake (in kilocalories) for each beverage category be- tween the
first BEVQ-PS and the mean of the FIRs using paired t tests and Pearson’s correlation
coefficient. Criteria for validity were nonsignificant mean differences in
grams and kilocalories from the first BEVQ-PS and mean of the FIRs beverage categories,
and significant correlation coefficients between beverage categories. Testeretest reli-
ability was assessed by comparing grams and kilocalories for each beverage category
in
the first BEVQ-PS with those from the second BEVQ-PS using Pearson’s correlation
coefficient. The criterion for reliability was a significant correlation coefficient between
beverage categories. Significance was set at P<0.05.
Results Mean differences between the first BEVQ-PS and FIR for water (42.4 T 23.1
g), sweetened juice drinks T(e1.6 11.0 g), whole milk T (18.3 9.91 g), sweetened
carbonated drinks
T (e13.0 7.9 g), and total sugar-sweetened beverages T (SSB) (1.4 8.9
g) were not
significantly different, but were significantly correlated (r ¼0.20 to 0.37; P<0.05). Thus,
validity criteria were met. With the exception of flavored milk and tea with or without
artificial sweeteners, the remaining beverage categories—total beverages and SSB—in
the first BEVQ-PS were correlated with those from the second BEVQ-PS (r¼0.20 to 0.68;
P<0.05), meeting reliability criteria.
Conclusions Researchers and clinicians may use the BEVQ-PS to assess SSB, water, and
whole-milk intake in Hispanic children. Additional modifications should be

P
evaluated to assess total beverage intake.
J Acad Nutr Diet. 2016;116:1951-1960.

EDIATRIC OVERWEIGHT AND OBESITY REMAIN MA-
jor public health concerns and the focus of preven-
tion efforts.1 Racial and ethnic disparities in
childhood obesity prevalence in the United States
exist. Hispanic preschool-aged children have higher obesity
prevalence than children of other racial and ethnic back-
grounds.1 Socioeconomic disparities, prevalent in minority
groups, augment obesity prevalence. Among low-income
children, almost 3% of Hispanic children aged 2 to 4 years
are extremely obese vs 1.6% of non-Hispanic white
children.2 These facts underscore the importance of racial
or ethnic and socioeconomic disparities in obesity starting
at young ages and the need to examine lifestyle factors that
may exacerbate this condition.
Consumption of sugar-sweetened beverages (SSB) in-
fluences childhood obesity.3,4 Greater SSB consumption has
RESEARCH
ª 2016 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
1951
 carbonated beverages and juice drinks.8
been linked with higher risks of obesity, type 2 diabetes,
hypertension, and metabolic syndrome. 5,6 SSB comprise the
largest source of added sugar in the American diet. 6 In
chil- dren aged 2 to 5 years, SSB have contributed to a 26-
kcal/day increase from 1988-1994 to 1999-2004.7 Fruit
drinks and sweetened carbonated beverages are the top
sources of added sugars in children aged 2 to 5 years8 and
represent 44% and 27%, respectively, of total kilocalories
per day from added sugars in children of this age range. 9
The large SSB intake of young children emphasizes the need
to examine the rela- tionship of total SSB intake and
pediatric obesity, particularly in Hispanic children who
consume large amounts of SSB.10,11 Understanding dietary
habits requires gathering informa- tion about habitual food
consumption. Food intake records and recalls are
commonly used to assess dietary intake.12 Such methods are
resource-intensive, time-consuming, and only provide
recent dietary intake information.12,13 Food frequency
questionnaires (FFQs) assess intake over longer periods
and reduce response burden.12 FFQ are essential to
understanding the association between habitual food
consumption and health.12,14 Although several FFQs have
been developed to assess dietary intake in adults,15 they do
not adequately es- timate dietary intake in children.
Children’s intakes tend to be overestimated due to bigger
portion sizes in the list of foods16,17 or underestimated due
to lack of foods consumed.18 Thus, efforts must be made to
develop or adapt and validate child-specific FFQs that are
easy to administer and minimize respondents’ burden. One
standardized instrument, the 15- question Beverage Intake
Questionnaire (BEVQ-15), was developed to assess habitual
beverage intake in adults.19,20 In pediatric populations,
Marshall and colleagues 21 validated a 7-item beverage
frequency questionnaire for use in children aged 6 months
to 5 years. Other validated tools that assess beverages as
part of the instrument have been reported for children
from age 6 months to 16 years.22-25 However, only one was
validated in a multiethnic sample of children in which
minority children were underrepresented. Recognition of
cultural differences in dietary intake assessment and the
cultural appropriateness of a tool are important.26,27 In-
struments that have been validated in one group must be
reevaluated for use in groups that differ substantially in cul-
tural background, language, or country of origin. 28
Sociocultural behaviors influence food intake.18,26,27 Mis-
conceptions of the so-called healthfulness of certain SSBs
(eg, sport drinks) and culturally relevant sweetened drinks
(eg, aguas frescas, which contain sugar, fruit, and water)
have been reported among Hispanic youth.29 A large
assortment of Mexican soft drinks (eg, Jarritos [Novamex],
Yoli [The Coca- Cola Company], Charritos, Mexican Coca-
Cola [The Coca-Cola Company]) have been found in corner
stores in southern Texas where Hispanic families purchase
foods.30 Knowledge of the types of foods that members of
minority groups may consume is important in the
development of culturally appropriate tools.27,31 For
instance, national data reporting consumption patterns of
types of SSB indicate that although Hispanic children aged
2 to 11 years are more likely to consume fruit drinks than are
white children, the odds for heavy sweetened carbonated
beverage consumption is lower in Hispanic children than in
their white counterparts. 32 In Mexican-American children
aged 2 to 18 years, the main re- ported SSBs are sweetened

