Nutrition and Food-related behaviour (ancillary study)

Nutrition and Food-related Behaviour study 2014-2015 (ancillary study)

Filename: LASAxxxx (to be determined)
Contact: Marjolein Visser

Background
Lifestyle plays a major role in health and disease. Unhealthy diets and physical inactivity are amongst the most important causes of major non-communicable diseases, such as cardiovascular disease, obesity, diabetes mellitus type II and certain cancers (1). In contrast, a good nutrient status and a healthy food intake, including high intakes of fruit, vegetables, fish and wholegrains, are associated with health benefits (2-4) and lower mortality risk (5, 6). More recently, a link between diet and mental health has been suggested, such as depression and cognition (7-10). As diet is a modifiable risk factor, it plays an important role in the prevention of these diseases. With data on diet, many determinants and outcomes in relation to food(-related behaviour) can be studied.

Dietary data within LASA
Qualitative information on specific diets, use of fruits, vegetables and dairy products, and number of eating moments during the day was obtained at some regular waves in the first LASA cohort (waves B, C, D and E, see documentation on Diet and food consumption). Further, quantitative information on dietary intake (fruit, vegetables, fish, alcohol) and eating habits was collected from 1058 respondents in the Lifestyle side study in 2007. Data on use of food supplements have also been collected, mainly in the I- and J-wave (see documentation on medication and food supplement use). In addition, the Nutrition and Food-related Behaviour study has collected quantitative data on respondents’ complete al intake as well as food-related behaviour. This extensive study was conducted between the fall of 2014 and spring of 2015 as part of the European Union project called MooDFOOD: a Multi-country cOllaborative project on the rOle of Diet, FOod-related behaviour, and Obesity in the prevention of Depression (www.moodfood-vu.eu).

Measurement instruments in LASA
The Nutrition and Food-related Behaviour study consisted of a questionnaire and, in a subgroup, multiple 24-hour dietary recalls.

Questionnaire
The questionnaire consisted of a semi-quantitative food frequency questionnaire (FFQ), questions on food-related behaviour (such as emotional eating, overeating, meal skipping, snacking, food preparation, sustainability and mindful eating), and questions on body weight, weight change in the past 6 months, depressive symptoms and under (see Table 1).
The questionnaire was available in a paper version and online version. The variable ‘vrlversie’ indicates which version the respondent has completed. During the development, the questionnaire was pilot tested for understandability and duration of completion (18 persons in total: 7 on paper, of which 2 persons out loud, and 11 online).

Table 1: Content of the questionnaire

Section	Topic	Subtopic	Heading in questionnaire (in Dutch)	No. of items
0	General	Date + person of completion Date of birth + gender	Datum + invuller Geboortedatum + geslacht	2 2
1	Food frequency questionnaire	Eating pattern Food intake	A. Voedingspatroon B. Voedingsmiddelen	10 76
2	Food-related behaviour	Weight(loss) and appetite Mindful eating Meals and snacks Interoceptive awareness of hunger and satiety Alexithymia Binge eating Eating styles Problems food intake Use of amenities Food products for older adults Dietary recommendations	C. Gewicht G. Eten met aandacht H. Maaltijdgebruik en tussendoortjes I. Honger en verzadiging J. Gevoelens K. Eetbuien L. Eetgedrag M. Problemen voedingsinname N. Gebruik voorzieningen O. Voedingsmiddelen voor ouderen P. Voedingsadviezen	13 25 8 4 12 1 20 10 7 5 8
3	Sustainability	Sustainable behaviour	Q. Duurzaamheid	6
4	Mental health	Change in sleep and change in appetite Depressive symptoms Mental health problems	D. Slaap en eetlust E. Stemming F. Psychische problemen	2 20 3

The dataset is splitted in two parts: the Food Frequency Questionnaire (FFQ; including sections 0 and 1; dataset ‘FFQ’) and the Food-related Behaviour part (FRB; including sections 0, 2, 3 and 4). The FRB part is further subdivided per subtopic and there is a dataset for each subtopic (‘FRB_Xcrude’). Below, the subtopics are described.

