Background
Diet and physical activity are key lifestyle factors to improve overall health, including diabetes prevention and enhancement of glycemic control throughout the lifespan. A recent review of clinical trials suggests that both diet and physical activity interventions are capable to reduce the risk of type 2 diabetes, especially in the high risk population, with their combinations being more potent [
1]. In school-aged children, interventions for prudent eating habits [
2] and increased levels of physical activity [
3] have been also associated with increased insulin sensitivity after a 2 years follow up.
Diet and physical activity have qualitative and quantitative aspects and their precise assessment is of major importance in identifying those at risk, in developing targeted interventions and also in measuring the efficacy of these interventions. Unfortunately, all methods of measuring dietary intake are hampered by errors of precision [
4]. Assessments of intakes of specific nutrients obtained with a food frequency questionnaire, in comparison to intake with a gold standard method, have yielded low correlation coefficients in both adults [
5] and children [
6]. It has been proposed that measuring consumption of food groups and their integration into dietary patterns, rather than assessment of single nutrients intake, may be more closely associated to various health outcomes, due to the highly interrelated nature of dietary exposures [
7]. However, reported correlations between actual and measured intakes of specific food groups have been also weak to moderate in children [
8]. The same constraints apply when assessing physical activity levels in various age groups [
9,
10].
A relatively new era of research suggests that food choice and physical activity are influenced by multiple environmental factors that may augment or diminish a healthy behavior [
11]. At the individual level, it has been observed that many healthy or unhealthy behaviors do not occur by chance, but rather they cluster [
12] and may be interrelated. For example, screen time has been associated with poor eating habits in children and adolescents [
13]. Delineating these complex interactions and their environmental determinants is of critical importance in order to target specific diet and physical activity behaviors that can be modified by behavioral change based interventions. Unfortunately, there is scarcity of well-designed tools for the assessment of such aspects of diet and physical activity at the community level.
In this paper we describe the development of questionnaires for diet and physical activity assessment in adults and school-aged children in the context of the Feel4Diabetes Study. The study regards a school- and community-based intervention in 6 European countries, aiming to promote a healthy lifestyle and tackle obesity and obesity-related metabolic factors related to increased risk for type 2 diabetes. We aimed to develop questionnaires capable in assessing not only dietary intake and physical activity status, but also overall energy balance-related behaviors, perceptions and environmental barriers or facilitators for each behavior.
Discussion
Despite substantial advances in nutritional epidemiology, assessment of diet and other lifestyle factors, such as physical activity remains a growing field, as respective tools need to capture multiple aspects of nutrition and overall lifestyle. In the present manuscript we described the development of five questionnaires, one for dietary habits in adults and children, one for physical activity in adults and children and one for overall family’s energy balance-related behaviors. We focused not only on the single assessment of dietary intake and physical activity levels, but also on the behaviors towards them, thus evaluating barriers and/or facilitators of a healthy (or unhealthy) lifestyle. Results from our reliability study suggest that the developed tools have at least good reliability and thus may be used for evaluation of the effectiveness of interventions at the community level, such as the Feel4Diabetes study.
The tools for the assessment of both diet and physical activity are commonly characterized by moderate reproducibility. Our reliability results in the food frequency and eating behaviors questionnaire were similar with those reported to other food frequency questionnaires, in both adults [
19,
20] and children [
21‐
24]. Similarly, the physical activity and sedentary behaviors questionnaire had comparable reliability with other physical activity questionnaires for adults [
17,
25,
26] and children [
10]. Of note, in both questionnaires, questions regarding attitudes and perceptions, social support or knowledge did not show higher reliability, compared to questions regarding dietary or physical activity habits. Therefore, the accurate reporting of such aspects of lifestyle should not be taken for granted and the reproducibility of such questions should also be confirmed by reliability studies. This observation is of high importance in behavioral interventions, as it may confound the evaluation of their effectiveness.