1952 JOURNAL OF THE ACADEMY OF NUTRITION AND December 2016 Volume 116 Number
12
 version 2013 food composition tables (Nutrition
The purpose of our study was to modify the adult Coordinating Center, University of Minnesota). 33 Energy
BEVQ-15 for preschool-aged children (BEVQ-PS) and drinks were not
test its initial validity and testeretest reliability in low-
income Hispanic children aged 3 to 5 years. The food
intake record (FIR) was used to evaluate comparative
validity.

METHODS
Participants and Setting
The study design was cross-sectional. Hispanic
mothers (n 112) and their 3- to-5-year-old children were ¼
recruited from four day-care centers in Oklahoma City,
OK, between July 2013 and July 2014. Using a mean total
SSB consumed in grams of 357 and standard deviation of
47,19 a sample size of 72 participants was determined to
have a 92% power to detect equivalence using a 5% margin
equivalence. Sample size was increased to 112 to account
for incomplete dietary data. Type I error of 5% was used
with two one-sided paired t tests for calculations.
Mothers’ inclusion criteria were self- identification as
Hispanic, living with the target child, and ability to
read/write/speak in English or Spanish. Children were
eligible if they were without chronic diseases or disability
that prevented participation. In cases where multiple
children per family were eligible, the mother was asked to
record information for only one child who attended the
participating day-care center. Teachers verbally provided
child’s dietary information to mothers to report consump-
tion that took place while the child was at a day-care
center for the FIR. Data collection was conducted through
one-on- one interviews. Two bilingual (English-Spanish)
researcher interviewers were available. Mothers were
given the option to complete the interview and BEVQ-PS
in English or Spanish (Figures 1 and 2). However, all
participants chose to have the interviews and complete the
BEVQ-PS in Spanish. Mothers and teachers provided
written informed consent before data collection. The
University of Oklahoma Health Sciences Center
institutional review board approved the protocol.

Development and Scoring of the BEVQ-PS

The BEVQ-15 estimates mean daily grams and energy
intake of 15 beverages, including water and SSBs, in
adults.19,20 To modify the BEVQ-15 for children aged 3 to
5 years, 20 His- panic mothers were recruited from day-
care centers to complete a semistructured interview
regarding the types and amounts of beverages
consumed by their preschool-aged children. Mothers
were compensated with a $5 gift card.
This information was used to identify applicable
bever- ages from the BEVQ-15, add new beverages,
and adapt serving sizes for preschool-aged children.
Frequency of intake was unchanged from the original
BEVQ-15. The modified tool (ie, the BEVQ-PS)
included 12 beverage cate- gories (water, fruit juice,
sweetened juice drinks, whole milk, reduced-fat milk,
low-fat milk, flavored milk, sweetened carbonated
drinks, diet carbonated drinks, sweet tea, tea with or
without artificial sweetener, and sport drinks) and
one open-ended section for other beverages not listed
(see Figures 1 and 2). Beverage categories were
grouped based on energy and macronutrient content
using the Nutrition Data System for Research (NDSR)

December 2016 Volume 116 Number JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
12
RESEARCH

Beverage Questionnaire for Preschoolers (BEVQ-PS)

Participant ID: Date:

Instructions:
In the past month, please indicate your response for each beverage type your child may drink by
marking an "X" in the bubble for "how often" and "how much each time."
1. Indicate how often your child drank the following beverages, for example, if your child drank 5
glasses of of water per week, mark 4-6 times per week under "HOW OFTEN"
2. Indicate the approximate amount of beverage your child drank each time, for example, if your child
drank 1 cup of water each time, mark 1 cup under "HOW MUCH EACH TIME"
3. Do not count beverages used in cooking or other preparations, such as milk in cereal.

