European Journal of Clinical Nutrition (2003) 57, 629635

2003 Nature Publishing Group All rights reserved 09543007/03 $25.00

www.nature.com/ejcn

ORIGINAL COMMUNICATION
Validation of a semi-quantitative adolescent food
frequency questionnaire applied at a public school
o Paulo, Brazil
in Sa
B Slater1*, ST Philippi1, RM Fisberg1 and MRDO Latorre2
1
Department of Nutrition, School of Public Health, University of Sao Paulo, Sao Paulo, Brazil; and 2Department of Epidemiology,
o Paulo, Sa
o Paulo, Brazil
School of Public Health, University of Sa

Objective: To develop a food frequency questionnaire for adolescents (AFFQ) and demonstrate its relative validity.
Design: The final version of the AFFQ was composed of 76 food items previously identified according to their contribution in
nutrients and overall importance within the eating habits of this population group. The validation study, which was undertaken
during a 6 month period (June to November 1999), was administered to a sample of 79 who answered at least three 24 h dietary
recalls (R24 h) applied at intervals of 45 days and one AFFQ at the end of the study. Applying the paired t-test and calculating
Pearson correlation coefficients on nutrient data, differences in the mean of nutrients were obtained. Correlation coefficients
between the mean energy-adjusted nutrients computed by the two methods were calculated, and correction was made for
within-person variability. Agreement was evaluated by distribution of the adolescents according to quartiles of consumption.
Locus: A public school within the metropolitan region of Sao Paulo city.
Results: A high variability in the dietary intake of adolescents was observed, with high rates of variability for cholesterol, retinal
and vitamin C. The Pearson correlation coefficients, after being adjusted and corrected for variability, ranged from 0.10 to 0.72
among females and from 0.16 and 0.91 among males. The mean correlation coefficient for the entire group was 0.52.
Conclusions: These results indicate that the AFFQ provides a potentially reliable scale for categorizing individuals by level of past
intake of most nutrients, excluding retinol and iron.
European Journal of Clinical Nutrition (2003) 57, 629 635. doi:10.1038=sj.ejcn.1601588
Keywords: nutritional assessment; food frequency questionnaire; adolescents

Introduction
In the last few years, evidence has emerged concerning the
possible relations between diets of children and adolescents
and chronic diseases in adult life (Ludwig et al, 2001).
Adolescent eating habits are highly influenced by family
patterns, habits and the peer group, and by the growing

o da Faculdade de
*Correspondence: B Slater, Departamento de Nutrica
Saude Publica=USP, Av. Dr Arnaldo, 715-CEP: 01246-904, Cerqueira Cesar,
o Paulo, SP, Brazil.
Sa
E-mail: betzy_slater@hotmail.com
Guarantor: B. Slater
Contributors: BS responsible for research design, conduction of the
study and for the writing the document. STP was the advisor of
the study. RMF collaborated in the interpretation and discussion
of the studys results. MRDOLT collaborated in the statistical
analyses and interpretation of the results.
Received 27 February 2002; revised 1 July 2002;
accepted 2 July 2002

concern with body image. Habits such as skipping a meal

(particularly breakfast), consuming high-energy foods which
are poor in nutrients and the tendency, among girls, to make
dietetic restrictions are part of the repertoire of Brazilian
adolescents eating behavior (Fisberg et al, 2000).
Since longitudinal studies that evaluate adolescent food
intake are non-existent in Brazil, we have relied solely on
cross-sectional studies that make use of dietary records or
24 h recalls. These methods are accepted conceptually as
means of providing valid information about present diet
(Thompson & Byers, 1994), however an important
limitation is that a single day of application does not represent habitual diet.
Food frequency questionnaires (FFQ) are widely accepted
in epidemiological studies which associate diet with
chronic diseases for two reasons: first because they substitute the measurement of one or several days of food intake
for global information on a wider period of time and,

Validation of semi-quantitative adolescent FFQ

B Slater et al

630
second, because they are relatively inexpensive when selfadministered (Jime nez & Martn-Moreno, 1995; Ocke et al,
1997). The literature indicates that studies which utilize
FFQs in order to evaluate childrens and adolescents food
intake are scarce. There is, therefore, a need to develop new
instruments which can be easily administered to large
groups and which are simple so they can be self-administered
and which will be able to evaluate habitual diet among
adolescents.
The main objective of this study was to develop a food
frequency questionnaire for adolescents, AFFQ , and evaluate
the relative validity of the estimates of energy, macronutrients, retinal, cholesterol, dietary fiber, vitamin A, calcium
and iron consumption.