When comparing the developed questionnaires, overall reliability was lower in the family’s energy balance-related behaviors questionnaire, compared to the other two questionnaires. This is an expected finding, due to the nature of the questions included in this questionnaire: most of the questions were wide-ranging and qualitative and thus a definite and reproducible answer was more difficult to be obtained. A lower reliability does not necessarily diminish its value, but may limit its use. In fact, this questionnaire was developed as a tool to assess the school-based intervention of the Feel4Diabetes study, and not the intervention on high-risk families. As such, it may be applied in large populations for the detection of individuals at risk of poor health behaviors, where a high sensitivity is not required.
The developed questionnaires have several strengths. They have been designed for a multi-country population, under standardized procedures, including reliability studies in various populations, with different socio-economic background, thus making them applicable for various populations. They also provide a holistic approach of diet and physical activity, exploring various aspects regarding their determinants. On the other hand, they are subjected to inherent limitations that are common in the assessment of lifestyle parameters. Even if we overcome the constraints on precision, self-report bias due to social desirability and approval [
27] or intervention-associated bias [
28] may compromise the accuracy of the information obtained. In addition, the developed questionnaires have been tested for their reliability in European countries and thus their application in other populations may require additional validity studies. Nevertheless, the use of questionnaires still remains the only choice when it comes to the evaluation of lifestyle in large population groups and their use may provide valuable information that should always be interpreted keeping in mind their limitations.
Acknowledgments
The authors would like to thank the members of the Feel4Diabetes-study group: Coordinator: Yannis Manios, Steering Committee: Yannis Manios, Greet Cardon, Jaana Lindström, Peter Schwarz, Konstantinos Makrilakis, Lieven Annemans, Ignacio Garamendi.
Harokopio University (Greece): Yannis Manios, Meropi Kontogianni, Odysseas Androutsos, Christina Mavrogianni, Konstantina Tsoutsoulopoulou, Christina Katsarou, Eva Karaglani, Irini Qira, Efstathios Skoufas, Konstantina Maragkopoulou, Antigone Tsiafitsa, Irini Sotiropoulou, Michalis Tsolakos, Effie Argyri, Mary Nikolaou, Eleni-Anna Vampouli, Christina Filippou. Katerina Gatsiou, Efstratios Dimitriadis.
National Institute for Health and Welfare (Finland): Jaana Lindström, Tiina Laatikainen, Katja Wikström, Jemina Kivelä, Päivi Valve, Esko Levälahti, Eeva Virtanen.
Ghent University (Belgium): Department of Movement and Sports Sciences: Greet Cardon, Vicky Van Stappen, Nele Huys; Department of Public Health: Lieven Annemans, Ruben Willems; Department of Endocrinology and Metabolic Diseases: Samyah Shadid.
Technische Universität Dresden (Germany): Peter Schwarz, Ivonne Panchyrz, Maxi Holland, Patrick Timpel.
National and Kapodistrian University of Athens (Greece): Konstantinos Makrilakis, Stavros Liatis, George Dafoulas, Christina-Paulina Lambrinou, Angeliki Giannopoulou, Lydia Tsirigoti, Evi Fappa, Costas Anastasiou, Konstantina Zachari.
International Diabetes Federation Europe (Belgium): Lala Rabemananjara, Maria Stella de Sabata, Winne Ko, Ignacio Garamendi.
Universidad De Zaragoza (Spain): Luis Moreno, Fernando Civeira, Gloria Bueno, Pilar De Miguel-Etayo, Esther M Gonzalez-Gil, Maria I Mesana, Germán Vicente-Rodriguez, Gerardo Rodriguez, Lucia Baila-Rueda, Ana Cenarro, Estíbaliz Jarauta, Rocío Mateo-Gallego.
Medical University of Varna (Bulgaria): Violeta Iotova, Tsvetalina Tankova, Natalia Usheva, Kaloyan Tsochev, Nevena Chakarova, Sonya Galcheva, Rumyana Dimova, Yana Bocheva, Zhaneta Radkova, Vanya Marinova, Yuliya Bazdarska, Tanya Stefanova.
University of Debrecen (Hungary): Imre Rurik, Timea Ungvari, Zoltán Jancsó, Anna Nánási, László Kolozsvári, Csilla Semánova.
Extensive Life Oy (Finland): Remberto Martinez, Marcos Tong, Kaisla Joutsenniemi, Katrina Wendel-Mitoraj.
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