A-Hyun Lim; Suk-Young Choi; Ji-Yun Hwang; Hyun-Kyung Moon; Kirang Kim

doi:10.4163/jnh.2015.48.5.407

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Lim, Choi, Hwang, Moon, and Kim: Development of dietary behavior items available in Korea National Health and Nutrition Examination Survey∗

Research Article

J Nutr Health 2015;48(5):407-418.

Published online: 19 January 2015

DOI: https://doi.org/10.4163/jnh.2015.48.5.407

Development of dietary behavior items available in Korea National Health and Nutrition Examination Survey^∗

A-Hyun Lim¹, Suk-Young Choi¹, Ji-Yun Hwang³, Hyun-Kyung Moon¹, Kirang Kim^1,^†

¹Department of Food Science and Nutrition, Dankook University, Chungnam 31116, Korea

²Department of Food and Nutrition, Daejeon University, Daejeon 34520, Korea

³Nutrition Education Major, Graduate School of Education, Sangmyung University, Seoul 03016, Korea

^†To whom correspondence should be addressed. tel: 82-41-550-3472, e-mail: kirangkim@dankook.ac.kr

^∗ This research was supported by a fund by Research of Korea Centers for Disease Control and Prevention (2014-E3500600).

Received 15 September 2015 Revised 1 October 2015 Accepted 1 October 2015

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose:

Given that the indicators related to chronic diseases are important to evaluating goals of the national health policy, the aim of this study was to develop dietary behavior items available in the Korea National Health and Nutrition Examination Survey.

Methods:

The dietary behavior items were developed based on the literature reviews, need assessment of the field, expert focus-group interviews, and expert advisory meeting. Questions for each dietary behavior item were developed by reflecting on environmental, personal, and behavior factors of the ecological frame and then revised through expert focus-group interview and expert advisory meeting. The understanding and reliability of the developed questionnaire were assessed by cognitive interview and test-retest reliability.

Results:

The developed items were sodium and salt intake, added and simple sugar intake, enough time to consume a meal for all ages, caffeine drinks and fresh/healthy food intake for children and adolescents, and limited dietary intake, fresh/healthy food intake for seniors. In most questions except some questions on sodium and salt intake, subjects understood over 70% and consistency of responses based on the kappa values was acceptable.

Conclusion:

Developed dietary behavior items are expected to be useful for evidence-based nutrition policy, interventions and research targeting dietary patterns through investigating and monitoring dietary behavior patterns.

Keywords: dietary behavior, food behavior survey, eating behavior survey, Korean National Health and Nutrition Examination Survey

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Fig. 1.

The development procedure of dietary behavior questionnaire.

Table 1.

General characteristics of participants in the cognitive interview

	Total	Men	Woman
	(n = 32)	(n = 16)	(n = 16)
Age (Mean ± SD)	43.0 ± 25.9¹⁾	42.9 ± 27.3	43.1 ± 25.3
Age group
≤65	21 (65.6)²⁾	10 (62.5)	11 (68.8)
>65	11 (34.4)	6 (37.5)	5 (31.2)
Education
No education	1 (3.1)	1 (6.2)	0 (0.0)
Elementary school	9 (28.1)	5 (31.2)	4 (25.0)
Middle school	7 (21.9)	3 (18.7)	4 (25.0)
High school	5 (15.6)	1 (6.2)	4 (25.0)
College/University or higher	10 (31.3)	6 (37.4)	4 (25.0)

¹⁾ Mean ± SD

²⁾ (Standard deviation) 2) n (%)

Table 2.

Candidates of survey items that are not included in the Korea National Health and Nutrition Examination Survey based on the literature review

Dimension	Items from dietary guideline	Items from international national survey	Items from literatures
Balance			Unbalanced diet intake
Variety		Reason of supplement use
		Special food intake
		Reasons of food avoidance
Moderation	Perception of the control of portion size	Perception of moderate amount of diet	Perception of sodium intake
	Compliance with low-salt eating	Dietary control by special reason	Intake frequency of fried or roasted food
	Compliance with low fat diet	Perception of salt or sodium intake	Intake frequency of processed food intake
	Compliance with low energy dense and nutrient poor food intake	Intake frequency of added-sugar beverage
		De-caffeinated beverage consumption
Others	Perception of food hygiene	Enough time to eat	Eating speed
	Compliance with healthy eating	Compliance with and perception of dietary guideline
	Compliance with healthy lifestyle	Subjective evaluation of dietary intake
	Perception of table manners	Perception of healthy lifestyle and nutrition knowledge
		Food allergy and type of food allergy
		Perception of national health promotion plan
		Dietary behavior related to psychosocial factor

Table 3.