Methods
Development of the AFFQ structure
Data concerning food habits registered in a study on nutritional evaluation conducted by Nuzzo (1998) was utilized in
the elaboration of the AFFQ list of foods. The information
regarding diet in the former study corresponds to the application of 2 days of the dietary record method in 200 adolescents of both sexes. The foods were grouped together
according to their physical characteristics and nutritive
value in 140 food items. Based upon this grouping, the
foods that made a greater contribution, both energetically
and in terms of their nutrients, were identified (Block et al,
1985a,b).
Having defined a food list, the AFFQ was tested in a pilot
study, in which 76 food items were included. This questionnaire evaluated the quantity of foods and nutrients consumed during the preceding 6 month period. The frequency
of consumption was evaluated by means of simple questions

Figure 1

Format of the adolescent food frequency questionnaire.

European Journal of Clinical Nutrition

and closed answers in which different time units were

established. The seven categories of responses for each food
item were: never, less than once a month, 1 3 times a
month, once a week, 2 4 times a week, once daily, and
twice daily or more (see Figure 1).
The size of the portions of food express mean intake in
grams for each food item except for 10 items which presented differences in intake between males and females
participating in the study. For these items, the median
value of side portion of food was utilized.

Validation study
Description of the population and of the design of the
validation study. The validation study was conducted
between June and December 1999, the period during
which data were collected. The population study consisted
of 106 adolescent volunteers of both sexes, aged 14 18 y and
11 months, registered in the first year of a junior high school
located in the western region of Sao Paulo city. The relative
validity of the study was evaluated by comparing the standard measure with the data collected by the AFFQ. During
this period the students completed three 24 h dietary recalls
administered on nonconsecutive days including one day
during a weekend, with 45 day intervals between them and
one AFFQ applied at the end of the period.

Data processing
Once the data was collected, the food intake registered by
the 24 h dietary recall and the AFFQ were converted into
energy and nutrients by the Virtual Nutri program (Philippi
et al, 1996).

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631
Statistical analysis
The differences in mean consumption of energy and nutrients obtained by the AFFQ and by the 24 h dietary recalls
were analyzed using paired t-test. The correlation coefficient (r), which compared the energy and nutrient values
obtained by both methods, was calculated before and after
adjustment for total energy intake (Willett & Stampfer,
1986).
Within-person variance (ie day-to-day variation in diet)
estimated in the recalls could attenuate correlations between
the AFFQ and the 24 h recalls, due to the relatively low
number of replicates. In order to obtain a measure of validity,
the correlation coefficient was multiplied by factor
(1 (s2w=s2b)n)0.5) where n represents the number of replicate
measurements, s2w is the within-person variation and s2b is
the between person variation. The result thus obtained is the
de-attenuated correlation coefficient (Willet, 1998). To evaluate the agreement of classification according to the levels
of nutrient intake between the AFFQ and the 24 h-dietary
recall, we compared the quartile classification obtained by

both methods. The cut-off point was determined separately

for the questionnaire and for the mean of the three 24 h
dietary recalls. In this way, agreement and disagreement
between categories were evaluated by the total proportion
of participants correctly classified in the same quartile and in
opposite quartiles.