HOW OFTEN (MARK ONE) HOW MUCH EACH TIME (MARK

ONE)

Never or
less than 1 2-3 4-6 1 2+ 3+ 1-3 fl 4-6 fl oz 9- 10 fl 12 fl oz
7-8 fl
1 time per time time time tim time time oz (1/2 oz or
Type of Beverage oz
week (go per s s e s per s per (1/3 cup or (~1 more
(~1
to next week per per per day day cup or 3/4 1/4 (~1 1/2
cup)
beverage) week week da less) cup) cups) cups)
y
Water O O O O O O O O O O O O
100% Fruit Juice O O O O O O O O O O O O
Sweetened Juice
Beverage/Drink (fruit
ades, lemonade,
O O O O O O O O O O O O
punch, Sunny Delighta)
Whole Milk O O O O O O O O O O O O
Reduced Fat Milk (2%) O O O O O O O O O O O O
Low Fat/Fat Free Milk
(Skim, 1%, Buttermilk, O O O O O O O O O O O O
Soymilk)
Flavored milk
(chocolate, strawberry)
O O O O O O O O O O O O

Sweetened Carbonated O O O O O O O O O O O O
Drinks or Regular Soda
Diet Carbonated Drinks
or Diet Soda/or Other
O O O O O O O O O O O O
Artificially Sweetened
Drinks (Crystal Lightb)
Sweetened Tea O O O O O O O O O O O O
Tea with/without
artificial sweetener (no O O O O O O O O O O O O
cream or sugar)
Sports Drinks (Gatorade,c
Powerade,d etc)
O O O O O O O O O O O O

Other (list):
O O O O O O O O O O O O
Figure 1. The Beverage Intake Questionnaire for Preschoolers English version. Scoring procedures are available from
corresponding author upon request. aSunny Delight Beverages Co. bKraft Foods. cPepsiCo. dThe Coca-Cola Company.

included, because mothers did not report feeding their
preschool-aged children this type of beverage. Other
omitted items included alcoholic beverages.
To determine beverage intake frequency (“How often”),
the BEVQ-PS asked, “In the past month, please indicate
how often your child drank the following beverages.”
Response options
were: never or less than one time per week, 1 time per week,
2 to 3 times per week, 4 to 6 times per week, 1 time per day,
2 times per day, and 3 times per day or more. To assess
serving size (“How much each time’), the questionnaire
asked, “For each beverage, please indicate how much your
child drank each time.” Response options were: 1 to 3 fl oz,
4 to 6 fl oz,
 Cuestionario de Bebidas para Niños(as) de Edad Pre-escolar
(BEVQ-PS)

Participante ID:

Fecha:

Instrucciones:
Por favor indique su respuesta para cada tipo de bebida que su hijo(a) pudo haber consumido en el último
mes. Marque una "X" en el circulo para especificar "que tan frequentemente" y "cuanta cantidad cada
vez"
1. Indique que tan frecuentemente su hijo(a) bebio las siguientes bebidas, por ejemplo, si su hijo(a) bebio
5 vasos de agua a la semana, marque 4-6 veces por semana debajo de "QUE TAN
FRECUENTEMENTE"
2. Indique la cantidad aproximada de esa bebida que su hijo(a) bebio cada vez, por ejemplo si su
hijo(a) bebio 1 taza de agua cada vez, marque 1 taza debajo de "CUANTA CANTIDAD CADA
VEZ"
3. No considere bebidas utilizadas para cocinar o en otras preparaciones, como por ejemplo la
leche en el cereal

QUE TAN FRECUENTEMENTE CUANTA CANTIDAD CADA VEZ

(MARQUE UNO) (MARQUE UNO)
Nunca or
menos 1 2-3 4-6
1 2+ 3+ 1-3 fl 12 fl
de 1 vez vez vece vece 4-6 fl oz 9- 10 fl
ve vece vece oz (1/3 7-8 fl oz oz or
Typo de Bebida por por s por s por (1/2 or oz (~1
z s por s por taza o (~1 taza) más
semana sem sema sema 3/4 1/4 taza)
po día día menos (~1 1/2
(vaya a la a na na na taza)
r ) taza)
proxima
dí
bebida)
a
Agua O O O O O O O O O O O O
100% Jugo de fruta O O O O O O O O O O O O

Bebidas dulces (bebida

de fruta, limonada, O O O O O O O O O O O O
punch, Sunny Delight a)

Leche entera O O O O O O O O O O O O
Leche reducida en grasa
O O O O O O O O O O O O
(2%)
Leche baja en grasa/sin
grasa (Desnatada, 1%,
Suero de leche, Leche
O O O O O O O O O O O O
de soja)
Leche con sabor
(chocolate, fresa)
O O O O O O O O O O O O

Soda regular (bebida

gaseosa regular)
O O O O O O O O O O O O
Soda de dieta/Bebidas
endulzadas
O O O O O O O O O O O O
artificialmente (Crystal
Lightb)
Te dulce O O O O O O O O O O O O
Te con/sin edulcorante
artificial (sin crema o O O O O O O O O O O O O
azucar)
Bebidas deportivas
(Gatorade,c Powerade,d O O O O O O O O O O O O
etc)
Otro (indique cual):
O O O O O O O O O O O O

Figure 2. The Beverage Intake Questionnaire for Preschoolers Spanish version. Scoring procedures are available from
corre- sponding author upon request. aSunny Delight Beverages Co. bKraft Foods. cPepsiCo. dThe Coca-Cola Company.

