RESEARCH
Current Research
Diet Quality of Montreal-Area Adults Needs
Improvement: Estimates from a Self-
Administered Food Frequency Questionnaire
Furnishing a Dietary Indicator Score
BRYNA SHATENSTEIN, PhD; SYLVIE NADON, MSc; CATHERINE GODIN, MSc; GUYLAINE FERLAND, PhD
ABSTRACT
Objective/design Time and budget constraints limit nutri-
tion evaluation in Canadian health surveys. To encour-
age regular population diet monitoring in Canada, we
developed and assessed the relative validity of a popula-
tion-based food frequency questionnaire (FFQ) to assess
usual diet in Quebecers. A 73-item, self-administered
semiquantitative FFQ was designed in French and English
from the Block National Cancer Institute Health Habits
and History Questionnaire to capture usual food consump-
tion among Quebec adults. The US Department of Agricul-
ture Healthy Eating Index (HEI) (maximum score⫽100)
was adapted to Canadian age- and sex-specific dietary
recommendations, validated, and programmed to score
the FFQ for diet quality.
Subjects The FFQ was pretested, pilot tested, and admin-
istered by mail to a random sample of 248 adults aged 18
to 82 years in the Montreal area (57% women) who were
recruited by random digit dialing (64% response rate). A
subgroup (n⫽94) furnished four nonconsecutive 1-day
food records for validation of the FFQ.
Results Mean FFQ energy intakes were 2,216 kcal (me-
dian 2,110 kcal) for men and 1,785 kcal (median 1,680
kcal) for women. Proportional median macronutrient con-
sumption was similar in both sexes at 17% protein, 34%
to 35% fats, and 48% to 49% carbohydrates, but differed
by age group in women. Adequacy of micronutrient in-
takes relative to Dietary Reference Intakes varied by age,
B. Shatenstein and G. Ferland are research scientists
with the Centre de recherche at the Institut universitaire
de gériatrie de Montréal, Montréal, Canada, and associ-
ate professor and full professor, respectively, with the
Département de nutrition, Université de Montréal, Can-
ada. S. Nadon and C. Godin are research assistants
with the Centre de recherche at the Institut universitaire
de gériatrie de Montréal, Montréal, Canada.
Address correspondence to: Bryna Shatenstein, PhD,
Centre de recherche, Institut universitaire de gériatrie
de Montréal, 4565 Queen Mary, Montréal, QC Canada
H3W 1W5. E-mail: bryna.shatenstein@umontreal.ca
Copyright © 2005 by the American Dietetic
Association.
0002-8223/05/10508-0007$30.00/0
doi: 10.1016/j.jada.2005.05.008
© 2005 by the American Dietetic Association
sex, and nutrient. Whereas most mean or median intakes
were at or exceeded recommendations, calcium intakes
were low overall and levels of several other nutrients
were very low at the 10th percentile. Mean Canadian HEI
(range 46 to 99) was higher in women (74.9) than men
(70.3, P⬍.001). Women’s scores showed they met recom-
mendations for intakes of vegetables and fruit, choles-
terol, and sodium better than men (P ranged from ⬍.01 to
⬍.0001), while men fared better at meeting recommended
fat intake levels (P⬍.05).
Conclusions The Canadian HEI adequately discriminates
overall diet quality based on dietary data estimated from
our FFQ. Examination of subscores within and between
quartiles may best reveal which food groups require at-
tention to improve diet quality, providing valuable infor-
mation for teaching and planning. Future studies should
test diet quality indicators in populations recruited to
reflect greater dietary diversity and reporting ability and
include members of disadvantaged groups to provide a
broader set of behaviors that could shed light on factors
influencing diet quality.
J Am Diet Assoc. 2005;105:1251-1260.
C
omprehensive, regular, country-wide dietary moni-
toring is not a consistent feature of health surveys in
Canada. Summary nutrition indicators, in conjunc-
tion with a regular nutrition surveillance program, could
be useful for rapid screening of diet quality, thereby con-
tributing to effective, targeted nutrition interventions.
This would be particularly helpful in population sub-
groups at risk of nutrition-related chronic disease.
Evaluation of a complex entity like diet requires assess-
ment of the frequency and quantity of foods eaten, food
combinations, cooking practices, and dietary variety. Al-
most 3 decades ago, it was suggested that diet quality
indicators based on nutrient intakes, foods or food group-
ings, or a combination of nutrients and foods (1) could be
used to quickly evaluate survey results and the efficacy of
dietary programs (2,3). Indeed, it has been stated that by
describing global dietary quality these indexes communi-
cate more about dietary adequacy and disease risk than
the intake of single nutrients or foods (1,4,5). Diet quality
may thus be evaluated in relation to nutrient adequacy
(3), compliance with dietary guidelines (6-8), or nutrition
recommendations (ie, adequate nutrient intakes, fat and
carbohydrate balance, dietary variety, and control of salt
Journal of the AMERICAN DIETETIC ASSOCIATION 1251
and alcohol) (8,9), association with risk of chronic dis-
eases (ie, obesity, cancer, and heart disease) (6,7,10), or
mortality (8,11,12), and used to assess interventions (13).
Examining the indicator’s component subscores could al-
low health professionals to target specific dietary prob-
lems. Furthermore, when repeated over time, scores can
track changes in overall diet quality and compare popu-
lation subgroups, giving health professionals valuable
insight for planning nutrition interventions.
A nutrition indicator reflects the researchers’ a priori
definition of diet quality, the elements included in its
calculation, and the source of the dietary data used to
compute the score. Whereas most diet quality indicators
have been calculated from (multiple) food recalls or
records, some investigators have used food frequency
questionnaires (FFQs) to develop and test their scores
