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Open access Cohort profile
Nutrition Questionnaires plus (NQplus) BMJ Open: first published as 10.1136/bmjopen-2017-020228 on 30 July 2018. Downloaded from
study, a prospective study on dietary
determinants and cardiometabolic
health in Dutch adults
Elske Maria Brouwer-Brolsma, Linde van Lee, Martinette T Streppel,
Diewertje Sluik, Anne M van de Wiel, Jeanne H M de Vries, Anouk Geelen,
Edith J M Feskens
To cite: Brouwer-Brolsma EM, AbstrACt strengths and limitations of this study
van Lee L, Streppel MT, et al. Purpose During the past decades, the number of people
Nutrition Questionnaires plus with cardiometabolic conditions substantially increased.
(NQplus) study, a prospective To identify dietary factors that may be responsible for ► A unique asset of this study is the extensive quantity
study on dietary determinants this increase in cardiometabolic conditions, the Nutrition of dietary data collected, including Food Frequency
and cardiometabolic health Questionnaires plus (NQplus) study was initiated. The aim of Questionnaires, multiple 24-hour recalls and nutri-
in Dutch adults. BMJ Open this article is to provide an overview of the study design and tional biomarkers.
2018;8:e020228. doi:10.1136/ ► The wide range of cardiometabolic factors and age-
bmjopen-2017-020228 baseline characteristics of the NQplus population. ing-related health outcomes measured allow the ex-
► Prepublication history for Participants The NQplus study is a prospective cohort ploration of a broad variety of associations between
this paper is available online. study among 2048 Dutch men (52%) and women (48%) diet and human health.
To view these files, please visit aged 20–70 years. ► Nutrition Questionnaires plus (NQplus) participants
the journal online (http:// dx. doi. Findings to date At baseline, we assessed habitual dietary are higher educated, have a higher body mass index
org/ 10. 1136/ bmjopen- 2017- intake, conducted physical examinations (measuring, eg, and less often smoke than the general Dutch popu-
020228). anthropometrics, body composition, blood pressure, pulse lation. Therefore, the NQplus study population does
wave velocity, advanced glycation end product accumulation, not fully represent the general Dutch population.
Received 24 October 2017 cognitive performance), collected blood and 24-hour urine ► Further expansion of the database is possible using
Revised 11 June 2018 and administered a variety of validated demographic, health stored frozen blood and urine samples. Moreover,
Accepted 12 June 2018 and lifestyle questionnaires. Participants had a mean BMI participants can still be contacted to fill-out newly http://bmjopen.bmj.com/
of 26.0±4.2 kg/m2
, were mostly highly educated (63%), developed questionnaires.
married or having a registered partnership (72%) and having
a paid job (72%). Estimated daily energy and macronutrient
intakes (mean±SD) were 8581±2531 kJ, 15±2energy obese (body mass index (BMI) ≥30 kg/
(en%) of protein, 43±6 en% of carbohydrates, 36±5 en% m2 1
of fat and 11±13 g of alcohol. Mean systolic blood pressure ) according to WHO. In addition,
was 126±15 mm Hg, total cholesterol 5.3±1.1 mmol/L and the prevalences of hypertension (systolic
haemoglobin A1c 36±5 mmol/mol. A total of 24% of the blood pressure 140+ and/or diastolic
participants reported to be diagnosed with hypertension, 18% blood pressure 90+ or using antihyperten- on January 5, 2023 by guest. Protected by copyright.
with hypercholesterolaemia and 4% with diabetes mellitus. All sive medication), hypercholesterolaemia
measurements were repeated after 1 and 2 years of follow- (total cholesterol ≥5.0 mmol/L) and
up. hyperglycaemia (fasting plasma glucose
Future plans We endeavour to continue measurements value ≥7.0 mmol/L) among the adult popula-
on the long-term. Moreover, dietary assessment methods 2
tion have been estimated to be around 40%,
used in the NQplus study will be extensively validated, 3 4
39% and 9%, respectively. As all these factors
© Author(s) (or their that is, Food Frequency Questionnaires, 24-hour recalls are known to adversely affect cardiometabolic
employer(s)) 2018. Re-use and urinary and blood biomarkers of exposure. As such, health, attempts to lower these prevalences
permitted under CC BY-NC. No the NQplus study will provide a unique opportunity to should be encouraged. Lifestyle changes
commercial re-use. See rights study many cross-sectional and longitudinal associations might help to achieve this goal and dietary
and permissions. Published by between diet and cardiometabolic health outcomes using
BMJ. the best dietary assessment methods available so far. changes may play an important role in this.
