Assessing dietary intake in a population undergoing …...Dietary intake and development of a quantitative food-frequency questionnaire for the Barbados National Cancer Study Sangita

Dietary intake and development of a quantitative food-frequencyquestionnaire for the Barbados National Cancer Study

Sangita Sharma1,*, Xia Cao1, Rachel Harris2, Anselm JM Hennis2,3, M Cristina Leske3,Suh-Yuh Wu3and The Barbados National Cancer Study Group†1Cancer Etiology Program, Cancer Research Center of Hawaii, University of Hawaii, 1236 Lauhala Street, Honolulu,HI 96813, USA: 2Barbados National Cancer Study, Sir Winston Scott Polyclinic, Jemmott’s Lane, St Michael,Barbados: 3Department of Preventive Medicine, *Stony Brook University, Stony Brook, NY 11794, USA

Submitted 1 March 2006: Accepted 4 August 2006

Abstract

Objective: To develop a quantitative food-frequency questionnaire (QFFQ) for theBarbados National Cancer Study (BNCS) that will permit examination of associationsof diet with breast and prostate cancer.Design: Population intake data from the year 2000 Barbados Food Consumption andAnthropometric Surveys (BFCAS 2000) were used to derive a list of foods consumedby the population. A 192-item draft QFFQ was developed from this list.Setting: Barbados, West Indies provides an ideal environment to understand cancerrisk in African-origin populations, with high relevance to African-Americans. TheBNCS is a population-based case–control study examining risk factors for breast andprostate cancer in such populations.Subjects: A total of 1600 persons, 18 years and older, completed a 24-hour recall in theBFCAS 2000. Fifty of 63 randomly selected residents (79% response rate) gaveadditional updated information on foods consumed.Results: The 50 participants provided a one-time 24-hour recall and completed thedraft QFFQ. The final instrument contains 148 items: breads, cakes, cereals ¼ 17; rice,pastas, noodles ¼ 8; dairy ¼ 10; meat, fish, poultry ¼ 42; fruit ¼ 16; vegetables ¼ 26;soft drinks ¼ 14; alcoholic beverages ¼ 5; others ¼ 10. Additional questions includesupplement use and food preparation methods such as grilling.Conclusion: The final instrument is concise, complete and the most up-to-date forassessing the food and nutrient intake of African-origin Barbadians and theassociations with breast and prostate cancer.

KeywordsDietary assessment

Food and nutrient intakeBarbados National Cancer Study

Quantitative food-frequencyquestionnaire

African-origin populations

The Barbados National Cancer Study (BNCS) is a

population-based case–control study examining risk

factors for breast and prostate cancer in an African-origin

population. Although both cancers are particularly

important causes of morbidity and mortality in persons of

African descent1, the underlying reasons for these cancer

disparities are unknown. Barbados, West Indies, with a

population of .270 000 (.90% of African descent),

provides an ideal environment to understand cancer risk

in African-origin populations. African-Barbadians (AfBas)

and African-Americans share a common ancestry, but

AfBas remained fairly isolated with lesser subsequent

admixture2–4; they are therefore an appropriate reference

group for comparisons with African-Americans regarding

genetic and environmental risk factors for these cancers.

However, associations with these potential factors have not

been examined in AfBas. There has never been a method to

assess long-term dietary intake in Barbados, thus preclud-

ing association studies between diet and cancer.

Due to the importance of nutrition-related factors and

growing interest in the role of nutrient–gene interactions in

cancer aetiology, the development of a method for

assessing long-term dietary intake is of paramount

importance. The aim of this report is to describe the

development of a quantitative food-frequency question-

naire (QFFQ) for the BNCS, which can be used to examine

associations of diet with breast and prostate cancer, as well

as to test emerging hypotheses on nutrient–gene

interactions. No such QFFQ exists for Barbados, and

currently there are very limiteddata on food composition of

*Corresponding author: Email [email protected] q The Authors 2007

†Coordinating Center, Department of Preventive Medicine, Stony

Brook University, Stony Brook, NY, USA: M Cristina Leske, Barbara

Nemesure, S-Y Wu. Clinical Center, Ministry of Health, Barbados, and

University of the West Indies, Bridgetown, Barbados: Anselm Hennis,

Rachel Harris, Lynda Williams, Lyndon Waterman. NHGRI Center,

National Human Genome Research Institute, Bethesda, MD, USA:

Joan Bailey-Wilson. Gene Discovery Center, Translational Genomics

Institute, Phoenix, AZ, USA: John Carpten, Jeffrey Trent. Cancer

Etiology Program, Cancer Research Center of Hawaii, University of

Hawaii, Honolulu, HI, USA: Sangita Sharma, Xia Cao.

Public Health Nutrition: 10(5), 464–470 doi: 10.1017/S1368980007220531

composite dishes and usual portion size consumed, two

essential requirements for analysing a QFFQ. We provide

information on how we obtained and analysed these data

to develop the QFFQ for the BNCS.

Methods

Sources of data

Barbados Food Consumption and Anthropometric Survey

(BFCAS)

In 2000, the BFCAS obtained 24-hour recall data from a

nationwide population sample, based on a systematic

random two-stage cluster design5. A total of 1704

respondents from 1051 households participated in the

survey (average age of 48.9 years (standard deviation

17.6)), and included 945 (55.5%) women. A total of 60.0%

were employed, 44.2% had completed secondary edu-

cation, and 10.0 and 17.3%, respectively, reported diabetes

and hypertension. A subset of 1600 respondents com-

pleted a detailed dietary intake assessment using the

24-hour recall, and were included in the final data analysis.

A complete list of all foods, beverages and supplements

reported during the survey was obtained from the Ministry

of Health. Household units such as cups, teaspoons and

tablespoons had been shown to the participants to aid

their estimation of portion size.

Pilot study for the draft QFFQ

The pilot study involved the development of a draft QFFQ

and the administration of a 24 hour recall. The respective

methods and training protocols follow.

Draft QFFQ. Any food item that was reported by at least

two of the 1600 BFCAS respondents was listed to provide

foods for a draft QFFQ. Foods low in energy and nutrients,

such as condiments and spices, were not included as their

contribution to overall dietary intake was minor.

Additional foods that had not appeared in those BFCAS

recalls but were considered relevant to the BNCS, such as

soy products and seasonal foods that may have been

omitted, were added to the draft QFFQ. Additional blank

lines were added under each food group on the draft

QFFQ for respondents to list any additional foods or

drinks that they consumed frequently. This draft QFFQ

was pilot tested in a sample of individuals randomly

selected from a nationwide database of Barbados citizens

21 years and older, updated for 2004–2005. This sampling

methodology was used to select BNCS population-based

controls, as well as participants in previous epidemiologic

studies6.

Two interviewers (one nurse and one dietitian) were

trained for 5 days in the administration of the instrument

and a manual of procedures was developed to document

all protocols to be followed. To ensure standardisation of

the data collection, each interviewer practised multiple

pilot QFFQ administrations, under the supervision of the

first author (S.S.). To evaluate the ease of completing the

draft QFFQ, additional questions were included to obtain

the respondents’ opinion on the instrument and sugges-

tions for improvement.

Twenty-four hour recall. Individuals in the sample

selected for pilot testing were also asked to complete one

24-hour recall interview before completing the inter-

viewer-administered draft QFFQ. These 24-hour recall

interviews systematically sought and recorded information

about foods and drinks consumed during the preceding

24 hour period. Portion size was assessed using familiar

household units such as a pot spoon of rice, using

standard units such as a slice of bread, or using three-

dimensional models (NASCO) that had been carefully

chosen to estimate best the amount consumed. Each

interviewer was given a set of food models as well as

bowls, cups, glasses and spoons. Interviews were

conducted at home or in the BNCS office by the same

dietitian and nurse mentioned above, who were also

trained for collection of 24-hour recalls and supervised by

S.S. Data from each 24-hour recall were recorded on

dietary assessment forms. An additional list of questions

was included to prompt for easily forgotten foods such as

sweets, alcohol and snacks. We also included questions on

any special dietary practices the respondent followed such

as a weight loss diet, or a low fat diet. All data were

examined by the project coordinator and, if any data were

incomplete, the interviewer was asked to re-contact the

respondent for the additional information. Recalls covered

both weekdays and weekends in March 2004. Both

respondents and interviewers were also asked to complete

a separate evaluation form of the instrument.