(10,14). This approach to assessing usual diet quality
could be more meaningful than recalls or records as it has
been shown that the intra- and interperson variability of
indicators depends on the nature of the dietary data and
on the number and timing (ie, consecutive vs nonconsec-
utive) of replicate dietary measurements used to generate
the scores (5). Interestingly, the variance ratios also de-
pend on certain sociodemographic, lifestyle, and health-
related characteristics of the population, which are in
turn known to influence the reliability and accuracy of
diet quality measures (5). It is generally agreed that
socioeconomic status, age, and sex are consistent deter-
minants of food choice (15,16) and hence diet quality
(8,17) and nutritional adequacy (18,19), so this is not a
surprising observation.
The US Department of Agriculture (USDA) developed
the Healthy Eating Index (HEI) as a measure of overall
diet quality to evaluate how well Americans meet dietary
guidance (9,20). It assesses the extent of compliance with
the Food Guide Pyramid (21), as well as several aspects of
the Dietary Guidelines for Americans (22). The HEI con-
sists of 10 components, each worth 10 points. The first
five components are based on consumption of foods from
the five groups of the Food Guide Pyramid. The other four
components consider intakes of fats, saturated fats, cho-
lesterol, and sodium, as in the Dietary Guidelines for
Americans (22), which are similar to Canadian guidance
(23). The final component evaluates dietary variety. An
HEI score ⱕ50 indicates a poor diet, 51 to 80 signifies a
diet that needs improvement, and ⱖ81 reflects a good diet
(20). In their examination of different diet quality indexes
applied to data from a Quebec nutrition survey, Dubois
and colleagues (24) determined that the HEI is an appro-
priate indicator for assessing the diet quality of Quebec-
ers.
To encourage regular population diet monitoring in
Canada, we developed and assessed the relative validity
of a population-based FFQ to assess usual diet in Que-
becers (25). As a global diet quality indicator calculated
from the FFQ could provide a focus for nutrition health
promotion and effective targeted interventions, we also
adapted the HEI to Canadian guidance and evaluated
this score (the Canadian HEI) for assessing overall diet
quality from data gathered by the FFQ. This article de-
scribes the adaptation and evaluation of the diet quality
indicator and its application in an adult population.
1252 August 2005 Volume 105 Number 8
METHODOLOGY
Instrument Development and Sampling
The development and assessment of relative validity of
the FFQ as well as sample selection are described in
detail elsewhere (25). Briefly, a 73-item self-adminis-
tered, semiquantitative FFQ was developed in French
and English for Quebec adults, to assess usual food con-
sumption during the previous 12 months. The FFQ was
modified from the Health Habits and History Question-
naire, available at the time with diet analysis software
(DietSys) in the public domain from the National Can-
cer Institute Website (www.dccps.ims.nci.nih.gov/ARP/
DietSys/uguide.html, accessed June 1, 2000). A list-
based approach (26) drawing on the most recent Quebec
population dietary data [the 1990 Québec nutrition sur-
vey (27)] was used to build the food list and determine
consumption frequency options and food portion sizes. No
information is collected on supplement use. When neces-
sary, the Canadian Nutrient File (28) was used to modify
the USDA food composition database supplied with Diet-
Sys to reflect Canadian food composition data. The FFQ
was pretested among volunteers using a qualitative cog-
nitive interview approach as described by Subar and col-
leagues (29). A revised version was submitted to a second
pretest and the instrument was finalized for testing (ie,
feasibility, acceptability, time, and cost) and validation.
The FFQ was tested in a sample of 248 adults (a target
sample size of 250 was selected to detect significant dif-
ferences in diet quality and provide sufficient numbers to
permit subgroup analyses) who were recruited by random
digit dialing using a computer-generated list covering the
local calling area of metropolitan Montreal, which has a
population base of 3 million. Birthdate and sex of all
household members aged 18 years or older were ascer-
tained and listed in descending order, and one person was
recruited per household using a random number proce-
dure. Eligible subjects were aged 18 years or older, able to
read and write French or English, and living in a private
household with no intention to move during their study
participation. The study was conducted from the Institut
universitaire de gériatrie de Montréal and approved by
the Ethics Review Board. All participants provided in-
formed consent before data were collected. Recruitment
began in November 2000 and ended in August 2001.
Data Collection and Instrument Assessment
Data collection was carried out by mail with telephone
follow-up as FFQs were received to clarify responses or
complete missing information. The validation subsample
consisted of 94 persons from the FFQ development sam-
ple who agreed to be recontacted. They were given de-
tailed instructions for completing their food records and
provided four 1-day, nonconsecutive food records by tele-
phone (61%), fax (18%), and E-mail (21%) during a
3-week period following completion of the FFQ, with tele-
phone follow-up where necessary as they were received.
This prospective method was used because it is indepen-
dent of memory, which eliminates difficulties in assessing
validity due to a similar error structure between test and
reference instruments (30). Data collection and handling
were done by two bilingual (ie, French and English) re-
search dietitians.
 Score range Criteria for maximum score,
Componentsa (points) by sex and agebc Criteria for minimum score

