AMERICAN JOURNAL OF EPIDEMIOLOGY VOL 122, No.

1
Copyright © 1985 by The Johns Hopkins University School of Hygiene and Public Health Printed in U.SA.
All rights reserved

REPRODUCIBILITY AND VALIDITY OF A SEMIQUANTITATIVE

FOOD FREQUENCY QUESTIONNAIRE

WALTER C. WILLETT, u LAURA SAMPSON,1 MEIR J. STAMPFER,U BERNARD ROSNER,1

CHRISTOPHER BAIN,' JELIA WITSCHI,1 CHARLES H. HENNEKENS,1 AND
FRANK E. SPEIZER1

Willett, W. C. (Charming Laboratory, Harvard Medical School, Boston, MA

02115), L Sampson, M. J. Stampfer, B. Rosner, C. Bain, J. WHschi, C. H. Henne-
kens, and F. E. Speizer. Reproducibilrty and validity of a semiquantitative food
frequency questionnaire. Am J Epidemiol 1985; 122:51-65.
The aim of this study was to evaluate the reproducibilrty and validity of a 61-
item semiquantitative food frequency questionnaire used in a large prospective
study among women. This form was administered twice to 173 participants at an
interval of approximately one year (1980-1981), and four one-week diet records
for each subject were collected during that period. Intradass correlation coeffi-
cients for nutrient intakes estimated by the one-week diet records (range = 0.41
for total vitamin A without supplements to 0.79 for vitamin B, with supplements)
were similar to those computed from the questionnaire (range = 0.49 for total
vitamin A without supplements to 0.71 for sucrose), indicating that these methods
were generally comparable with respect to reproducibilrty. With the exception of
sucrose and total carbohydrate, nutrient intakes from the diet records tended to
correlate more strongly with those computed from the questionnaire after adjust-
ment for total caloric intake. Correlation coefficients between the mean calorie-
adjusted intakes from the four one-week diet records and those from the ques-
tionnaire completed after the diet records ranged from 0.36 for vitamin A without
supplements to 0.75 for vitamin C with supplements. Overall, 48% of subjects in
the lowest quintile of calorie-adjusted intake computed from the diet records
were also in the lowest questionnaire quintile, and 74% were in the lowest one
of two questionnaire quintiles. Similarly, 49% of those in the highest diet record
quintile were also in the highest questionnaire quintile, and 77% were in the
highest one or two questionnaire quintiles. These data indicate that a simple serf-
administered dietary questionnaire can provide useful information about individ-
ual nutrient intakes over a one-year period.

diet; epidemiologic methods; food; nutrition; nutrition surveys; questionnaires

Increasing recognition of the potential for methods to measure individual dietary

importance of diet in the etiology of cancer intake that are sufficiently simple to be
and heart disease has highlighted the need used in large epidemiologic studies and

Received for publication July 18, 1984, and in final
form November 13, 1984.
1
The Charming Laboratory, Department of Medi-
cine, Harvard Medical School and Brigham and Worn-
en's Hospital, Boston, MA.
1
Departments of Epidemiology and Nutrition, Har-
vard School of Public Health, Boston, MA.
3
Department of Social and Preventive Medicine,
University of Queensland, Australia.
Reprint requests to Dr. Walter C. Willett, Chan-
ning Laboratory, 180 Longwood Avenue, Bos-
ton, MA 02115.
This work was supported by Research Grants
HL24074, CA16686, CA23645, and CA26560 from the
National Institutes of Health. Dr. WUIett is the recip-
ient of a Research Career Development Award (HL
01018) from the National Heart, Lung, and Blood
Institute.
The authors thank the registered nurses who partic-
ipated in the study, and the American Nurses' As-

