Journal of Epidemiology Vol.8.No.

4 Oct

Self-Administered Diet History Questionnaire Developed for Health Education: A

Relative Validation of The Test-Version by Comparison with 3-Day Diet Record in
Women

Satoshi Sasaki 1, Ryoko Yanagibori 2, and Keiko Amano 3

A self-administered diet history questionnaire has been developed for the use in health
education in Japan. The relative validity of the test-version was examined using 3-day diet record
(DR) as a reference method. Subjects were mildly hypercholesterolemic 47 women aged 38-69
years living in Hikone, Japan. The questionnaire provided close estimation of nutrients compared
to the DR (mean of the 3-days), 1-25 % differences between the two methods were observed for
total energy and 17 nutrients examined. The differences were in general smaller for
macronutrients, 1-3 %, than for micronutrients, 1-25 %. Pearson correlation coefficients between
the questionnaire and the DR (mean of the 3-days) ranged from 0.16 for niacin to 0 .60 for
saturated fatty acid (mean = 0.41). The energy-adjustment using regression analysis and the
correction of attenuation due to error from a limited number of days of DR slightly improved the
results. The correlations ranged from 0.19 for niacin to 0.75 for saturated fatty acid (mean = 0.48).
Average 37 and 6 % subjects were classified into same quartile and opposite quartile
respectively between the two methods. This questionnaire may be useful to assess individual
nutrient intake level at least for the subjects examined. J Epidemiol, 1998 ; 8 : 203-215 .

diet, nutrition, validity, assessment

Diet modificationis one of the key factors for the prevention
of cardiovascular disease and cancer, and for the control of
their risk factors '). To assess habitual diets at an individual
level as much correctly as possible is important in health edu-
cation. Diet record (DR) and diet history methods have usually
been used for this purpose. But burden of both subjects and
dietitians is substantial 2).Subjects without enough motivation
tend to have difficulty to keep DR, for example for 3-days, cor-
rectly. The financial burden does not necessarily allow the pro-
if with reasonable ability to assess individual dietary habits 4).
Short and inexpensive dietary assessment methods were also
suggested to be as responsive as multiple-day diet records to
assess change in dietary interventions 5).
Several self-administered diet assessment methods have
been developed and validated in Western countries 6. 7.Those
developed in Japan are, however, scarce 8-12).Moreover, to our
knowledge, those for health education with a reasonable validi-

grams to allocate enough number of dietitians. Although DR
and diet recall methods are more preferable than diet history
method to assess a true intake of a limited number of days, a
long-term dietary habits can be assessed only by the latter
method 3).For health education programs, assessment of a
long-term dietary habits rather than of a true intake of a limited
number of days is required. Self-administered diet history
method was therefore considered more practical and preferable
ty does not yet exist in Japan. We, therefore, developed a self-
administered diet history questionnaire (DHQ) and its associat-
ed nutrient analysis program for the use in health education in
Japan. We validated the test-version with DR as a reference
method. Subjects who participated in a health education pro-
gram for mildly hypercholesterolemic persons were used for
this study.

Received June 15, 1997; accepted July 8, 1998.

Epidemiology and Biostatistics Division, National Cancer Center Research Institute , East, Kashiwa, Japan.
'Aichi Prefectural College of Nursing and Health
, Nagoya, Japan.
'Tokyo University of Fisheries
, Tokyo, Japan.
Address for correspondence : Satoshi Sasaki, Epidemiology and Biostatistics Division , National Cancer Center Research Institute,
East, 5-1, Kashiwanoha 6 cho-me, Kashiwa-city, Chiba 277-8577, Japan .