7 to 8 fl oz, 9 to 10 fl oz, and 11 to 12 fl oz or more. To amount consumed (“How much each time”) to provide
score the BEVQ-PS, frequency (“How often”) was converted average daily beverage consumption in fluid ounces.
to the unit of times per day and then multiplied by the
 Energy and grams per fluid ounce were estimated for
each beverage using NDSR. Total energy and grams
were deter- mined by multiplying the number of fluid
ounces per day by the energy and grams per fluid ounce
of each beverage cate- gory. Total SSB consumption was
quantified by summing
beverage categories containing added sugars (eg, sweetened children’s intake. At session 2, mothers in Sequence 1 were
juice drinks, sweetened carbonated drinks, flavored milk, provided with an FIR log sheet and reminded of instructions.
sweet tea, and sport drinks). Total beverages consumption Sequence
was quantified by summing all beverages. The newly 2 mothers provided information for the BEVQ-PS1 and
modified tool was pilot-tested in an interviewer-
administered format in Spanish with a sample (n 5) of
¼
mothers of preschool-aged children recruited from day-care
centers. Minor modifica- tions were made (questionnaire
formatting, including commercial beverage names [eg,
Kool-Aid and Capri-Sun
{both from Kraft Foods}] within a category). Mothers
indicated that the BEVQ-PS was easy to understand.
However, mothers preferred to have interviewers read the
questions to them. Pilot testing of the BEVQ-PS took 3 to 5
minutes, on average.

Procedures
The comparative validity and testeretest reliability of the
BEVQ-PS was then evaluated. Consistent with national di-
etary data collection procedures, 34 mothers reported their
preschool-aged children’s food and beverage intake. Until
approximately age 8 years, parents and caregivers should
serve as proxy respondents for children under their care. 35
Mothers met with the interviewer three times within a 2-
week period to reduce the likelihood of changes in children’s
intakes due to factors such as season-related changes or
beverage preferences, and to follow methodology similar to
that used in validation of the BEVQ-15. At the screening and
enrollment session, mothers provided consent, completed a
demographic questionnaire, and were trained in how to
complete the FIR. Then, mothers were randomly assigned
to complete one of two previously used test session se-
quences19; Sequence 1: session 1 (BEVQ-PS1), session 2 (4-
day FIR), session 3 (BEVQ-PS2), or Sequence 2: session 1
(4-day FIR), session 2 (BEVQ-PS1), session 3 (BEVQ-PS2).
There were 5 to 6 days between each session, and 6 to 9
days
between testingeretesting of the BEVQ-PS. Interviewers
met
with teachers to explain the study and obtain consent. In-
terviewers requested day-care center menus to check for
accuracy in maternal reporting of foods or beverages
consumed at day care. In cases where discrepancies arose
between the types of foods or beverages the mothers re-
ported in the FIR and those on the menu, interviewers
checked variations with the day-care center’s head cook.
Mothers were instructed to ask teachers about the types and
amounts of foods and beverages that her child consumed
while at the day-care center and to record the information on
the FIR log sheet. Per day-care center policy, mothers were
advised to be the only recorders of the children’s dietary
intake at the screening and enrollment sessions. Food records
were kept either from Saturday through Tuesday or Thursday
through Sunday, to capture weekend and weekday intake.
Randomization forms were used to assign participants to one
of the two sequences. The forms were generated using sta-
tistical software to make sequence assignments in randomly
chosen blocks of size 2 and 4, to ensure that the number of
subjects in each sequence group remained balanced.
At session 1, sequence 1 mothers provided information for
BEVQ-PS1. Mothers in sequence 2 received an FIR log sheet
and instructions on the date to start recording their
returned their child’s FIR log sheet. At session 3, 11.5 kcal (whole milk).
Sequence 1 mothers provided information for the BEVQ-
PS2 and returned the child’s FIR log sheets. Sequence 2
mothers provided information for the BEVQ-PS2.
All mothers received paper food models to assist with
portion sizes. Interviewers checked returned FIRs for
accuracy in food or beverage description and serving
sizes. Mothers in the pilot study preferred that the
interviewer administered the questionnaire. Thus, this
procedure was followed to collect and to minimize
missing data: tumblers (5 oz, 8 oz, and 12 oz), visuals (ie,
a study-developed beverage catalog), measuring cups, and
three-dimensional food models were used by in-
terviewers to facilitate estimation of serving sizes and,
when appropriate, description of the food or beverage in
the FIR. FIR data were analyzed using NDSR. Research
assistants were available by telephone 7 days a week to
respond to partici- pants’ study-related questions.
Mothers received a $25 gift card. Teachers received a $10
gift card.