The study was approved by the University of the West

Indies Research Ethics Review Committee and the Stony

Brook University Committee on Research Involving

Human Subjects. All participants signed informed consent

forms before their interviews took place.

Data on nutrition composition of mixed dishes

To calculate the nutrient composition of foods reported in

the recalls and listed on the QFFQ, itwas necessary to collect

additional data involving weighed recipes of dishes, as there

were limited data available on the composition of these

dishes. For this additional step, S.S. trained and certified a

dietitian and a nurse for 3 days in how to collect, record and

weigh ingredients for composite dishes. A recipe collection

form and a manual of procedures were developed. The

trained dietitian and nurse collected recipes from BNCS

participants and volunteers. The dietitian and nurse

scheduled appointments at the homes of these volunteers,

where they weighed all the ingredients and the final cooked

weight of the dishes. For most of the 35 composite dishes

involved in this process, five different recipes were

collected. An average recipe was then calculated for each

dish. Thedietitian attempted to obtainweighed recipes from

at least six different households of varied socio-economic

Dietary intake and development of a QFFQ for the BNCS 465

status, to be representative of the Barbadian population.

Individuals were reimbursed for the cost of the ingredients.

To derive weights from portion sizes that respondents

reported consuming in the 24-hour recalls, the dietitian

and S.S. weighed portions for all reported foods. For

example, 10 rotis were weighed from many sources

including home made, and an average weight obtained.

Weights were also obtained for all household units for

each food item recorded, such as taking the average of 10

pot spoons of rice and of rice and peas and lasagna. All

food weights were obtained using an electronic kitchen

scale (Aquatronic Baker’s Dream Scale (11 lb); Salter

Houseware Ltd).

All data were entered into Excel to calculate the average

weights.

Analyses

Nutrient intakes of respondents were estimated from the

single interviewer-administered 24-hour recalls. All dietary

data were coded and entered by a graduate nutrition

student (X.C.) and analysed using Nutribase Clinical

Nutrition Manager version 5.18 (Cybersoft Inc.), which

calculated nutrient intakes per person. The food

composition tables in Nutribase were updated to include

the weighed recipes. All other data analyses were

undertaken using SAS version 9.1 (SAS Inc.).

Foods that were reported as being consumed on the

one-time 24-hour recall were compared with the foods

listed in the draft QFFQ. This was done to ensure that no

foods had been omitted and that currently available foods

were included, as the BFCAS5 had been undertaken 4

years previously.

Results

Fifty of the 63 individuals contacted participated (79%

response rate). This group of 22 men and 28 women

provided the 24-hour recalls and completed the draft

QFFQ. The population sample consisted of adults with a

mean age for men and women of 53.9 years and 51.4

years, respectively (Table 1). All foods reported at least

twice in the recalls had been included on the draft QFFQ,

showing it to be complete and up to date.

A total of 160 recipes were collected for 35 composite

dishes. The mean nutrient composition was calculated for

the 35 dishes. In addition, we obtained ,350 average

portion weights for all food and drink items reported in the

24-hour recalls and on the QFFQ.

Nutrient intakes

Table 1 describes the nutrient intake of the participants

based on 49 dietary recalls; the remaining recall was

excluded as an outlier (.5000 kcal of daily energy intake).

As our sample size is small and the purpose of the recalls

was primarily to ensure the food list for the QFFQ was up

to date, we present and discuss limited nutrient intake

results.

Whilst the overall energy intake was somewhat lower

than expected (mean daily energy intake for men

2114 kcal and 1646 kcal for women), 28% had reported

eating less than usual on the day of the recall and 61% of

participants reported being on a special diet, which would

probably have resulted in a lower energy intake. The

special diets reported were low-fat, low-sugar, diabetic

and higher-fibre diets.

Table 1 Mean and median daily energy and nutrient intake of the BNCS participants obtained from the 24-hour recalls and the BFCAS*

Women Men

BNCS BNCS

Mean ^ SD Median BFCAS Mean ^ SD Median BFCAS

Number 27 27 199 22 22 161Age (years) 51.4 ^ 13.0 49 50–64 53.9 ^ 16.9 51 50–64Energy (kcal) 1646 ^ 677 1520 1698 2114 ^ 794 1854 2002Fat (g) 51.7 ^ 27.7 44.6 49.7 52.1 ^ 26.8 49.2 49.3Saturated fat (g) 14.6 ^ 10.6 11.5 n/a 14.0 ^ 9.2 12.3 n/aProtein (g) 63.5 ^ 31.9 57.3 69.5 77.3 ^ 34.5 68.0 85.5Carbohydrate (g) 231.4 ^ 105.1 210 245 326.2 ^ 144.5 275 277Sugar (g) 108.5 ^ 76.0 82.6 n/a 156.3 ^ 103.8 116.9 n/aDietary fibre (g) 15.6 ^ 7.6 15.1 n/a 18.2 ^ 8.4 16.8 n/aVitamin C (mg) 110.7 ^ 127.0 75.8 62.1 185.0 ^ 165.2 144.8 57.4Vitamin A (mg RE) 815 ^ 731 638 760 1744 ^ 1263 1534 1000Vitamin D (IU) 60.3 ^ 103.5 13.2 n/a 26.3 ^ 34.4 5.0 n/aCalcium (mg) 662.5 ^ 476.8 391 427 754.0 ^ 417.4 687 507Iron (mg) 11.8 ^ 8.0 10.3 11.9 16.4 ^ 12.4 12.6 14.5% energy from total fat 27.2 ^ 9.3 27.8 26.3† 22.2 ^ 7.5 22.5 22.2†% energy from carbohydrate 56.4 ^ 12.1 57.8 57.7† 60.4 ^ 12.2 62.3 55.3†% energy from protein 15.1 ^ 4.0 14.4 16.4† 14.5 ^ 3.8 14.3 17.1†

BNCS – Barbados National Cancer Study; BFCAS – Barbados Food and Consumption and Anthropometric Surveys: SD – standarddeviation; RE – retinol equivalents; n/a – data not available.* Only median available in this study5.† Comparable data not available; therefore calculated by the authors.

S Sharma et al.466

Dataare alsopresented fromtheBFCAS,basedon24-hour

recalls in people aged 50–64 years5. Median energy intakes

from our study are similar, although slightly lower (150–

200kcal), than those reported in the BFCAS5. In general, the

median nutrient intakes are similar between the BNCS and

the BFCAS population samples5, except for vitamin A and

vitaminCwhicharehigher in theBNCSmen, and thismaybe

a reflection of seasonal consumption of fruits or vegetables

in the BNCS as recalls were collected during March only.

The percentage of energy provided by fat was ,22% for

men and 28% for women, similar to those reported in the

BFCAS5, and is also probably reflective of the numbers who

reported following a low-fat diet7. Mean daily calcium and

dietary fibre intakes were low for both men and women.

The QFFQ

Administration of the draft QFFQ was lengthy, and both

respondents and interviewers suggested reducing its

length. To shorten the 192-item draft QFFQ to contain

only significant contributors of energy and nutrients, foods

that were reported fewer than six times in the 50 24-hour

recalls or the draft QFFQ and contributed little to nutrient

intake (,0.5%) were excluded, with the exception of

whole milk and alcoholic drinks. Foods that were similar

in nutritional composition (such as cakes) were combined.

As a result, the final QFFQ contains 148 food and drink

items and includes 17 items of bread, cakes and cereals;

eight items of rice, pastas and noodles; 10 dairy items; 42

items of meat, fish and poultry; 16 fruit items; 26 vegetable

items; 14 items of soft drinks; five items of alcoholic

beverages; and 10 other food items.

Additional questions were included on supplement use,

and meat preparation methods such as grilling, in order to

be able to determine heterocyclic amine intake.

The foods listed on the final QFFQ are shown in

Appendix A.

Appendix B displays a sample page of the final QFFQ

and the frequency categories which range from ‘never or

less than 1 time per month’ to ‘2 or more times per day’.

The QFFQ assesses usual food and drink intake consumed

over the last 12 months. Portion size is assessed using a

household unit such as a cooked spoon or coffee mug for

33 items, using a food model for 64 items and using a

standardised portion such as a slice of bread or a cracker

for 51 items. The final QFFQ takes ,35 min to administer.