Eating pattern (A. Voedingspatroon)
Ten questions are asked about meal preparation, frequency of meals, type of meals, and following a specific diet or regime.

Food intake (B. Voedingsmiddelen)
The Dutch version of the FFQ of the HELIUS Study (Amsterdam Medical Center; AMC) is used. This FFQ was developed by the AMC, the National Institute for Public Health and the Environment (RIVM) and Wageningen University. It consists of 76 questions about 238 food items and asks for consumption during the past 4 weeks. A nutrient database was constructed based on the Dutch Food Composition Table (Nederlands Voedingsstoffenbestand (NEVO)) 2011 (11). Each food item in the FFQ was linked to one or more foods of the nutrient database to calculate the intake of macro- and micronutrients (see Table 2). More information on the development of the FFQ can be found in Beukers et al. (12).

Next to the original FFQ items, the following information on food intake is available in the FFQ dataset:

• Cleaned frequency of consumption of each food item in number of times per day in the past 4 weeks (‘NXX_freq’). For this cleaned frequency, it was assumed that if the frequency question – question a – was missing, the food item was not eaten in the past 4 weeks.
• title=”table 2 nutrients FFQ”>Table 2).
• Several ‘inconsistency variables’ (in Dutch: foutvariabelen): additional variables were computed to indicate inconsistencies in respondents’ answers (see also below under ‘Recommendations and remarks FFQ’).

Weight (loss) and appetite (C. Gewicht)
Current body weight is asked (C1) as well as perception of body weight (C2, C3). Body dissatisfaction is measured with Stunkard’s Figure Rating Scale; respondents are asked to select the silhouette that best indicates his or her current body size and the silhouette that reflects his or her ideal body size (C4, C5) (15). Please note that Stunkard’s Scale is asked at earlier regular waves. In addition, five items of the Short Nutritional Assessment Questionnaire 65+ (SNAQ65+) are included about unintentional weight loss change in past 6 months, appetite and physical functioning (C6 to C10) (16). Last, three items from the Simplified Nutritional Appetite Questionnaire (SNAQ) are asked about appetite and satiety; the fourth SNAQ-item is asked in ‘Meals and snacks’ as question H1 (17).

Instead of self-reported body weight (C1), measured body weight and height from the regular waves before (wave H/3B) and after (wave I) this side study can be used. For example, BMI can be calculated from measured body weight. This has been done by using the mean weight of wave H/3B and wave I, and the height of wave I. The mean of these two waves was chosen because the side study was performed between them (see Availability of information, elsewhere on this page). The computation of BMI – including syntax – is explained in this file (pdf).

Mindful eating (G. Eten met aandacht)
This subtopic can be divided into ‘mindful eating’ (G1 to G20) and ‘routine’ (G21 to G25). All answer categories range from ‘never’ (1) to ‘very often’ (5).

Mindful eating is measured with the Mindful Eating Behaviour Scale (MEBS) (18). This scale consists of 17 items on four domains: ‘Focused Eating’, ‘Hunger and Satiety Cues’, ‘Eating with Awareness’ and ‘Eating without Distraction’. Because of low inter-factor correlations, a total score combining the four domains should not be computed. More information on the development and psychometric properties can be found in Winkens et al. (18).

The questions on routine are not part of the Winkens Mindful Eating Behaviour Scale. ‘Eating routine’ is measured with four items from the subscale ‘Routine’ (G21 to G24) and one item (‘I need to eat like clockwork’ G25) from the subscale ‘Non-reactivity’ of the Mindful Eating Scale (19).

Meals and snacks (H. Maaltijdgebruik en tussendoortjes)
Next to the fourth SNAQ item about the number of meals per day (H1, see ‘Weight (loss) and appetite’), there are questions about the frequency of eating a warm meal and replacing the warm meal with something easy to prepare (H2, H3). The next five questions are about the frequency of eating snacks at specific times during the day (H4-8).