1. Intakes of grain products 0-10 Females 18-49 y: 9 servings 0 servings

Females 50⫹ y: 6 servings
Males 18-49 y: 12 servings
Males 50⫹ y: 9 servings
2. Intakes of vegetables and fruit 0-20 Females 18-49 y: 7 servings 0 servings
Females 50⫹ y: 5 servings
Males 18-49 y: 10 servings
Males 50⫹ y: 7 servings
3. Intakes of milk products 0-10 2 portions 0 servings
4. Intakes of meat and meat 0-10 Females 18-49 y: 2.5 servings 0 servings
alternatives Females 50⫹ y: 2 servings
Males 18-49 y: 3 servings
Males 50⫹ y: 2.5 servings
5. Total fat intake (%) 0-10 ⬍30% total energy from fat ⱖ45% total energy from fat
6. Saturated fat intake (%) 0-10 ⬍10% total energy from ⱖ15% total energy from
saturated fat saturated fat
7. Cholesterol intake 0-10 ⱕ300 mg cholesterol ⱖ450 mg cholesterol
8. Sodium intake 0-10 ⱕ2,400 mg sodium ⱖ4,800 mg sodium
9. Dietary variety 0-10 ⱖ1 portion from each of four ⬍1 serving from each of four
food groups of CFGHE food groups of CFGHE
a
The first four components are based on Canada’s Food Guide for Healthy Eating (CFGHE) (30); evaluation considers daily intakes.
b
Number of servings is based on approximate energy intakes (2,200 kcal/d for women aged 18-49 y, 1,600 kcal/d for women aged 50⫹ y, 2,800 kcal/d for men aged 18-49 y, 2,200
kcal/d for men aged 50⫹ y), adapted from Bowman and colleagues (20).
c
Proportional scores are computed for intakes situated between the maximum and minimum criteria.

Figure. Criteria used in Canadian adaptation of the Healthy Eating Index.

Adaptation and Evaluation of the Canadian HEI
The Canadian HEI was adapted to Canadian dietary and
nutritional guidance using Canada’s Food Guide for
Healthy Eating (31) and Nutrition Recommendations for
Canadians (23) (see Figure). It has nine components, each
worth 10 points, except for the vegetables and fruits
subscore (to reflect that combined food group in Canada’s
Food Guide for Healthy Eating), which has a maximum of
20 points. The final component, dietary variety, was mod-
ified from the original HEI because that tool was devel-
oped for diet recalls. The HEI variety subscore is based on
the five food groups of the USDA Food Guide Pyramid
(21) and counts the total number of different foods eaten
during the 3 days of data collection contributing substan-
tially to meeting one or more of the five food group require-
ments (9). In the FFQ setting this was not possible because
the FFQ provides a summary indication of usual food in-
takes over a 12-month period. The variety subscore was
thus made more reflective of Canada’s Food Guide for
Healthy Eating recommendation for variety using a variant
of the Dietary Diversity Score (18). Like the USDA HEI, the
Canadian HEI has a maximum score of 100 points.
Analyses
FFQ dietary data were analyzed using DietSys, which
had been modified to reflect our food list and order, por-
tion sizes, and nutrient values. A programming algorithm
was written in SPSS language (version 10, 1999, SPSS
Inc, Chicago IL) to generate the Canadian HEI from FFQ
data. The total score and the distribution of its compo-
nents were examined. It was validated using Spearman
correlation analyses (due to non-normal distribution of
the data) assessing agreement between nutrition and
dietary recommendations and the total score and selected
components of the score, by sex and age group. Nutrient
recommendations were taken from the Dietary Reference
Intakes (32) except for energy and protein, which were
not available at the time of analyses; vitamin A, due to
changes in determining retinol equivalents that could not
be applied to our nutrient database; and folate, as our
nutrient database predated folate fortification of grain
products. These latter recommendations were taken from
the 1990 Canadian Recommended Nutrient Intakes (23).
Participants were ranked into quartiles by sex. This was
done to examine the progression of the Canadian HEI
subscores as the total score improved. All statistical anal-
yses were conducted using SPSS version 10.
RESULTS
The study sample is presented in Table 1. Two hundred
forty-eight adults aged 18 to 82 years adequately com-
pleted an FFQ. The response rate to the FFQ was 64%
(257 of 400 questionnaires mailed). Women outnumbered
men (57%). Demographic characteristics of the validation
subgroup resembled those of the full FFQ sample. A little
more than 80% were French speakers and the remainder
spoke English, which mirrors the linguistic composition
of Quebec’s population. More than 40% had a university