Discussion

To develop an FFQ, three steps are needed: compose the

food list; define the portion sizes; and assign nutrient values

to each food item8. Obtaining an appropriate food list for a

specific population is the most critical step in the process of

developing an FFQ. The foods selected must be: (1)

commonly consumed by a substantial segment of the

population; (2) contain significant amount of nutrients of

interest, or foods of interest; and (3) have a great variety of

consumption among the people9–11. We compiled our food

list byaggregating the foods collected from24-hour recallsof

1600 participants in the BFCAS and by collecting additional

up-to-date 24-hour recalls from a population-based sample

of 50 individuals. Establishing a food list for thedevelopment

of the QFFQ, based on national or community surveys, is

a method used by many other researchers8,12,13.

Portion sizes were assessed using appropriate food models

to assist participants in describing their usual amounts

consumed, as has been done in other studies14.Weused eight

categories of frequency in ascending order, in the final QFFQ.

We have obtained, for the first time, detailed amounts of

ingredients and foods in 160 recipes for 35 dishes commonly

consumed in Barbados, from which we calculated nutrient

composition values. While we appreciate that biochemical

analysis is ideal, this is extremely expensive and such

funding was not available. There were no other published

data on food composition for mixed dishes consumed

inBarbados. TheCaribbean food tables did not contain most

of the foods eaten as mixed dishes nor did they contain the

full range of nutrients of interest for our cancer analysis15,16.

Although our sample size was small and the primary

purpose of the recalls was not to assess nutrient adequacy,

clearly some nutrient intakes were less than recommended

especially for calcium and fibre, which is similar to that

reported in the BFCAS5.

Fat intakes reported in the BNCS pilot study were

relatively low, a finding also reported by the BFCAS5. The

latter survey found that the percentage of calories derived

from fat in the Barbadian diet (close to 25%) was below the

World Health Organization (WHO)-recommended maxi-

mum of 30%, but above the recommended Caribbean

maximum of 15–20%.

The BFCAS also noted that as many as 50 and 33% of

persons diagnosed with diabetes and hypertension,

respectively, claimed to follow special diets related to

their conditions5. This observation is relevant to the high

proportion of our pilot sample who similarly reported

special diets.

A comprehensive dietary assessment strategy is essential

for understanding the relationship between nutrition and

diseases. FFQs have advantages over other dietary

assessment methods, such as short-term recalls and diet

records, because they are relatively inexpensive and can

measure usual long-term dietary intake, especially for large

population samples as in our study9,17,18. Though short-

term recalls or dietary records provide more precise data

than FFQs, the research question regarding the relationship

between diet and chronic diseases focuses on whether a

specific food or nutrient is frequently consumed or never

eaten9. The QFFQ is appropriate for the BNCS to assess the

usual foodandnutrient intake 12monthsprior to thedate of

cancer diagnosis for cases or a comparable reference date

for controls. These data can be used to examine the

association between past dietary intake and incident breast

and prostate cancer.


Some limitations exist with this study. Deleting infre-

quently used food items from the QFFQ may omit some

foods with higher between-person variation, but we only

omitted those foods thatwould contribute little to the overall

diet. At this point, validation of the instrument is currently

underway, using 4-day food diaries and a repeat QFFQ.

Overall, a draft QFFQ was developed from 24-hour

recall records obtained from a sample of 1600 participants.

The additional data we collected from the 50 24-hour

recalls enabled us to revise the draft QFFQ to develop an

appropriate QFFQ for the African-origin populations in

Barbados.

The QFFQ is presently being used in the BNCS to allow

future assessments of: (1) overall nutrient intake; (2) food

group intake; (3) the association of some nutrient intakes

with the risk of breast and prostate cancer; (4) the

association of the dietary patterns with the risk of breast

and prostate cancer; and (5) eventual hypotheses on

nutrient–gene interactions.

Conclusion

The final QFFQ contained 148 items, is up to date and will

provide a comprehensive tool for assessing overall dietary

intake, which can be used to determine associations of

diet with prostate and breast cancer in AfBas. This is the

first time a QFFQ has been developed from a representa-

tive population sample for Barbados. The instrument will

also allow us to examine our hypotheses related to

nutrient–gene interactions.

Acknowledgements

The BNCS was funded by the US National Human Genome

Research Institute National Institutes of Health, Contract #

N01-HG-25 487. This research was also aided by the

Developmental Funds award from the Cancer Research

Center of Hawaii. We are also grateful to the Ministry of

Health, Barbados, and the Food and Agriculture Organiz-

ation of the United Nations for conducting the Barbados

Food Consumption and Anthropometric Survey 2000. We

thank all staff and participants in the Barbados National

Cancer Study, without whose help the QFFQ data could not

have been collected.

References

1 Ries LAG, Eisner MP, Kosary CL, Hankey BF, Miller BA, CleggL, et al., eds. SEER Cancer Statistics Review, 1975–2002[online]. Bethesda, MA: National Cancer Institute, based onNovember 2004 SEER data submission, posted to the SEERwebsite 2005. Available at http://seer.cancer.gov/csr/1975_2002/

2 Goodridge R. The African background of the Barbadospopulation. In: Cobley AG, Thompson A, eds. The

African-Caribbean Connection: Historical and CulturalPerspectives. Bridgetown, Barbados: Department of History,University of the West Indies, 1990; 28–48.

3 Cobley AG, Thompson A, eds. The African–CaribbeanConnection: Historical and Cultural Perspectives. Bridge-town, Barbados: Department of History, University of theWest Indies, 1990.

4 Hoyos FA. Barbados Comes of Age: From Early Strivings toHappy Fulfillment, 2nd ed. London: Macmillan PublishersLtd, 1987.

5 Food and Agriculture Organization of The United Nations(FAO) & The National Nutrition Center Ministry of Health,Government of Barbados. The Barbados Food Consumptionand Anthropometric Survey 2000. Rome: FAO, 2005.

6 Leske MC, Connell AM, Schachat AP, Hyman L. TheBarbados Eye Study. Prevalence of open angle glaucoma.Archives of Ophthalmology 1994; 112: 821–9.

7 Sharma S, Jackson M, Mbanya JC, Cade J, Forrester T, WilksR, et al. Development of food frequency questionnaires inthree population samples of African origin from Cameroon,Jamaica and Caribbean migrants to the UK. EuropeanJournal of Clinical Nutrition 1996; 50: 479–86.

8 Shahar D, Fraser D, Shai I, Vardi H. Development of a foodfrequency questionnaire (FFQ) for an elderly populationbased on a population survey. Journal of Nutrition 2003;133: 3625–9.

9 Willett W. Nutritional Epidemiology. New York: OxfordUniversity Press, 1998.

10 Stark A. An historical review of the Harvard and the NationalCancer Institute food frequency questionnaires: their simi-larities, differences, and their limitations in assessment of foodintake. Ecology of Food and Nutrition 2002; 41: 35–74.

11 Cade J, Thompson R, Burley V, Warm D. Development,validation and utilization of food frequency questionnaires –a review. Public Health Nutrition 2002; 5: 567–87.

12 Block G, Hartman AM, Dresser CM, Carroll MD, Gannon J,Gardner L. A data-based approach to diet questionnairedesign and testing. American Journal of Epidemiology 1986;124: 453–69.

13 Subar AF, Midthune D, Kulldorff M, Brown CC, ThompsonFE, Kipnis V, et al. Evaluation of alternative approaches toassign nutrient values to food groups in food frequencyquestionnaires. American Journal of Epidemiology 2000;152: 279–86.

14 Sharma S, Cade J, Landman J, Cruickshank JK. Assessing thediet of the British African-Caribbean population; frequency ofconsumption of foods and food portion sizes. InternationalJournal of Food Sciences and Nutrition 2002; 53: 439–44.

15 The Caribbean Food and Nutrition Institute, the PanAmerican Health Organization, Pan American SanitaryBureau, Regional Office of the World Health Organization.Food Composition Tables for Use in the English-speakingCaribbean, 2nd ed. Kingston, Jamaica: Caribbean Food andNutrition Institute, 1998.