Division of Human Nutrition, Unfortunately, it is not that easy to examine
Wageningen University, the impact of diet on human health since
Wageningen, The Netherlands dietary assessment methods (eg, duplicate
Correspondence to IntroduCtIon 24-hour recalls and Food Frequency Ques-
Dr Edith J M Feskens; Globally, more than half a billion adults tionnaires (FFQs)) are often suboptimal to
Edith. Feskens@ wur. nl aged ≥20 years are classified as being measure habitual dietary intake. Duplicate
Brouwer-Brolsma EM, et al. BMJ Open 2018;8:e020228. doi:10.1136/bmjopen-2017-020228 1
Open access
24-hour recalls are often not sufficient to assess episodi- between meal timing and metabolic health as well as the BMJ Open: first published as 10.1136/bmjopen-2017-020228 on 30 July 2018. Downloaded from
cally consumed foods, micronutrients and trace elements association between vitamin D, glucose intolerance and
as they can be easily missed and as such result in misclas- cognition.9
sification. For larger studies, FFQs are often the method Given the variety of measurements conducted in view of
of choice. However, also FFQs are susceptible to bias, for the NQplus study, the purpose of this article is to provide
instance, due to imprecise assessment of portion sizes, an overview of the: 1) study design and 2) baseline char-
errors in food composition tables and the large variation acteristics of the study population.
in obtainable foods. Ideally, the validity of an FFQ is exam-
ined before diet-health associations are explored, but
time and budget are often limiting factors in this process. Cohort desCrIPtIon
To reduce the costs and time burden associated with vali- Participants
dation studies, we initiated the National Dietary Assess- The NQplus study is a prospective cohort study,
ment Reference Database (NDARD) project.5 In order to primarily conducted among Caucasian Dutch adults
establish the NDARD database, we included 2048 partic- aged 20–70 years living in the central part of the Neth-
ipants providing us with dietary data collected by means erlands (ie, Wageningen and vicinity), initiated as an
of FFQs, repeated 24-hour recalls, as well as urinary/ 5
add-on study to the NDARD project. The NQplus study
blood biomarkers. As the questions in Dutch FFQs are aimed to recruit 1750 men and women that were able
generally linked to the food items in the national food to speak and write Dutch and competent to make their
composition table, this database allows the validation of own decisions. Recruitment started in June 2011 and
existing dietary assessment methods and the develop- was completed in February 2013. During this period,
ment of new dietary assessment methods in a more cost 2048 men and women were included in the study
and time effective manner. Therefore, it is expected that (figure 1). Baseline measurements included the assess-
the FFQs generated with the use of this new database will ment of habitual dietary intake by an FFQ and repeated
provide more accurate dietary data than the FFQs that 24-hour recalls; physical examinations including
are currently used. measurements of anthropometrics, body composition,
Given the unique nature of the dietary data collected blood pressure, pulse wave velocity, advanced glycation
in view of the NDARD project, we decided to expand the end product (AGE) accumulation by skin autofluo-
NDARD database by collecting extensive data on partici- rescence and cognitive performance; blood sampling;
pant characteristics, including cross-sectional and longi- 24-hour urine collection and a variety of validated
tudinal data on demographics, lifestyle, medical history health and lifestyle questionnaires completed online
and (cardiometabolic) health outcomes: the Nutrition using the open-source survey tool Limesurvey (Lime-
Questionnaires plus (NQplus) study. This study provides Survey Project Team/Carsten Schmitz, Hamburg,
the opportunity to explore a large number of interesting Germany) (table 1). All measurements were repeated at http://bmjopen.bmj.com/
research questions related to diet and (cardiometabolic) 1 and 2 years of follow-up and performed according to
health outcomes using the best dietary intake assessment a standardised protocol by trained research assistants.
methods available so far. Associations that can be studied All participants gave written informed consent before
using NQplus data include the potential role of poly- commencement of the study.
phenol intake in relation to blood pressure and arterial
6 blood collection
stiffness, Na/K excretion in relation to blood pressure,
7 Fasting blood samples were collected in the morning
arterial stiffness and metabolic syndrome, associations
between dietary lignans and serum lipids,8 associations at hospital Gelderse Vallei (Ede) or hospital Rijnstate on January 5, 2023 by guest. Protected by copyright.