August 2005 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1253

 folate, calcium, and zinc in both sexes, and to a lesser
Table 1. Demographic characteristics of Montreal-area residents extent, vitamin B-6 and iron among women), intakes
participating in a food frequency questionnaire development and were substantially lower than recommended levels.
relative validation study (N⫽248) Subscores and the total Canadian HEI score calculated
Attribute n % from the FFQ data are presented by sex and for the whole
sample in Table 3. The overall total mean Canadian HEI
Sex was 73 out of a possible 100 points. This mean score was
Male 106 43 significantly higher (P⬍.001) among women (74.9) than
Female 142 57 men (70.3). For the eight components scored on 10 points,
Language the mean score ranged from 5.3 for grain products, to 9.3
French 201 81 for dietary variety, and the average subscore for vegeta-
English 47 19 bles and fruit was 12.7 out of a possible 20 points. Wom-
Age group (y) en’s scores showed they met recommendations for intakes
18-34 67 27 of vegetables and fruit, cholesterol, and sodium better
35-49 86 35 than men (P ranged from ⬍.01 to ⬍.0001), whereas men
50-64 62 25 fared better meeting recommended fat intake levels
65⫹ 34 14 (P⬍.05). Compared with other age groups, men and
Education women aged 50 to 64 years achieved the highest sub-
Primary 9 4 scores for grain products (P ranged from ⬍.01 to ⬍.0001),
Secondary 65 26 whereas men aged 18 to 34 years had the best dairy
College 69 28 products (P⬍.01) and dietary variety subscores (P⬍.05)
University or higher 105 42 compared with other men. Among women, those aged 50
Current smoker 57 23 to 64 years also had the highest scores for vegetable and
Physical activity level fruit intakes (P⬍.05) and the highest total Canadian HEI
Low 119 58 score compared with other age groups. Younger women
Moderate 71 35 (aged 18 to 34 years) achieved the best subscores indicat-
High 13 6 ing adherence to recommendations for levels of fat in-
Body mass indexa takes (P⬍.01) (data not shown).
⬍20 8 7.1 The progression of subscores within quartiles of Cana-
20-25 55 49.1 dian HEI scores is shown in Table 4. Not surprisingly,
25-27 24 21.4 overall subscore improvement generally contributed to
⬎27 25 22.3 higher total Canadian HEI scores. The most notable di-
Perceived economic status etary improvements by quartile were in the vegetables
Adequate or well-off 210 85 and fruit subscores, which almost doubled from quartile 1
Poor/very poor 36 15 to quartile 4 among both men and women. Even more
a striking improvement from quartile 1 to 4 can be seen in
Calculated as kg/m2.
the mean scores denoting extent of adherence to guide-
lines for fat, saturated fat, and dietary cholesterol. So-
dium scores were less noteworthy contributors to im-
education. It is noteworthy that around 85% considered proved diet quality, whereas the dietary variety subscore
themselves financially well-off or having adequate eco- did not appear to discriminate participants’ diet quality.
nomic resources. Twenty-three percent of respondents Associations between the Canadian HEI and individual
were current smokers, and most reported low (58%) or specific nutrients (examined as crude nutrient intakes)
moderate (35%) physical activity levels. Although the varied greatly depending on the nutrient and by sex of
majority (49%) had a body mass index indicating a the participant (Table 5). For example, the Canadian HEI
healthful body weight, a small number were thin, approx- showed modest-to-strong positive, highly significant
imately 20% were overweight, and around 22% could be Spearman correlations (rs) ranging from rs⫽0.36 to 0.54
considered obese. (P⬍.001) with vitamin C, folate, and fiber intakes among
On average, the FFQ estimated daily energy intakes as both men and women. A similar but weaker relationship
2,216⫾835 kcal among men and 1,785⫾600 kcal in women. was observed, in women only, between the Canadian HEI
Macronutrient contributions to energy intakes (without al- and thiamin (rs⫽0.34, P⬍.001), vitamin B-6 (rs⫽0.28,
cohol) were similar among men and women. Protein con- P⬍.001), and iron (rs⫽0.25, P⬍.01). On the other hand,
tributed to 17% to 18% of energy; fat made up 34% to 36% our diet quality indicator showed a statistically signifi-
of energy in men and women, respectively; and proportional cant negative correlation with vitamin B-12 and zinc
energy intakes as carbohydrates were 48% among women among male study participants, as well as fat, saturated
and 50% among men (data not shown). fat, and cholesterol among both men and women.
Most mean and median nutrient intakes met or exceeded Finally, selected subscores of the Canadian HEI were
recommended intake levels (derived as described in the examined in relation to certain Canadian nutrition guide-
previous section) for both men and women (Table 2). This lines and nutrient intakes (Table 6). Subscores that re-
was not the case for the median value for vitamin A flect achievement of Canada’s Food Guide for Healthy
among men, or the mean and median intakes of calcium Eating recommendations along with advice to eat from a
for both men and women. In addition, at the 10th percen- variety of food groups showed a strong positive associa-
tile of intakes for several nutrients (vitamin A, vitamin C, tion with dietary fiber intakes (rs⫽0.56, P⬍.001). The

1254 August 2005 Volume 105 Number 8

 Table 2. Adequacy and distribution of nutrient intakes of Montreal-area residents participating in a food frequency questionnaire development
and relative validation study, by sex
Selected nutrients Men (nⴝ105) Women (nⴝ143)