Result of need assessment of dietary behavior items fo Korea National Health and Nutrition Examination Survey

Ranking	Score¹⁾
1. Salt and sodium intake	114
2. Added sugar beverage intake	80
3. Caffeine beverage intake (included energy drink)	38
4. Perception and compliance of dietary guideline	38
5. Enough time to eat and eating speed	33
6. Avoidant food and reasons of food avoidance	32
7. Ways to get the health and dietary information	18
8. Perception of national health promotion plan	10

5 items for multiple-response were scored by ranking of priority for the survey item (1st = 5 points, 2nd = 4 points, 3rd = 3 points, 4th = 2 points, 5th = 1 point).

Table 4.

The number of questions for dietary behavior items developed by social cognitive theory

Subjects	Items	Three factors in Social Cognitive Theory
Subjects	Items	External environment	Personal factor	Behavior factor
All	Total number of questions	4¹⁾	5	14
	Salt or sodium intake	1	3	4
	Added sugar or sweets intake	1	2	6
	Dietary behavior	2	0	4
Children	Total number of questions	3	4	11
	Caffeine intake	0	1	4
	Snack and healthy food intake	3	3	7
Elders	Total number of questions	7	4	7
	Limited food intake	4	0	1
	Snack and healthy food intake	3	4	6

¹⁾ All values are number of questions.

Table 5.

Reliability of dietary behavior questionnaires for all subjects

All	All Kappa (95% CI)	Children Kappa (95% CI)	Adult Kappa (95% CI)	Elders Kappa (95% CI)
Environments to eat unsalty food	0.38 (0.06~0.71)^∗	0.62 (-0.04~1.00)^∗	0.78 (0.39~1.00)^∗∗	-0.22 (-0.73~0.29)
Preference for a salty taste	0.70 (0.50~0.90)^∗∗	0.72 (0.38~1.00)^∗∗	0.85 (0.67~1.00)^∗∗	0.44 (0.02~0.86)^∗
Perception of low-salt eating	0.51 (0.14~0.88)^∗∗	0.80 (0.44~1.00)^∗∗	0.00 (0.00~0.00)	0.00 (0.00~0.00)
Efforts to eat low-salt food	0.59 (0.27~0.91)^∗∗	1.00 (1.00~1.00)^∗∗	0.41 (-0.18~1.00)	-0.15 (-0.37~0.07)
Choice of low-salt food	0.77 (0.53~1.00)^∗∗	1.00 (1.00~1.00)^∗∗	0.78 (0.39~1.00)^∗∗	0.56 (0.06~1.00)^∗
Level of salt intake	0.75 (0.57~0.93)^∗∗	0.31 (-0.32~0.94)	0.68 (0.37~0.99)^∗∗	1.00 (1.00~1.00)^∗∗
Soy sauce use for fried food	0.75 (0.61~0.88)^∗∗	0.87 (0.69~1.00)^∗∗	0.76 (0.57~0.96)^∗∗	0.49 (0.23~0.75)^∗∗
Soup intake during meal time	0.56 (0.33~0.79)^∗∗	0.43 (-0.06~0.91)^∗	0.68 (0.34~1.00)^∗∗	0.52 (0.10~0.93)^∗∗
Frequency of salty food intake	0.60 (0.37~0.83)^∗∗	0.62 (0.21~1.00)^∗∗	0.74 (0.42~1.00)^∗∗	0.41 (0.02~0.80)^∗
Environments related to added-sugar beverages	0.64 (0.42~0.86)^∗∗	0.59 (0.23~0.95)^∗∗	0.83 (0.61~1.00)^∗∗	0.30 (0.05~0.55)
Preference for sweetness	0.68 (0.50~0.87)^∗∗	0.89 (0.68~1.00)^∗∗	0.76 (0.54~0.98)^∗∗	0.48 (0.16~0.81)^∗∗
Frequency of drinking water instead of added sugar beverages	0.36 (0.14~0.58)^∗∗	0.37 (-0.08~0.82)	0.25 (-0.11~0.61)	0.14 (-0.20~0.48)
Frequency of soda intake	0.61 (0.39~0.83)^∗∗	0.53 (0.16~0.89)^∗∗	0.68 (0.51~0.85)^∗∗	-0.05 (-0.15~0.04)
Frequency of coffee intake	0.78 (0.61~0.95)^∗∗	0.71 (0.51~0.91)^∗∗	0.85 (0.62~1.00)^∗∗	0.59 (0.22~0.95)^∗∗
Frequency of fruit juice intake	0.67 (0.44~0.90)^∗∗	0.76 (0.43~1.00)^∗∗	0.57 (0.22~0.91)^∗∗	0.49 (0.17~0.80)^∗
Frequency of sports drink intake	0.67 (0.42~0.92)^∗∗	0.77 (0.44~1.00)^∗∗	0.53 (0.24~0.82)^∗∗	0.52 (0.14~0.90)^∗∗
Frequency of fruit flavored beverages	0.57 (0.34~0.81)^∗∗	0.76 (0.45~1.00)^∗∗	0.39 (-0.11~0.88)^∗	0.42 (0.05~0.78)^∗
Frequency of tea and traditional beverages	0.40 (0.15~0.66)^∗∗	0.61 (0.23~1.00)^∗∗	0.39 (0.00~0.78)^∗∗	0.22 (-0.06~0.50)
Enough time to eat breakfast	0.50 (0.29~0.70)^∗∗	0.47 (0.13~0.81)^∗	0.53 (0.15~0.90)^∗	0.33 (-0.02~0.69)^∗
Frequency of eating fast	0.54 (0.24~0.84)^∗∗	0.67 (0.33~1.00)^∗∗	0.55 (0.12~0.98)^∗	0.13 (-0.29~0.55)