Interoceptive awareness of hunger and satiety (I. Honger en verzadiging)
Respondents are asked about the frequency of a feeling of have eaten too much/less during the day at the end of the day (I1, I2). Poor interoceptive awareness (IA) is measured with two items of the 10-item IA-scale of the Revised Eating Disorder Inventory-II (I3, I4) (20, Dutch version: 21). The wording of one item (I3) was adjusted based on results of a pilot study; the answer categories range from ‘never’ (1) to ‘very often’ (5).

Alexithymia (J. Gevoelens)
Alexithymia is a personality construct characterized by the subclinical inability to identify and describe emotions in the self. It is measured with the scales ‘Difficulty Identifying Feelings’ (7 items) and ‘Difficulty Describing Feelings’ (5 items) from the Toronto Alexithymia Scale-20 (TAS-20; 22). The third scale ‘Externally Oriented Thinking’ was not included because it appears to be unreliable (23).

Binge eating (K. Eetbuien)
It is asked whether the respondent experiences binge eating episodes. If the respondent’s answer is ‘yes’, (s)he needed to indicate the frequency of these episodes in the past three months and the frequency of loss of control during an episode. This item is an additional question from the Dutch Eating Behaviour Questionnaire (see ‘Eating styles’).

Eating styles (L. Eetgedrag)
The eating styles emotional, external and restrained eating are measured with the brief 20-item version of the 33-item Dutch Eating Behaviour Questionnaire (DEBQ) (24, Dutch version: 25). Six items of the DEBQ-20 are on emotional eating; the scales on external and restrained eating have seven items each.

The 33-item DEBQ has been rated as ‘up to the mark’ or ‘good’ by the Dutch Committee on Tests and Testing (COTAN) on all European Federation of Psychologists’ Association (EFPA) criteria (e.g. norms, reliability (internal consistency, test-re-test) and validity (dimensional validity, construct validity and criterion validity) (26). The psychometric properties of the brief 20-item version has yet to be determined.

The DEBQ (all language versions) is protected by copyright by the publisher of the manual and questionnaire: Hogrefe, Amsterdam. Since the DEBQ-20 consists of a selection of the items of the 33-item DEBQ, also the DEBQ-20 is protected by copyright.

Problems food intake (M. Problemen voedingsinname)
Ten questions address potential al problems, such as problems with chewing, swallowing, autonomously eating, doing groceries and preparing a meal. For each problem – if answering yes – it is asked how often this problem leads to a lower intake than what is preferred.

Use of amenities (N. Gebruik voorzieningen)
The frequency of using several amenities concerning groceries and meals are asked, such as groceries delivery, Meals on Wheels (“Tafeltje-dek-je”), eating ready-to-eat meals and eating outdoors at a care home or at family/friends’ homes.

Food products for older adults (O. Voedingsmiddelen voor ouderen)
In the future, more food products specifically developed for older adults may become available in the supermarkets. Five potential reasons to buy such products are asked for, such as to eat healthily and to prevent a disease. Answer categories range from to ‘strongly disagree’ (1) to ‘strongly agree’ (5).

Dietary recommendations (P. Voedingsadviezen)
For eight dietary recommendations, it is asked how important this recommendation is for the respondent. Answer categories range from to ‘not important’ (1) to ‘very important’ (5).

Sustainable behaviour (Q. Duurzaamheid)
Six questions address sustainable food-related behaviour, such as bringing your own shopping bag, buying locally produced products and using food left-overs. Answer categories range from to ‘never’ (1) to ‘very often’ (5). The English items were translated to Dutch and back-translated to English (US) by a US native speaker.

Change in sleep and appetite (D. Slaap en eetlust)
Questions about change in sleep and change in appetite during the past 4 weeks are asked. If the respondent’s answer is ‘yes’, (s)he need to indicate whether (s)he sleeps/eats less or more. These questions are based on two items of the Beck Depression Inventory II (BDI-II) (27).

Depressive symptoms (E. Stemming)
Depressive symptoms in the past week are measured with the Center for Epidemiological Studies Depression Scale (CES-D), a self-report symptoms-rating scale consisting of 20 items (28). Please note that the CES-D is also assessed at each regular LASA wave using an interviewer-administered questionnaire (see documentation on Depressive Symptoms). Please be aware of the mode difference between self-completed questionnaires and interviewer-administered CES-D assessments, which affects the CES-D scores (29).