203
 204 S. Sasaki,
MATERIALS AND METHODS
Study design
Between May and June, 1995, 189 mildly hypercholes-
terolemic subjects, serum cholesterol = 220-259 mg/dL (5.69-
6.70 mmol/L) for women aged more than or equal to 55 years
and 200-239 mg/dL (5.17-6.18 mmol/L) for women aged less
than 55 years and men, were screened from the annual health
check-up service performed in Hikone, Japan, and enrolled to a
health education program organized by the city. The subjects
were considered to need a health education before pharmaceu-
tical treatment.
A self-administered diet history questionnaire has been
mailed with an inviting letter to the program in the beginning
of September, 1995. Ninety subjects agreed to participate in
the program. Public health nurses visited their home after mak-
ing appointment by telephone, and checked and collected the
questionnaire one to two weeks later. When participants could
not answer the questions correctly, the nurses asked the ques-
tions again with brief explanations and obtained the answers.
Seventy subjects completed the DHQ. At the moment, the sub-
jects were not informed that they would be asked to keep DR
later. About two weeks later, when the program has started in
the late of September, the participants took a 30 min lecture
using a written pamphlet on how to keep DR from one dietit-
ian. Fifty-five subjects kept the DR for three days. Among
them four were excluded because of the incompleteness of the
DR. In the remained fifty-one subjects, 47 and four were
women and men respectively. Only 47 women were included
in the analysis. Mean (standard deviation) age was 55.9 (9.9)
years old, and age-range was 38 - 69 years old. No subject was
a current smoker.
Three-day diet record
The subjects kept DR, either consecutively or non-consecu-
tively, for three weekdays. The three days were chosen by sub-
jects not to include a day with substantially abnormal eating.
The subjects were recommended to weigh all foods eaten. But
some did not have a scale at home. Foods eaten out of their
home were not weighed. They were advised to report volume
of foods eaten when the weight was not available and they did
so. One dietitian estimated weight of foods eaten described
with volume and other explanations by subjects. In this popula-
tion, most of foods were eaten at home and they were cooked
by themselves or their family members. A computer program
with the Japanese food composition tables, 4th edition 13,14),and
additional tables for fatty acid compositions 15)was used to ana-
lyze the diet records 16)
Self-administereddiet history questionnaire
A self-administered diet history questionnaire has been
developed for the use in health education. It consists of seven
et al.
sections; 1) eleven questions on dietary behaviors such as `how
often and how much do you usually use "Shoyu (soy-sauce)"
at table?' 2) semi-quantitative frequency questions on selected
110 food items, 3) questions on frequency and quantity on
core-foods on rice, 4) major cooking methods for vegetables,
fish, and meats, 5) frequency and quantity of alcohol beverage
("go"/drink), and major types of alcoholic beverages, 6) types,
frequency, and quantity of supplement, 7) open-ended ques-
tions to describe food names and the quantities eaten regularly
(at least once a week). The questions were designed to ask diet
in a previous month. For questions about rice, sizes of bowls
usually used were asked. For foods listed in the semi-quantita-
tive frequency questions, commonly consumed portion sizes
were explained in words such as `halffor apple and `one big
leaf for cabbage. The 110 food items and the portion sizes list-
ed in the semi-quantitative frequency question section were
chosen as foods consumed commonly in Japan. They were
selected mainly from a food list used in National Nutrition
Survey of Japan'). Foods with similar compositions were cate-
gorized into one food item. Some foods with different compo-
sitions listed as one food item in the food list of National
Nutrition Survey of Japan were divided into more than one
food items. For example, milk was divided into two types of
milk, i.e., regular fat milk and low fat milk. Local foods or
menus were not considered for the. food selection. This was
done for that the results of this validation study can indirectly
indicate validities when the DHQ was used to other popula-
tions in Japan. The food-names listed in the questionnaire and
the food-codes used for nutrient calculation are shown in
Appendix. The frequency was answered using a combination
of the two questions; 1) per day, week or month, and 2) once,
twice,three times, or more than or equal to four times. Relative
quantity was answered compared to the normal portion size
indicatedin a question; very small (50 % or less), small (about
70-80 %), medium (about same as the portion size), large (20-
30 % larger), or very large (50 % larger or more). In the sec-
tion of the open-ended questions, one dietitian estimated the
weight of foods reported when the sizes of the foods or of the
packages were described. When a missing or questionable
answer was detected after the collection of the DHQ, the pub-
lic health nurses checked and filled the answer by a telephone
interview.
Nutrient intake was calculated using an ad-hoc computer
program developed to analyze the questionnaire . As a data-
:)aseof food composition tables, the Japanese food composi-
:ion tables, 4th edition 13.14),and the other 15)were used .
sodium, sugar, and cooking oil added during cooking were
