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Developed and validated food frequency questionnaires in Iran: A systematic literature review

frequency Background: Food frequency questionnaires (FFQs) are inexpensive, easy to administer, and practical tools for dietary assessment in epidemiological studies. Several studies have investigated the validity and reproducibility of FFQs for the Iranian population. This systematic review aimed to assess the developed and validated FFQs for use in the Iranian population and compare their features and the validation studies in this regard. Materials and Methods: A comprehensive search was conducted in ISI Web of Knowledge, PubMed, Scopus, and Iranian databases without time constraints to retrieve the relevant English and non‑English publications. Studies would be included if they were focused on the design and validation of FFQs in Iran. Results: In total, 782 articles were found, 22 of which met the eligibility criteria and evaluated 18 FFQs. Validation studies had been conducted on 18 out of 20 FFQs. The median of the correlation coefficients for the comparison of the FFQ intakes and the dietary reference method by nutrients varied within the range of 0.19–0.65, indicating reasonable validity. The median of the correlation coefficients for the comparison of two FFQs by nutrients was 0.28–0.85, showing appropriate reproducibility. However, low validity was observed in some nutrients and food groups, such as egg, legumes, iron, folate, and α ‑tocopherol. In seven studies, biomarkers were used for the assessment of nutrient intake using an FFQ with the median correlation coefficient of −0.07–0.42. In addition, the quality of methodology was evaluated in the FFQ validation studies, with 18 out of 20 studies reporting good and excellent quality. Conclusion: Although the FFQs used to assess the dietary intake of the Iranian population have different features, they have acceptable validity and reproducibility. Nevertheless, some food groups and nutrients have poor validity and must be considered attentively.


INTRODUCTION
Dietary intake assessment is a complex task and a significant challenge in epidemiological research. [1] The assessment of dietary intake is fundamental in the study of the interrelations between diets and diseases. Most epidemiological studies use food frequency foods with some possible options regarding the frequency of their consumption (e.g., once a day, once a week, once a month). In FFQs, portion size is either standard or selected from the provided portion size images. Other methods of dietary assessment are 24-h recalls, weighted food records, and diet histories.
Currently, no "gold standard" methods are available for dietary intake assessment or the measurement of the intake of specific foods or nutrients. The available methods have specific strengths and limitations and heavily rely on the participants' willingness to cooperate. An FFQ is used to assess the habitual intakes of a population over time and is also expected to rank individuals based on their nutrient intakes. [3] On the other hand, food records or recalls only assess certain days or weeks, and although they are more accurate, they may not fully represent the usual dietary intakes. Moreover, since diet in general but also types of foods consumed vary in different populations, it is imperative to use population-specific FFQs.
In Iran, various FFQs have been designed and validated to evaluate the dietary intake of various age groups in the population based on food records, dietary recalls, or biochemical markers. [4][5][6] This systematic review aimed to evaluate the FFQs that have been specifically designed to assess the dietary intake of the Iranian population and compare their features and the validation studies in this regard. Our findings could be practical for designing new FFQs and performing validation studies on the Iranian population.

Search strategy
This systematic review was conducted based on the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses, [7] with the specification of the methods before commencing the literature search. A systematic search for the relevant articles regarding Iranian FFQs was performed up to July 2020 in databases such as ISI Web of Knowledge, PubMed, Scopus, and Iranian SID database using various keywords, including "food frequency questionnaire" OR "FFQ" OR "diet history questionnaire" in combination with "validity" and "Iran." After eliminating duplicate references, the eligibility assessment of the identified studies was carried out independently by two investigators (S. S. A. and Z. Y.).

Eligibility criteria
The eligibility criteria were as follows: (1) study design (design, validation, and reproducibility assessment of FFQs); (2) study participants (all types of study participants included with any age, both patients and healthy participants); (3) type of dietary assessment tool (FFQ and diet history); (4) comparable with questionnaires (dietary reference methods such as food records and recalls), biomarkers, and expert opinion; and (5) English and Persian articles published until July 2020. Review studies were excluded.