Results
Within the study period, from June to November 1999, 79 of
the 106 students completed three 24 h dietary recalls and the
AFFQ. Among the students who participated in this study,
50.6% were female and 49.4% were males. The average age
was 15.8 y (s.d. 1.09).
No statistically significant differences were found between
the mean values estimated by the three 24 h recalls and the
AFFQ for energy intake, total fat, vitamin C and calcium. On
the other hand, the AFFQ overestimated the values of carbohydrates and fiber and underestimated those of proteins,
cholesterol, unsaturated fat and iron (Table 1). Upon

Table 1 Mean, standard deviation and median daily intake assessed by three 24 h recall and AFFQa among 79 adolescents
attending public high school in Sao Paulo, Brazil
24 h recall
Nutrients
Energy (kcal)
Female
Males
Total proten (g)
Female
Males
Total carbohydrates (g)
Female
Males
Total fat (g)
Female
Males
Polyunsaturated fat (g)
Female
Males
Dietary fiber (g)
Female
Males
Cholesterol (mg)
Female
Males
Retinal (mg ER)
Female
Males
Vitamin C (mg)
Female
Males
Calcium (mg)
Female
Males
Iron (mg)
Female
Males

AFFQ

Median

Mean

s.d.

Mean

s.d.

24 h recall

AFFQ

Pb

2004.87
1731.94
2284.79
79.52
66.12
93.27
242.18
210.89
274.29
78.63
67.87
89.65
31.63
26.08
37.33
10.56
7.87
13.31
239.70
204.60
275.70
745.64
608.28
886.52
69.83
64.28
75.52
584.88
481.30
691.12
11.73
9.09
14.45

728.76
572.58
766.87
34.83
28.10
35.80
90.23
78.22
90.73
39.02
30.60
43.53
20.79
16.41
23.21
6.32
4.82
6.50
153.50
138.75
160.02
831.98
830.23
813.39
86.59
81.43
91.58
384.17
301.13
429.83
5.62
4.18
5.62

2023.59
1763.71
2290.11
69.14
62.27
76.18
265.40
226.82
304.97
76.60
68.52
84.90
25.74
22.93
28.62
11.70
10.31
13.13
204.56
182.98
226.70
614.94
596.55
633.80
79.91
69.84
90.24
561.40
507.00
617.20
8.43
8.44
10.15

563.36
451.10
546.46
20.04
17.95
19.83
75.96
61.96
68.76
24.83
19.96
26.78
9.54
7.82
10.35
4.40
4.08
4.30
83.38
89.30
71.35
243.50
272.89
211.06
41.62
33.43
46.83
223.49
232.67
201.63
2.49
2.49
2.79

1927.28
1686.84
2125.93
77.29
62.48
86.61
222.78
206.77
253.05
74.72
62.91
82.25
28.49
23.92
36.21
9.95
7.11
12.26
222.74
182.11
249.78
612.66
547.53
695.74
55.33
44.23
57.69
577.55
421.44
622.18
11.04
8.84
13.45

1920.47
1681.79
2270.48
65.34
63.27
74.39
264.94
218.90
318.34
72.28
66.68
79.91
24.87
22.32
28.00
10.90
9.86
12.47
198.16
175.34
221.99
581.04
511.91
611.98
74.35
61.82
81.44
569.07
471.23
597.04
8.63
7.89
9.39

0.560
0.407
0.919
0.001
0.213
0.001
0.001
0.029
0.001
0.370
0.826
0.167
0.001
0.061
0.001
0.012
0.001
0.787
0.003
0.197
0.003
0.048
0.895
0.010
0.103
0.526
0.096
0.386
0.387
0.105
0.001
0.209
0.001

AFFQ, adolescent food frequency questionnaire.

Paired students t-test (P < 0.05).

European Journal of Clinical Nutrition

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632
examining the 11 dietetic variables, it was found that only
two of them presented different mean intakes among the
female participants of this study, being the overestimation of
dietetic fiber in approximately 30% (P > 0.001) the most
relevant difference found. Among the male participants,
five nutrients presented different mean intakes, these were:
protein, carbohydrate, dietetic fiber, unsaturated fat, cholesterol and iron (P < 0.05).
The ratio of the components of within-person and
between-person variability which ranged from 1 to 2 for
energy, protein, carbohydrates, dietetic fiber and iron for
all individuals and which was greater than 2 for the rest of
the nutrients studied, being that patterns of within-person
variability were more pronounced among the adolescent
boys than among the adolescent girls. However, retinol was
an exception for the pattern of within-person variability
being, in this case, more pronounced among the girls. The
ratios for cholesterol and vitamin C among the adolescent
boys caught our attention, as they were extremely high
(Table 2).