Figure 1 Study flow of the Nutrition Questionnaires plus (NQplus) study. Please note that the n’s given for the demographic
variables, dietary intake variables and health outcomes are based on a key variable with the most observations within that
specific group.
2 Brouwer-Brolsma EM, et al. BMJ Open 2018;8:e020228. doi:10.1136/bmjopen-2017-020228
Open access
Table 1 Overview of the measurements in the NQplus study BMJ Open: first published as 10.1136/bmjopen-2017-020228 on 30 July 2018. Downloaded from
Domain Method(s) Main parameters
Demographics, General questionnaire Age, sex, postal code, birth country of participant and his/her father
lifestyle and general and mother, marital status, household composition, educational
health level, work situation, smoking habits, medical history regarding
allergies, cancer, diabetes mellitus, cardiovascular health, renal health,
thyroid disorders, eyesight, hearing problems, dental problems,
gastrointestinal health, incontinence, epilepsy, women’s health,
whether a participant was breast fed or not, birth weight, sunlight
exposure, etc.
Short QUestionnaire to ASsess Questionnaire assessing the time being physically active, eg, sports,
Health enhancing physical domestic activities, leisure time activities, activities related to home-
activity/Activity Questionnaire for work travelling, resulting in three overall scores, including the total
Adults and Adolescents activity time (min), total activity score taking into account duration and
intensity and a dichotomous variable indicating whether a participant
met the national physical activity guideline of being physically activity
for at least 30 min for 5 or more days per week.
Habitual dietary FFQs and 24-hour recalls Intake levels of macronutrients, micronutrients, trace elements, foods,
intake food groups and dietary patterns.
Eating behaviour Dutch Eating Behaviour Questionnaire resulting in three main scores, including an emotional
Questionnaire eating score, restrained eating score and external eating score.
Food Choice Questionnaire Nine factors that may influence our daily dietary choices, ie, health,
mood, convenience, sensory appeal, natural content, price, weight
control, familiarity and ethical concern.
Food Neophobia Scale Questionnaire resulting in a total food neophobia score.
Eating rate question Eating rate judged as very slow, slow, average, fast or very fast.
Questionnaire developed by Parameters on purchase and cooking habits, eating behaviour during
Hooft van Huysduynen and dinner, presence/access to (un)healthy foods, knowledge/skills to make
colleagues healthy food choices, etc.
Questionnaire by research Three items covering general statements; 13 items covering time,
institute Wageningen Economic location and company during meals; 18 items covering sweet snack
Research consumption; 7 items covering intentions towards consumption of
sweet snacks; 4 items covering meat consumption and 15 items http://bmjopen.bmj.com/
covering intentions towards consumption of meat and meat
substitutes.
Biomarkers Plasma Total cholesterol, LDL cholesterol, HDL cholesterol, glucose.
Serum Triglycerides, ALP, ALT, AST, γGT, albumin, creatinine, calcium, sodium,
potassium, phosphate, urea, uric acid.
Whole blood HbA1c, Hb, Ht, thrombocytes, erythrocytes, leucocytes, lymphocytes,
monocytes, eosinophils, basophils, neutrophils.
Urine PABA, potassium, sodium, creatinine, nitrogen. on January 5, 2023 by guest. Protected by copyright.
Anthropometrics Stadiometer Height.
Digital weighing scale Weight.
Measuring tape Waist and hip circumference.
Body composition DXA or Tanita body composition Total fat mass, lean body mass, body fat percentage and bone mineral
analyser density.
Body weight Questionnaire Opinion on own body weight, desire to lose weight, currently dieting,
dieting frequency, weight at age 18, weight at age 20, highest weight in
past 5 years, lowest weight in past 5 years and unwanted weight loss.
Advanced glycation AGE-Reader Skin autofluorescence and skin reflection.
end products
Vascular Digital blood pressure monitor Systolic and diastolic blood pressure.
measurements
Applanation tonometry Augmentation index and resting heart rate.