Data extraction from eligible studies
The extracted data from the retrieved articles included the aim of the questionnaire design in terms of variable measurement, number of food items, items on frequency and portion size, method of questionnaire design (experience based/data based), reference methods of the validation studies (e.g., dietary reference methods, biomarkers, expert panel), number of the participants, gender and age of the participants, method of questionnaire administration, dietary assessment method in the validation studies (dietary recall or food record), duration of the dietary reference method (record/recall), food group/nutrients, blood biomarkers, urine biomarkers, statistical methods in the FFQ validation studies (e.g., correlation coefficients [high or low validity]), [8] energy adjustment, de-attenuation (adjustment for within-person variation of food intake on different days), reproducibility of food groups/nutrients, and interval between the two administrations of the FFQs in the reproducibility studies.
The methodology quality of the selected studies was scored by two reviewers who used the previously applied scores [9] as adapted from the study by Serra-Majem et al.; [10] the highest score was seven (highest quality), and the lowest score was zero (lowest quality). The scores were assigned based on various components, including the samples and sample size (maximum score: 1), type of statistics (score 3), administration method (score 0.5), food grouping details (score 1), frequency scale, and portion size (score: 1), and consideration of seasonality (score: 0.5). [9] The quality of each study was scored as poor (scores ≤2), acceptable (scores 2.5≤-<3.5), good (scores 3.5≤-<5), and excellent (scores 5≤). [9] The four main methods used in the validation studies were as follows: 1. FFQ data were compared with the actual intake calculated by another dietary reference method (food records/24-h recalls) [11] 2. FFQ data were compared with blood and urine biomarkers, hair, and body tissues [11] 3. Factors could be calculated based on the FFQ data and compared with the factors of the dietary reference method [12][13][14] 4. The validity of the FFQ items could be calculated by an expert panel, and based on their feedback regarding the essentiality of an item, the content validity ratio would be calculated. In addition, the content validity index would be calculated based on expert opinion regarding the correlation between the aim of the questionnaire design with an item. [15] FFQ reproducibility could be assessed by the comparison of the data of two FFQ administrations and the calculation of factors such as the correlation coefficients, intraclass correlation, and Cronbach's alpha. In the selected studies, the median of the correlation coefficients between dietary reference methods and FFQs were summarized to assess validity; if two or more correlation coefficients were observed in one study, their median would be used. Notably, the intraclass correlations were summarized in similar manners.

Study selection
As depicted in Figure 1, 782 studies were identified. After the initial review of the titles and abstracts, 760 articles were excluded, and 22 studies that met the eligibility criteria were selected for further analysis [ Figure 1].

Methods of food frequency questionnaires development
The methods of FFQ development were categorized as experience based and data based. In the first approach, experienced dietitians or epidemiologists selected food items from food composition tables. The selected food items had to be popular and have considerable nutrient contents with varied consumption by the general population. The experience-based approach was used in four FFQs. [20][21][22]31] In the second approach, food items were selected based on the data of other dietary reference methods, such as food records and dietary recalls. [4,5,[13][14][15]17,19,[23][24][25][26][27][28][29][30] The data-based approach was classified into three subcategories, as follows:    1. Six FFQs were modified based on a previous version of the questionnaires, which were shortened to select the food items of target nutrients [4,13,14,17,19,29] 2. Four FFQs were the culturally adapted versions of the validated FFQs used in other countries [5,17,19,[28][29][30] 3. In six FFQs, food items were selected based on food records or 24-h recalls of the previous studies conducted in Iran. [15,[23][24][25][26][27] The selected food items defined the intake percentage of target nutrients.
Notably, the method of FFQ development was not mentioned in three articles. [12,16,18]

Number of food items and frequency questions
In the reviewed studies, the number of the selected food items was within the range of 40-189 (mean: 109.4, median: 130.5).