4™™™™™™™™™™™™™™™™™™™™™ mean⫾SD (P10 , P50 , P90d) ™™™™™™™™™™™™™™™™™™™™™3

a b c
e
Protein (%RNI90 ) 150⫾58 (82,145,236) 165⫾63 (94,152,258)
Vitamin A (%RNI90) 100⫾54 (42,88,178) 119⫾66 (58,104,195)
Vitamin C (%EARf) 188⫾133 (46,149,356) 200⫾137 (67,174,384)
Thiamin (%EAR) 169⫾69 (88,156,265) 144⫾54 (80,136,214)
Riboflavin (%EAR) 197⫾83 (107,175,298) 197⫾77 (102,180,310)
Niacin (%EAR) 323⫾121 (190,310,478) 279⫾107 (167,259,419)
Vitamin B-6 (%EAR) 139⫾55 (77,130,204) 119⫾44 (66,112,183)
Vitamin B-12 (%EAR) 247⫾122 (119,212,442) 201⫾104 (91,177,353)
Folate (%RNI90) 134⫾64 (66,122,211) 132⫾64 (66,121,211)
Calcium (%AIg) 95⫾55 (42,84,163) 86⫾47 (35,79,146)
Iron (%EAR) 231⫾89 (133,217,348) 161⫾71 (82,155,248)
Zinc (%EAR) 132⫾51 (74,124,208) 148⫾55 (84,137,225)

Fiber (g) 13.3⫾7 (6,12,22) 11.4⫾5.5 (5,11,20)

Total fat (% energy) 34.1⫾6.5 (26,34,42) 35.5⫾7.6 (25,36,45)
Saturated fat (% energy) 12.1⫾3.0 (8,12,16) 12.4⫾3.4 (9,12,17)
Cholesterol (mg) 292⫾132 (125,282,466) 239⫾107 (120,218,378)
Sodium (mg) 2,944⫾1,389 (1,553,2,614,4,809) 2,377⫾961 (1,271,2,239,3,785)
a
SD⫽standard deviation.
b
P10⫽10th percentile.
c
P50⫽50th percentile, or median.
d
P90⫽90th percentile.
e
RNI90⫽1990 Canadian Recommended Nutrient Intake.
f
EAR⫽Estimated Average Requirement.
g
AI⫽Adequate Intake.

Table 3. Subscores and total Canadian adaptation of the Healthy Eating Index (C-HEI) (9) score calculated from self-administered food frequency
questionnaire data collected from Montreal-area residents, by sexa
Highest possible Male Female All
C-HEI components score (nⴝ105) (nⴝ143) (Nⴝ248)

Grain products 10 5.1⫾2.5 5.4⫾2.5 5.3⫾2.5

Vegetables and fruit 20 11.0⫾5.3 14.0⫾5.2**** 12.7⫾5.4
Milk products 10 7.5⫾2.8 7.5⫾2.9 7.5⫾2.9
Meat and alternatives 10 9.2⫾1.5 8.9⫾1.9 9.0⫾1.7
% Total fat 10 7.3⫾2.8* 6.5⫾3.2 6.9⫾3.1
% Saturated fat 10 6.1⫾3.7 5.9⫾3.8 6.0⫾3.8
Cholesterol 10 7.3⫾3.9 8.8⫾2.8*** 8.2⫾3.3
Sodium 10 7.3⫾3.4 8.6⫾2.5** 8.1⫾3.0
Dietary variety 10 9.4⫾1.1 9.3⫾1.3 9.3⫾1.2
Total score 100 70.3⫾10.5 74.9⫾10.9*** 73.0⫾11.0
a
Differences between men and women assessed by t tests for independent samples.
*P⬍.05.
**P⬍.01.
***P⬍.001.
****P⬍.0001.

total Canadian HEI was significantly associated with
recommendations addressing percent energy as carbohy-
drates (rs⫽0.64, P⬍.001) and fiber intakes (rs⫽0.43,
P⬍.001). On the other hand, subscores including Cana-
da’s Food Guide for Healthy Eating and percent energy as
fat (with or without the sodium subscore) were signifi-
cantly inversely related to participants’ proportional en-
ergy intakes of fat (rs⫽⫺0.34 to ⫺0.46, P⬍.001) or satu-
rated fat (rs⫽⫺0.25 to ⫺.0.36, P⬍.001).
DISCUSSION
The purpose of a dietary index is to synthesize a large
amount of food and nutrient consumption information

August 2005 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1255

 Table 4. Mean Canadian adaptation of the Healthy Eating Index (9) subscores calculated from food frequency questionnaire data from
Montreal-area residents completing a self-administered food frequency questionnaire by quartile among men and women
Mean Subscores within Quartilesa (Q) Mean Subscores within Quartilesb (Q)
among Men among Women
Subscore Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

Grains 4.8 4.6 5.5 5.5 4.4 5.2 5.8 6.1

Vegetables and fruit 8 9.3 11.1 15.7 9.7 11.7 15.5 18.8
Milk products 8.1 7.4 6.9 7.7 7.4 6.8 7.6 8.4
Meat and alternatives 9.3 8.8 9.2 9.4 8.3 9.1 8.8 9.5
% Total fat 3.9 7.2 8.6 9.5 3.7 6.4 7.2 8.8
% Saturated fat 2.1 5.3 7.9 9.1 2.6 5.8 6.6 8.5
Cholesterol 4.8 7.0 8.2 9.1 7.4 8.7 9.2 9.9
Sodium 6.3 7.6 7.4 8.1 8.2 8.7 8.2 9.1
Dietary variety 9.4 9.3 9.4 9.4 9 9.1 9.4 9.8
a
Scoring range: Q1⫽46-62, Q2⫽63-70, Q3⫽71-79, Q4⫽80-91.
b
Scoring range: Q1⫽49-67, Q2⫽68-74, Q3⫽75-82, Q4⫽83-99.