,stimated from the questions in the dietary behavior questions,
he major cooking methods of vegetables, fish , and meats, and
weightof foods obtained in the semi-quantitative food frequen-
;y questions. Salt from Miso-soup and the use of table salt
were added to the salt intake. Fat preference asked in the
 Validity of Diet History Questionnaire
dietary behavior questions were considered to choose food-
codes for meats. For some foods without compositions for
fatty acids and/or cholesterol, similar foods with the composi-
tions were substituted (Appendix). In this case, the composi-
tion of substituted fatty acids was adjusted for total fat.
Additional information was used for fatty acid compositions of
some foods 19.For foods, most of them are beverages, fruits or
vegetables, with total fat less than 1.0 % of total energy, fatty
acid compositionsremained missing when without the compo-
sitions. For cooked foods which are not listed in the food com-
position tables of Japanese foods 13, 14, the nutrient composi-
tions were calculated using the recipes prepared by one dietit-
ian. Foods listed in the open-ended questions were checked by
dietitians. They were erased, removed to the correct questions,
or remained in this section. After considering the contribution
to nutrientintake levels, all foods remained in the section were
not includedin the analysis.
Nutrients included in the study
We calculated intake levels of total energy, four macro- and
11 micro-nutrients from the both surveys, i.e., the DHQ and
the DR. Fat was furthermore divided into three subgroups, i.e.,
saturated fatty acid (SFA), monounsaturated fatty acid, and
polyunsaturated fatty acid. Eighty-nine and 72 % of the sub-
jects reported no alcohol intake in the 3-day DR and in the
DHQ respectively. Alcohol was therefore excluded from the
analysis. Nutrients from supplements were not included in the
analyses in this study.
Statistical methods
Firstly, we compared the subject means and standard devia-
tions between the DR and the DHQ. For the DR, the mean of
the 3-days was used as a representative value of each nutrient
for each subject. Both crude values and ones expressed as
energy density, except for total energy, were calculated. To
examine the difference between the means for each nutrient
between the DR and the DHQ, the mean differences of nutri-
ents between them with the 95 % confidence intervals by a
paired t-test were calculated. The relative differences with the
DR as a reference were also calculated.
Secondly, Pearson product-moment correlation coefficients
were used to compare the two dietary assessment methods. We
calculated also Spearman correlation coefficients. They were
not apparently different each other, therefore only the Pearson
correlationcoefficients are presented in this report. To examine
the correlation between nutrient intakes after removing covari-
ation due to total energy intake, we calculated energy-adjusted
nutrient intakes, which indicate the nutrient composition of the
diet by regressing nutrient intake on total energy 14.The distri-
butions of most nutrients were skewed towards high values.
Nutrients were transformed (loge) to improve normality for the
correlation analysis. The presence of day-to-day intra-individ-
205
ual variation tends to attenuate the correlation between the DR
and the DHQ 19).In order to correct this factor, we used the
within- and between-person components of variation in the DR
intake (treating each day as random unit of observation). We
thus obtained 'de-attenuated' correlation coefficient (see foot-
note of Table 3) to estimate the correlation between nutrient
intake calculated from a single question and multiple days of
diet recording.
The distributions of nutrients derived from the DR and from
the DHQ were divided into quartiles to examine how well indi-
viduals were classified into quartiles by means of the DHQ
compared with the DR. Classification error and overall agree-
ment. were examined here. Furthermore, we calculated the
mean intake of nutrients from the DR for groups of subjects
who were defined by quartile of intake of the same nutrient on
the DHQ. This validation can be used to fit models for true
nutrient intake (from the DR) as a function of measured intake
(from the DHQ) 20).The means between the lowest quartile and
the corresponding quartiles were compared with one-way
ANOVA (Dunnett's method). A significance level was put at
p<0.05. In the analysis for Pearson product-moment correla-
tion coefficients, most of all coefficients were statistically sig-
nificant. Moreover, since the purpose of the analysis was on
the quantification of misclassification rather than hypothesis
testing, we have not presented p-values in this analysis.
RESULTS
Average nutrient intakes
Table 2 shows means and standard deviations of energy and
17 nutrient intake levels. Slightly higher means were obtained
from the DHQ than from the DR in most nutrients examined.
The relative differences (%) of the mean intake levels obtained
from the DR and from the DHQ were 1 - 3 % for total energy
and macronutrients and 1 - 25 % for the micronutrients. For
calcium, phosphorus, cholesterol, and iron, the means obtained
from the DHQ were statisticallylower than those from the DR
(p<0.05 - 0.001 by paired t-test). In thiamin and riboflavin, the
means obtained from the DHQ were statistically higher than
Table 1. Characteristics of the subjects (n=47).
aRange =38-69
b 1 mg/dL = 0 .02586 mmol/L
206 S. Sasaki, et al.