51
52 WILLETT ET AL.
whose reproducibility and accuracy have
been quantified (1). Epidemiologists ad-
dressing the effects of diet have generally
used questionnaires that inquire about the
usual frequency that specified foods are
eaten, and that sometimes also attempt to
quantify usual portion sizes. This approach
is attractive because the data are simple to
collect and process and in theory represent
intake over an extended period, which is
the usual temporal frame of interest for
chronic diseases. The reproducibility of re-
sponses to food items in these question-
naires (2-4) and the similarity of data from
subjects with data obtained from their
spouses (5, 6) provide support for their
utility, although the value of data obtained
from spouses has recently been questioned
(7). A number of investigators have at-
tempted to validate food frequency ques-
tionnaires by comparing data derived from
them with those obtained by more detailed
methods of dietary assessment. Most of
these studies have been small, and they
have yielded variable results (8-14), with
correlation coefficients between dietary
methods in these studies ranging from es-
sentially zero (12) to very high (0.69-0.94)
(8).
We developed a semiquantitative food
frequency questionnaire that was com-
pleted in 1980 by more than 95,000 mem-
bers of a large cohort of female registered
nurses being followed for the occurrence of
cancer and coronary heart disease (15, 16).
To assess the validity of our method, we
wanted to compare nutrient intake scores
obtained from this simple form with those
from a more detailed and quantitative es-
timate of dietary intake over an extended
period. We chose diet records (17) as our
comparison method since their use does not
depend on memory and since this is prob-
ably the most accurate and feasible method
sociation, Mildred Schmidt, and Thelma M. Schorr
for providing assistance. Drs. Jonathan Samet and
Frank Sacks provided helpful comments. Charlotte
Petro and Martin VanDenburgh performed the com-
puter analysis and Rosa Bova helped with the manu-
script.
to measure food intake, especially when
quantities are primarily based on weighed
portions. Since the day-to-day variation of
intakes of many nutrients is substantial
(18, 19), we collected four one-week diet
records at approximately three-month in-
tervals for each person. The administration
of the questionnaire both before and after
the period of diet record collection allowed
us to quantify the reproducibility of both
methods and the accuracy of the question-
naire compared with an extensive and de-
tailed assessment of dietary intake over one
year.
MATERIALS AND METHODS
The semiquantitative food frequency
questionnaire
We designed the semiquantitative food
frequency questionnaire with the objective
of categorizing individuals by intake of se-
lected nutrients hypothesized to effect the
occurrence of cancer and heart disease: pro-
tein, animal fat, vegetable fat, saturated
fatty acids, oleic acid, linoleic acid, choles-
terol, total carbohydrate, sucrose, dietary
and crude fiber, carotene, preformed vi-
tamin A, vitamins B6, C, and E, and me-
thionine. In consultation with an experi-
enced dietitian (J. W.), we prepared an
extensive list of foods that contain appre-
ciable amounts of these nutrients and that
were thought to be commonly used. Some
foods, such as cruciferous vegetables, were
included because of specific previously re-
ported associations with cancer (20). The
list of foods was reduced to 99 by eliminat-
ing some items found to be infrequently
used in small scale pilot testing. For each
food item, we specified a portion size using
natural units whenever possible (e.g., slice
of bread; 8-ounce (227 ml) glass of milk)
and otherwise chose portions commonly
used (21) or based on our experience. Sub-
jects were asked to indicate how often, on
the average, they consumed the specified
amount of each food during the past year.
There were nine possible responses, rang-
ing from never to six or more times per day,
 SEMIQUANTITATTVE FOOD FREQUENCY QUESTIONNAIRE
designed to limit the range within each
frequency category to a factor of two or
less. Additional items not presented in the
frequency format included the types of fat
used for frying and for cooking, the type of
margarine used, the amounts of bran and
sugar added to food, the usual brand and
type of cold breakfast cereal, the frequency
and brand of multiple vitamin supple-
ments, and the dose, frequency, and dura-
tion of vitamin A, C, and E supplementa-
tion. Additional description of this ques-
tionnaire and its capacity to predict plasma
carotenoid and vitamin E have been pub-
lished elsewhere (22, 23).
To accommodate the final questionnaire,
a further reduction in items was required.
Therefore, we mailed the questionnaire
with 99 food items to a random sample of
2,000 Nurses' Health Study participants
residing in states other than Massachusetts
and used responses of the 1,742 women (87
per cent) who returned the forms to identify
the food items that were most predictive of
the nutrients of interest. For these analy-
ses, nutrient scores were computed by mul-
tiplying the relative frequency that each
food item was used (with once a day equal
to 1) by the nutrient content of the speci-
fied portion size, primarily using United
States Department of Agriculture food
composition sources (24) but supplemented
with other published data and information
from manufacturers when necessary (25-
27). Responses to questions on types of fat,
margarine, and brands of cereal and mul-
tiple vitamins were used to compute the
nutrient composition of these items and
home-baked or fried foods. Vitamin supple-
ments were included in the computations
unless otherwise indicated. Using total nu-
trient scores as dependent variables, we
employed stepwise multiple regression to
identify the foods most predictive of total
scores. We thus identified 61 foods that,
along with vitamin supplements, accounted
for most of the between-person variability
in the specified nutrients and included
these items in a comprehensive health
53
questionnaire that was sent to more than
120,000 Nurses' Health Study participants
in 1980.
Participants in the validation study
We randomly selected an age-stratified
sample of 225 women residing in the
Greater Boston area who answered the first
mailing of the 1980 Nurses' Health Study
questionnaire and invited them to partici-
pate in a validation study involving the
recording of dietary intake. Of these, 24 (11
per cent) declined to participate, five
women dropped out during the first week
of data collection, and two women withdrew
after completing two weeks of records. The
other 194 women (86 per cent of the origi-
nal sample) completed the recording of food
intake. In computing nutrient intake scores
from the questionnaire, we considered
items left blank as never used. For these
analyses, however, we excluded 21 women
with 10 or more blank food items on either
their 1980 questionnaire or a second semi-
quantitative food frequency questionnaire
administered at the end of the validation
study. (Application of this exclusion crite-
ria to the entire cohort resulted in the elim-
ination of only 4 per cent of those who
returned dietary questionnaires.) The re-
maining 173 women, with age uniformly
distributed between 34 and 59 years, are
the subjects of these analyses.
Collection of diet records
Two to four months after completing the
1980 questionnaire, participating women
were contacted by a research dietitian
(L. S.) and instructed at home to record all
food and beverages consumed for a one-
week period in a specially designed booklet.
Women were provided with a dietetic scale
for weighing food servings whenever possi-
ble. Alternative methods employing com-
mon household measures were taught for
use when away from home. Participants
were instructed to provide detailed descrip-
tions of each food, including brand and
method of preparation and recipes when-
ever possible. After completion, records
54 W1LLETT ET AL.
were reviewed by one dietitian (L. S.) who
telephoned participants to obtain any in-
formation that was incomplete. The partic-
ipants completed additional one-week rec-
ords at intervals of approximately three
months for a total of four weeks, represent-
ing a full year, after which they were given
$75 as a token in appreciation of their
efforts. Because participants were highly
motivated and professionally experienced
in quantitative measurements and provided
unusually detailed data, we believe that the
food records kept by these women were
exceptionally accurate and complete.
The diet records were initially coded by
several dietitians, but were all reviewed by
L. S. to minimize variability in interpreta-
tion. Nutrient intakes from diet records
were computed using the University of
Massachusetts data base system developed
by Dr. Kenneth Sammonds. In these anal-
yses, we computed the mean daily intake
for periods of one week as the primary unit
of measurement. Although the question-
naire was designed to measure other nutri-
ents in addition to those presented here,
analyses were limited to those nutrients
also computed by the University of Mas-
sachusetts data base.
In designing a study that compares a
simple questionnaire with a more detailed
method, the sequence of dietary assessment
is problematic since it is possible that the
completion of one method might affect the
performance of the other method. In this
case, the questionnaire asks about food in-
take during the previous year, so that re-
sponses should appropriately be compared
with diet record data collected during the
year before the questionnaire. We therefore
administered the questionnaire a second
time concurrent with the collection of a
fasting blood specimen at the completion
of either the third or fourth diet record
(figure 1).
Statistical analyses
We used Pearson product-moment, in-
traclass (28), and interclass (29) correlation
R«cord2
Questionnaire 1 Questionnaire 2
Jun*. 1980 June. 1931
FIGURE l. Time sequence of diet validation study
conducted among 173 Boston area female registered
nurees aged 34-59 years, 1980-1981.
coefficients to evaluate the reproducibility
of nutrient measurements and to compare
questionnaire with diet record values. The
interclass r was used to provide an estimate
of the correlation coefficient between the
questionnaire and a single one-week diet
record based on the association between
the questionnaire and four intercorrelated
one-week records. Since nutritional meas-
urements are usually utilized as categorical
variables in epidemiologic studies, we also
divided both questionnaire and diet record
nutrient scores into quintiles to examine
their joint classification.
Nutrient intake scores were adjusted for
total caloric intake by first computing re-
siduals from regression models, with total
caloric intake as the independent variable
and the nutrient intake score as the de-
pendent variable. The residuals were added
to the expected nutrient value for the mean
caloric intake to obtain a score adjusted to
the average caloric intake. In these analy-
ses, questionnaire intake scores were ad-
justed for the caloric intake from the same
form. We employed this method of adjust-
ment instead of the more traditional ap-
proach of simply dividing by caloric intake
since the regression approach adjusts for
caloric intake only to the extent that it is
correlated with intake of each specific nu-
trient. For total fat intake and other ma-
cronutrients, the two approaches yield sim-
ilar results. For micronutrients, which are
usually more weakly associated with total
caloric intake, however, dividing by caloric
intake creates a variable that is partly a
function of caloric intake and its associated
measurement error.
Since most nutrient intake scores were
skewed toward higher values, we used log,-
 SEMIQUANTITATIVE FOOD FREQUENCY QUESTIONNAIRE
transformed variables in our computations.
Pearson correlation coefficients obtained
with these values were similar to Spearman
nonparametric correlations; thus, only the
former are presented. Since the emphasis
in these analyses is on the quantification
of misclassification rather than hypothesis
testing, we have not presented p values for
individual correlation coefficients. With
173 subjects, the standard error for corre-
lation coefficients is 0.074, such that coef-
ficients greater than 0.15, which includes
nearly all those presented, are "statistically
significant."
RESULTS
Despite the fact that the goal of the ques-
tionnaire was to provide relative categorical
rankings of individuals by intake, the ab-
solute mean daily intakes estimated by our
questionnaire and by four one-week diet
records were roughly comparable, although
the distributions as estimated by the ques-
tionnaire were somewhat wider (table 1).
The reproducibility of unadjusted nutrient
intake scores measured by one-week diet
records at intervals of approximately three,
55
six, and nine months is shown in table 2.
There was little overall tendency for the
magnitude of coefficients to change over
this interval. Correlation coefficients were
lowest for total vitamin A without supple-
ments (intraclass r = 0.41) and highest for
vitamin B 6 with supplements (intraclass r
= 0.79). Intraclass correlation coefficients
between nutrient scores measured by two
questionnaires administered approximately
one year apart ranged from 0.49 for total
vitamin A without supplements to 0.71 for
sucrose and were generally similar to those
obtained by one-week diet records. No im-
portant changes in reproducibility were ob-
served when nutrient intakes were adjusted
for total caloric intake (data not shown).
We compared nutrient intake scores es-
timated by both semiquantitative food fre-
quency questionnaires with intakes esti-
mated by each one-week diet record (see
table 3 for calorie-adjusted values). The
coefficients between the first questionnaire
and individual one-week records exhibited
no major trends over the approximately
one-year period. Coefficients for the second
questionnaire, however, tended to increase