16 The Caribbean Food and Nutrition Institute, the PanAmerican Health Organization, Pan American SanitaryBureau, Regional Office of the World Health Organization.Food Composition Tables for Use in the English-speakingCaribbean, 2nd ed. Kingston Jamaica: Caribbean Food andNutrition Institute, 2000.

17 Solomons NW, Valdes-Ramos R. Dietary assessment tools fordeveloping countries for use in multi-centric, collaborativeprotocols. Public Health Nutrition 2002; 5: 955–68.

18 Taren D, Dwyer J, Freedman L, Solomons NW. Dietaryassessment methods: where do we go from here? PublicHealth Nutrition 2002; 5: 1001–3.

S Sharma et al.468

Appendix A – Food and drink items listed on the final QFFQ

Category Food items

Breads, cakes and cereals (17) Salt bread, white; Salt bread, whole wheat; Turnover, white/whole wheat; Buns, hotdog buns,rolls; Other white bread; Other whole wheat bread; Crackers, white/whole wheat; Coconutbread; Cake; Doughnuts, currant slices, jam puffs; Sweet biscuits; Conkies; Cornflakes, RiceKrispies, Bran Flakes; Weetabix, Shredded Wheat; Hot porriage; Granola/muesli; Bakes

Rice, pastas, noodles (8) Rice and peas; Plain rice; Pilau; Rice and vegetables; Macaroni pie; Spaghetti/macaroni/noodles/chow mein; Bajan soup; Dumplings

Dairy (10) Full cream milk; Milk, 2%; Condensed milk; Evaporated milk – full cream; Evaporated milk low fat;Flavoured milks or milkshakes; Hard cheese, cheddar; Ice cream; Eggs; Soy milk

Meats, poultry, fish, soy products (42) Seasoned mince beef/ground beef/beef stew; Lasagne; Shepherd’s pie; Hamburgers; Meatpatties/rolls; Roti; Lamb stew; Lamb grilled/baked; Pork stew; Ham or pork grilled/roast/baked; Steam pudding; Souse; Sausages, hotdogs, frankfurters; Bacon; Pre-packaged slicedmeats (ham/turkey); Pre-packaged sliced meats (salami/bologna); Corn beef or luncheonmeat; Liver; Chicken giblets fried; Chicken, fried; Chicken, barbequed/baked/grilled/rotisserie;Turkey wings; Stew chicken; Tuna, in oil; Tuna, in brine/water; Mackerel, in oil/tomato sauce;Mackerel, in brine/water; Sardines, in oil/tomato sauce; Sardines, in brine/water; Salmon,in brine/water; Fish cakes; Saltfish, cooked; White flesh fish, grilled/baked; White fish,steamed/poached/boiled; White fish, fried; Flying fish, steamed/poached/boiled; Flying fish,fried; White fish, banga-marie, butter fish, snapper – steamed/poached/boiled; White fish,banga-marie, butter fish, snapper – fried; Cou Cou; Tofu, soy chunks; Soy burger, vita burger,grain burger

Fruits (16) Banana; Apple; Golden apple; Orange, tangerine; Grapefruit; Grapes; Pawpaw; Mango, fresh;Local plums/hog plums; Plums, imported; Water melon, honey dew, musk or cantaloupe;Guava; Pineapple, fresh; Fruit salad, fresh; Tinned fruit; Ackees/Guineps

Vegetables (26) English potatoes, creamed/mashed; English potatoes, fried; English potatoes, baked/boiled;Potato salad; Sweet potato, baked/boiled; Yam, baked/boiled/creamed; Cassava, boiled;Breadfruit, boiled/pickled/roasted; Breadfruit, cou cou/crushed; Green banana, boiled/pickled;Green banana, cou cou/crushed; Plantain, boiled; Plantain, fried; Mixed vegetables; Broccoli;Cauliflower; Coleslaw; Carrots; String beans; Pumpkin or squash; Corn; Okra; Avocado;Cabbage, spinach and other dark green leafy vegetables; Tomatoes; Tossed salad

Other foods (10) Pizza; Nuts; Peanut butter; Chips; Chocolate bar; Sugar cake, tamarind balls, peanut cake;Candy, sweets, mints; Margarine; Gravy, homemade, with meat dripping; Gravy, homemade,without meat dripping

Soft drinks (14) Sweetened fruit juice, pineapple, golden apple grape, orange, grapefruit, guava, passion fruit,fruit punch, other; Sweetened fruit juice Bajan cherry, black currant; Unsweetened fruit juice;Kool Aid, Tang, Fresh Start; Homemade drinks; Carbonated soft drinks, regular; Dietcarbonated soft drinks; Coconut water; Ovaltine, Horlicks, Milo, Bournvita, malt drink, hotchocolate, cocoa (dry powder); Boost, Lasco, Nutrament, Complan, Ensure, Enterex DM,Choice DM, Glucerna; Tea, black; Tea, herbal, fruit, green; Coffee; Honey/syrup/sugar

Alcohol (5) Wine, white; Wine, red; Liquor; Beer; Stout, malt


Appendix

B–Asample

pageoftheQFFQ

S Sharma et al.470

RESEARCH PAPER

Assessing dietary patterns in Barbados highlightsthe need for nutritional intervention to reduce riskof chronic disease

S. Sharma,* X. Cao,* R. Harris,� A. J. M. Hennis,�,� S.-Y. Wu� & M. C. Leske� for theBarbados National Cancer Study Group1

*Cancer Etiology Program, Cancer Research Center of Hawaii, University of Hawaii, Honolulu, HI, USA; �Barbados National

Cancer Study, Sir Winston Scott Polyclinic, St Michael, Barbados; �Department of Preventive Medicine, Stony Brook University,

Stony Brook, NY, USA

� 2008 The Authors. Journal compilation.

150 � 2008 The British Dietetic Association Ltd 2008 J Hum Nutr Diet, 21, pp. 150–158

CorrespondenceSangita Sharma,

Cancer Etiology Program,Cancer Research Center of Hawaii,

University of Hawaii,

Honolulu,HI,

USA.

Tel.: 808 564 5845

Fax: 808 586 2982E-mail: [email protected]

1See Appendix for the Study GroupParticipants.

KeywordsAfrican Barbadians, dietary assessment,

dietary pattern, food diary, the

Barbados National Cancer Study.

Abstract

Background The dietary habits of the Caribbean have been

changing to include more fast foods and a less nutrient dense diet.

The aims of this study are to examine dietary patterns in Barbados

and highlight foods for a nutritional intervention.

Methods Four-day food diaries collected from control participants

in the population-based, case–control Barbados National Cancer

Study (BNCS).

Results Forty-nine adult participants (91% response) completed

the diaries providing 191 days of dietary data. Total energy intake

was almost identical to data collected 5-years earlier in the Barbados

Food Consumption and Anthropometric Survey 2000, but the percent

energy derived from fat was from 2.1% to 5.2% higher. Sugar intake

exceeded the Caribbean recommendation almost four-fold, while

intakes of calcium, iron (women only), zinc and dietary fibre were

below recommendations. Fish and chicken dishes were the two

largest sources of energy and fat. Sweetened drinks and juices pro-

vided over 40% of total sugar intake.

Conclusions These data provide existing dietary patterns and

strongly justify a nutritional intervention program to reduce dietary

risk factors for chronic disease. The intervention could focus on the

specific foods highlighted, both regarding frequency and amount of

consumption. Effectiveness can be evaluated pre- and post-inter-

vention using our Food Frequency Questionnaire developed for

BNCS.

Conflict of interests, source of funding and

authorship

The authors declare they have no conflicts of

interest.

The BNCS was funded by the National Human

Genome Research Institute of the United States,

National Institute of Health (NIH) of the United

States, Contract no. N01-HG-25487. This research

was also aided by the Developmental Funds award

from the Cancer Research Center of Hawaii.

SS, AH and CL developed the conception and

design of the study. All authors were responsible for

data interpretation, and XC and SYW for data

analysis. SS, XC and RH drafted the manuscript.

All authors critically reviewed its content and have

approved the final version submitted for

publication.