Statistical Analysis
Descriptive statistics (frequencies and mean standard error T
of the mean) were computed for demographic variables,
BEVQ-PS1, BEVQ-PS2, and FIR responses (grams and
energy). Validity was assessed by comparing grams and
energy intake for each beverage category in the BEVQ-PS1
with those from the mean of the four FIRs using Pearson’s
correlation coeffi- cient and paired t test. Criteria for validity
were nonsignifi- cant mean differences in grams and
kilocalories between the BEVQ-PS1 and mean of the FIR
beverage categories, and
significant correlation coefficients between beverage cate-
gories. Testeretest reliability was assessed by comparing
grams and energy intake for each BEVQ-PS1 beverage
cate- gory with those from the BEVQ-PS2 using Pearson’s
correla- tion coefficient. The criterion for reliability was a
significant
correlation coefficient between beverage categories.
Analyses were performed using SAS version 9.3.36

RESULTS
Of 112 mothers enrolled, 109 completed all study visits (97%
completion). Mothers’ mean age was 32.7 8.6 years; chil- T
dren’s mean age was 4.4 1.3 years (51% boys). Eighty-three T
percent of mothers were from Mexico, 61% spoke only
Spanish, or Spanish better than English, in the home, and
71% had completed high school or less. Finally, 39% received
Special Supplemental Nutrition Program for Women,
Infants, and Children assistance.
Validity and reliability results are presented in the
Table. Water, juice drinks, whole milk, sweetened
carbonated drinks, and total SSB intake met validity
criteria for nonsig- nificant mean differences between the
BEVQ-PS1 and the FIR. Grams and energy values of these
beverages between the two measures were significantly
correlated (P<0.05). Reduced-fat milk, fat-free milk,
flavored milk, diet carbonated drink, tea with or without
artificial sweetener, and sport drinks had nonsignificant
mean differences between the measures in grams and/or
energy, but were not significantly correlated. Fruit juice
and total beverages had significant grams and energy
mean differences, but were not significantly corre- lated.
Differences in beverage energy content for beverages that
met validity criteria ranged from 2 kcal (juice drinks) to
 Table. Validity and testeretest reliability of the Beverage Intake Questionnaire for Preschoolers (BEVQ-PS): Comparison with a
4-day food intake record (FIR), and results of two BEVQ-PS administrations (BEVQ-PS1 and BEVQ-PS2)a

Validity TesteRetest Reliability

Difference with Difference with
Beverage BEVQ-PS1 FIR BEVQ-PS1b rc BEVQ-PS2 BEVQ-PS1b rc

meanTstandard error of the mean ! meanTstandard error of the mean!

——
Water (g) 384.0T17.0 342.0T23.0 42.4T23.1 0.37*** 383.0T19.0 1.0T21.0 0.35***
Fruit juice ——
Grams 227.0T15.0 141.0T8.0 86.5T16.6*** 0.11 234.0T17.0 e7.9T17.0
0.45*** Kilocalories 115.0T8.0 72.0T4.0 42.8T8.3*** 0.08
118.0T8.0 e4.0T8.0 0.45***
Juice drink
Grams 71.0T11.0 72.0T8.0 e1.6T11.0 0.37*** 69.0T9.0 0.6T12.0
0.32*** Kilocalories 32.0T5.0 30.0T3.0 2.0T4.9
0.35*** 31.0T4.0 0.3T5.0 0.32***
Whole milk
Grams 27.0T10.0 9.0T5.0 18.3T9.9 0.22* 5.5T2.0 16.0T8.0
0.20* Kilocalories 17.0T60.0 6.0T3.0 11.5T6.2 0.22*
3.4T1.0 10.0T5.0 0.20*
Reduced-fat milk
Grams 215.0T18.0 180.0T14.0 32.9T21.4 0.16 219.0T16.0 e3.0T15.0
0.64*** Kilocalories 106.0T90.0 90.0T7.0 14.8T10.6 0.16
108.0T8.0 e2.0T7.0 0.64***
Low-fat/fat-free milk
Grams 2 03.0T14.0 167.0T12.0 34.2T17.7 0.18 205.0T14.0 1.0T11.0 0.68***
Kilocalories 87.0T6.0 70.0T5.0 15.8T7.5 0.18 87.0T6.0 0.5T5.0 0.68***
Flavored milk
Grams 16.0T6.0 13.0T3.0 3.2T6.3 0.16 15.0T4.0 e0.2T6.0 0.13
Kilocalories 12.0T4.0 9.0T2.0 2.9T4.8 0.16 12.0T3.0 e0.2T5.0 0.13
Sweetened carbonated
drink
Grams 36.0T6.0 47.0T6.0 e13.0T7.9 0.26** 34.0T4.0 1.0T5.0 0.52***
Kilocalories 15.0T2.0 18.0T2.0 e4.6T3.1 0.26** 14.0T2.0 1.0T2.0 0.52***
Diet carbonated drink
Grams 11.0T6.0 14.0T7.0 e3.1T9.4 0.02 18.0T11.0 e7.0T11.0 0.24**
Kilocalories 0.2T0.1 0.1T0.1 0.2T0.1 e0.03 0.4T0.2 e0.2T0.2 0.24**
Sweet tea
Grams 7.0T3.0 3.0T1.0 3.5T3.1* 0.12 2.0T1.0 1.0T3.0 0.38***
Kilocalories 2.0T1.0 0.5T0.3 1.6T1.0 0.12 5.0T3.0 0.5T1.0 0.38***
Tea with or
without artificial
sweetener
Grams 1.0T1.0 2.0T1.0 e0.0T0.0 e0.02 0.5T0.5 0.6T1.0 e0.01
Kilocalories 0.0T0.0 0.0T0.0 e43.0T1.5 e0.02 0.0T0.0 0.0T0.0 e0.01
Sport drink
Grams 17.0T4.0 11.0T4.0 6.2T5.6 0.03 20.5T5.0 e3.0T4.0 0.68***
Kilocalories 4.0T11.0 3.0T1.0 1.5T1.5 0.04 5.0T1.0 e0.9T1.0 0.68***
(continued on next page)
 Table. Validity and testeretest reliability of the Beverage Intake Questionnaire for Preschoolers (BEVQ-PS): Comparison with
a 4-day food intake record (FIR), and results of two BEVQ-PS administrations (BEVQ-PS1 and BEVQ-PS2)a
(continued)