∗p-value < 0.05

∗∗p-value < 0.01

Table 6.

Reliability of dietary behavior questionnaire for children and elders

Children	Kappa (95% CI)	Elders	Kappa (95% CI)
Efforts to drink low caffeine beverage	0.51 (0.19~0.84)^∗	Environment related to teeth and oral problem	0.00 (0.00~0.00)
Frequency of drinking high caffeine beverage	-0.07 (-0.17~0.03)	Difficulty of cooking due to lack of place or facility equipment	1.00 (1.00~1.00)^∗∗
Frequency of drinking tonic drinks	0.03 (-0.43~0.50)	Difficulty of cooking due to physical disability	0.30 (-0.18~0.78)
Frequency of drinking chocolate beverage	0.44 (0.00~0.89)	Difficulty of buying due to physical disability	1.00 (1.00~1.00)^∗∗
Frequency of drinking black tea	0.53 (0.02~1.00)^∗	Frequency of cooking	0.34 (0.02~0.67)^∗∗
Environment to eat fruits	0.29 (-0.17~0.75)	Availability of fruit at home	0.65 (0.42~0.87)^∗∗
Availability of fruit at home	0.63 (0.39~0.86)^∗∗	Availability of milk at home	0.85 (0.69~1.00)^∗∗
Availability of milk at home	0.08 (-0.25~0.41)	Accessibility to grocery stores for buying vegetables and fruits	0.38 (-0.19~0.95)
Efforts to eat fruit	0.67 (0.40~0.95)^∗∗	Efforts to eat fruit	0.59 (0.40~0.79)^∗∗
Efforts to eat milk product	0.53 (0.21~0.86)	Efforts to eat milk products	0.68 (0.42~0.93)^∗∗
Efforts to eat vegetables	0.40 (0.16~0.65)^∗	Efforts to eat vegetables	0.43 (0.03~0.83)^∗
Frequency of fruit intake	0.74 (0.42~1.00)^∗∗	Efforts to eat high-protein foods	0.34 (0.11~0.57)^∗
Frequency of instant food intake	0.68 (0.10~0.98)^∗∗	Frequency of fruits intake	0.79 (0.62~0.95)^∗∗
Frequency of fast food intake	0.68 (0.41~0.96)^∗∗	Frequency of milk and milk product intake	0.45 (0.05~0.85)^∗
Frequency of fried food intake	0.66 (0.30~1.00)^∗∗	Frequency of vegetables intake	-0.03 (-0.42~0.35)
Frequency of milk and milk product intake	0.57 (0.22~0.92)^∗∗	Frequency of high-protein food intake	0.55 (0.29~0.81)^∗∗
Frequency of vegetable dishes intake	0.40 (0.10~0.69)^∗

∗p-value < 0.05

∗∗p-value < 0.01

Table 7.