Introduction

Rates of chronic noncommunicable disease such as

diabetes, hypertension, cardiovascular disease and

cancer have been increasing in the Caribbean

(Ragoobirsingh et al., 1995, 2002; Wilks et al.,

1998, 1999; Figueroa et al., 1999; Rotimi et al.,

1999; Cruickshank et al., 2001, Figueroa, 2001;

Sargeant et al., 2001; Hennis et al., 2002a,b; Corbin

et al., 2004; Wolfe et al., 2006). Approximately

10% and 20% of the population over 20 years of

age suffers from diabetes and hypertension,

respectively, with prevalences more than doubling

at older ages (Hennis et al., 2002a,b). The most

striking epidemic among the Caribbean population

is the high prevalence of overweight [body mass

index (BMI) >25 kg m)2] and obesity (BMI

>30 kg m)2). Approximately half of the adult

Caribbean population is overweight and 25% of

adult Caribbean women are obese (Henry, 2004).

The dietary habits of the Caribbean have also

been changing to include more fast foods and a

less nutrient dense diet (CFNI, PAHO and WHO,

2004).The shifts in disease patterns could be ex-

plained at least in part by these dietary modifica-

tions. To study associations between diet and

chronic disease, methods for assessing long-term

dietary intake must be developed. These methods

allow information on usual dietary intake and

major contributors to overall diet to be obtained,

as well as data about specific nutrients of interest

such as fat and sugar; such data are needed to

develop nutritional intervention programs aimed

at reducing risk of these chronic diseases.

The Barbados National Cancer Study (BNCS) is

a population-based case–control study examining

risk factors for breast and prostate cancer in an

African-origin population. Both cancers are

particularly important causes of morbidity and

mortality in persons of African descent (IARC,

2001; Ries et al., 2005). Barbados has a population

of approximately 270 000 persons, 94% being of

African-origin and sharing a common heredity

with African-Americans. According to the United

Nations Human Development Index, this country

is the leading developing nation (Country fact

sheets Human Development Report [Internet]

2007/2008), and its socioeconomic development

and infrastructure provides an ideal environment

to understand cancer risk in African-origin pop-

ulations. However, potential cancer risk factors

including diet, have not been examined in African

Barbadians. Prior to the BNCS, there has never

been a method to assess long-term dietary intake

in Barbados, thus precluding association studies

between diet and cancer, or indeed any other

chronic disease.

We recently developed a Quantitative Food

Frequency Questionnaire (QFFQ) specifically to

assess food and nutrient intake in African Barba-

dians for the BNCS (Sharma et al., 2007a).

The overall aims of the current paper are to

describe the diets of African Barbadians, and to

highlight the new dietary data being collected in

the BNCS, including the nutritional composition

of the most commonly consumed foods (mostly

composite dishes), which was previously unavail-

able. The current paper describes the diets of a

subsample of the BNCS control participants who

provided a total of almost 200 days of dietary data

from food diaries. We present the nutrient intake

and a list of the most commonly consumed foods,

and compare our results with the Caribbean Rec-

ommended Dietary allowances (RDA) (CFNI,

1994). In addition, we present the major sources of

energy, carbohydrate, fat, sugar and dietary fibre,

as such data are necessary to guide nutritional

Assessing dietary patterns in Barbados 151


� 2008 The British Dietetic Association Ltd 2008 J Hum Nutr Diet, 21, pp. 150–158

intervention programs aimed at reducing risk of

chronic disease in this population.

Materials and methods

Sampling

The dietary data were collected on a sample of

individuals randomly selected from a computer-

ized nationwide database of Barbados citizens

21 years and older, updated for 2004–05.

This sampling methodology was used to select

BNCS population-based controls, as well as par-

ticipants in previous epidemiologic studies

(Sharma et al., 2007a). BNCS controls were se-

lected from the national database and frequency-

matched to the incident cases of prostate and

breast cancer in Barbados by 5-year age groups.

Fifty consecutive individuals who were part of the

BNCS control group completed the QFFQ between

August and September 2004. Between January and

February 2005, 47 of the original 50 participants

were invited to take part in a second interview,

both to complete the same QFFQ for the second

time, and to complete a 4-day food diary at home.

Three persons were not re-contacted because of

difficulties during their first interviews.

Two of the 47 participants declined to complete

the second interview due to ill health, and another

two persons could not be located. We therefore

invited seven randomly selected BNCS controls to

participate. These seven individuals completed the

QFFQ for the first time, and then approximately

1 month later they completed the same QFFQ for a

second time and the 4-day food diary. This report

therefore included a total of 54 (47 + 7) individ-

uals who were invited to participate in both first

and second interview.

In this report, we present only the 4-day food

diary data. The repeat QFFQs and the food diaries

were collected as part of the validation study,

which is currently underway.

Data collection

Food diary collection

A trained dietitian visited the homes of all partici-

pants who agreed to complete the 4-day food diary.

Appointments were scheduled either over the

phone or by direct face-to-face contact. The dieti-

tian reviewed the methods for completing the diary

and showed the participant an example of a com-

pleted diary. Each participant was asked to record

all foods and drink items consumed (at the time of

consumption), and to estimate portion sizes using

familiar household measuring units such as a pot

spoon (e.g. for rice), a slice of bread, or by retaining

the packets of items such as crisps and candies. The

dates for completion of the diary were given as the

four consecutive days after the diary was given.

The dietitian called or visited the respondent each

day during the period that the diary was to be com-

pleted, to answer any questions and to encourage

the complete recording of all information.

The day after each diary had been completed,

the dietitian went to the home of the respondents

and clarified all foods and drinks recorded, par-

ticularly with regard to brand names, amounts

consumed and the times of consumption.

The dietitian also sought information for missing

data and frequently missed items, such as whether

the skin on the chicken had been consumed and

the type of milk added to tea or coffee.

The dietitian also administered an additional list

of questions to obtain information about easily

forgotten foods such as sweets, alcohol and snacks.

In addition, she determined whether any special

practices were being followed such as a weight loss

diet, or a low fat diet.

Recipe collection

There were no locally available food composition

data for many food and drink items reported in the

food diaries. To calculate the nutritional composi-

tion of these dishes, a substudy was conducted by

weighing all ingredients and the final cooked dish.

These methods have been explained elsewhere

(Sharma et al., 2007a). For most of the composite

dishes, five different recipes were collected.

A total of 152 weighed recipes were collected for

32 dishes and the average nutritional composition

was calculated and is available, if requested, for

the following dishes: frizzled salt fish, steamed

fish, fishcakes, fish soup, fried flying fish, minced

meat, sauteed corned beef, chicken soup, chicken

potato roti, stewed liver, fried giblets, lamb soup,

S. Sharma et al.152



lamb stew, pork stew, pilau rice, rice and peas,

vegetables and rice, dumpling, chopped seasoning,

coconut bread, bakes, macaroni pie, souse, cou-

cou, gravy, conkies, creamed yam, steamed pud-

ding, roti skin, pumpkin fritters, mauby drink,

ginger beer and lemonade.

The study was approved by the University of

Hawaii Committee on Human Studies, the Uni-

versity of the West Indies Research Ethics Review

Committee and the Stony Brook University

Committee on Research Involving Human Sub-

jects. All participants signed informed consent

forms before their interviews took place.

Analyses

Nutrient intakes of respondents were estimated

from the 4-day food diary. All food diary data were

coded and entered by a graduate nutrition student

(XC) and analysed using Nutribase Clinical

Nutrition Manager v. 5.18 (CyberSoft Inc., 2004).

Nutribase Clinical has a research quality nutrient

database analysing 121 nutrients and calories for a

variety of food items by using the USDA National

Nutrient Database for Standard Release as the

foundation.

The nutritional composition of each weighed

recipe collected was calculated per 100 grams by

entering the weight of the ingredients and the final

cooked weight into Nutribase Clinical (CyberSoft

Inc., 2004). The average nutritional composition of

each dish was calculated per 100 grams from all

samples of each composite dish as previously de-

scribed (Sharma et al., 2007b). The food compo-

sition tables in Nutribase Clinical were updated to

include the weighed recipes.

To determine the major foods contributing to

the intake of energy, fat, sugar and fibre, and to

highlight the foods for intervention, we combined

the percentage contribution for similar foods such

as fruit juices and similar crisps. All other data

analyses were undertaken using SAS version 9.1

(SAS Institute Inc., 2005).

