Development and validation testing of a short nutrition questionnaire to identify dietary risk factors in preschoolers aged 12–36 months

Figures & data

Fig. 1 Overview of the development and validation process of NutricheQ.

Table 1 Details of items asked in NutricheQ questionnaire

Section 1
1. My toddler first moved onto cow's milk as his main milk drink (at what age)
2. My toddler usually drinks the following amount of milk, in total, each day (including any used on cereals)
3. My toddler usually eats ‘red’ meat (not including chicken or poultry) OR oily or dark fish
4. My toddler usually eats cereal fortified with iron and vitamins
Section 2
5. I avoid giving my toddler certain foods because of allergy or a food intolerance
6. My toddler eats plenty of fruit (not counting fruit juice)
7. My toddler eats plenty of vegetables
8. My toddler usually has dairy products, including milk (e.g. milk, cheese, yoghurt, fromage frais, milk pudding, custard)
9. My toddler may have more ‘convenience/fast food’ than he/she probably should or than I would like (e.g., chips, burgers, sausages, chicken nuggets, fried rice or noodles, whether home prepared or takeaway)
10. My toddler may have more treats than he/she probably should or than I would like (e.g. chocolate, sweets, biscuits, ice-cream, crisps, other salty snack foods)
11. My toddler usually drinks fruit juice, squash or other sweetened drink (If you add water to juice, only count the juice. Don't include sugar-free drinks)
Section 3
12. My toddler drinks from a bottle (how often per day)
13. My toddler has had difficulty transitioning from smooth textures and has swallowing/chewing problems that concern me
14. I have to be especially careful to control how much my toddler eats, or he would tend to eat too much
15. I use treats and desserts to reward my toddler for good behaviour (or withhold treats if he doesn't behave or finish his meal)
16. My toddler generally has a regular ‘3 meals and mid meal snacks’ routine with meals eaten at table with me/others
17. Mealtimes with my toddler tend to last (the following length of time)
18. My toddler sees me eating healthy meals most or every day with plenty of fruit and vegetables

Each question has three possible responses, a, b, and c with answers in the ‘a’ category having a minimum score of 0 (minimal risk) and answers in the ‘c’ category having a maximum score of 2 (indicating a potential cause for concern). The intermediate category ‘b’ was classed as ‘less than ideal’ with a score of 1. Questions 1–4 relate to Section 1 focusing on iron and vitamin D status, questions 5–11 correspond to Section 2 focusing on risk factors for other dietary imbalances, and questions 12–18 relate to Section 3, which aimed to identify risk factors for longer term nutritional risk. For each section, the question responses are summed with an increased overall score indicating increased risk. As this validation study focused on Sections 1 and 2, the maximum score for these two sections was 22.

Table 2 Descriptive characteristics of Irish preschool children aged 1–3 years from the National Preschool Nutrition Survey who participated in the NutricheQ validation study

	Total population	1 year	2 years	3 years	p ^†
Number of participants (n)	371	123	122	126
Gender (%), male: female	50:50	50:50	52:48	49:51	0.929
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
Anthropometrics
Weight (kg)^‡	14.3 (2.8)	11.9 (1.7)	14.2 (1.9)	16.7 (2.2)	0.001
Height (cm)^§	91.1 (8.4)	82.6 (4.6)	91 (5.2)	99.2 (4.7)	0.001
BMI (kg/m^2)^‡	17 (2.0)	17.4 (1.8)	17.1 (1.3)	16.9 (1.3)	0.759
Weight z-scores WHO^‡	1.6 (1.1)	2.0^a (1.2)	1.43^b (1.0)	1.28^c (1.0)	0.001
Height z-scores WHO^§	1.8 (1.8)	3.10^a (1.9)	1.45^b (1.6)	0.98^c (1.2)	0.001
BMI z-scores WHO^‡	0.84 (1.1)	0.5^a (1.4)	1.05^b (0.9)	1.01^c (0.9)	0.001
WHO centiles (%)^?
Normal (≤91st centile)	70	−	73	68	0.565
Overweight (>91st to ≤98th centile)	21	−	20	21
Obese (>98th centile)	9	−	7	11
Social class (%)^¶
Professional/managerial	64	74	64	57	0.108
Non-manual	15	13	13	19
Skilled manual	14	7	16	19
Semi-skilled and unskilled	6	6	7	6
Education (%)
Primary/intermediate	5	2	7	6	0.219
Secondary	13	12	9	17
Tertiary	82	85	84	78