The unadjusted values were loge transformed since the

observed distribution was asymmetric for all nutrients studied. Analysis of the correlation between the values of the
nutrients estimated by the AFFQ and those estimated by the
average of the three 24 h recalls demonstrated a high correlation for energy (r 0.87) and reasonable correlations for
macro and micronutrients (r 0.42 0.77). Retinal was the
only exception, presenting a low correlation, r 0.28
(Table 3).
All the values of the correlation coefficients tended to
decrease after being adjusted for energy. The adjusted values
were 50% lower than the unadjusted values, however, when
adjusted, the correlation coefficients of cholesterol, retinol
and iron were no longer significant. The correlations ranged
from 70.07 to 0.49 for the adolescent girls and from 0.11 to
0.62 for the adolescent boys.
Adjustment for within-person variability increased all
values of the correlation coefficients. Whereas the unadjusted value for retinal was r 0.06, the adjusted value was
r 0.10 and, as for fiber, the unadjusted value was r 0.54

Table 2 Variance components of the nutrient intakes estimated by three 24 h recalls among 79
adolescents attending public high school in Sao Paulo, Brazil
24 h dietary recalls
Nutrients
Energy (kcal)
Female
Males
Total protein (g)
Female
Males
Total carbohydrates (g)
Female
Males
Total fat (g)
Female
Males
Polyunsaturated fat (g)
Female
Males
Dietary fiber (g)
Female
Males
Cholesterol (mg)
Female
Males
Retinal (mg ER)
Female
Males
Vitamin C (mg)
Female
Males
Calcium (mg)
Female
Males
Iron (mg)
Female
Males
a

l Sw=Sb.

European Journal of Clinical Nutrition

Variance ratios
1.4
1.3
2.9
1.7
2.1
3.8
1.2
1.4
1.7
2.5
2.5
4.1
2.5
2.9
3.6
1.6
2.6
3.4
5.9
7.6
10.4
4.7
26.4
2.5
8.2
5.1
14.35
2.7
3.2
3.8
1.4
2.4
3.6

Within-person variance

Between-person variance

311 761.95
189 326.37
437 336.91
772.93
533.38
1018.64
4383.26
3542.82
5245.24
1090.01
673.40
1517.30
310.55
200.58
423.33
24.74
16.91
32.77
20 186.06
17 056.30
23 396.08
571 837.34
664 563.15
476 333.94
6687.93
5554.74
7850.17
107 741.82
69 433.99
147 031.90
18.51
12.37
24.80

221 210.21
140 889.1
153 400.34
444.05
260.64
267.79
3790.12
2619.84
3040.60
426.41
267.95
383.97
122.78
69.91
117.36
15.33
6.52
9.60
3411.42
2232.16
225 013
121 374.90
25 135.21
88 109.09
816.73
1094.60
546.97
40 183.66
21 610.00
38 379.83
13.17
5.21
6.95

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633
Table 3 Pearson correlation coefficients between daily intake of energy and nutrients assessed by three 24 h recalls and AFFQa among 79
adolescents attending public high school in Sao Paulo, Brazil
Correlation coefficients
Non-adjusted b r
Nutrients

De-attenuated c r

Energy-adjusted r

Total

Female

Male

Total

Female

Male

Total

Female

Male

Energy (kcal)
Total protein (g)
Total carbohydrates (g)
Total fat (g)
Polyunsaturated fat (g)
Dietary fiber (g)
Cholesterol (mg)
Retinol (mg ER)
Vitamin C (mg)
Calcium (mg)
Iron (mg)