TABLE l
Mean absolute daily nutrient intakes estimated by four one-week diet records and by questionnaires (data
provided by 173 Boston area female registered nurses aged 34-59 years, 1980-1981)
Diet record Questionnaire 1 Questionnaire 2
Mean (SD)' Mean (SD) Mean (SD)
Protein (g) 68.4 (12.0) 78.2 (28.6) 71.6 (24.2)
Total fat (g) 68.6 (16.3) 57.6 (24.8) 56.1 (22.0)
Saturated fat (g) 24.9 (6.8) 22.8 (10.6) 21.9 (9.3)
Polyunsaturated fat (g) 11.1 (3.4) 7.1 (3.7) 7.5 (4.0)
Cholesterol (mg) 311 (83) 291 (130) 267 (99)
Total carbohydrate (g) 170 (46) 147 (63) 145 (66)
Sucrose (g) 46.9 (21.9) 45.4 (28.4) 45.4 (32.4)
Crude fiber (g) 3.27 (1.09) 4.07 (2.24) 3.53 (1.86)
Total vitamin A (IU)t 6,566 (4,039) 9,309 (5,478) 8,550 (4,226)
Without supplements 5,250 (1,920) 8,153 (4,984) 7,153 (3,450)
Vitamin B« (mg) 4.13 (18.1) 2.34 (1.35) 2.14 (1.21)
Without supplements 0.85 (0.28) 1.82 (0.69) 1.60 (0.61)
Vitamin C (mg) 187 (300) 192 (221) 199 (331)
Without supplements 106 (43) 130 (70) 112 (59)
Total calories (kcal) 1,620 (323) 1,418$ (496) 1,371* (482)
* SD, standard deviation.
t IU, international units.
± Does not include alcohol intake.
56 W1LLETT ET AL.