Validity TesteRetest Reliability

Difference with Difference with

Beverage
BEVQ-PS1 FIR BEVQ-PS1b rc BEVQ-PS2 BEVQ-PS1b rc
Total sugar-
sweetened
beverages
Grams 146.0T16.0 145.0T11.0 1.4T8.9 0.20* 144.0T12.0 0.0T15.0 0.40***
Kilocalories 65.0T8.0 61.0T5.0 e7.1T17.6 0.13* 62.0T5.0 2.0T8.0 0.30***
Total beverages
Grams 1,222.0T40.0 999.0T29.0 233.0T48.0*** 0.09 1,234.0T37.0 e18.0T34.0 0.62***
Kilocalories 395.0T17.0 299.0T9.0 94.0T18.6*** 0.14 390.0T14.0 2.0T12.0 0.69***
a
Paired-samples t tests were used to compare the paired differences of BEVQ-PS1 to FIR for validity and to compare the paired differences of BEVQ-PS1 to BEVQ-PS2 for testeretest
reliability. Pearson correlations among these measures were also computed and tested for significance.
b
By use of a paired sample t test.
c
Pearson’s correlation coefficient.
*P<0.05.
**P<0.01.
***P<0.001.

Although there were nonsignificant mean differences in

The tool demonstrated testeretest reliability for all
beverage categories, total beverages, and SSB ¼ (r 0.20 to
0.68; P<0.05), except flavored milk and teas with/without
artificial sweetener. Whole milk, diet carbonated drinks,
juice drinks, water, fruit juice and sweet tea had significant
reliability coefficients in the range of 0.20 to 0.45. Reduced-
fat milk, fat- free milk, sweetened carbonated drinks, and
sport drinks had significant reliability coefficients in the
range of 0.52 to 0.68.

DISCUSSION
This study examined the validity and reliability of a short
beverage intake questionnaire for children aged 3 to 5 years
in a sample of Hispanic children. The BEVQ-PS is a valid
tool for assessing intake of sweetened juice drinks,
sweetened carbonated drinks, whole milk, water, and total
SSB. Reli- ability was demonstrated for all beverages except
for flavored milk and teas. Assessment of child consumption
of SSB has been a topic of interest due to reported negative
health im- plications of SSB consumption.5,6 Although short
dietary tools exist to assess intake of foods or nutrients in
adults, few have been developed for children. 37 Further,
short dietary assess- ment instruments tested in low-
income minorities are lacking.