Mental health problems (F. Psychische problemen)
Questions on previous and current mental health problems are asked: type of problems, being under treatment of a doctor/psychologist and the use of medication for mental health problems prescribed by a doctor (in the past three years and currently).

24-hour dietary recalls
Twenty-four-hour dietary recalls were collected by telephone in a subsample of 93 respondents (response rate 95.9%; see the variable ‘selectionrecalls’). These respondents, who had filled out the questionnaire and had indicated to be willing to participate in a supplementary study, were randomly selected stratified for type of questionnaire (paper or online) and receipt date. The participants were sent a booklet with colour pictures of various food products (ranging from a buttered slice of bread to a plate with vegetables or pasta sauce) using different portion sizes. They were also instructed to measure the content of frequently used glasses, cups, bowls and serving spoons. To exclude the influence of season on food intake between the FFQ and the three recalls, the first recall was performed within 3 weeks after the researchers received the completed questionnaire; a second and third recall were performed within 3 weeks after the first recall.

All recalls (two weekdays and one weekend day per respondent) were performed from November 14th until December 22nd 2014. Specifically trained researchers and students telephoned the participants unexpectedly to recall their food intake of the previous day covering all foods and beverages consumed from waking up until the next morning. The weight of the reported food products was estimated by the respondent (used portion of the total packaging), or by use of the portion size booklet, the measured content of commonly used kitchenware and used recipes. Data were also collected on eating moment (ranging from before breakfast (1) to after dinner (7)), normal or special day (e.g. birthday), and special diets (e.g. energy restricted). To minimize daily variation, the 24-hour recalls were performed all days of the week.

The dataset with the recall information will be released in 2019.

Selection and response
In Figure 1, the selection and response of this side study is shown. Briefly, of the persons who participated in the LASA measurement wave of 2011/2012 (cohort 1 and 2) and 2012/2013 (cohort 3), 2089 persons were eligible to participate and were approached. Of them, 1439 (response rate 68.9%) persons took part in the side study; they (partly) completed the questionnaire either online (n=666; 46.3%) or on paper (n=773; 53.7%). The selection for the 24-hour recalls is shown in the lowest part of Figure 1. (open this figure in jpg here).

Figure 1. Flow chart of the selection and response of the Nutrition and Food-related Behaviour study
Blocks in dashed lines refer to the substudy with 24-hour recalls.

* For example: respondent has indicated to participate at LASA regular waves only, severe vision problems, etc.

Variable information
The questionnaire is available, as well as its codebook, which includes a list of all questions and the computed variables (see above under ‘Food intake’) in the datasets. Both questionnaire and codebook can be retrieved from the data manager. An overview of the variables of the 24-hour recalls will become available after data cleaning and processing.

Diet quality indices
Using data of the FFQ (part B), it is possible to examine not only the intake of nutrients, foods and food groups, but also dietary patterns. Four a priori diet quality indices have been computed: the Mediterranean diet score (MDS, 30), Alternative Healthy Eating Index (AHEI-2010, 31), Dietary Approaches to Stop Hypertension (DASH, 32), and Dutch Healthy Diet index 2015 (DHD15, 33). The SPSS-syntax for these indices can be retrieved from the data manager.

Availability of information ¹
The Nutrition and Food-related Behaviour study was conducted from October 2014 until April 2015. This was between wave H (2011/2012) and wave I (2015/2016) for the first and second cohort, and between wave 3B (2012/2013, baseline) and wave I (2015/2016) for the third cohort.
¹ More information about the regular LASA data collection waves is available here.