Table 5. Association between Canadian adaptation of the Healthy dated FFQ tested among 248 adults aged 18 to 82 years
Eating Index (9) and selected nutrients estimated by the self- living in metropolitan Montreal, Canada (25).
administered food frequency questionnaire completed by Montreal- The Canadian HEI calculated from our FFQ showed
area residents, by sex that a relatively small proportion of our sample—approx-
Correlations (rS)a imately 20% of men and 29% of women— had a “good”
diet, defined as a score ⬎80. In fact, 76% of men and 70%
Nutrient Male Female of women scored between 51 and 80, indicating that their
diets need improvement, and 2.4% overall (3.8% of men
Energy (kcal) 0.07 0.03 and 1.4% of women) scored under 51, which reflects a
Protein (g) ⫺0.20* 0.05 “poor” diet. The overall mean Canadian HEI scores in our
Vitamin A (REb) ⫺0.20* 0.13 sample, 70.3 in men and 74.9 in women, were higher than
Vitamin C (mg) 0.47*** 0.54*** HEI results based on the Continuing Survey of Food
Thiamin (mg) 0.16 0.34*** Intakes by Individuals, 1994-96, published for Americans
Riboflavin (mg) ⫺0.06 0.16 in 1998 (20) and than those from the 1997 Michigan
Niacin (NEc) ⫺0.14 0.07 Behavioral Risk Factor Surveillance System (8), where
Vitamin B-6 (␮g) 0.13 0.28*** mean HEI and Michigan Healthy Diet Indicator scores
Vitamin B-12 (␮g) ⫺0.26** ⫺0.02
were 63.8 and 55.7, respectively. Caution should be exer-
Folate (␮g) 0.37*** 0.46***
cised when comparing across instruments and popula-
Calcium (mg) ⫺0.12 0.05
tions. However, as others have observed (8,20), women in
Iron (mg) 0.03 0.25**
our study scored significantly higher on the HEI than
Zinc (mg) ⫺0.21* 0.05
Fiber (g) 0.36*** 0.40*** their male counterparts. This was particularly evident for
Total fat (g) ⫺0.36*** ⫺0.22** certain subscore components, most notably in the vege-
Saturated fat (g) ⫺0.42*** ⫺0.26** tables and fruit category.
Cholesterol (mg) ⫺0.36*** ⫺0.17* The Canadian HEI did not show consistent relation-
Sodium (mg) ⫺0.18 0.05 ships with individual nutrients. Kennedy and colleagues
(9) reported positive, albeit modest and variable, correla-
a
Spearman correlation coefficients. tions ranging from 0.06 to 0.42 between the HEI and a
b
RE⫽retinol equivalents. series of nutrients. Our results varied by nutrient and
c
NE⫽niacin equivalents. sex. In general, nutrients from vegetables and fruit (ie,
*P⬍.05.
folate, vitamin C, and fiber) and from high-fiber foods
**P⬍.01.
***P⬍.001.
were strongly associated with the Canadian HEI,
whereas nutrients from animal-source foods were poorly
correlated with the Canadian HEI. This supports earlier
analyses on another indicator, the Diet Quality Index-
into a single useful indicator (33). The USDA HEI was Revised, which had shown that higher Diet Quality In-
constructed to provide a measure of diet quality for mon- dex-Revised scores were related to lower fat consumption,
itoring consumption patterns and their changes, and higher intakes of fruit and vegetables, and better intakes
serve as a tool for nutrition education and health promo- of foods furnishing iron and calcium (34). It is noteworthy
tion (9). We adapted the HEI to Canadian dietary guid- that in our sample, negative correlations between the
ance (Canadian HEI) and used it to evaluate dietary Canadian HEI and individual nutrients were primarily
adequacy based on usual intakes estimated from a vali- observed among men, and that several of these nutrients