Table 2. Mean (standard deviation in parenthesis) daily intake of total energy and 17 nutrients (excluding supplements) measured by
three-day diet records and a self-administered diet history questionnaire (data based on information provided by 47 women
 Validity of Diet History Questionnaire 207

those from the DR (p<0.05 - 0.01 by paired t-test). The relative
differences (%) between the means of the two assessment
methods were not substantially different between the analysis
with crude values and with energy density.
Validity
Table 3 shows Pearson correlation coefficients for unadjust-
ed and energy-adjusted daily nutrient intakes between the aver-
age intake measured by means obtained from the DR and cor-
responding values obtained from the DHQ. The comparisons
between unadjusted nutrient intake ranged from r = 0.16 for
niacin to r = 0.60 for SFA. After the energy-adjustment for
nutrient intake, the mean of correlation coefficients improved
from 0.41 to 0.46. For some nutrients, sodium in particular,the
degree of the correlation decreased by the energy adjustment.
Table 3 also contains the de-attenuated correlation coefficients
taking within- and between-person variations in the DR into
consideration. The correlation coefficients ranged from r =
0.19 for niacin to r = 0.75 for SFA (mean = 0.48).
Table 4 summarizes the cross classifications for nutrient
intake using quartiles by the two assessment methods. Taking
total energy as an example, 58 and 67 % of the subjects classi-
fied into the lowest quartile by the DR was classified into the
lowest quartile and the lowest two quartiles by the DHQ
respectively. Among the subjects classified into the highest
quartile by the DR, 42 and 75 % was classified into the highest

Table 3. Pearson correlation coefficients for comparison of self-administered diet history

questionnaire scores with the means of 3-day diet records both unadjusted and
adjusted for total energy (data based on information provided by 47 women aged
38-69 in Hikone. Japan. 1995).

a Nutrient values were transformed (loge) to improve normality .

n Intakes adjusted for total energy intake using regression analysis .
The de-attenuated correlation coefficient is calculated using the ratio of the within- to
between-person variance measured from the 3-day diet records. The formula for this
corrected correlation is calculated as re = to [1+(S2w/S2b)/n]1/2where to is the observed
correlation, S2w is the within-person variation, and S2b is the between-person variation
and n is the number of replicate measurements. For this calculation n = 3 representing
each day of the diet record.
De-attenuation only d
208 S. Sasaki, et al.