TABLE 2
ReproducibiUty of one-week diet records and the semiquantitative food frequency questionnaire, unadjusted for
caloric intake (data based on information provided by 173 female registered nurses aged 34—59 years and
residing in the Boston area, 1980-1981)
Correlation coefficients

Nutrient* Record Record Record Records Questionnaire 1 vs. ques-

1 vs. 2 lvs.3 1 VS. 4 1-4 tionnaire 2
(Pearson r) (Pearson r) (Pearson r) (Intraclass r) (Pearson r) 1[Intraclass r)
Protein 0.53 0.57 0.56 0.56 0.54 0.52
Total fat 0.49 0.54 0.57 0.54 0.57 0.57
Saturated fat 0.54 0.56 0.57 0.56 0.55 0.55
Polyunsaturated fat 0.38 0.43 0.44 0.45 0.64 0.64
Cholesterol 0.51 0.56 0.54 0.53 0.64 0.63
Total carbohydrate 0.72 0.70 0.74 0.72 0.70 0.70
Sucrose 0.73 0.67 0.60 0.66 0.71 0.71
Crude fiber 0.64 0.58 0.65 0.65 0.67 0.64
Total vitamin A 0.56 0.53 0.47 0.56 0.57 0.58
Without supplements 0.38 0.35 0.34 0.41 0.52 0.49
Vitamin B« 0.68 0.69 0.68 0.79 0.60 0.60
Without supplements 0.61 0.58 0.60 0.60 0.57 0.52
Vitamin C 0.65 0.79 0.67 0.70 0.59 0.58
Without supplements 0.68 0.68 0.63 0.68 0.62 0.59
Total calories 0.60 0.63 0.67 0.63 0.63 0.63
' Nutrient values were transformed using log, to improve normality.

from the first record through the third rec-
ord, but decreased with the fourth record
(which for approximately one half of the
participants was collected after the second
questionnaire). Correlation coefficients
were consistently lower between the diet
records and the first questionnaire than the
second questionnaire, which inquired di-
rectly about the period covered by the diet
records.
The correlation coefficients between the
questionnaire nutrient scores and the nu-
trient means from the four one-week diet
records (table 4) were consistently higher
with the second questionnaire. For macro-
nutrients except sucrose and total carbo-
hydrate, adjustment for total caloric intake
increased the correlation coefficients with
the questionnaire. In the case of vitamin
intakes, which are minimally correlated
with caloric intake, adjustment for the lat-
ter made little difference in the magnitude
of the coefficients.
We separately compared the question-
naire and a single one-week diet record with
a third assessment of dietary intake to de-
termine their relative ability to categorize
individuals with respect to usual nutrient
intake. We utilized the mean of the first
three one-week diet records as the third
assessment for comparison with both the
second questionnaire and the fourth one-
week diet record (table 5), using calorie-
adjusted values. With the exception of cho-
lesterol intake, the first three one-week diet
record intakes were more strongly corre-
lated with the fourth one-week diet record
intake values than with the questionnaire
scores. The differences between methods
were generally small, however, except in
the case of total carbohydrate and fiber
intakes, for which the one-week diet record
performed appreciably better.
To evaluate the degree of misclassifica-
tion associated with categorized intakes as-
sessed by our simple dietary method, we
examined the joint classification of nutri-
ent intakes derived from questionnaire in-
take scores and means from four one-week
diet records. Using cholesterol as an ex-
ample, 18 of the 34 women (53 per cent) in
the lowest quintile according to the diet
records were also in the lowest quintile
according to the second questionnaire, and
 TABLE 3
Comparison of semiquantitative food frequency questionnaire nutrient scores with those from one-week diet records, adjusted for total caloric intake (data
based on information provided by 173 female registered nurses aged 34-59 years and residing in the Boston area, 1980-1981)

MIQ
Questionnaire 1 vs. Questionnaire 2 vs.
Nutrient* Record 1 Record 2 Record 3 Record* Records 1-4 Record 1 Record 2 Record 3 Record 4 Records 1-4
(Pearson r) (Pearson r) (Pearson r) (Pearson r) (Interclass r) (Pearson r) (Pearson r) (Pearson r) (Pearson r) (Interclass r) |
Protein 0.28 0.33 0.36 0.26 0.30 0.45 0.42 0.40 0.37 0.41t
Total fat 0.40 0.41 0.39 0.32 0.33 0.36 0.46 0.45 0.39 0.35
Saturated fat 0.32 0.42 0.46 0.35 0.35 0.41 0.47 0.53 0.46 0.44 5
Polyunsaturated fat 0.39 0.34 0.26 0.34 0.31 0.31 0.39 0.40 0.40 0.35 3
Cholesterol 0.53 0.48 0.46 0.43 0.46 0.47 0.46 0.50 0.49 0.48 o
Total carbohydrate 0.33 0.39 0.46 0.44 0.39 0.31 0.41 0.43 0.44 0.37 o
Sucrose 0.27 0.40 0.41 0.39 0.37 0.46 0.51 0.54 0.41 0.46t g
Crude fiber 0.40 0.41 0.46 0.45 0.45 0.45 0.47 0.49 0.52 0.49
Total vitamin A 0.47 0.28 0.33 0.26 0.34 0.40 0.38 0.40 0.36 0.39
Without supplements 0.27 0.23 0.22 0.09 0.21 0.23 0.28 0.27 0.22 0.25
sa
•<
Vitamin B« 0.53 0.40 0.40 0.42 0.39 0.47 0.54 0.60 0.53 0.46
Without supplements 0.30 0.44 0.34 0.31 0.35 0.41 0.46 0.41 0.44 0.44t
Vitamin C 0.59 0.46 0.52 0.47 0.51 0.68 0.58 0.77 0.67 0.67t s
K

MOIJ
Without supplements 0.44 0.46 0.44 0.50 0.46 0.49 0.60 0.60 0.60 0.58

INAIf
Mean 0.39 0.39 0.39 0.36 0.37 0.42 0.46 0.49 0.45 0.44
* Nutrient values were transformed using log, to improve normality.
t p < 0.05 for comparison of interclass r for questionnaire 1 versus records 1-4 with interclass r for questionnaire 2 versus records 1-4. Computed
from interclass correlation of (questionnaire 2 - questionnaire 1) versus diet records 1-4 (41).
58 WILLETT ET AL.