Dietary behavior questionnaire for all subjects

Salt and sodium intake¹⁾
1	When you eat out, are there any place to eat, if you want to eat low salty food?
2	Usually, how salty do you like to eat?
3	Usually, do you think that it is necessary to eat low salty food?
4	Do you choose low salty menus at restaurants or food service facilities if available?
5	Usually, how salty is what you eat?
6	Do you dip food like pancake or fried food into soy sauce generally?
7	Usually, do you tend to consume almost all when you eat soup (seaweed soup, soybean past soup etc.) or noodle (ramen,
	banquet noodle, rice-cake soup, chopped noodle, udon, spicy seafood noodle soup, etc.)?
8	Usually, do you tend to eat salted and pickled and salted seafood (salted shrimp, salted mackerel, salted pollack roe,
	sauced cuttle fish), pickled vegetable (pickled garlic, pickled chili, pickled perilla leaf, etc.), or soy sauce marinated crab?
Added sugar and sweets intake²⁾
1	During the past year, are there always soda, juice, fruit juice, sport drink?
2	Do you like sweets?
3	When you are thirsty, do you tend to drink added sugar beverage rather than water?
4	During the past year, how often do you drink following beverage?
4-1	Soda (Cola, Cider, Fanta, etc.)
4-2	Coffee (except sugar free coffee and syrup free coffee)
4-3	Fruit juice (tangerine juice, orange juice, grape juice, etc.)
4-4	Sports drink (Pocari sweat, Getorade, Powerade, etc.)
4-5	Fruit syrup drink (citron, plum, omija etc.)
4-6	Tea or traditional beverages (sweet rice drink, Job's tears tea, ginger tea, powder of roast grain drink, iced tea, etc.)
Dietary behavior³⁾
1	Usually, how long does it take to eat a meal?
1-1	Breakfast
1-1-1	Usually, is it enough to eat breakfast?
1-2	Lunch
1-3	Dinner
1-3-1	Usually, what time do you eat a dinner?
2	During the past month, how often does it happen that you eat fast?

¹⁾ For salt or sodium Intake 1,3,4,8 items, response options were: (a) yes, (b) no, (c) don’t know. For 2,5 items, response options were: (a) No salty, (b) Less salty, (c) Average (d) a little salty, (e) salty. For 6,7 items, response options were: (a) hardly, (b) sometimes, (c) usually, (d) often, (e) always. 2) For Added Sugar or Sweetness Intake 1 items, response options were: (a) hardly, (b) irregularly, (c) always. For 2 items, response options were: (a) yes, (b) no, (c) don’t know. For 3 items, response options were: (a) hardly, (b) sometimes, (c) usually, (d) often, (e) always. For 4-1-6) items, response options were: (a) hardly, (b) once a month, (c) 2-3 a month (d) once a week, (e) 2-3 a week, (f) 5-6 a week, (g) once a day, (h) twice a day, (i) three times a day. 3) For Added Meal Behavior 1-(1-3) items, response options were: (a) don’t eat, (b) ○○ minutes. For 1-1-1 items, response options were: (a) yes, (b) no, (c) don’t know. For 1-3-1 items, response options were: at ○○:○○. For 2 item, response options were: (a) less than once a week, (b) 1-3 times a week, (c) 4-6 times a week, (d) once a month, (e) more than twice (total ○○ times)

Table 8.