Table 4. Cross-classification (%) of total energy and 17 nutrient intakes between the mean of 3-day diet records and the self-
administered diet history questionnaire for energy-adjusted intake except for total energy (data based on information provided
by 47 women aged 38-69 in Hikone. Japan, 1995)a.

a All nutrient , except for total energy, intakes were adjusted for total energy intake using regression analysis.

quartile and the highest two quartiles by the DHQ respectively.
Thirty-four % of the subjects were classified into the same
quartile by the DR and by the DHQ. Two percent of them were
classified into the opposite quartile (the lowest versus the high-
est). More than or equal to 40 % of the subjects were classified
into same quartile for seven nutrients out of total energy and 17
nutrients examined.
Table 5 shows the mean intake of total energy and 17 nutri-
ents from the DR for groups of subjects who were defined by
quartile of intake of the same nutrient on the DHQ. In total
energy and 6 nutrients, mean intakes increased monotonically
across quartiles. When the means of the highest and of the low-
est quartiles were compared, in total energy and 13 nutrients a
statistical difference was observed (p<0.05 - 0.001 by
Dunnett's method).
DISCUSSION
Development of a dietary assessment questionnaire for
Oriental populations has scarcely been reported21).We exam-
ined a relative validity of a self-administered diet history ques-
tionnaire and its associated nutrient analysis program devel-
oped for Japanese population using a 3-day DR as reference.
The group means suggested a reasonable ability of the ques-
tionnaire to estimate population means of nutrient intakes. The
observed mean total energy intakes were 807 kJ/day for the
DHR and 861 kJ/day for the DR lower than those observed in
women of a similar age range, 50 - 59 years, in the National
Nutrition Survey, 1995 22) . The subjects in this study who were
health conscious might have underreported the foods eaten in
both survey methods. The correlations observed suggested a
moderate ability of the questionnaire to rank individuals along
the distribution of intake. The overall median correlations
observed in this study (median = 0.42 for crude values and
0.48 for energy adjusted and de-attenuated ones) were similar
to or slightly lower than those reported in previous studies. The
mean or median correlation coefficients of nutrients in previ-
ous studies, which used DR as a reference method, ranged
 Validity of Diet History Questionnaire 209

Table 5. Mean intake of total energy and 17 nutrients from 3-day diet records within quartiles of intake determined by the self-
administered diet history questionnaire (data based on information provided by 47 women aged 38-69 in Hikone, Japan,
1995)a.

a All nutrient , except for total energy, intakes were adjusted for total energy intake using regression analysis.
Significance level by Dunnett's method of one-way ANOVA between the group means of the lowest and a corresponding quaff
* p<0 .05, ** p<0.01, *** p<0.001.

between0.41 to 0.66 18,23-33).
To our knowledge, some self-administered dietary assess-
ment methods have been developed in Japan 8-12). Date et al.
developed semi-quantitative menu-based frequency question-
naire and reported a reasonable validity 8).They used voluntary
dietetic students for the study subjects. Kono et al. developed a
semi-quantitative food frequency questionnaire and failed to
obtain enough validity 9).Takatsuka et al. validated a simplified
diet history questionnaire and reported that the mean correla-
tion coefficients for 17 nutrients were 0.41 for crude values
and 0.37 after energy-adjustment 10).Some other studies report-
ed a reasonable validity for macronutrients and limited
micronutrients 11,12).On the other hand, Japanese showed high-
er degree of Pearson correlation coefficients of nutrient intakes
between diet history method and diet records among the five
major ethnic groups in Hawaii 34).The questionnaire used in the
study in Hawaii asked more number of foods and more dietary
behaviors in detail, and the structure was more complicated
than most questionnaires previously developed in Japan. The
structure of the questionnaire of the study is more complicated
and has more volume of questions compared to the question-
naires of previous studies in Japan 8-12). Although the results
were not satisfactory enough, they were thought to be compa-
rable to those of the self-administered diet assessment methods
developed in Western countries18,23-33).The questionnaire pro-
duced close group mean nutrient intake estimates compared to
the 3-day DR. The results were in agreement with previously
developed similar questionnaires in the United States 4,21).
When the correlations between the DR and the DHQ (Table
3) were compared between the nutrients, fat, especially SFA,
showed a relatively high degree of correlation. It was also rela-
tively higher than those reported in previous studies in Western
populations 18,23-33).
It may partly be because that fat-, especially
SFA-, rich foods were limited in Japanese diets compared to
Western diets. In contrast, the degree of the correlation on
sodium was low. It may partly be due to the quality of the pro-
gram for estimating seasoning use. An estimation of salt added
during cooking and at table is difficult by DR too 34).We exam-
ined validity of the DHQ on sodium and potassium with single
24-hour urinary excretions using 223 university students35).
Although a reasonable validity was observed on potassium, the
result on sodium was inconclusive because the duration of
210 S. Sasaki. et at.