Results

Of the fifty-four persons invited to participate, two

were subsequently not located. Fifty-two persons

were therefore asked to complete a 4-day food

diary; two refused (due to ill health), and one

person did not complete the diary (response rate

91%).

Of the 49 who participated, 44 respondents

completed food diaries for at least 4 days (42

completed the 4-day diary, one completed 7 days

and one completed 5 days), two respondents

completed 3 days, two respondents completed

2 days and one respondent completed just 1 day.

A total of 191 days of food diary data were pro-

vided from 26 women and 23 men with mean

(�SE) age of 54 (�2.5) years and 67 (�2.0) years

respectively. One respondent who completed the

4-day food diary had 1 day where the energy

exceeded 5000 kcal; these data were excluded as

a result of being considered outlier information.

All data were examined for completeness by the

project coordinator. Diaries covered both week

days and weekend days (59/190 days = 31%

weekend days) during January and February

2005.

All the dietary analyses were performed on the

basis of the data from the remaining 190 food

records.

Table 1 presents mean and median daily energy

and nutrient intake of our sampled African Bar-

badians, as derived from food diaries. For com-

parison, the table presents the RDA for the

Caribbean countries (CFNI, 1994) and the data

from the Barbados Food Consumption and

Anthropometric Survey 2000 (BFCAS) undertaken

in 1051 households in the year 2000, which used

one-time 24-h dietary recall to obtain daily dietary

intake (FAO & NNCMH, 2005). The median daily

energy intake of African Barbadians in our sample

was very similar to the median energy intake in the

BFCAS [(47–84 kcal) difference: BNCS men med-

ian intake of 1979 kcal and BFCAS men 2026 kcal;

median intake of 1782 kcal for BNCS women and

1698 kcal for BFCAS women]. The median per-

centages of energy intake from fat of our sampled

Barbadians were higher in both men (27.0% versus

22.2%) and women (28.4% versus 26.3%) com-

pared to the BFCAS. In both studies the men had a

lower median percentage energy provided by fat

than the women. As noted in the table, many more

nutrients are available from our sample than from




the BFCAS. These nutrient intakes have been

previously unknown for Barbadians.

Our sampled Barbadians had a higher mean

daily percentage of energy from fat intake than

recommended (CFNI, 1994) (BNCS women: 28%;

recommendation: 15–20%; BNCS men: 26%; rec-

ommendation: 15–20%) (Table1). The mean daily

intake of sugar in Barbadian men and women in

our sample was much higher than the Caribbean

RDA (BNCS women 108 g versus ‘less than 24 g’

as the recommended; BNCS men 102 g versus ‘less

than 25.5 g’ as the recommended). In contrast,

dietary fibre intake was lower compared to the

Caribbean RDA (20.5 g in BNCS women versus the

recommendation of 30 g; 25.2 g in BNCS men

versus the recommendation of 30 g). The mean

daily intake of iron (12.1 mg) was lower than that

recommended (15 mg) in BNCS women although

higher than that recommended in BNCS men

(17.2 mg versus 10 mg). The recommendation for

calcium intake is 700 mg for Barbadian men and

women; however, our sample reported a much

lower mean daily intake of calcium (660 mg in

men and 595 mg in women). Zinc intakes were

also much lower in both Barbadian men and

women compared to the recommendations.

Table 2 presents the ten major sources of

energy, fat, sugar and dietary fibre from the

4-day food records. The greatest sources of

energy are fish, chicken and rice dishes, which

Table 1 Mean and median daily energy and nutrient intake of Barbadians obtained from 4-day food diary from the BarbadosNational Cancer Study (BNCS) compared with the Barbados Food Consumption and Anthropometric Survey 2000 (BFCAS)* andthe Recommended Dietary Allowance (RDA) for the Caribbean�

Women Men

RDA�

Mean � SE� Median Median

RDA�

Mean � SE� Median Median

BNCS BNCS BFCASa BNCS BNCS BFCAS*

Number (n) – 26 26 199 – 23 23 149Age (years) 30–60 54 � 2.5 52 50–64 >60 67 � 2.0 67 >64Energy (kcal) – 1832 � 64 1782 1698 – 2127 � 82 1979 2026Protein (g) 45 70 � 3 68 69.5 53 92 � 4 85 84.8Carbohydrate (g) – 258 � 11 247 245 – 297 � 13 283 270Fat (g) – 59.4 � 3.3 51.7 49.7 – 64 � 4 55.5 51.0Saturated fat (g) <24 15.7 � 1.3 13.0 – <25.5 16.3 � 1.1 13.9 –Monounsaturated fatty acid (g) – 15.4 � 1.3 14.1 – – 16.9 � 1.2 14.1 –Polyunsaturated fatty acid (g) – 7.9 � 0.5 6.6 – – 9.7 � 0.7 7.5 –Omega-3 fatty acid (g) – 0.6 � 0.1 0.3 – – 0.8 � 0.1 0.5 –Omega-6 fatty acid (g) – 3.7 � 0.3 3.0 – – 4.9 � 0.4 3.6 –Cholesterol (mg) <300 221 � 17 182 – <300 271 � 21 233 –Sugar (g) <24 108 � 7 97 – <25.5 102 � 7 83 –Dietary fibre (g) 30 20.5 � 1.3 17.2 – 30 25.2 � 1.5 22.7 –Vitamin C (mg) 60 117 � 10 83 62.1 60 143 � 11 117 74.8Vitamin A (lg-RE–) 560 1631 � 199 982 760 650 1571 � 166 898 963Vitamin B6 (mg) 0.8 1.5 � 0.1 1.4 – 0.7 2.1 � 0.1 2.0 –Vitamin B12 (lg) 1.5 54 � 4 48 – 1.5 76 � 6 63 –Total folate (lg) 200 167 � 13 138 189 200 222 � 18 198 208Calcium (mg) 700 595 � 34 550 427 700 660 � 39 538 507Iron (mg) 15 12.1 � 0.6 11.2 11.9 10 17.2 � 0.9 15.9 14.5Zinc (mg) 12 5.9 � 0.4 4.9 5.4 15 7.6 � 0.4 6.4 7.2% energy from total fat 15–20 28.1 � 1.0 28.4 26.3§ 15–20 25.9 � 0.9 27.0 22.2§

% energy from protein – 15.5 � 0.4 14.9 16.4§ – 17.4 � 0.5 16.4 17.1§

% energy from carbohydrate 55–60 55.3 � 1.2 55.1 57.7§ 55–60 55.0 � 1.1 55.1 55.3§

% energy from alcohol – 1.0 � 0.3 0 – – 1.7 � 0.5 0 –

*Only median available in this study (FAO & NNCMH, 2005).�Recommended dietary allowance for the Caribbean (CFNI, 1994).�Standard error.§Comparable data not available, therefore calculated by authors.–Retinol equivalent.

S. Sharma et al.154



provided almost one-quarter of total energy

intake. Fish and chicken dishes were also the

largest source of fat, providing over 26% of total

fat intake. Sweetened drinks and juices (includ-

ing homemade drinks, chocolate drinks and

honey/sugar/syrup) provided over 40% of total

sugar intake. Foods high in fibre such as bread

and cereal dishes (including rice-based dishes)

contributed a total of almost 33% to dietary fibre

intake. A more detailed description of each dish

and exactly which foods are included in fish,

chicken and rice dishes is available elsewhere

(Sharma et al., 2007b).

Table 3 presents the 20 most commonly con-

sumed food and drink items recorded in the food

diaries. The most frequently reported items were

sugar, whole wheat and multigrain breads, rice

dishes and bananas (reported between 66–104

times). Within the 20 most commonly reported

food items, seven (35%) were fruits or vegetables.