0.87**
0.63**
0.77**
0.72**
0.57**
0.59**
0.44**
0.28*
0.42**
0.61**
0.46**

0.86**
0.47**
0.70**
0.68**
0.46**
0.48**
0.33*
0.18
0.27
0.60**
0.30

0.82**
0.66**
0.71**
0.69**
0.60**
0.56**
0.44**
0.39*
0.56**
0.50**
0.43**

0.31**
0.58**
0.40**
0.35**
0.56**
0.26
0.06
0.47**
0.51**
0.17

0.17
0.12
70.07
0.26
0.48**
0.20
0.01
0.37
0.50**
0.10

0.21
0.43**
0.33*
0.37*
0.62**
0.30
0.18
0.56**
0.46**
0.11

0.38
0.68
0.54
0.48
0.69
0.52
0.10
0.91
0.70
0.22

0.22
0.15
70.10
0.36
0.66
0.37
0.03
0.61
0.72
0.13

0.32
0.53
0.51
0.55
0.91
0.64
0.24

0.69
0.16

Mean

0.57

0.48

0.58

0.37

0.36

0.52

0.34

0.51

0.23

AFFQ, adolescent food frequency questionnaire.

Nutrient values were transformed (loge) to improve normality.
c
The de-attenuated correlation coefficients was calculated using the ratio of the within- to between-person variability measured from three 24 h dietary
2
2
0.5
recalls. The formula used was: rc ro(1 (sw = sb)n) .
*P < 0.05; **P < 0.01.
b

Table 4 Cross-classification of nutrient distribution quartiles from 24 h recalls and AFFQa calculated from energy-adjusted nutrient intake (except
for total calories), Sao Paulo, Brazil
Lowest quartile 24 h recall

Highest quartile 24 h recall

Overall

Lowest quartile
AFFQ (%)

Highest quartile
AFFQ (%)

Highest quartile
AFFQ (%)

Lowest quartile
AFFQ (%)

Exact
agreement (%)

Opposite
(%)

Total protein (g)

Total carbohydrates (g)
Total fat (g)
Polyunsaturated fat (g)
Dietary fiber (g)
Cholesterol (mg)
Retinal (mg ER)
Vitamin C (mg)
Calcium (mg)
Iron (mg)

26
42
32
37
47
26
32
47
63
16

16
11
16
5
0
16
21
0
11
10

30
45
25
30
45
30
30
55
55
25

20
10
10
20
5
5
10
5
10
20

30
35
28
29
39
23
25
43
56
20

9
5
6
6
1
5
8
1
5
8

Mean

37

11

37

12

33

Nutrients

AFFQ, adolescent food frequency questionnaire.

and the adjusted value was 0.67. Relatively high values

were also observed for fiber and vitamin C among the
adolescent boys.
Table 4 demonstrates that, on average, 33% of the
individuals were classified in the same quartile and 5%
were misclassified. The proportion of individuals classified
in the lowest quartile both by the 24 h recalls and the AFFQ
appear in the first column of the same table. This proportion ranged form 16% for iron to 63% for calcium. Agreement within this category for the different nutrients
averaged 37%.