Appendix. Food-names listed in the questionnaire and food-codes used for nutrient calculation.
 Validity of Diet History Questionnaire 211

Appendix. (Continued)
212 S. Sasaki, et al.

Appendix. (Continued)
 Validity of Diet History Questionnaire
Appendix. (Continued)
8 AL : alcoholic beverage section , C : calculated from the combination
"Label" indicates the composition was obtained from food label
.
"Recipe" indicates the composition was calculated from the recipe
.
"Ref" indicates the composition was obtained from the reference (15)
urine collection was too short.
The results on niacin, iron, vitamin A, and cholesterol were
less satisfactory compared to macronutrients. Longer days of
diet recording are necessary to assess individual habitual
intakes for these nutrients 36.37),
0. Therefore, the relatively lower
degree of the correlations between the DR and the DHQ on
these nutrients may be due to a shortcoming of the study
design and not to a quality of the DHQ. Three-day DR is not
long enough to estimate individual habitual diet also for other
nutrients36.37.38).
Seasonal variation in dietary habits exists in rural Japanese
population 39).The comparison with repeated records across
one year should be performed 26,29). We, however, asked to
answer dietary habit of the previous month in the DHQ. A pos-
sible seasonal variation of diet is presumably not a major prob-
lem of this study-design.
The 110 foods listed in the closed-ended semi-quantitative
frequency question section of the DHQ were mainly selected
from a food list used in the National Nutrition Survey of
Japan 17).The foods listed there were not substantially different
from the reported major foods actually eaten in rural Japanese
populations 40).But some local foods, for example a kind of
preserved fish, which were not listed in the Japanese food
composition table 13.14),was replaced by a similar food listed in
it for calculation of nutrients. It might be a bias. A data-based
approach is usually used for a selection of food-items for a
development of a dietary assessment questionnaire 41)with an
exception 18).Because the food items and their portion sizes
were not determined from data obtained from the population
examined, the observed validity of the DHQ may be somewhat
lower than a questionnaire developed by a data-based approach
213
of questions, F : food frequency section, M: main staple section.
.
for food-item selection and their portion-size determination.
Self-administered dietary assessment questionnaires do not
necessarily use picture- or model-aids to estimate portion size
except some 26,33,42).Some studies on portion size estimates in
food frequency questionnaire concluded that the value of the
aid was limited43,44,45).The questionnaire validated in the study
did not use any aid for estimation of portion size.
This questionnaire has been developed for the use in health
education. Both to estimate individual intakes of nutrients of
interest and to rank individual in the population for nutrients
are necessary. The results indicated that the questionnaire and
its associated nutrient analysis program may be useful to assess
individual habitual nutrient intake in health education at least
in the population examined. However, the small sample size,
the short days of diet recording, the incompleteness of food-
weighing, and the low response rate of the dietary recording
have limited the validity of the study. Validity of the DHQ to
other populations such as men and/or healthy subjects has also
remained to resolve. Further validation studies overcoming
these problems should therefore be performed. Improvement is
still required especially for some nutrients which are important
for the prevention of cardiovascular disease and cancer.
ACKNOWLEDGEMENTS
The authors are grateful to Yoshiko Imamura, Miwae
Deguchi, Kazuyo Iwamoto, and Yoshiko Okuda for the data-
collection and the data-processing, Tomiko Tsuji for her tech-
nical support for the development of the food composition
table, and to Shoichiro Tsugane and Akane Katagiri for techni-
cal comments.
214 S. Sasaki,
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