1256 August 2005 Volume 105 Number 8

 Table 6. Relationship between selected Canadian adaptation of the Healthy Eating Index (C-HEI) (9) subscores calculated from food frequency
questionnaire data from Montreal-area residents and selected nutrient intakes
Subscores % Energy as carbohydrate
CFGHEc⫹variety 0.06
CFGHE⫹% fat 0.35**
CFGHE⫹% fat⫹sodium 0.46**
C-HEI total score 0.64**
a
Nutrition Recommendations for Canadians (23).
b
Spearman correlation coefficients.
c
CFGHE⫽Canada’s Food Guide for Healthy Eating (C-HEI subscores 1-4).
*P⬍.01.
**P⬍.001.
are derived from intakes of foods from the meat and meat
alternatives food group. These nutrients are also associ-
ated with foods providing substantial intakes of fat, sat-
urated fat, and dietary cholesterol. In fact, in our FFQ
validation study we found that among men, poor correla-
tions between protein and niacin from the FFQ and the
reference method (four nonconsecutive food records)
could be traced to FFQ overestimates for meat and meat
alternatives, which ranged from 18% in men older than
age 65 years, to 36% in men aged 18 to 34 years. Such
observations suggest that a sex-based perceptual bias
may confound reported intakes of certain foods, in this
case, meats. Since assessment of the FFQ’s internal va-
lidity and its potential to represent usual diet revealed no
substantial omissions of regularly consumed foods (25),
variations in strength of association between the Cana-
dian HEI and various nutrients could thus be attribut-
able to reported food sources of the nutrients and the
relationship between these foods and component sub-
scores of the Canadian HEI, as well as to differing intakes
of foods among men and women.
Data from FFQs have been used by others to construct
measures of overall diet quality based on dietary variety
(14). These investigators assessed adherence to Food
Guide Pyramid recommendations and validated their
food categories in relation to estimated intakes of nutri-
ents associated with chronic disease risk, and the extent
of compliance with (current) dietary guidance. The mea-
sures were found to be associated with several attributes
of diet quality, and compared favorably with the HEI.
However, other studies using the HEI in the FFQ context
have had mixed results. McCullough and colleagues (6,7)
reported that dietary patterns determined in two large
US populations of female (35) and male health profession-
als (36), which signaled adherence to the US Dietary
Guidelines (reflected by high HEI scores), showed little
relationship to risk of developing major chronic diseases,
although risk reduction related to following the dietary
guidelines was more apparent in women than men. These
authors proposed that the absence of clear findings could
be due to the fact that the HEI was developed for use with
24-hour recalls. More recently, McCullough and col-
leagues (10) developed an alternate HEI that targets food
choices and macronutrient sources specifically associated
with reduced risk for chronic disease, and tested it in the
Nutrition Guidelinesa (rs)b
% Energy as fat % Energy as saturated fat Fiber
–0.02 0.04 0.56**
–0.34** –0.25* 0.58**
–0.46** –0.36** 0.55**
–0.66** –0.62** 0.43**
same populations of male and female health professionals
as in their previous reports (6,7). They found a relation-
ship between attainment of the alternate HEI goals and
reduced chronic disease risk, most notably due to reduc-
tion in cardiovascular disease risk, and they attributed
this finding to the ability of the alternate HEI to capture
certain dietary choices (eg, white vs red meat and type of
fat consumed). However, they observed that it is difficult
to target a score to chronic diseases that differ in their
etiology and postulated that measurement error and ab-
sence of certain details (eg, high-heat cooking practices
related to cancer etiology) could obscure relationships.
It was for this reason that we sought to evaluate the
Canadian HEI in a general dietary surveillance context
rather than from the perspective of disease risk. Our
findings show that selected subscores of the Canadian
HEI do indeed reflect achievement of these dietary guide-
lines. Canadian HEI subscores indicating adherence to
dietary guidelines for fiber, fat, and saturated fat showed
robust associations with subjects’ reported intakes of
these dietary substances on the FFQ, suggesting that the
Canadian HEI is capable of discriminating diet quality.
We were initially unsure if we could validate the Ca-
nadian HEI because it was not clear which reference
method should be used. It was therefore reassuring to
note that others have used a set of plasma biomarkers of
dietary exposure to validate HEI scores, and that signif-
icant correlations have been found between the HEI and
certain circulating plasma carotenoids, as well as plasma
vitamin C concentrations (37). In addition, when the Diet
Quality Index-Revised was validated using a 131-item
FFQ, it performed similarly to the HEI as reported in the
previous study (37) when compared with plasma bio-
chemical measurements (38). Finally, Neuhouser and col-
leagues (39) assessed the reproducibility and validity of
the Diet Quality Index-Revised using the Women’s
Health Initiative FFQ (40) and reported that selected
concentration-based nutritional biomarkers do predict
diet quality as assessed by the Diet Quality Index-Re-
vised. These findings attest to the potential validity of a
diet quality index obtained from FFQ dietary estimates.
However, it is worth noting the possible discordance be-
tween the FFQ usual nutrient estimates and the shorter
timeframe provided by plasma biomarkers. More work
August 2005 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1257
needs to be done to find temporally appropriate biomar-
kers.
Our observations of a predominant concordance be-
tween the vegetables and fruits subscore and improve-
ment in overall diet quality as assessed by the total
Canadian HEI are bolstered by significant positive corre-
lations between the Canadian HEI and individual crude
nutrient intakes reflecting consumption of vegetables and
fruit (for vitamin C, r⫽0.47 and 0.54, P⬍.001, and for
folate, r⫽0.37 and 0.46, P⬍.001, for men and women,
respectively). They thus provide further support for our
analyses (37-40) and are consistent with those from a