Food frequency questionnaires validation based on dietary reference methods
In 14 studies, FFQs were validated based on dietary reference methods, including food records and 24-h recalls.
According to the findings, the validity of food group consumption was high (median of correlation coefficient of FFQs ≥0.60) for tea and coffee and fruits and refined grains, while it was moderate (median of correlation coefficient: 0. Among fatty acids, validity was highest for saturated fatty acids, followed by monounsaturated fatty acids and PUFAs.

Factor analysis
According to the current review, three studies used factor analysis to identify the dietary patterns in FFQs and assess their validity. In this approach, the correlations between the factors of the FFQ and dietary reference methods were calculated as well. [12][13][14] Expert panel In one study, an expert panel calculated the content validity ratio and content validity index in order to the assess validity of FFQs. [15] Statistical approaches in the validation process In 16 studies, correlation coefficients were used to compare the FFQ data by a dietary reference method, [4,5,[16][17][18][19]21,22,[24][25][26][27][28][29][30][31] while three studies used the Bland-Altman plot in addition to correlation coefficients. [17,26,31] In one study, the triad method was employed, which is a three-way comparison of the FFQ with detailed measures of dietary intake, such as a dietary record and biochemical measure. [5,11] The content validity index was also used for this purpose in one research. [15] Three studies identified dietary patterns using factor analysis to assess the validity of dietary patterns. [12][13][14] Methodology quality of food frequency questionnaires validation studies In this literature review, the selected studies were   [24] 64 males and 59 females 15 Bijani et al., 2018 [17] 100 males and 100 females 20 Esfahani et al., 2010 [19] Males Females

0.49
FFQ=Food frequency questionnaire; CC=Correlation coefficient; HVO=Hydrogenated vegetable oil scored against a validation study methodology tool. [9] Correspondingly, two studies had acceptable quality, [15,26] eight studies had good quality, and 10 studies were considered to have excellent quality.