TABLE 4
Pearson correlation coefficients for comparison of semiquantitative food frequency questionnaire scores with the
means of four one-week diet records, both unadjusted and adjusted for total caloric intake (data based on
information provided by 173 female registered nurses aged 34-59 years and residing in the Boston area,
1980-1981)
Quo
Questionnaire 1 vs. mean* of Questionnaire 2 vs. means of
Nutrient* 4 records 4 records

Unadjusted Adjustedt Unadjusted Adjustedt

Protein 0.18 0.37 0.33 0.47

Total fat 0.27 0.48 0.39 0.53
Saturated fat 0.31 0.49 0.44 0.59
Polyunsaturated fat 0.31 0.42 0.40 0.48
Cholesterol 0.46 0.61 0.52 0.61
Total carbohydrate 0.48 0.44 0.53 0.45
Sucrose 0.52 0.41 0.60$ 0.54$
Crude fiber 0.43 0.51 0.46 0.58
Total vitamin A 0.37 0.43 0.41 0.49
Without supplements 0.21 0.28 0.26 0.36
Vitamin B, 0.44 0.47 0.54$ 0.58$
Without supplements 0.32 0.43 0.43$ 0.54$
Vitamin C 0.53 0.56 0.73$ 0.75$
Without supplements 0.46 0.52 0.63$ 0.66
* Nutrient Intakes transformed using log. to improve normality.
t Intakes adjusted using the residuals from regression models with caloric intake as the independent variable
and nutrient intakes as the dependent variables.
$ p < 0.05 for comparison of Pearson r for questionnaire 2 versus means of four records with Pearson r for
questionnaire 1 versus means of four records (41).

26 (76 per cent) were in the lowest two
quintiles according to the questionnaire
(table 6). Likewise, of those 34 women in
the highest diet record quintile of calorie-
adjusted cholesterol, 17 (50 per cent) were
in the highest corresponding questionnaire
quintile, and 23 (68 per cent) were in the
highest two questionnaire quintiles. Simi-
lar relationships were observed for other
nutrients (summarized in table 7); overall,
74 per cent of those in the lowest diet record
quintiles were in the lowest one or two
semiquantitative food frequency question-
naire quintiles, and 77 per cent of women
in the highest diet record quintiles were in
the highest one or two questionnaire quin-
tiles. On the average, only 3 per cent were
misclassified into extreme quintiles.
Although epidemiologic studies have typ-
ically addressed differences in risk of dis-
ease by relative categories of nutrient in-
take, a quantitative description of the re-
lationships between nutrient intake and
disease would be more desirable. To de-
scribe the distributions of nutrient intakes
in our study population, we first examined
the means for each quintile of diet record
intake (mean of four one-week records) us-
ing both absolute and calorie-adjusted in-
takes (see table 8). The degree of variation
between subjects differed appreciably ac-
cording to specific nutrient. For example,
the mean calorie-adjusted intakes of
women in the highest quintiles for protein
and total fat are, respectively, 48 per cent
and 39 per cent higher than in the lowest
quintiles; the corresponding percentages
are 242 and 603 for vitamins A and C.
Furthermore, the variation in macronu-
trient intake decreased substantially after
adjusting for total caloric intake. To quan-
tify the actual nutrient intakes defined by
categories of our questionnaire, we com-
puted mean nutrient intakes from the four
one-week diet records for the persons in
each quintile defined by questionnaire in-
take scores (see table 8). Because of mis-
classification associated with the simple
 SEMIQUANTITATIVE FOOD FREQUENCY QUESTIONNAIRE 59
TABLE 5 modest, being 23 per cent and 16 per cent
Comparison of the second semiquantitative food of the values for the lowest quintiles, while
frequency questionnaire and diet record 4 nutrient for micronutrient intakes these differences
scores with mean nutrient scores from diet records 1-
3 (data based on information provided by 173 female were approximately twofold.
registered nurses aged 34-59 years and residing in the
Boston area, 1980-1981) DISCUSSION
Pearson correlation coeffi-
cients for calorie-adjusted in-
We evaluated the performance of a sim-
Nutrient* takes ple questionnaire by comparing nutrient
Questionnaire 2 1 Record 4 vs. scores obtained from this instrument with
vs. records 1-3 records 1-3 those derived from four one-week diet rec-
Protein 0.48 0.66t ords kept over a one-year period. Nutrient
Total fat 0.52 0.64 intakes assessed by the two methods were
Saturated fat 0.58 0.64 generally more strongly correlated when
Polyunsaturated fat 0.46 0.60t
Cholesterol 0.58 0.56
adjusted for total caloric intake, and diet
Total carbohydrate 0.42 0.76t record intakes were more strongly associ-
Sucrose 0.56 0.63 ated with the questionnaire completed at
Crude fiber 0.56 0.78t the end of the year than with the question-
Total vitamin A 0.49 0.63t naire completed before the diet record data
Without supplements 0.36 0.49
Vitamin B, 0.59 0.80t
collection. The diet records were also used
Without supplements 0.51 0.62t to provide independent quantification of
Vitamin C 0.76 0.75 nutrient intakes defined by categories of
Without supplements 0.64 0.72 the questionnaire.
* Nutrients transformed using log. to improve nor- In the validation of nutritional assess-
mality. ment methods, the reference measurement
t p < 0.05 for comparison of Pearson r for record 4 should be as accurate and as precise as
versus records 1-3 with Pearson r for questionnaire 2
versus records 1-3 (41).
possible, and any errors associated with the
two methods should be independent. In this
TABLE 6 study, we employed the diet record method
Joint classification of calorie-adjusted cholesterol as a reference because it is minimally de-
intake assessed by the second semiquantitative food pendent on memory and allows direct
frequency questionnaire and four one-week diet measurement of food quantities, in this
records (data based on information provided by 173
registered nurses aged 34-59 years and residing in the case primarily by using a dietetic scale. At
Boston area, 1980-1981) all stages, we attempted to obtain maximal
details of the foods consumed, including
Questionnaire Diet record quintile
Total brands and details of recipes. The nurses'
quintile l(low) 2 3 4 5 (high)
training and experience in record keeping
1 (low) 18 9 2 3 2 34 are likely to have substantially enhanced
2 8 11 8 4 4 35 the quality of the data. We thus believe
3 4 7 9 9 5 34
4 2 8 9 11 6 36
that it would be difficult to further improve
5 (high) 2 0 7 8 17 34 the accuracy of the diet record information.
A major limitation of this method for eval-
Total 34 35 35 35 34 173 uating the usual nutrient intakes of sub-
jects is that one week cannot fully represent
questionnaire and the resulting regression the usual intake of subjects. Therefore, we
toward the mean, these differences between employed four one-week data collection pe-
quintiles are less than for quintiles defined riods spaced to account for seasonal as well
by the diet records themselves. The con- as short-term variability. The use of four
trasts between extreme quintiles of calorie- rather than a single one-week record clearly
adjusted protein and total fat intakes are strengthened correlations with the ques-
60 WILLETT ET AL.