^†One-way analysis/chi-squared tests.

^‡Four participants missing.

§Five participants missing.

^?Aged ≥2 years, n=246 (two participants missing).

^¶Three participants missing. ^abcUnlike superscript significantly different from each other.

Table 3 Pearson's correlations between mean daily nutrient intake, mean daily intake of fruit and vegetables, and NutricheQ score for Sections 1 and 2 and for the total NutricheQ scores (Sections 1 and 2)

	Section 1	Section 2	Total NutricheQ score (Sections 1 and 2)
Energy (MJ)	0.016	−0.040	−0.024
Protein (g/day)	0.057	−0.199**	−0.132*
Dietary fibre (g/day)	−0.312**	−0.254**	−0.271**
Total fat (g/day)	0.061	−0.059	−0.015
Saturated fatty acids (g/day)	0.139**	−0.125*	−0.026
Total sugars (g/day)	−0.024	−0.010	−0.020
Non-milk sugars (g/day)	0.057	0.117*	0.119*
Iron (mg/day)	−0.360**	−0.152**	−0.309**
Vitamin D (µg/day)	−0.331**	−0.085	−0.236**
Zinc (mg/day)	−0.234**	−0.233**	−0.308**
Calcium (mg/day)	0.054	−0.300**	−0.214**
Sodium (mg/day)	0.094	0.050	0.085
Riboflavin (mg/day)	0.028	−0.269**	−0.205**
Niacin (mg/day)	−0.202	−0.060	−0.153**
Folate (µg/day)	−0.020	−0.186**	−0.157**
Thiamin (mg/day)	−0.122**	−0.105**	−0.147**
Vitamin C (mg/day)	−0.125*	−0.019	−0.082
Phosphorous (mg/day)	0.105	−0.264**	−0.159**
Potassium (mg/day)	0.071	−0.275**	−0.189**
Carotene (µg/day)	−0.101	−0.251**	−0.283**
Retinol (µg/day)	−0.071	−0.178**	−0.179**
Total fruit (g)	−0.050	−0.199**	−0.191**
Total veg. (g)	−0.129*	−0.396**	−0.390**

*Significant at p<0.05 level; **significant at the p<0.01 level, Pearson's correlation coefficient.

Table 4 Mean daily intakes of nutrients [% total energy (TE), mg or µg/10 MJ/day] for Irish children from the National Preschool Nutrition Survey by quartiles of total NutricheQ score (Sections 1 and 2)