DISCUSSION
This systematic review was a comprehensive study of the FFQs developed to assess the dietary intakes of the Iranian population. In total, 20 FFQs have been developed so far, 18 of which have been the subject of validation studies. According to our findings, the most commonly used validation method was comparison with another dietary reference method. Correlation coefficients were also used in almost all the validation studies. According to the obtained results, the median correlation coefficient for nutrients between various FFQs and dietary reference methods was 0.39, which is similar to the FFQ applied in Japan, [8] while lower than western countries, where the correlation coefficients have been reported to be within the range of 0.60-0.70. [2] The lower correlation coefficient between FFQs and dietary reference methods in Iran could be due to the complexity of the Iranian diet since it is a combination of traditional dishes, western dishes, fast foods, and local foods. Another source of complexity arises as traditional foods may be similar in terms of description or nomenclature, while the recipes may vary. Moreover, fast foods are most commonly consumed by some populations (e.g., young adults), and local foods are mainly consumed by some ethnicities only and may not be incorporated into the developed questionnaires in this regard.
With regard to validity, the current systematic review revealed that the correlation coefficients between the Contd...  [25] 93 males and 87 females 8 Malekahmadi et al., 2016 [21] 86 males and 99 females Total 15 Bijani et al., 2018 [17] 100 males and 100 females 16 Doustmohammadian et al., 2020 [18] 230 total 17 Toorang et al., 2019 [30] 138 males and 106 females Total FFQs and dietary reference methods varied in terms of food groups, which could be due to the differences in the number and clarity of the food items, portion sizes, and interpersonal variability. Food groups such as tea and coffee, refined grains, and fruits could be assessed with high validity, which may be attributed to their frequent consumption and the fact that they could be easily remembered by the individual. In the reviewed studies, dairy products had moderate validity, which may be due to their frequent consumption and inclusion of sufficient items with detailed questions in the questionnaires. There seems to be better consistency between FFQs and other dietary assessment methods in terms of the foods that are consumed frequently (e.g., rice, bread, vegetables, sugar, soft drinks, and fast food) rather than seasonally compared to the foods that are consumed less frequently. According to our findings, the median of the correlation coefficients for nuts was 0.445, which indicated moderate validity probably due to the high interpersonal variability in nut consumption. According to the current systematic review, the validation of 70% of FFQs was based on another dietary reference method, which compares well to the study conducted by Cade et al., in which the value was reported to be 75%. [32] Among Iranian validation studies, 40% have been performed based on biomarkers, which are considered to be a "gold standard" method. [2] This rate is higher compared to the reported values in the studies conducted in other countries, in which the validation of only 19% of FFQs has been based on biomarkers. [32] The more frequent use of biomarkers in Iran may be attributed to the lack of national food composition tables, which in turn leads to the preference of biomarker-based validation studies. [2] Nevertheless, the use of biomarkers has some limitations since not only these factors are influenced by diet but also by the degree of absorption and metabolism. [2] Therefore, the correlation between biomarkers and questionnaires is expected to be less significant than the correlation between questionnaires and dietary reference methods. As it was predicted, our findings showed a nonsignificant correlation between biomarkers and nutrient intake, and the correlation coefficients were within the range of −0.07-0.42.
In the reviewed articles, the expected intraclass correlation for the reproducibility of functional FFQs was within the range of 0.5-0.7, [2] which indicated acceptable reproducibility.
Commonly consumed food groups (e.g., tea and coffee) were observed to have higher correlation coefficients. Notably, the seasonal variation in the food intakes, which affected reproducibility, was investigated in only few studies, [5,12,16,18,19,22,24] and the lack of this item may cause false reproducibility due to systematic error.
In the current review, the methodology quality of the validation studies was considered acceptable in 90% of the reviewed articles, which is higher than the value reported in a similar study (59%) [9] and regarded as an advantage of Iranian validation studies. Furthermore, most of the questionnaires (90%) were administered through face-to-face interviews, which shows the superiority of this method for the Iranian population. It is expected that the questionnaires administered through interviewers have higher correlations owing to the guidance of the interviewer.
In the self-administered questionnaire used by Nouri et al., [26] the correlation coefficients of nutrients were lower than the interviewer-administered questionnaires. In the review of the foreign validation studies conducted by Cade et al., [32] 67% of the questionnaires were interviewer-administered and resulted in higher correlation coefficients for some nutrients. Although interview administration and the immediate assessment of the responses is an advantage, the costs of the recruitment and training of interviewers may be disadvantageous.
According to the current review, the mean food items in the FFQs was 109.4, which is higher than the findings of the worldwide systematic review study by Cade et al.; [32] the value was estimated at 88 in the mentioned research. The discrepancy could be due to the complexity of the Iranian diet. The mean sample size of the FFQ validation studies was 189.6 (range: 30-498), while the mean sample size of international FFQ validation studies has been estimated at 255 (range: 6-3750). [32] Nevertheless, it seems that a larger sample size has no significant impact on the correlation coefficients in validation studies. [32] Strengths and limitations This systematic review aimed to assess the features and validation studies of Iranian FFQs. The quality of the reviewed studies was scored to better judgment in the generalizability of study results. The major limitation of this review was the heterogeneity of the reported data in the reviewed studies. Although adjustment for energy intake and within-person variation (de-attenuation) would make the data more accurate, we used crude correlation coefficients since adjustment was not performed in all the studies.

CONCLUSION
According to the results of this systematic review, the FFQs in Iran may be representative of the regular Iranian diet and have acceptable validity and reproducibility despite the variations in their features. Furthermore, the validation studies had acceptable quality. The FFQs also had some limitations; for instance, they had low validity for some food groups and nutrients, such as egg, legumes, sweets, potassium, Vitamin E, Vitamin A, Vitamin B6, Vitamin B12, α-tocopherol, folate, copper, and fructose. Therefore, Iranian FFQs may not be applicable in some cases, and FFQ validity must be assessed for the intended items before the selection of the questionnaire.

Financial support and sponsorship
Nil.

Conflicts of interest
There are no conflicts of interest.