TABLE 7
Comparisons of semiquantitative food frequency questionnaire scores with mean daily intakes derived from four
one-week diet records, based on joint classification by quintiles (both intake scores adjusted for total caloric
intake; data provided by 173 Boston area registered nurses aged 34-59 years, 1980-1981)*
Lowest quintile on diet record Highest quintile on diet record
Lowest Lowest 2 Highest Highest Highest 2 Lowest
quintile on quintiles on quintile on quintile on quintiles on quintile on
questionnaire questionnaire questionnaire questionnaire questionnaire questionnaire

Protein 44 68 0 47 71 9
Total fat 53 71 3 33 70 3
Saturated fat 47 88 3 47 82 0
Polyunsaturated fat 47 71 9 41 79 3
Cholesterol 53 76 6 50 68 6
Total carbohydrate 47 71 9 46 71 0
Sucrose 38 62 9 50 82 0
Crude fiber 41 69 3 41 79 3
Vitamin A 44 68 3 44 79 3
Vitamin B« 47 88 0 74 88 3
Vitamin C 68 85 0 62 79 0

Mean 48 74 4 49 77 3
* Intakes adjusted using the residuals from regression models with caloric intake a« the independent variable
and nutrient intakes as the dependent variables.

tionnaire (compare tables 3 and 4). It is not
likely, however, that the use of more than
four weeks would appreciably increase the
observed associations since the increase
from two to four records yielded only a
small increment in correlation coefficients
(data not shown). Similarly, since long-
term studies may provide an opportunity
for repeated questionnaire assessments, we
examined the correlations between nutri-
ent intakes calculated as the means of the
two questionnaires and the means of four
one-week records. These correlation coef-
ficients, however, did not differ appreciably
from those between the second question-
naire and the diet record means (data not
shown).
Nonindependent errors in the measure-
ment of nutrient intakes by the two meth-
ods would tend to create falsely elevated
correlations, while errors in the estimation
of intake by diet record that were inde-
pendent of questionnaire scores would tend
to underestimate the effectiveness of the
questionnaire. Nonindependent errors in
recording food intakes could occur, for ex-
ample, if a participant consistently under-
estimated intakes of or misnamed certain
foods in both methods. Since the two meth-
ods were quite different, we believe that
this source of common error is minimal. In
the calculation of nutrients, however, both
methods ultimately depend on a common
body of food composition data that assumes
a constant nutrient concentration. While
this assumption is probably not seriously
violated for most nutrients we examined, it
is of potential concern for some less stable
water-soluble vitamins, such as vitamin C.
For example, a subject may consume orange
juice frequently, thus having a high vitamin
C intake as assessed by both methods, but
she may not refrigerate the juice properly,
causing a loss of vitamin C activity, so that
the true intake would actually be less than
the assigned value. The result of this type
of error would be that an estimate of valid-
ity based on the comparison of the two
dietary methods would overstate the true
validity.
The sequential administration of several
dietary assessment methods to the same
individual raises concern that completion
of one method may influence responses to
 SEMIQUANTITATIVE FOOD FREQUENCY QUESTIONNAIRE
the other. Although it is possible that the
process of measuring and recording food
intake could itself influence dietary habits,
it is implausible that completing the initial
questionnaire, a 10- to 15-minute section
embedded in a general medical question-
naire, could have appreciably affected the
consumption and recording of food during
the subsequent year. Since this question-
naire asked about food intake during the
year prior to the diet record collection, cor-
relation coefficients between this question-
naire and the diet records almost certainly
underestimate the true correlation for the
year actually measured. They may, how-
ever, provide a realistic estimate of the
association between the questionnaire and
intake over a multiyear time span. It is
conceivable that the completion of diet rec-
ords could have sensitized participants with
respect to their food consumption so that
they may have completed the second ques-
tionnaire more accurately than the first,
thus creating artificially strong correlation
coefficients between methods. Although we
have no way to assess this directly, we
believe that this effect is not large, since
the limitations of the questionnaire largely
relate to the simplification of dietary intake
into a modest number of multiple choice
questions rather than to subject recognition
and recall of food. Moreover, subjects did
not in general complete the second ques-
tionnaires more carefully; indeed, it was
necessary to eliminate 18 second question-
naires because of incomplete responses
compared with nine initial questionnaires.
Although we have presented data both
for crude and calorie-adjusted nutrient in-
takes, we believe that the adjusted intakes
are generally more useful for biologic,
methodological, and public health reasons.
Although a precise measure of caloric in-
take is of interest, its meaning with respect
to disease causation will generally be ob-
scure since caloric intake is a combined
function of body size, physical activity, and
(possibly) intrinsic individual metabolic ef-
ficiency, e.g., thermogenesis. Our interest
61
with respect to disease causation would
usually be in caloric intake independent of
these three factors. Since physical activity
and metabolic efficiency cannot be meas-
ured accurately by questionnaire, associa-
tions between caloric intake and disease
will, at best, be difficult to interpret. On
the other hand, changes in weight or a
combination of weight and height provide
easily obtainable and sensitive measures of
caloric balance. For these reasons, estima-
tion of caloric intake was not a primary
objective of our questionnaire.
We suspect that some individuals tend
to generally under- or overestimate their
food intake such that nutrient intakes may
be better estimated as a proportion rather
than as an absolute amount. This may be
one reason why correlation coefficients be-
tween diet record and questionnaire intakes
tend to be higher for calorie-adjusted in-
takes than for absolute intakes. Finally,
calorie-adjusted intakes are likely to be
more appropriate with respect to public
health policy since it is difficult for free-
living individuals to make major, long-term
adjustments in their caloric intake, as evi-
denced by the limited success of weight loss
programs that employ food restriction
alone (30). On the other hand, it may be
easier to change the proportions of nutri-
ents that contribute to total intake.
The week-to-week variation we observed
using diet records unadjusted for caloric
intake was greatest for vitamin A without
supplements and polyunsaturated fat (in-
traclass correlation coefficients = 0.41 and
0.45) and least for vitamin B6 with supple-
ments and total carbohydrate (intraclass
correlation coefficients = 0.79 and 0.72).
These values are somewhat lower than cor-
relation coefficients between two seven-day
records observed among male British bank
clerks (31, 32), which ranged from 0.64 for
animal fat to 0.81 for total caloric intake,
and probably reflect a greater true variation
in the diets of contemporary American
women than of British bank workers 25
years ago who were chosen because of their
 62 WILLETT ET AL.