Continued
Brouwer-Brolsma EM, et al. BMJ Open 2018;8:e020228. doi:10.1136/bmjopen-2017-020228 3
Open access
Table 1 Continued BMJ Open: first published as 10.1136/bmjopen-2017-020228 on 30 July 2018. Downloaded from
Domain Method(s) Main parameters
Cognitive Symbol Digit Modalities Test Number of encoded symbols.
performance
Letter Fluency Test Average number of generated words.
Story Recall Number of correct items, direct and postponed.
Mental well-being Rosenberg Self-Esteem Scale 10-item scale resulting in a total self-esteem score.
Brief Self-Control Scale 13-item scale resulting in a total trait self-control score.
Mindful Attention Awareness 15-item scale resulting in a total mindful attention awareness score.
Scale
Consideration of Future 12-item scale resulting in a total score indicating the extent to which
Consequences Scale people emphasise short-term or long-term consequences.
Sense of Coherence 13-item scale covering comprehensibility, manageability and
meaningfulness.
Perceived Stress Scale-4 4-item scale questioning feelings and thoughts during the past 2 weeks
resulting in a total stress score.
Long-term Difficulties Inventory 12-item scale resulting in a total score of chronic stress due to eg,
home, work, relationships, leisure activities, finances, health, school
and religion.
Center for Epidemiological 20-item scale asking for depression-related symptoms, eg, insomnia,
Studies Depression Scale loss of appetite and loneliness, resulting in a total depression score.
Short Form 36-item Health 36-item health-related quality of life questionnaire evaluating eight
Survey elements: physical functioning, limitations due to physical health,
bodily pain, general health, vitality, social functioning, limitations due to
emotional health and mental health.
EuroQol Group EQ-5D Health 5-item questionnaire measuring generic health status (mobility,
Questionnaire self-care, usual activities, pain/discomfort and anxiety/depression)
supplemented with a visual analogue scale evaluating overall health
status.
Social Production Function 9-item questionnaire covering affection, behavioural confirmation,
Instrument for the Level of Well- status, comfort and stimulation. http://bmjopen.bmj.com/
being
Gastrointestinal Questionnaire based on Rome III Questionnaire including questions related to presence of abdominal
health criteria pain (including menstrual pain), obstipation, type of stool, gasification/
swollen abdomen, having an unpleasant feeling full after a normal meal,
eating difficulties, existence of a burning sensation lower abdomen,
etc.
Sleep Munich Chronotype 6-item questionnaire providing information on the time from
characteristics Questionnaire wakefulness into sleep, wake-up time, sleep duration and mid-point on January 5, 2023 by guest. Protected by copyright.
between time to fall asleep and wake-up time.
Medication use Registered during physical Classification according to Anatomical Therapeutic Chemical
assessment classification system.
FFQ, Food Frequency Questionnaire; AGE, advanced glycation end products; DXA, dual-energy X-ray absorptiometry; LDL, low-density
lipoprotein; HDL, high-density lipoprotein; HbA1c, haemoglobin A1c; ALP, alkaline phosphatase; ALT, alanine aminotransferase; AST,
aspartate aminotransferase; γGT, gamma-glutamyltranspeptidase; Hb, haemoglobin; Ht, haematocrit; PABA, para-aminobenzoid acid.
(Velp). Samples were analysed in the respective hospital isolated from buffy coats and successfully extracted for
laboratories, which both joined the external quality 721 participants using a Puregene 5Prime-kit. Currently,
control programme in the Netherlands (SKML) and these samples are being genotyped with the Illumina
used the same methodology and standardised protocols OmniExpress chip covering >90% of all common
for risk factor assessments. Analyses were performed variation in the genome. Remaining EDTA plasma
using Dimension Vista 1500 automated analyser (6×0.5 mL+1×1.5 mL), citrate plasma (5×0.5 mL),
(Siemens, Erlangen, Germany) or Roche Modular P800 serum (3×0.5 mL+2×1 mL) and one buffy coat sample
chemistry analyser (Roche Diagnostics, Indianapolis, were stored at −80°C in the NQplus biobank for future
USA), unless specified otherwise. Moreover, DNA was analysis.
4 Brouwer-Brolsma EM, et al. BMJ Open 2018;8:e020228. doi:10.1136/bmjopen-2017-020228
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