In this study, we evaluated the validity of a FFQ as a means of estimating dietary folate intake in the population for which the FFQ was originally developed. We also attempted to identify foods that differentiated the level of folate intake in individuals by stepwise regression, and tested the validity of assessing folate intake based on the intake of these foods. The results were also cross-validated in an independent population to evaluate generalizability.
Validity of the FFQ in estimating folate intake was moderate in both the internal and external populations. In previous studies, the validity of questionnaires in estimating energy-adjusted dietary folate intake varied from 0.2 to 0.6, depending on the study population [15–21]. In studies that reported intake from the diet and from dietary supplements separately, CC was 6–21% higher for folate intake that included supplements than for intake from diet alone. Although none of the subjects used supplements that contained folic acid, which had only just become available at the time of the study, the validity of our FFQ in estimating folate from the diet was relatively high, probably because the dietary folate intake of our subjects was as high as that of supplement users in some of the previously cited studies.
Although the largest proportion of folate intake was from vegetables, these did not necessarily explain the differences in intake between individuals. For example, spinach, which is very rich in folate and was one of the highest contributors to mean folate intake, could not explain inter-individual variation because it was consumed by almost every subject. In contrast, green tea contributed greatly to both individual intake and to inter-individual variation, probably because consumption was strongly dependent on individual preference. Although the analysis provided us with information about foods that predicted inter-individual variation in folate intake, some foods which had a moderate partial R-square value contributed less than 0.1% to total folate intake, such as luncheon meat, ham, and so on. These may have been selected by chance alone. In this kind of analysis, even unimportant contributors to the cumulative R-square value may be statistically significant, but can nevertheless be ignored . In any case, it is noteworthy that individuals could be ranked by folate intake based on only 33 foods, with the same level of validity as with the long FFQ.
Any analysis of the possible effects of folate intake on disease also requires analysis of the effect of food items which contribute to total intake and inter-individual variation of folate. It is of great research interest to determine whether the association between food intake and disease is the result of folate intake. For example, we might hypothesize that folate intake may help explain the protective effect of green tea on gastric cancer described in the recent report of the JPHC study . The mechanism of carcinogenesis through DNA instability and methylation abnormalities as a result of folate deficiency has been studied in animal and in vitro studies [23–25], and an association between folate and gastric cancer has been reported in a number of case-control studies [26–29]. Other prospective studies, however, have failed to show a consistent association between green tea and gastric cancer [30–32]. We speculate that the association was strong in the JPHC population owing to the large contribution of green tea to the variation in folate intake, which was not seen in the other populations.
One of the strengths of our study is the precision of the reference data. The ratio of intra- to inter-individual variation in our data was somewhat higher (1.9–4.8) than in several studies in Western countries [33, 34]. When intra-individual variation is larger, an increased number of dietary assessment days is required to obtain a valid standard. Although intra-individual variation among our subjects was high, we had more than a sufficient numbers of days (28 days) of data to represent the true intake of the individuals, because the number of DR days needed to estimate true intake within 20% of the true mean with our data was only about 17 to 19 days according to our analysis. By comparison, the greatest number of days of dietary assessment used as standard in previous studies was 14 days .
In addition, our analysis is unique because we used regression analysis to identify the foods most predictive for inter-individual variation in dietary folate, and then evaluated both the internal and external validity of the intake of those foods. It is important to test external validity, because there is no assurance that explanatory variables selected by regression analysis are valid in an external population . To our knowledge, this is the first study to attempt to identify foods that contribute to inter-individual variation of folate intake in Japan, where folate intake is almost exclusively from natural sources. We developed a list of foods that contribute to inter-individual variation in folate intake in the population for which FFQ was originally developed, and tested the generalizability of the results to an external population. The two populations covered various geographic areas throughout Japan. Our results imply the possibility that a shorter questionnaire which specifically targets folate intake in Japanese populations can be developed.
One limitation of our study is that because the subjects needed to be highly motivated to complete the 28-day DRs, they were not a randomly selected sample. Mean folate intake based on DRs was slightly higher than in the entire cohort, probably because the validation study subjects were likely more health conscious and consumed more vegetables. If all subjects had consumed a similar amount of certain foods, inter-individual variation in the food might have been falsely low. The generalizability of questionnaire results needs to be established with care.