TABLE 8
Mean unadjusted and calorie-adjusted daily nutrient intakes derived from four one-week diet records for
quintiles of intake defined by the diet records and by quintiles defined by semiquantitatwe food frequency
questionnaire scores (data based on information provided by 173 female registered nurses aged 34-59 years and
residing in the Boston area, 1980-1981)
Total
Protein Total fat Saturated fat Polyunsaturated Cholesterol
carbohydrate
(g) fat (g) (mg)
Quintile
Diet Question- Diet Question- Diet Question- Diet Question- Diet Question- Diet Question-
record naire record naire record naire record naire record naire record naire

Unadjusted
1 53 63 47 58 16 20 7 9 204 252 106 131
2 61 64 59 64 21 24 9 10 262 275 147 153
3 67 66 68 68 24 23 11 10 325 292 168 164
4 74 73 75 67 27 26 13 12 345 320 188 174
5 86 71 93 79 35 28 16 13 436 380 235 202
Adjustedt
1 56 61 56 61 19 21 7 9 216 248 133 146
2 62 65 64 64 22 22 9 10 268 281 152 162
3 67 67 69 67 24 25 11 11 301 304 166 166
4 72 69 72 70 26 26 12 12 337 313 177 168
5 83 75 78 71 30 27 14 12 423 374 200 179

"settled" diets. Our correlation coefficients
are closer to those observed by Keys (33)
among men in seven European countries
who completed two seven-day diet records
at unspecified time intervals (range = 0.39-
0.73 for protein intake as a per cent of
calories).
Although several investigators have ex-
amined the reproducibility of reported fre-
quencies for individual foods (2-4, 34), few
have examined the reproducibility of nutri-
ent scores computed from simple frequency
questionnaires. Hankin et al. (35) reported
that a "seven-day recall," which inquired
about the frequency of use of 41 foods dur-
ing the previous week, was reasonably re-
producible among a group of Japanese-Ha-
waiian women when repeated after three
months. Among healthy Caucasian women,
however, the correlation coefficients be-
tween these "recalls" were 0.18 for animal
protein, 0.29 for cholesterol, 0.40 for satu-
rated fat, and 0.49 for total fat. As they
suggested, a one-week period is probably an
inappropriately short interval of reference
for a food frequency questionnaire.
Although a dietary method must be rea-
sonably reproducible to be useful, reproduc-
ibility does not directly imply validity,
which must be evaluated using an inde-
pendent detailed dietary method. Balogh
(8) found impressively high agreement be-
tween nutrient intakes from a food fre-
quency interview and a one-week diet rec-
ord in a pilot study conducted among 14
Israeli men (r ranged from 0.69 for poly-
unsaturated fat to 0.94 for total fat intake).
When this method was used among a group
of 90 Israeli men and women, however, the
correlations were more modest, ranging
from 0.22 for linoleic acid to 0.71 for oleic
acid (14). Browe et al. (13) compared nu-
trient intakes computed from a brief food
frequency interview with a detailed diet
history interview conducted among a group
of 29 men. Correlation coefficients compar-
ing the two methods were high, ranging
from 0.69 for total caloric intake to 0.79 for
cholesterol intake, but probably overstate
validity since the two methods have com-
mon features and interviews were con-
ducted only several weeks apart. Using a
similar approach, Jain et al. (11) compared
nutrient intakes of 50 women computed
from a 69-item food frequency question-
naire with those obtained from a detailed
 SEMIQUANTITATIVE FOOD FREQUENCY QUESTIONNAIRE 63

TABLE 8—Continued

Sucrose Crude fiber Vitamin A Vitamin B, Vitamin C

(g> (g) (IU)* (mg) (mg)

Diet Question- Diet Question- Diet Question- Diet Question- Diet Question-
record naire record nflire record naire record naire record naire