	Quartile 1		Quartile 2		Quartile 3		Quartile 4		p*	Trend
Total NutricheQ score (Sections 1 and 2)	0–3		4–5		6–7		8–13
N	74		104		96		87
Gender (male:female)	43:57		49:51		50:50		57:43		0.344
	Mean	(SD)	Mean	(SD)	Mean	(SD)	Mean	(SD)
Age (years)	1.70^a	0.79	1.95^a	0.83	1.96^a	0.81	2.36^b	0.73	0.001
Nutrient analysis
Energy (MJ)	4.6	1.1	4.6	1.1	4.5	0.9	4.6	1.0	0.723	0.266
Protein (% TE)	16.0^a	2.8	15.4^ab	2.4	15.2^ab	2.0	14.5^b	2.5	0.009	0.001
Carbohydrate (% TE)	47.8	5.5	49.1	6.1	49.4	5.8	49.1	5.9	0.473	0.583
Dietary fibre (g/10 MJ)	27.7^a	6.7	25.0^b	7.2	24.7^b	6.6	21.4^c	6.8	0.001	0.001
Total fat (% TE)	34.5	4.6	34.0	5.3	33.8	5.3	34.7	5.2	0.300	0.456
Sat. fat (% TE)	15.9	3.4	15.8	3.6	15.4	3.4	15.6	3.7	0.816	0.885
Total sugars (% TE)	24.8	4.5	25.9	6.0	26.1	5.6	24.8	6.3	0.282	0.515
Non-milk sugars (% TE)	14.0^a	5.1	16.1^ab	5.3	17.1^b	6.3	16.9^ab	7.0	0.032	0.026
Iron (mg/10 MJ)	18.0^a	6.0	16.3^ab	5.6	15.1^bc	5.6	13.2^c	4.4	0.001	0.001
Vitamin D (µg/10 MJ)	8.4^a	7.9	6.4^ab	6.9	5.2^b	5.9	4.4^b	5.1	0.002	0.001
Zinc (mg/10 MJ)	13.1^a	3.4	11.6^b	2.6	10.9^bc	2.7	10.0^c	2.3	0.001	0.001
Calcium (mg/10 MJ)	1935.1^a	513.3	1771.1^ab	503.0	1641.9^b	512.4	1561.6^ab	571.8	0.012	0.003
Sodium (mg/10 MJ)	2390.3	680.8	2304.9	644.8	2506.4	623.4	2583.3	644.9	0.092	0.274
Vitamin B6 (mg/10 MJ)	2.9	1.0	2.9	0.9	2.8	0.7	2.6	0.7	0.055	0.012
Vitamin B12 (µg/10 MJ)	9.6	5.1	8.7	3.8	8.5	3.5	7.6	3.5	0.209	0.035
Riboflavin (mg/10 MJ)	3.6^a	1.0	3.4^a	1.0	3.2^ab	0.9	2.9^b	1.0	0.007	0.001
Niacin (mg/10 MJ)	24.5^a	6.1	24.3^a	8.4	23.1^ab	6.5	21.5^b	7.2	0.003	0.001
Folate (µg/10 MJ)	411.1^a	169.3	382.0^ab	154.7	343.6^b	118.7	340.8^b	171.4	0.011	0.002
Thiamin (mg/10 MJ)	2.2^ab	0.4	2.3^a	1.1	2.1^b	0.5	2.0^b	0.5	0.006	0.010
Vitamin C (mg/10 MJ)	172.8	75.6	159.9	81.9	167.1	87.9	153.3	106.3	0.672	0.366
Phosphorous (mg/10 MJ)	1917.7^a	359.7	1845.0^a	335.8	1786.0^ab	330.2	1696.1^b	359.3	0.041	0.005
Potassium (mg/10 MJ)	3950.1^a	612.9	3976.0^a	656.9	3772.5^ab	631.3	3476.7^b	744.0	0.001	0.001
Carotene (µg/10 MJ)	6022.3^a	6329.4	5179.7^ab	3711.1	3800.9^bc	3900.4	2631.9^c	2877.2	0.001	0.001
Retinol (µg/10 MJ)	1020.8^a	1686.4	676.7^ab	353.7	579.8^b	274.8	560.1^b	390.6	0.008	0.004

*Age-adjusted one-way analysis of covariance followed by Bonferroni's test; chi-squared test (age only); ^abcUnlike superscript significantly different from each other.