Recommendations and remarks regarding the use of the data

General recommendations and remarks: for FFQ dataset and Food-related Behaviour (FRB) datasets

1. Date of completion: Many respondents who filled out the paper version did not fill in the date of completion (‘invuldatumpapier’, n=172). The receipt date of the completed questionnaire at the Vrije Universiteit (‘ontvangenpapier’) can be used as an alternative (e.g. invuldatumpapier = ontvangenpapier – 345600 (=4 days)). The latter was done for calculating the respondent’s age (‘mfage’) if the date of completion was missing.
2. Late questionnaires: please note that questionnaires of four respondents were received more than a year after the start of the study (‘verlatevrl’). Two (R31909 and R71857) filled in the questionnaire within the study period (winter of 2015), one (R41498) at March 1st, 2016, and from one (R41366) the date of completion is unknown.
3. Written comments: some respondents wrote a comment in the questionnaire. This not-specifically asked, extra information is summarized in 7 variables: deviating eating pattern (‘afwijkend eetpatroon’), non-community dwelling (‘onzelfstandig wonen’), use of prednisone or levothyroxine (‘gebruik van prednison of Thyrax’), disease affecting body weight (‘ziekte van invloed op lichaamsgewicht’), negative event or disease (‘nare gebeurtenis of ziekte’), diabetes mellitus (‘diabetes mellitus’) and wheelchair user (‘rolstoelgebruiker’). These variables may have an influence on food intake, eating behaviour or mood. Depending on the research question, it might be important to treat these persons differently.
4. Note for the variable ‘Deviating eating pattern’ (‘afwijkend eetpatroon’): some persons indicated that their eating pattern differed from their habitual diet due to circumstances, such as illness (cancer), medical surgery, loss of sense of taste and smell, ileostoma, diabetes mellitus, on a diet (and using Modifast products, protein shakes or meal replacement shakes), or unintentional weight loss/gain. The duration or reason of this deviation is given in the answer categories. If the research question includes dietary data (from the FFQ), it might be important to treat these persons differently, for example exclude (some of) them.

Recommendations and remarks: for FFQ dataset

1. Missing values or stopped halfway: Not all respondents filled out the FFQ completely: they skipped questions (not possible for online version) or stopped halfway (i.e. did not complete the FFQ). Missings on questions about amount, portion size and product type (b, c, d, e questions) are imputed if the reported frequency was at least ‘1 day per 4 weeks’. The imputed values are the means of respondents who filled out the specific question. The total number of missing FFQ-items (before imputation) is calculated for each respondent (‘totaalmissing’, range 0-131). It is recommended to exclude respondents with 11 or more missings (n=18); see the variable ‘morethan10missings’ (0/1).
2. In total, 8 respondents stopped halfway the FFQ, of which 7 also have 11 or more missing values. So, one respondent, with less than 11 missings on the FFQ, stopped ‘halfway’: at question N74 (soft drinks). Depending on the research question it is recommended to exclude these persons as their nutrient intakes are based on less food items; see the variable ‘stoppedhalfwayFFQ’ (0/1). For example, if total energy intake is needed as a covariate, then it is advised to exclude these persons; while exclusion may not be needed if intake of one food product is investigated (and total energy intake is not).
3. Inconsistency in answers: For some food products, it is checked for inconsistencies in respondents’ answers. Fifteen ‘inconsistency variables’ (in Dutch: foutvariabelen) are made covering the following 5 food groups: margarine/butter versus bread, spreads on bread versus bread, cooked and raw vegetables, meat and alcohol. Persons showing an inconsistency are marked on the specific inconsistency variable (0/1) and a sum score is calculated (‘totaalfout’, range 0-15). In Table 3, the meaning of a value of ‘1’ on each inconsistency variable is explained. Depending on the research question, it might be important to check persons scoring on a specific ‘inconsistency variable’. For example, when studying meat intake, exclusion of persons scoring ‘1’ on the inconsistency variables ‘vleestotgroter’, ‘vleessrtgroter’ or ‘vleessrtgroter2LASA’ should be considered.
4. Implausible energy intake: Depending on the research question, it might be important to exclude respondents whose total energy intake estimated from the FFQ is very low or very high. For this, Willett’s cut off values are often used: females: <500 kcal/d (n=2), >3500 kcal/d (n=7); and males: <800 kcal/d (n=5), >4000 kcal/d (n=15), see the variable ‘implEintakeWillett’ (0/1) (34).