Discussion

We have provided nutrient intakes for a sample of

control participants within the BNCS and haveTab

le2

Ten

maj

or

food

sourc

esof

ener

gy

and

mac

ronutr

ients

from

four-

day

food

dia

ries

ina

subsa

mple

of

the

Bar

bad

os

Nat

ional

Can

cer

Study

Food

sourc

esof

ener

gy

%co

ntr

ibution

toen

ergy

Food

sourc

esof

tota

lfa

t%

contr

ibution

toto

talfa

tFo

od

sourc

esof

tota

lsu

gar

%co

ntr

ibution

tosu

gar

Food

sourc

esof

fibre

%co

ntr

ibution

tofibre

Fish

dis

hes

9.8

Fish

dis

hes

16.7

Swee

tened

fruit

juic

es/d

rinks

20.4

Whea

t/m

ultig

rain

bre

ad11.8

Chic

ken

dis

hes

7.0

Chic

ken

dis

hes

9.7

Hom

emad

edrinks

incl

.gin

ger

bee

r,m

auby

drink

and

lem

onad

e6.8

Hot

porr

idges

8.2

Ric

edis

hes

6.1

Nuts

5.7

Honey

/sugar

/syr

up

5.6

Ric

edis

hes

4.8

White

bre

ad/b

un

5.2

Har

dch

eese

3.8

Cak

es5.2

Apple

4.3

Swee

tened

fruit

juic

es/d

rinks

4.8

Evap

ora

ted

milk

-full

crea

m3.3

Reg

ula

rca

rbonat

edso

ftdrinks

4.1

Fish

dis

hes

3.9

Whea

t/m

ultig

rain

bre

ad4.7

White

bre

ad/b

un

2.5

Ban

ana

4.1

Cold

cere

als

3.7

Hot

porr

idges

2.7

Mar

gar

ine/

butt

er2.4

Choco

late

drinks

,m

alt

and

coco

adrinks

4.0

White

bre

ad/b

un

3.6

Cak

es2.6

Eggs

2.4

Apple

3.8

Couco

u3.4

Cra

cker

s2.2

Whea

t/w

hole

whea

tbre

ad2.3

Man

go

3.4

Chic

ken

dis

hes

3.1

Nuts

2.0

Ric

edis

hes

2.3

Ora

nge/

tanger

ine

2.4

Ora

nge/

tanger

ine

2.9

Tota

l47.1

Tota

l51.1

Tota

l59.6

Tota

l49.7

Table 3 Most commonly consumed food and drink itemsreported in the food diaries in a subsample of the BarbadosNational Cancer Study

Most commonly reported foodsNo. of timesreported

Sugar 104Oat bran bread, multigrain bread,whole wheat bread

88

Rice and peas or plain rice 68Banana 66Evaporated milk (whole) 61White bread including buns 57Crackers 57Carrots 49Vegetable salad 46Apple 44Sweetened juice 44Oat porridge or cream of wheat 36Fried flying fish or frizzled salt fish 33Evaporated milk (partly skimmed) 33Cheddar cheese 32Orange 32Sweet potato 32Cakes 27Plantain 27Gravy 26




compared our nutrient results to those provided

by the BFCAS and the Caribbean RDAs. Although

there are differences in methodology between the

BNCS (food diary) and the BFCAS (recall), very

similar median daily energy intakes were reported

in both studies. However, the composition of the

energy sources in each study, one undertaken in

2000 (BFCAS) and the other (BNCS) 5 years later,

is consistent with a rapidly worsening diet. For

example, in 2005, the BNCS showed a 2.1–5.2

higher percentage of energy provided by fat in

men and women than the BFCAS. The intakes of

dietary fibre, iron and zinc appeared to be lower

than Caribbean RDAs in our sampled Barbadians.

Furthermore, the overall energy intake of BNCS

men and women was somewhat lower than rec-

ommended (mean daily energy intake for men

2127 kcal and 1832 kcal for women) and this

could be related to the special dietary practices

followed during the days of data collection. Thus,

we have previously shown that 28% of participants

had reported eating less than usual on the day of

the recall and 61% reported being on a special

diet, such as low fat, low sugar, diabetic and higher

fibre diets (Sharma et al., 2007a). Hence, the in-

take of energy, fat and sugar would have been even

higher if these individuals had been excluded from

our sample.

To determine the sources of energy and key

nutrients, and to highlight foods for an interven-

tion, we presented the major food sources of en-

ergy, fat, sugar and fibre intake, as well as the most

frequently reported food and drink items, as have

previous similar studies (Sharma et al., 2007a;

Sharma et al., 2007c, 2008). Fish dishes, chicken

dishes, whole wheat/multigrain bread, white

bread/bun, porridges and rice dishes were the

major sources of energy, fat and fibre intake.

Sugary food items such as sweetened juices/drinks

were frequently consumed in African Barbadians

and hence major contributors to energy and sugar

intake.

As with many Caribbean countries, there is

currently a rise in diet-related chronic disease in

Barbados; the high prevalence of these conditions

suggests the need for nutritional interventions, if

these increasing rates are to be halted. Effective

nutritional intervention programs must be based

on foods that either contribute significantly to

overall dietary intake or to the nutrients of

greatest concern, such as fat and sugar. In addi-

tion, foods that are, or are not commonly con-

sumed by the majority of the population need to

be considered. For example, sweetened juices and

drinks were consumed frequently in Barbados, but

these could easily be replaced by unsweetened

juices, sugar free, or diet drinks, which currently

did not appear in the list of frequently consumed

foods.

Our study was undertaken to focus on the foods

in the ‘as eaten’ form (such as chicken soup) and

we are therefore able to target specific foods for

intervention. However, this was not the case for the

BFCAS, where foods contributing to energy and

nutrients were provided as the ingredients (such as

fresh meat, cooking oil, potatoes). For example,

our five major contributors to fat were fish and

chicken dishes, nuts, hard cheese and full fat

evaporated milk. The major five contributors in the

BFCAS were fresh meat, cooking oil, canned fish,

cheddar cheese and margarine. Dietary data that

are provided in the ‘as eaten’ form allow for very

specific targeting of key foods and this is the first

time such data are available for Barbadians.

Foods were identified for intervention based on

existing dietary patterns and locally acceptable

foods. Replacing the most common sources of fat

and total energy with lower fat or lower sugar

alternatives will help focus an intervention on

foods that would likely have the greatest impact on

diet. Intervention programs may not only target

specific food items, but could focus on cooking

methods that would reduce fat intake by decreas-

ing intake of fried foods, and recommending

stewing, steaming or grilling, and decreasing the

addition of fats to foods during cooking.

For almost all the foods that are major contrib-

utors to energy, fat and sugar, a healthy alternative

could be recommended and incorporated into the

diet with a small effort and little change to taste.

For example, for fish dishes, steaming could be

recommended rather than frying; for the chicken

dishes, the prefrying stage could be eliminated and

the chicken skin removed; rice dishes could be

prepared with less oil and more beans, or vegeta-

bles could be added; white bread could be replaced

S. Sharma et al.156



by whole meal or multigrain breads; for porridges

and cereals, less sugar or a sugar free sweetener

could be used, along with a low sugar, high fibre

cereal; roasted rather than fried nuts, maybe a

better snack food; an effort to increase fruit and

vegetable intake may also be beneficial.

We have already developed the QFFQ for the

BNCS and this instrument could be further mod-

ified to list, not only the original foods already

included, but also the healthier alternatives, so we

will be able to track changes in consumption pre-

and post-intervention, enabling an evaluation of

effectiveness of the intervention.

One of the strengths of this study is its popu-

lation-based sampling frame, with high participa-

tion. An important limitation is its small sample

size and results must be interpreted accordingly.

Nonetheless, the primary purpose of the food

diaries was to help us identify foods that con-

tribute significantly to the diet, so we may develop

a culturally appropriate nutritional intervention

program to reduce risk of chronic disease. Such

data were not previously available for imple-

menting dietary intervention studies in Barbados.

We believe that such purpose was achieved. While

the small sample size limited a meaningful evalu-

ation of the impact on food consumption of fac-

tors such as socio-economic status, including

education and occupation, as well as of dietary

patterns by age, future investigations of these is-

sues will be conducted on the overall BNCS par-

ticipants. Likewise, the representativeness of the

small subsample included in this report may have

been limited. However, the subsample and the

overall BNCS controls had a similar age distribu-

tion, with mean ages being 60 and 61 years

respectively.

The food diaries have determined nutrient in-

take and food sources of energy and macronutri-

ents in the diets of a population-based sample of

Barbadians, and provided strong justification for a

nutritional intervention program to reduce dietary

risk factors for chronic disease in this population

undergoing a rapid transition in diet. The inter-

vention could focus on specific foods, both in

terms of frequency of consumption and the

amount consumed. The BNCS QFFQ is a new

assessment tool that could be used at baseline and

then at follow-up to assess the impact of the

nutritional intervention on the overall diet of

Barbadians and similar populations.

