Integrative development of a short screening questionnaire of highly processed food consumption (sQ-HPF)

Celia Martinez-Perez, Lidia Daimiel, Cristina Climent-Mainar, Miguel Ángel Martínez-González, Jordi Salas-Salvadó, Dolores Corella, Helmut Schröder, Jose Alfredo Martinez, Ángel M Alonso-Gómez, Julia Wärnberg, Jesús Vioque, Dora Romaguera, José López-Miranda, Ramón Estruch, Francisco J Tinahones, José Lapetra, Lluis Serra-Majem, Aurora Bueno-Cavanillas, Josep A Tur, Vicente Martín Sánchez, Xavier Pintó, Miguel Delgado-Rodríguez, Pilar Matía-Martín, Josep Vidal, Clotilde Vázquez, Emilio Ros, Javier Basterra, Nancy Babio, Patricia Guillem-Saiz, María Dolores Zomeño, Itziar Abete, Jessica Vaquero-Luna, Francisco Javier Barón-López, Sandra Gonzalez-Palacios, Jadwiga Konieczna, Antonio Garcia-Rios, María Rosa Bernal-López, José Manuel Santos-Lozano, Maira Bes-Rastrollo, Nadine Khoury, Carmen Saiz, Karla Alejandra Pérez-Vega, María Angeles Zulet, Lucas Tojal-Sierra, Zenaida Vázquez Ruiz, Maria Angeles Martinez, Mireia Malcampo, José M Ordovás, Rodrigo San-Cristobal, Celia Martinez-Perez, Lidia Daimiel, Cristina Climent-Mainar, Miguel Ángel Martínez-González, Jordi Salas-Salvadó, Dolores Corella, Helmut Schröder, Jose Alfredo Martinez, Ángel M Alonso-Gómez, Julia Wärnberg, Jesús Vioque, Dora Romaguera, José López-Miranda, Ramón Estruch, Francisco J Tinahones, José Lapetra, Lluis Serra-Majem, Aurora Bueno-Cavanillas, Josep A Tur, Vicente Martín Sánchez, Xavier Pintó, Miguel Delgado-Rodríguez, Pilar Matía-Martín, Josep Vidal, Clotilde Vázquez, Emilio Ros, Javier Basterra, Nancy Babio, Patricia Guillem-Saiz, María Dolores Zomeño, Itziar Abete, Jessica Vaquero-Luna, Francisco Javier Barón-López, Sandra Gonzalez-Palacios, Jadwiga Konieczna, Antonio Garcia-Rios, María Rosa Bernal-López, José Manuel Santos-Lozano, Maira Bes-Rastrollo, Nadine Khoury, Carmen Saiz, Karla Alejandra Pérez-Vega, María Angeles Zulet, Lucas Tojal-Sierra, Zenaida Vázquez Ruiz, Maria Angeles Martinez, Mireia Malcampo, José M Ordovás, Rodrigo San-Cristobal

Abstract

Background: Recent lifestyle changes include increased consumption of highly processed foods (HPF), which has been associated with an increased risk of non-communicable diseases (NCDs). However, nutritional information relies on the estimation of HPF consumption from food-frequency questionnaires (FFQ) that are not explicitly developed for this purpose. We aimed to develop a short screening questionnaire of HPF consumption (sQ-HPF) that integrates criteria from the existing food classification systems.

Methods: Data from 4400 participants (48.1% female and 51.9% male, 64.9 ± 4.9 years) of the Spanish PREDIMED-Plus ("PREvention with MEDiterranean DIet") trial were used for this analysis. Items from the FFQ were classified according to four main food processing-based classification systems (NOVA, IARC, IFIC and UNC). Participants were classified into tertiles of HPF consumption according to each system. Using binomial logistic regression, food groups associated with agreement in the highest tertile for at least two classification systems were chosen as items for the questionnaire. ROC analysis was used to determine cut-off points for the frequency of consumption of each item, from which a score was calculated. Internal consistency of the questionnaire was assessed through exploratory factor analysis (EFA) and Cronbach's analysis, and agreement with the four classifications was assessed with weighted kappa coefficients.

Results: Regression analysis identified 14 food groups (items) associated with high HPF consumption for at least two classification systems. EFA showed that items were representative contributors of a single underlying factor, the "HPF dietary pattern" (factor loadings around 0.2). We constructed a questionnaire asking about the frequency of consumption of those items. The threshold frequency of consumption was selected using ROC analysis. Comparison of the four classification systems and the sQ-HPF showed a fair to high agreement. Significant changes in lifestyle characteristics were detected across tertiles of the sQ-HPF score. Longitudinal changes in HPF consumption were also detected by the sQ-HPF, concordantly with existing classification systems.

Conclusions: We developed a practical tool to measure HPF consumption, the sQ-HPF. This may be a valuable instrument to study its relationship with NCDs.

Trial registration: Retrospectively registered at the International Standard Randomized Controlled Trial Registry ( ISRCTN89898870 ) on July 24, 2014.

Keywords: Food processing-based classification; Highly processed food; NOVA; PREDIMED-Plus; Questionnaire; Ultra-processed food.

Conflict of interest statement

J.S-S reports grants from CIBEROBN, ISCIII (Spain), during the conduct of the study; non-financial support from Nut and Dried Fruit Foundation, personal fees from Instituto Danone Spain, other from Danone S.A., other from Font Vella Lanjaron, personal fees and grants from Eroski Distributors, grants from Nut and Dried Fruit Foundation, grants from Eroski Distributors, personal fees from Nut and Dried Fruit Foundation, outside the submitted work. E.R reports grants, personal fees, non-financial support and other from California Walnut Commission, grants, personal fees, non-financial support and other from Alexion, personal fees, non-financial support and other from Ferrer International, personal fees from Amarin, personal fees, non-financial support and other from Danone, outside the submitted work. J. L-M reports personal fees and non-financial support from AMGEN, personal fees and non-financial support from SANOFI, personal fees from MSD, personal fees from Laboratorios Dr. Esteve, personal fees from NOVO-NORDISK outside the submitted work.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Flowchart of the PREDIMED-Plus participants. Number of subjects shown in bold
Fig. 2
Fig. 2
Agreement plots of tertiles of HPF consumption. Visual representation of contingency tables between the sQ-HPF tertiles and A NOVA HPF tertiles, B IARC HPF tertiles, C IFIC HPF tertiles and D UNC HPF tertiles. Marginal totals of the contingency table are located on the top and right axis. Shading represents the level of agreement, black indicates “perfect agreement”, and grey indicates “partial agreement”. The extent to which rectangles deviate from the diagonal line of no bias indicates the extent of disagreement, and the position (above/below) indicates direction of the disagreement. HPF: highly processed food

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