recent report by Weinstein and colleagues (41) that fur-
ther attests to the validity of the HEI as a measure of
total diet quality. Furthermore, relationships between
the Canadian HEI and Canadian dietary guidelines and
nutrition recommendations demonstrate the ability of the
Canadian HEI to clearly recognize consumption of a diet
containing adequate servings from all four food groups
while maintaining moderate intakes of fat, saturated fat,
cholesterol, and sodium.
Several issues must be considered when interpreting
findings. Because self-reported data from a self-adminis-
tered FFQ are subject to measurement error, the relative
validity of the dietary assessment approach is crucial to
the robustness of the results. Indeed, although it was
determined that certain participants in our FFQ valida-
tion study underreported their intakes (42), correlations
between nutrients estimated by our FFQ and those from
the mean of four nonconsecutive food records were posi-
tive and statistically significant (P ranged from .01 to
.001). The mean correlation was rs⫽0.45, with a range of
0.30 (vitamin A) to 0.57 (energy, fat, and saturated fat),
and strongly resembled those reported by other studies
using either the Willett or Block FFQ (25,43). Agreement
between the FFQ and food records was considerably and
consistently stronger among women than men.
The representativity of the sample must also be con-
sidered. It is generally agreed that socioeconomic status,
age, and sex are consistent determinants of food choice
(15,16) and, hence, diet quality (8) and nutritional ade-
quacy (18,44). Although they were recruited using a ran-
dom selection process, our study participants, as is the
case in many health-oriented studies (45), tended to have
higher education and income levels overall than the gen-
eral population (46,47). This phenomenon could have an
effect on self-reports of food intakes, as these participants
are often health conscious and may eat a better quality
diet. Such respondents could also report more socially
desirable dietary intakes that could bias the results, or
even provide more complete and reliable data than others
in lower sociodemographic strata due to difficulties re-
lated to completing an FFQ (48,49). We were unable to
pursue investigations of relationships beyond simple bi-
variate analyses between Canadian HEI scores and so-
ciodemographic variables other than sex because of small
or unbalanced cell sizes within variable categories. Be-
cause the language spoken in Quebec (French vs English)
has traditionally represented substantial cultural differ-
ence with a clear influence on food choice (50), we looked
at diet quality by linguistic origin to explore potential
cultural difference in dietary adequacy. Whereas the lin-
guistic groups may have been too unbalanced (81%
1258 August 2005 Volume 105 Number 8
French speaking) to permit meaningful cross-tabulation
of results by this variable, it was also instructive to note
that the distribution of Canadian HEI scores was virtu-
ally identical in French- and English-speaking partici-
pants. This suggests either a blunted cultural influence
on diet among Montrealers or, more likely, that equiva-
lent diet quality can be provided by differing dietary
choices. As most other studies examining assessment of
diet quality using indicators have focussed on relatively
health-conscious populations with higher levels of socio-
demographic attributes, future research should therefore
test diet quality indicators in ethnically diverse popula-
tions and in disadvantaged groups.
The variety component of the Canadian HEI may have
limited the indicator’s capacity to better discriminate
participants’ diet quality. Indeed, the progression of
scores within quartiles showed that there was little vari-
ation in this component which ranged from 9 to 9.8 across
quartiles, and may partly explain why these participants
had higher diet quality scores than those based on US
data (8,20). Indicators can only represent true dietary
variety in relation to the number of items in the FFQ (14)
and the reasoning behind derivation of the component.
CONCLUSIONS
Our results suggest that the Canadian HEI adequately
discriminates overall diet quality based on dietary data
estimated from our FFQ. Nutrients from vegetables and
fruit and from high-fiber (ie, whole-grain) foods were
strongly positively associated with the Canadian HEI,
whereas certain dietary components from animal-source
foods (ie, fat, saturated fat, and cholesterol) were nega-
tively correlated with the Canadian HEI. Although men
and women appear to obtain their nutrients from differ-
ent food sources, it is also possible that under- and/or
overreporting could differ by sex. High reported intakes
of meat and meat alternatives, particularly among men,
may be the most likely explanation for weaker and less
consistent correlations between the Canadian HEI and
nutrients from meat and dairy foods (eg, protein, zinc,
iron, vitamin B-12, and calcium) in men.
However, the Canadian HEI scores obtained for this
sample of relatively educated and affluent adults suggest
fairly widespread suboptimal diet quality among study
participants, with indicator subscores revealing poor in-
takes from certain food groups compared with age- and
sex-based recommendations. It is likely that the general
population fares considerably worse. Examination of sub-
scores within quartiles, particularly as diet quality im-
proves, may reveal useful information on the true con-
tributors to diet quality. Consequently, subscores could
be even more useful than the total Canadian HEI score in
a clinical or health-promotion setting, or as a teaching
and planning tool.
To be truly useful, diet quality assessment must be able
to relate the outcome to other markers or components of
healthful eating practices. Future studies should test diet
quality indicators in populations recruited to reflect
greater dietary diversity and reporting ability and in-
clude members of disadvantaged groups to provide a
broader set of behaviors that could shed light on factors
influencing diet quality.
This research was supported by a grant from the joint
Fonds de la recherche en santé du Québec-Santé Québec
programme for the analysis of survey data (project No.
001027).
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