Acknowledgments

We are also grateful to the Ministry of Health, Bar-bados, for conducting the BFCAS. We thank all staffand participants in the Barbados National CancerStudy (BNCS), without whose help the data could nothave been collected.

References

CFNI, PAHO and WHO: The Caribbean Food and Nutrition

Institute, The Pan American Health Organization, and

The World Health Organization. (2004) Uses of Food

Consumption and Anthropometric Surveys in the

Caribbean - How to Transform Data into Decision-

making Tools. Rome: Food and Agriculture Organiza-

tion of the United Nations.

CFNI: The Caribbean Food and Nutrition Institute. (1994)

Recommended Dietary Allowances for the Caribbean.

Kingston, Jamaica: Caribbean Food and Nutrition

Institute.

Corbin, D.O., Poddar, V., Hennis, A., Gaskin, A., Rambarat,

C., Wilks, R., Wolfe, C.D. & Fraser, H.S. (2004) Inci-

dence and case fatality rates of first-ever stroke in a

black Caribbean population: the Barbados Register of

Strokes. Stroke 35, 1254–1258.

Country fact sheets Human Development Report [Internet].

2007/2008 Barbados. The Human Development Index

going beyond income. Available at: http://htrstats.

undp.org/countries/country_fact_sheets/cty_fs_BRB.html

(accessed on 16 February 2008).

Cruickshank, J.K., Mbanya, J.C., Wilks, R., Balkau, B., For-

rester, T., Anderson, S.G., Mennen, L., Forhan, A., Riste,

L. & McFarlane-Anderson, N. (2001) Hypertension in

four African-origin populations: current ‘Rule of Halves’,

quality of blood pressure control and attributable risk of

cardiovascular disease. J. Hypertens. 19, 41–46.

CyberSoft Inc. (2004) Nutribase Clinical Nutrition Manager

v. 5.18. Phoenix, AZ: CyberSoft Inc.

FAO & NNCMH: Food and Agriculture Organization of The

United Nations & The National Nutrition Center Min-

istry of Health, Government of Barbados. (2005) The

Barbados Food Consumption and Anthropometric

Survey 2000. Rome: FAO, Viale delle Terme di Caracalla,

00100.

Figueroa, J.P. (2001) Health trends in Jamaica. Significant

progress and a vision for the 21st century. West Indian

Med. J. 50(Suppl. 4): 15–22.

Figueroa, J.P., Fox, K. & Minor, K. (1999) A behaviour risk

factor survey in Jamaica. West Indian Med. J. 48, 9–15.




Hennis, A., Wu, S.Y., Nemesure, B., Li, X., Leske, M.C. & for

the Barbados Eye Studies Group. (2002a) Epidemiologic

profile and implications of diabetes in an African-

Carribean population. Int. J. Epidemiol. 31, 234–239.

Hennis, A., Wu, S.Y., Nemesure, B., Leske, M.C. & for the

Barbados Eye Studies Group. (2002b) Hypertension

prevalence, control and survivorship in an Afro-Carib-

bean population. J. Hypertens. 20, 2363–2369.

Henry, F. (2004) Public Polices to Control Obesity in the

Caribbean. Kingston, Jamaica: Caribbean Commission

on Health & Development - Consultant Reports. Avail-

able at: Pan American Health Organization (PAHO).

Office of Caribbean Program Coordination http://

www.cpc.paho.org/publications/publication.aspx?id=60

(accessed on 1 December 2006).

IARC: International Agency for Research on Cancer. (2001)

GLOBOCAN 2000: Cancer Incidence, Mortality and

Prevalence Worldwide. Version 1.0. IARC Cancer Base

No. 5. Lyon: IARC Press.

Ragoobirsingh, D., Lewis-Fuller, E. & Morrison, E.Y. (1995)

The Jamaican Diabetes Survey. A protocol for the

Caribbean. Diabetes Care 18, 1277–1279.

Ragoobirsingh, D., McGrowder, D., Morrison, E.Y., John-

son, P., Lewis-Fuller, E. & Fray, J. (2002) The Jamaican

hypertension prevalence study. J. Natl Med. Assoc. 94,

561–565.

Ries, L.A.G., Eisner, M.P., Kosary, C.L., Hankey, B.F., Miller,

B.A., Clegg, L., Mariotto, A., Feuer, E.J. & Edwards, B.K.

(eds). (2005) SEER Cancer Statistics Review, 1975-2002.

Bethesda, MD: National Cancer Institute. Also available

at: http://seer.cancer.gov/csr/1975_2002/ based on

November 2004 SEER data submission (accessed on 31

October 2006).

Rotimi, C.N., Cooper, R.S., Okosun, I.S., Olatunbosun, S.T.,

Bella, A.F., Wilks, R., Bennett, F., Cruickshank, J.K. &

Forrester, T.E. (1999) Prevalence of diabetes and im-

paired glucose tolerance in Nigerians, Jamaicans and US

blacks. Ethn. Dis. 9, 190–200.

Sargeant, L.A., Wilks, R.J. & Forrester, T.E. (2001) Chronic

diseases–facing a public health challenge. West Indian

Med. J. 50(Suppl. 4), 27–31.

SAS Institute Inc. (2005) SAS Version 9.1. Cary, NC: SAS

Institute Inc.

Sharma, S., Harris, R., Cao, X., Hennis, A.J.M., Leske, M.C.

& The Barbados National Cancer Study Group (2007a)

Nutritional composition of composite dishes for the

Barbados National Cancer Study. Int. J. Food Sci. Nutr.

58, 461–474.

Sharma, S., Cao, X., Harris, R., Hennis, A.J.M., Leske, M.C.

& The Barbados National Cancer Study Group (2007b)

Dietary intake and development of a quantitative food

frequency questionnaire (QFFQ) for the Barbados

National Cancer Study (BNCS). Public Health Nutr. 10,

464–470.

Sharma, S., Cao, X., Gittelsohn, J., Ethelbah, B., Anliker, J. &

Caballero, B. (2007c) Dietary intake and a food fre-

quency instrument to evaluate a nutrition intervention

for the Apache in Arizona. Public Health Nutr. 10, 948–

956.

Sharma, S., Cao, X., Gittelsohn, J., Ho, L.S., Ford, E.,

Rosecrans, A., Harris, S., Hanley, A.J.G. & Zinman, B.

(2008) Dietary intake and development of a quantitative

food frequency questionnaire for a lifestyle intervention

to reduce risk of chronic diseases in Canadian First

Nations in Northwestern Ontario. Public Health Nutr.

(In press).

Wilks, R., Bennett, F., Forrester, T. & McFarlane-Anderson,

N. (1998) Chronic diseases: the new epidemic. West

Indian Med. J. 47(Suppl. 4), 40–44.

Wilks, R., Rotimi, C., Bennett, F., McFarlane-Anderson, N.,

Kaufman, J.S., Anderson, S.G., Cooper, R.S., Cruick-

shank, J.K. & Forrester, T. (1999) Diabetes in the

Caribbean: results of a population survey from Spanish

Town, Jamaica. Diabet. Med. 16, 875–883.

Wolfe, C.D., Corbin, D.O., Smeeton, N.C., Gay, G.H., Rudd,

A.G., Hennis, A.J., Wilks, R.J. & Fraser, H.S. (2006)

Estimation of the risk of stroke in black populations in

Barbados and South London. Stroke. 37, 1986–1990.

Appendix

Coordinating Center, Department of Preventive

Medicine, Stony Brook University. Stony Brook,

NY: M. Cristina Leske, Barbara Nemesure, Suh-

Yuh Wu. Clinical Center, Ministry of Health,

Barbados, and University of the West Indies,

Bridgetown, Barbados: Anselm Hennis, Rachel

Harris, Lynda Williams, Lyndon Waterman.

NHGRI Center, National Human Genome

Research Institute, Bethesda, MD: Joan Bailey-

Wilson. Gene Discovery Center, Translational

Genomics Institute, Phoenix Arizona: John Carp-

ten, Jeffrey Trent. Cancer Etiology Program, Can-

cer Research Center of Hawaii, University of

Hawaii, Honolulu, Hawaii: Sangita Sharma, Xia

Cao.

S. Sharma et al.158



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