Main Results and Instrument Performance

Validity correlation coefficients for water, sweetened juice
drinks, whole milk, sweetened carbonated drinks, and total
SSBs in the present study ranged from 0.20 (total SSB) to
0.37 (water). Although validity correlation coefficients were
low, the differences in energy content of these beverages
between the BEVQ-PS and the FIR means were small (<11.5
kcal). This finding seems to indicate that the BEVQ-PS was
able to capture current intake for these beverage categories.
intake of reduced-fat milk, fat-free milk, flavored milk,
diet carbonated drinks, tea with or without artificial
sweetener, and sport drinks between the BEVQ-PS1 and
the mean of the four FIR, grams and energy intake of the
two measures were not significantly correlated. One
possible explanation for the observed poor validity
performance of these beverage cate- gories is that children
may not have regularly consumed the beverages, and did
not consume them during the period for which the FIR
was completed. This is a recognized limitation when
attempting to validate an FFQ using a reference method
that covers a limited period. 38 Another possible
explanation for meeting one but not both of the validity
criteria for intake of reduced-fat milk, fat-free milk,
flavored milk, diet carbonated drinks, tea with or without
artificial sweetener, and sport drinks could be due to that
the BEVQ-PS and the FIR measure different aspects of the
children’s diets (during the past month vs every day).
Compared with the FIR, the BEVQ-PS revealed higher
mean intake in four out of six of these beverage
categories. It has been reported that participants tend to
overestimate their actual intake when recalling the
frequency and usual amount of consumption of foods
from a list of several items in FFQ validation studies.12,13,39
Testeretest reliability correlation coefficients ranged from
0.20 (whole milk) to 0.68 (fat-free milk). The low
reliability of some beverage categories (eg, whole milk and
diet carbon- ated drinks) may be due to lower frequency
of consumption. Mean beverage intake in the BEVQ-PS is
a function of fre- quency of consumption and amount
consumed. Beverage categories that were infrequently
consumed could have been more difficult to recall than
those that were consumed more regularly, such as fat-free
milk or reduced-fat milk. Other validation studies have
reported similar patterns. 40,41 Although semistructured
interviews in the development of the BEVQ-PS did not
reveal ethnic beverages consumed by
preschool-aged children, and the questionnaire had an
open- ended line for participants to report other beverages
not included in the list, no cultural beverages were reported
during testing of the BEVQ-PS. Thus, cultural
appropriateness of the questionnaire may not have been an
issue.
It is important to discuss sample characteristics that may
have affected findings, and potential modifications and
testing of the BEVQ-PS that may increase its validity and
reliability. In our study, most reporting mothers had low
education, and two-thirds were low acculturated (per the
proxy language spoken at home). These characteristics may
have challenged our results, because validity results seem to
be affected by participants’ level of education.42 Difficulty
with responding to an FFQ may be influenced by level of
acculturation.43 Furthermore, systematic person-specific bias
(ie, personal characteristics like body weight, social or cul-
tural desirability, acculturation level, or literacy level) is
posited to influence the distribution of intake values, with a
larger variance and reduced correlations with true intake. 44,45
The larger the systematic error, the less valid the measure, 12,45
thus affecting the correlations of beverage cat- egories between
the BEVQ-PS and the FIR. In addition, sys- tematic intake-
related bias (mothers under- or overreporting, as indicated
earlier) may also influence the correlation with true intake
and, depending of the direction of the bias, may make the
correlations with true intake stronger or weaker.44,45 Potential
modifications include collapsing beverage categories that met
one but not both of the validity criteria and that may have been
difficult for mothers to differentiate between when recalling
beverages that their children consumed (eg, reduced-fat and
fat-free milk); removing beverage categories that may not be
usually consumed by children and were thus not valid or
reliable (eg, sweet tea), or their validity correlation coefficients
were negatively correlated (eg, diet carbonated drinks and tea
with/without artificial sweeteners); and changing the
wording of the BEVQ-PS instructions to simplify directions
for potential self-administration. Further, the addition of
different descriptions that may be more familiar to certain
cultural groups (ie, orange juice is known as China juice in
Puerto Rico) to the beverage categories may assist in
improving validity of the BEVQ-PS among Hispanic groups.
After BEVQ-PS content is modified, the use of emerging
mobile telephone-based technology (ie, apps) to collect
children’s dietary data while in day-care centers may be
worth exploring to assess feasibility and reduce reporters’
burdens. Findings from this work provided important infor-
mation for further modification and testing of the BEVQ-PS to
possibly improve its performance.
Comparisons with Other Studies
Compared with validity correlation coefficients for water,
milk, sweetened juice drinks, and sweetened carbonated
drinks reported for a beverage frequency questionnaire vali-
dated in children aged 6 months to 5 years of mostly white,
highly educated parents,21 the correlation coefficients for
similar beverages validated in the BEVQ-PS were lower. For
example, correlation coefficients for children aged 3 to 5
years old from Marshall and colleagues 21 and the BEVQ-PS
were, respectively, 0.70 vs 0.37 for water, 0.63 to 0.70 vs
0.22 for whole milk, 0.54 to 0.64 vs 0.37 for sweetened juice
drinks, and 0.56 to 0.59 vs 0.26 for sweetened carbonated
drinks. In a sample of 3-year-old Swedish children, the vali-
dation of a mobile-telephone-based tool to assess energy
and food intake against a web-based FFQ revealed that
although the correlation coefficient between the tools was
significant for fruit juice (0.42), it was not significant for
sweetened beverages (0.15).22 In our study, the BEVQ-PS
validated
¼ total SSBs (r 0.20), but not fruit juice (r 0.11).
Findings of an FFQ validated in a small sample of low-
income mostly Hispanic children aged 1 to 3 years indicated
a significant correlation coefficient between the FFQ and the
criterion diet records (0.69) for SSBs.46
In the present study, the lowest reliability coefficients
ranged from 0.20 to 0.45 for whole milk, diet carbonated
drinks, juice drinks, water, and fruit juice. A significant
reli- ability testeretest coefficient of 0.74 for SSB was
reported for a multiethnic sample of children aged 1 to 3
years in which Hispanics were the majority.46 Others
have reported a sig- nificant testeretest ¼ reliably value of
r 0.55 for sweetened beverages in Australian children
aged 4 to 16 years old.24 A study with a sample of mostly
white children with a mean age of 12.7 years reported
testeretest reliability values for fruit juice and SSBs
consumed in and out of school.25 For beverages
consumed at school, reliability coefficients were
0.65 fruit juice, 0.74 fruit drinks, 0.69 sport drinks, 0.80
diet carbonated drinks, and 0.73 regular soda. 25 Few studies
report testeretest reliability findings for beverage types in
children, and none to date has reported results for Hispanic
preschool-aged children alone.
Similar to studies with larger samples of children of the
same age,47,48 the BEVQ-PS identified sweetened juice drinks
and sweetened carbonated drinks as the highest
contributors to total SSB energy intake. However, the
proportions were different. Per the BEVQ-PS, sweetened
juice drinks and sweetened carbonated drinks represented
49% and 23% of total SSB intake, respectively, in our
Hispanic sample of preschool-aged children. In contrast,
in a large sample of primarily Hispanic children aged 2 to
4 years, fruit drinks and soda contributed approximately
¼
82% (1 serving 12 oz,
0.8 servings/day, and 14 kcal/oz) and 18% (1 serving¼ 12 oz,
0.2 servings/day, and 12.4 kcal/oz) of total SSB energy
intake.47 Further, healthy-weight Hispanic children aged 2 to
5-years participating in the National Health and Nutrition
Examination Survey 2007-2010 had an intake of 128.2 T7.9
kcal SSBs,48 about twice the energy intake from total SSBs for
children in our study.
The study had limitations. Data collection occurred during
a 2-week period. Although participants may remember their
responses when a short interval (ie, a few weeks) between
assessments occurs,13 reproducibility and validity assess-
ments with minority groups face challenges that may affect
participants’ responses. Other researchers found that a 3-
week period for data collection with low-income Hispanic
and African-American adolescents yielded low validity and
modest reliability. Literacy level may have contributed. 49
Although the modification of the BEVQ-PS accounted for
mothers’ input here, sweet tea, tea with or without artificial
sweetener, and diet carbonated drinks were consumed least.
Thus, true intake of these beverages by the study sample is
limited. Participant recruitment occurred only at day-care
centers to increase the likelihood of participant retention.
Children who participate in other types of child care
(eg, mother or family care, nanny or sitter, or family child- 4.
care homes) might have different beverage intakes.
Strengths include the culturally focused methodology, a
brief questionnaire, interviewer-administered methodology
to minimize missing data, pictorial aids and food models to
facilitate recall, and the use of the FIR as the gold standard
for validation due to a reduced likelihood of correlated
errors.13 The BEVQ-PS validated children’s top sources of
SSBs, consistent with previously reported data from
national samples. 8,9,32
In this initial development of the BEVQ-PS, only
Hispanic children were included. Testing a new tool in a
culturally homogenous group with similar socioeconomic
character- istics may be advantageous to obtain information
on factors that may influence responses (ie, interviewer-
administered vs self-administered, literacy, beverage items,
and instruc- tion wording). 50 The list of items in the BEVQ-
PS did not include culturally relevant beverages that may be
consumed by Hispanic children, and the open-ended
question in the BEVQ-PS did not reveal additional bever-
ages. Further, the beverages in the BEVQ-PS are commonly
consumed by preschool-aged children from other racial and
ethnic groups. 32 Thus, future development of the tool may
include testing with diverse samples of children. Future
work should also account for a shorter list of beverage
categories, testing the validity of the instrument with a
larger sample, administration of the BEVQ-PS in settings
other than day-care centers, and whether formatting and
clarification of directions may improve understanding and
reporting.