Discussion
The AFFQ was judiciously designed following the recommendations of Block et al, (1985a,b), Willett (1998), and
Nelson (1997) for determining a list of foods and portions
sizes according to gender and coherent with dietary patterns
and eating habits of the population group which was the
object of this study.
Comparing the AFFQ with the 24 h dietary recalls, similar
values for energy, carbohydrates, total fat and calcium intake
were observed, suggesting a high consistency in estimating
these nutrients. However there was a significant difference
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634
for the seven remaining nutrients (protein, polyunsaturated
fat, dietary fiber, cholesterol, retinal, vitamin C and iron).
The results of this validation study explain why there is
such considerable variability in the daily consumption calculated by means of the 24 h recalls. Our results are similar to
those of Beaton et al (1983), Sempos et al (1985) and Field et al
(1999), although only the latter was administered to children.
Patterns of within-person variability derive primarily from
individuals social behavior, although other factors are also
responsible. Harbottle and Duggan (1994), Tsubono et al
(1998) and Friis et al (1997) suggest that nutrients which
are part of the daily diet, that is, which are consumed on a
regular basis (eg macronutrient intake) have smaller variance
ratios (l) than those nutrients with a high within-person
variability, as in the of retinol, vitamin C and cholesterol in
the present study.
Considering the unadjusted correlation, higher values
(mean r 0.57) were observed compared with studies conducted by Rockett et al (1997), r 39, and Field et al (1999),
r 0.28.
The fact that the correlation diminished considerably
after adjustment for total energy intake led us to search for
possible answers. According to Willet (1998), this procedure
increases the correlation coefficient when variability of
nutrient consumption is related to energy intake, but
decreases when variability of the nutrient depends on systematic errors of overestimation and underestimation. In
studies focusing on adults by Willett et al (1985), Overvad
et al (1991) and Rimm et al (1992), this procedure confers
more relevant r values. In studies conducted in Greece, by
Gnardellis et al (1994) and in the USA by Munger et al (1992),
the two effects (increasing and decreasing the correlation)
happen simultaneously for the different nutrients analyzed.
On the other hand, in the study conducted by MartnMoreno et al (1993), in Spain, the effect is particularly
insignificant.
Although the 24 h recall is conceptually different from the
AFFQ , both methods have a common characteristic, namely,
they share some of the same sources of errors such as the sub
under- or overestimation of the quantities of foods consumed due to memory flaws. In this sense, artificially high
correlations, as is the case with energy (female, r 0.87;
male, r 0.82), may be explained.
Given a situation in which all elements of the diet are
informed proportionally, we can presume that energy adjustment may compensate for errors in general information. The
modest correction using the strategy of energy adjustment in
Flegal and Laarkins study, and the correlation coefficient
decrease in this study, led us to question the validity of this
statement. We may suppose that the subject in this study did
not report the nutrients in a similar way when answering
both instruments. Therefore, although energy adjustment
has made it possible to remove general and common differences between the methods, it did not permit differences
resulting from disproportional information to be removed
(Flegal & Laarkin, 1990; Flegal, 1999).
European Journal of Clinical Nutrition

Other aspects to be considered in dietetic studies carried

out among children and adolescents are the additional
difficulties related to cognitive skills in registering and recalling what food they have eaten (Rockett & Colditz, 1997).
Subjective aspects must also be taken into consideration: the
perception and quantification of the portion size and the
social value associated with some foods. According to Goran
(1998), children and adolescents tend to have better recall of
the preferred foods, informing that they have consumed
large portions. However, they tend to forget or underestimate those items which they do not like.
The values of energy-adjusted correlation coefficients
were corrected afterwards by variance. After this procedure,
more precise estimates were obtained for all nutrients,
mainly for fiber, vitamin C and calcium, for which there
were very good correlations. The increased values may be
attributed to elevated within-person variability observed,
particularly for retinol among the adolescent girls and vitamin C among the adolescent boys.
One of the arguments for adopting the cross-classification
procedure is that correlation coefficients do not capture
differential under- and over-reporting. The extent of such
biases, however, are difficult to address or quantify (Friis et al,
1997). This form of presentation of the data provides compact information concerning the capacity of both methods
to allocate individuals according to dietary intake distribution, being considered, in this sense, more adequate than the
correlation coefficient, which merely produces information
concerning the possible relations between the variables estimated by both methods.
A recent study by Cardoso et al (2001) among women
of Japanese ancestry living in Brazil showed similar proportion of subjects in the same quartile (exact agreement
mean 36%) and the extreme opposite quartile (4%). Nutrients such as protein, retinal and iron, displayed the highest
percentages of disagreements between the two methods in
the present study (9 and 8%, respectively), even 3 days of
24 h dietary recalls were insufficient to measure accurately
the habitual diet of this group of adolescents.
This fact illustrates an important component of variation
within the diet, particularly for this group of adolescents
where high rates of within-person variance were also
observed. This study demonstrated the questionnaires capacity to classify individuals according to their past intake of the
nutrients studied, excepting of retinol and iron. The AFFQ did
not perform as well for the females as it did for the males in
adequately classifying individuals according to their total fat
and protein intake. The procedure of energy adjustment, as
well as correction by within-person variance, allowed us to
obtain more precise estimates of the validity coefficient.

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