Table 5 Mean daily food group intake (g/day) for Irish children from the National Preschool Nutrition Survey by quartiles of total NutricheQ score (Sections 1 and 2)

	Quartile 1		Quartile 2		Quartile 3		Quartile 4
Total NutricheQ score (Sections 1 and 2)	0–3		4–5		6–7		8–13
N	74		104		96		87
Food groups	Mean	(SD)	Mean	(SD)	Mean	(SD)	Mean	(SD)	p*
	(g)/day		(g)/day		(g)/day		(g)/day
Grains, rice, pasta, and savouries	37.50	31.82	33.86	32.84	34.70	44.30	37.53	36.04	0.844
Bread and rolls	36.92	29.50	39.02	26.58	45.83	31.34	45.05	31.31	0.304
Ready to eat breakfast cereals (RTEBC)	20.40	13.64	23.13	26.68	18.13	14.43	17.32	14.74	0.078
Other breakfast cereals	24.87	35.44	26.94	43.45	17.40	37.73	20.86	51.81	0.441
Biscuits, cakes, and pastries	13.84	12.16	18.55	17.05	17.20	16.55	19.32	15.75	0.222
Infant milk	123.82^a	199.03	67.86^ab	157.28	42.74^b	125.86	22.23^b	100.95	0.006
Cow's milk	244.94	181.91	270.62	198.88	251.13	208.64	212.55	193.21	0.434
Other milk	11.63	53.75	33.70	117.03	13.69	44.98	28.60	92.82	0.100
Yoghurt and fromage frais	65.09	52.95	55.56	44.61	64.48	58.00	66.52	57.92	0.464
Creams, icecreams, and chilled desserts	15.56	22.15	19.06	26.87	21.42	36.85	15.96	22.14	0.418
Cheese	10.52	12.49	7.23	10.23	7.89	8.36	8.30	9.39	0.166
Butter, spreading fats, and oils	4.75	6.61	4.34	3.60	5.03	4.36	5.59	6.00	0.690
Egg and egg dishes	8.12	15.71	7.69	11.71	8.88	12.34	6.86	11.53	0.643
Potatoes	32.59^a	41.23	26.29^ab	26.36	26.88^ab	27.36	18.98^b	24.73	0.039
Vegetables and vegetable dishes	48.59^a	46.93	38.51^ab	33.13	31.25^bc	28.33	23.29^c	21.73	0.001
Fruit	140.88	78.40	138.70	91.20	142.29	90.37	92.87	82.29	0.393
Fish and fish dishes	17.60^a	22.71	10.10^b	14.88	9.53^b	14.63	9.76^ab	14.61	0.012
Processed foods	18.19^a	25.25	26.33^a	30.32	31.05^ab	28.33	42.49^b	35.52	0.001
Meat	72.86^a	63.82	66.55^ab	51.69	52.09^ab	36.39	48.05^b	46.17	0.007
Non-milk beverages^†	236.03^a	167.26	261.25^ab	181.83	313.94^ab	218.23	341.05^b	234.24	0.014
Sugars, confectionery, preserves, and savoury snacks	9.47^a	11.89	12.08^ab	13.91	16.74^ab	16.66	20.20^b	17.30	0.006
Soups, sauces, and miscellaneous foods	16.38	25.24	19.89	34.41	17.43	30.71	14.04	21.06	0.378
Nutritional supplements	16.98	39.35	13.12	46.14	15.55	39.12	23.24	44.40	0.632
Nuts, seeds, herbs, and spices	0.56	2.08	0.62	2.13	0.34	1.25	0.52	2.31	0.704
Total dairy foods^‡	461.42	208.24	441.20	185.91	385.59	208.10	346.43	212.24	0.054

*Age-adjusted one-way analysis of covariance followed by Bonferroni's test; ^abcunlike superscript significantly different from each other.

^†Includes teas, other beverages, carbonated and diet carbonated beverages, squash, cordials, and fruit juice drinks.

^‡Includes infant milk, cow's milk, other milk, yoghurt and fromage frais, creams, icecreams, and cheese.

Fig. 2 Receiver-operating characteristic (ROC) curve comparing NutricheQ total scores to an objective rating of nutritional risk based on analysis of actual dietary intake and anthropometric measurement using objective criteria. Area under the curve (AUC)=85%.