CONCLUSIONS
The BEVQ-PS demonstrated validity for assessing
sweetened juice drinks, sweetened carbonated drinks, water,
whole milk, and total SSB intake in Hispanic children aged
3 to 5 years. The questionnaire may be useful for rapid
assessment of preschoolers’ habitual intake of sweetened
beverages, water, and whole milk to identify groups at risk
for health problems, and areas for improvement in beverage
intake quality. Additional revisions to the instrument, such
as collapsing certain beverage categories that may be chal-
lenging to differentiate (eg, reduced-fat milk and fat-free
milk), or removing categories that may not contribute to
regular beverage intake in the study population (eg, diet
carbonated drinks, sweet tea, and tea with/without artificial
sweeteners) should be evaluated. Although evaluation of
questionnaires in multiethnic groups is becoming more
actively reported in the literature, more research is needed
to increase our understanding of the performance of dietary
assessment methods in minority cultural groups in the
United States.

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39.

AUTHOR INFORMATION
K. R. Lora is an adjunct professor, Department of Nutritional Sciences, and M. P. Anderson is an assistant professor, Department of
Biostatistics and Epidemiology, University of Oklahoma Health Sciences Center, Oklahoma City. B Davy is a professor and V. Hedrick is an
assistant professor, Department of Human Nutrition, Foods, and Exercise, Virginia Polytechnic Institute and State University,
Blacksburg. A. M. Ferris is a professor emerita and D. Wakefield is a research associate, Center for Public Health and Health Policy,
University of Connecticut Health, Farmington.
Address correspondence to: Karina R. Lora, PhD, Department of Nutritional Sciences, University of Oklahoma Health Sciences Center,
PO Box 26901, Oklahoma City, OK 73126-0901. E-mail: lora@uchc.edu
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
This study was supported by a College of Allied Health, University of Oklahoma Health Sciences Center Faculty Seed Grant. The study
sponsor did not have a role in the study design, collection and analysis of data, interpretation of findings, or manuscript writing.