Dietary behavior questionnaire for children

Caffeine intake¹⁾
1	When you drink beverages, do you think it is necessary to choose less caffeine drink?
2	During the past year, how often do you drink following beverage?
2-1	High-caffeine drinks (Hotsix, Redbull, etc.)
2-2	Tonic drink(Bacchus, Vita500, Wonbi-D, etc.)
2-3	Chocolate drink (cocoa, hot choco, ice choco, Nesquik, etc.)
2-4	Black tea (include milk tea, iced tea, ceylon tea)
Snack and healthy food intake²⁾
1	Are your family or friends tend to eat fruits frequently?
2	Are there fruits in your home usually?
3	Are there milk or milk products in your home usually?
4	Are you trying to eat fruits rather than bread or snack?
5	Do you think that it is necessary to eat milk or milk products (yogurt, liquid yogurt) every day?
6	Do you think that it is necessary to eat vegetable side dishes except kimchi and pickled vegetables every mealtime?
7	During the past year, how often did you eat following foods (without eating between meals)?
7-1	Instant food (ramen, triangular gimbap)
7-2	Fast food (pizza, hamburger, french fried, etc.)
7-3	Fried food (fried chicken, sweet and sour fried chicken, fried noodles in seaweed, fried dumplins, etc.)
8	During the past year, how often did you eat following foods?
8-1	Fruits
8-2	Milk and milk products (yogurt, liquid yogurt etc.)
8-3	Vegetable side dishes (except kimchi and pickled vegetables)
8-3-1	How many kinds of side dish of vegetables did you eat every mealtime?

¹⁾ For caffeine intake 1 item, response options were: (a) yes, (b) no, (c) don’t know. For 2-(1-4) items, response options are: (a) hardly, (b once a month, (c) 2-3 a month (d) once a week, (e) 2-3 a week, (f) 5-6 a week, (g) once a day, (h) twice a day, (i) three times a day. 2) For snack and healthy food intake 1,5,6 items, response options were: (a) yes, (b) no, (c) don’t know. For 2, 3 items, response option were: (a) hardly, (b) irregularly, (c) always. For 4 item, response options were: (a) hardly, (b) sometimes, (c) usually, (d) often, (e) always For 7-(1-3) and 8-(1-3) items, response options were: (a) hardly, (b) once a month, (c) 2-3 a month (d) once a week, (e) 2-3 a week, (f) 5 6 a week, (g) once a day, (h) twice a day, (i) three times a day. For 8-3-1 item, response options were: ○○ dishes.

Table 9.

Dietary behavior questionnaire for elders

Limited intake¹⁾
1	Do you have any support from government to solve teeth or oral problem, now or before?
2	Does a member of household (including you) who is in charge of cooking have difficulty to cook due to lack of cooking place, cooking facility or cooking equipment?
3	Do a member of household (including you) who is in charge of cooking have difficulty to cook due to physical disability?
4	Do a member of household (including you) who is in charge of purchasing foods have difficulty to buy foods due to physical disability?
5	How often a member of household (including you) who is in charge of cooking cook during the past month?
Snack and healthy food intake²⁾
1	Are there fruits in your home usually?
2	Are there milk or milk product in your home usually?
3	Are there nearby grocery stores (supermarket, food truck, street stall, etc.) convenient to buy vegetables and fruits?
4	Do you think that it is necessary to eat fruits every day?
5	Do you think that it is necessary to eat milk or milk products (yogurt, liquid yogurt) every day?
6	Do you think that it is necessary to eat vegetable side dishes except kimchi and pickled vegetables every mealtime?
7	Do you think that it is necessary to eat high-protein foods (meat, fish, egg, bean, etc.) at least once every mealtime?
8	During the past year, how often did you eat following foods?
8-1	Fruits
8-2	Milk and milk products (yogurt, liquid yogurts, etc.)
8-3	Vegetable side dishes (without kimchi and pickled vegetables)
8-3-1	How many kinds of side dish of vegetables did you eat every mealtime?
8-4	Side dishes containing meat, fish, egg, bean, etc.
8-4-1	How many kinds of high-protein food (meat, fish, egg, bean, etc.) for side dishes did you eat every mealtime?

¹⁾ For limited intake, 1,2,3,4 items response options were: (a) yes, (b) no. For 5 item, response options were: (a) less than once a week, (b) 1-3 times a week, (c) 4-6 times a week, (d) once a month, (e) more than twice (total ○○ times).

²⁾ For snack and healthy food intake, 1,2 items response options were: (a) hardly, (b) irregularly, (c) always. For 3 item, response options were: (a) yes, (b) no. For 4,5,6,7 items, response options were: (a) yes, (b) no, (c) don’t know. For 8-(1-4) items, response options were: (a) hardly, (b) once a month, (c) 2-3 a month (d) once a week, (e) 2-3 a week, (f) 5-6 a week, (g) once a day, (h) twice a day, (i) three times a day. For 8-3-1, 8-4-1 items, response options were: ○○ dishes.

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