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.
Dietary intake and development of a QFFQ for the BNCS 467
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.
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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
Dietary intake and development of a QFFQ for the BNCS 469
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
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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
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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
Assessing dietary patterns in Barbados 153
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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
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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
Assessing dietary patterns in Barbados 155
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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
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� 2008 The British Dietetic Association Ltd 2008 J Hum Nutr Diet, 21, pp. 150–158
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.
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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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� 2008 The British Dietetic Association Ltd 2008 J Hum Nutr Diet, 21, pp. 150–158