Recommendations and remarks: for Food-related Behaviour (FRB) datasets

1. Skipped subtopics. Not all respondents filled out all subtopics of the questionnaire (see Table 1). If a respondent skipped a subtopic completely, this is indicated with the variable ‘skippedpartX’.

Previous use in LASA
Data from the questionnaire of this side study have been used in several articles. Data of the FFQ (part B) and CES-D (part E) were used to study associations of depression determinants with a priori dietary patterns; current and past depressive symptoms were associated with poorer diet quality, particularly in men (Elstgeest et al., 2019). FFQ and CES-D data have also been used in the MooDFOOD meta-analysis, which examined associations between a prioridietary patterns and depressive symptoms in six cohorts (Nicolaou et al., 2019). Cross-sectional and prospective analyses showed statistically significant inverse associations between three diet quality indices (MDS, AHEI-2010 and DASH) and depressive symptoms. FFQ data were also used to develop a short questionnaire, the Protein Screener 55+ (Pro55+), which screens for low protein intake using 10 questions from the original FFQ (Wijnhoven et al. 2018).

Next, a couple of studies on mindful eating (part G) were performed. An instrument to measure mindful eating was developed using these LASA data: the Mindful Eating Behavior Scale consisting of 17 items on four domains (Focused Eating, Eating in response to Hunger and Satiety Cues, Eating with Awareness, and Eating without Distraction) (Winkens et al., 2018a). Higher scores on three of these domains were cross-sectionally associated with less depressive symptoms in the Dutch LASA sample as well as in Denmark and Spain (Winkens et al., 2018b). Furthermore, higher scores on the same three mindful eating domains were longitudinally associated with a decrease in depressive symptoms (Winkens et al., 2019). The longitudinal associations between mindful eating and depressive symptoms were mediated through the psychological eating style external eating (part L), except for the domain Focused Eating (Winkens et al., 2019). The longitudinal associations of Eating with Awareness and Eating without Distraction with depressive symptoms were also mediated by total energy intake, but not by diet quality (Winkens et al., accepted).

• Elstgeest LEM, Winkens LHH, Penninx BWJH, Brouwer IA, Visser M. Associations of depressive symptoms and history with three a priori diet quality indices in middle-aged and older adults. Journal of Affective Disorders. 2019;249:394-403.
• Nicolaou M, Colpo M, Vermeulen E, Elstgeest LEM, Cabout M, Gibson-Smith D, Knuppel A, Sini G, Schoenaker D, Mishra GD, Lok A, Penninx BWJH, Bandinelli S, Brunner EJ, Zwinderman AH, Brouwer IA, Visser M. Association of a priori dietary patterns with depressive symptoms: a harmonised meta-analysis of observational studies. Psychol Med 2019. doi:10.1017/s0033291719001958:1-12.
• Wijnhoven HAH, Elstgeest LEM, de Vet HCW, Nicolaou M, Snijder MB, Visser M. Development and validation of a short food questionnaire to screen for low protein intake in community-dwelling older adults: The Protein Screener 55+ (Pro55+). PLOS ONE. 2018;13(5):e0196406.
• Winkens LHH, Elstgeest LEM, van Strien T, Penninx BWJH, Visser M, Brouwer IA. Does food intake mediate the association between mindful eating and change in depressive symptoms? Public Health Nutr. accepted.
• Winkens LHH, van Strien T, Barrada JR, Brouwer IA, Penninx BWJH, Visser M. The Mindful Eating Behavior Scale: Development and Psychometric Properties in a Sample of Dutch Adults Aged 55 Years and Older. Journal of the Academy of Nutrition and Dietetics. 2018a;118(7):1277-1290.e1274.
• Winkens LHH, van Strien T, Brouwer IA, Penninx BWJH, Visser M, Lähteenmäki L. Associations of mindful eating domains with depressive symptoms and depression in three European countries. Journal of Affective Disorders. 2018b;228:26-32.
• Winkens LHH, van Strien T, Brouwer IA, Penninx B, Visser M. Mindful eating and change in depressive symptoms: mediation by psychological eating styles. Appetite. 2019;133:204-211.

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Date of last update: December, 2019