22 30 1.9 2.5 3,205 4,684 0.6 0.9 58 69

34 35 2.6 2.7 4,525 5,083 0.8 1.0 94 117
43 45 3.1 2.9 5,684 6,370 1.1 1.3 118 161
54 47 3.7 3.6 7,306 7,356 1.5 11.1 169 218
79 60 4.8 4.0 11,638 8,826 17.3 6.5 554 435

26 32 2.0 2.5 3,216 4,259 0.6 0.8 58 67

36 39 2.6 2.7 4,491 4,761 0.8 0.8 93 112
43 42 3.1 3.1 5,636 5,795 1.0 1.3 116 124
51 50 3.7 3.5 7,120 7,099 1.5 1.5 166 163
64 51 4.8 4.0 11,037 7,593 6.2 3.8 421 289
* IU, international units.
t Adjusted to the geometric mean intake of 1,587 kcal per day.

dietary history. They observed correlation
coefficients comparable to those found in
our study, ranging from 0.47 for cholesterol
intake to 0.72 for vegetable protein intake.
In another study, these same investigators
(10) compared intakes computed from de-
tailed diet histories obtained from 16 men
with 30-day diet records kept by their
spouses; correlations ranged from 0.24 to
0.61 (average 0.44) for the nutrients that
were examined (10). Gray et al. (36) re-
ported low correlations between a total vi-
tamin A index (r = 0.16) and a vitamin C
index (r = 0.36) computed from a food
frequency questionnaire when compared
with intakes estimated from a detailed in-
terview. These authors pointed out that
these weak associations may have resulted
from the very broad response categories
used in their food frequency questionnaire.
In an extensive evaluation of a dietary
method used in an epidemiologic study,
Morgan et al. (9) compared the nutrient
intake scores of 400 Canadian women ob-
tained from a structured interview with
those computed from four-day diet records
and obtained correlation coefficients that
ranged from 0.34 to 0.42. Although we
found consistently higher agreement be-
tween our questionnaire and a detailed di-
etary assessment than was found in the
Canadian study, this does not necessarily
imply that their method of dietary assess-
ment was inferior. It is possible that the
true variation in the Canadian study pop-
ulation was less than in ours, which would
tend to decrease the strength of observed
correlations. Moreover, it is likely that only
four days of diet record keeping provided a
poor estimate of individual long-term nu-
trient intake in their study since we found
that the use of four weeks rather than a
single week of intake consistently increased
the agreement between methods.
Short-term dietary methods (e.g., 24-
hour recalls) that have been employed in
most large surveys (37) do not provide use-
ful information on the distribution of indi-
vidual nutrient intakes since much of the
apparent variation actually represents
within-person variability (19, 38). Thus,
our extensive dietary data on individuals
collected over a one-year period provide an
unusual opportunity to observe a close ap-
64 WILLETT ET AL.
proximation to the true distribution of in-
dividual intake. It is apparent that the var-
iation in intake of the major components
of the diet (protein, fat, and carbohydrate)
is modest once total caloric intake is ac-
counted for, with the increase in means
from the bottom to top quintiles being 50
per cent or less. This represents the maxi-
mal possible contrast when quintiles are
used as categories in studies of dietary in-
take. The use of any questionnaire with an
accuracy less than that of four one-week
records will further attenuate the measur-
able contrasts. For example, the quintiles
defined by the semiquantitative food fre-
quency questionnaire represent only a 17
per cent increase in total fat intake as
measured by diet records from the bottom
to the top quintiles. Thus, it may be useful
to examine more extreme categories of in-
take. For example, the lowest questionnaire
decile of calorie-adjusted total fat intake
measured by the diet record was 58.4 g per
day, representing 33 per cent of caloric
intake in contrast to 40 per cent from fat
in the highest quintile. This will approach
a reasonable test of the National Research
Council's recent recommendation for re-
duction in total fat intake to 30 per cent of
calories (39), but the effect of appreciably
lower levels of fat intake will need to be
evaluated in other populations, since the
lower quintile defined by diet recoj-ds still
consumed an average of 32 per cent of
calories derived from fat. Similarly, the cal-
orie-adjusted diet record cholesterol intake
ranged from 248 mg per day in the lowest
quintile defined by the questionnaire to 374
mg per day in the highest questionnaire
quintile, while the contrast between ex-
treme deciles was from 231 mg to 406 mg
per day. With a sufficiently large study
population, these categories provide the ca-
pacity to evaluate quantitatively the effect
on coronary heart disease of implementing
the American Heart Association's recom-
mendation for cholesterol intake (40).
Our study population was selected to be
reasonably representative of the registered
nurse participants in an ongoing, national
investigation of causes of cancer and heart
disease. Although practical considerations
necessitated limiting the study to members
in the Boston area, there is no reason to
believe that the questionnaire would be any
less valid among participants in other
states; the pilot study used to construct the
questionnaire purposely excluded Massa-
chusetts women to avoid developing and
testing the method in the same population.
If anything, the variation of nutrients na-
tionwide should be greater than that among
the Boston area women participating in
this validation study. Thus, our findings
may underestimate the ability of the ques-
tionnaire to categorize individuals in the
full study. Although we believe that the
questionnaire method is sufficiently simple
that its performance would be similar in
most groups of American women, it would
be desirable to modify and revalidate the
method for use among more diverse popu-
lations.
The questionnaire used in this study was
able to reasonably categorize individuals by
nutrient intake, but this specific form was
constrained to a maximum length of two
pages. It is certainly possible to improve
the questionnaire. In particular, additional
analyses of the diet record data obtained in
this study can be employed to define further
the specific foods that contribute nutrients
of interest and to quantify the distributions
of portion sizes of these foods.
In summary, we have found that a simple
and inexpensive self-administered dietary
questionnaire can usefully measure individ-
ual intakes for a variety of nutrients. Com-
parison of nutrient intake scores computed
from this simple method with absolute in-
takes obtained from extensive diet record
collections among the same individuals can
provide a basis for quantifying relation-
ships between nutrient intakes and disease
in large-scale applications of the question-
naire.
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