San-Cristobal et al.

International Journal of Behavioral Nutrition and Physical Activity

(2017) 14:168
DOI 10.1186/s12966-017-0624-6

RESEARCH Open Access

Capturing health and eating status through

a nutritional perception screening
questionnaire (NPSQ9) in a randomised
internet-based personalised nutrition
intervention: the Food4Me study
Rodrigo San-Cristobal1, Santiago Navas-Carretero1,2*, Carlos Celis-Morales3, Katherine M. Livingstone3,
Barbara Stewart-Knox4, Audrey Rankin5, Anna L. Macready6, Rosalind Fallaize6, Clare B. O’Donovan7,
Hannah Forster7, Clara Woolhead7, Marianne C. Walsh7, Christina P. Lambrinou8, George Moschonis8,
Yannis Manios8, Miroslaw Jarosz9, Hannelore Daniel10, Eileen R. Gibney7, Lorraine Brennan7,
Thomas E. Gundersen11, Christian A. Drevon12, Mike Gibney7, Cyril F. M. Marsaux13, Wim H. M. Saris13,
Julie A. Lovegrove6, Lynn J. Frewer14, John C. Mathers3, J. Alfredo Martinez1,2,15,16
and on behalf of the Food4Me Study

Abstract
Background: National guidelines emphasize healthy eating to promote wellbeing and prevention of non-
communicable diseases. The perceived healthiness of food is determined by many factors affecting food intake. A
positive perception of healthy eating has been shown to be associated with greater diet quality. Internet-based
methodologies allow contact with large populations. Our present study aims to design and evaluate a short
nutritional perception questionnaire, to be used as a screening tool for assessing nutritional status, and to predict
an optimal level of personalisation in nutritional advice delivered via the Internet.
Methods: Data from all participants who were screened and then enrolled into the Food4Me proof-of-principle
study (n = 2369) were used to determine the optimal items for inclusion in a novel screening tool, the Nutritional
Perception Screening Questionnaire-9 (NPSQ9). Exploratory and confirmatory factor analyses were performed on
anthropometric and biochemical data and on dietary indices acquired from participants who had completed the
Food4Me dietary intervention (n = 1153). Baseline and intervention data were analysed using linear regression and
linear mixed regression, respectively.
(Continued on next page)

* Correspondence: snavas@unav.es
1
Centre for Nutrition Research, Department of Nutrition, Food Science and
Physiology, University of Navarra, C/Irunlarrea, 1, 31008 Pamplona, Spain
2
CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud
Carlos III, 28023 Madrid, Spain
Full list of author information is available at the end of the article

© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

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San-Cristobal et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:168 Page 2 of 12

(Continued from previous page)

Results: A final model with 9 NPSQ items was validated against the dietary intervention data. NPSQ9 scores were
inversely associated with BMI (β = −0.181, p < 0.001) and waist circumference (Β = −0.155, p < 0.001), and positively
associated with total carotenoids (β = 0.198, p < 0.001), omega-3 fatty acid index (β = 0.155, p < 0.001), Healthy
Eating Index (HEI) (β = 0.299, p < 0.001) and Mediterranean Diet Score (MDS) (β = 0. 279, p < 0.001). Findings from
the longitudinal intervention study showed a greater reduction in BMI and improved dietary indices among
participants with lower NPSQ9 scores.
Conclusions: Healthy eating perceptions and dietary habits captured by the NPSQ9 score, based on nine questionnaire
items, were associated with reduced body weight and improved diet quality. Likewise, participants with a lower score
achieved greater health improvements than those with higher scores, in response to personalised advice, suggesting that
NPSQ9 may be used for early evaluation of nutritional status and to tailor nutritional advice.
Trial registration: NCT01530139.
Keywords: Food4Me, Personalised nutrition, Survey, Healthy eating index, Mediterranean diet score, NPSQ9,
Nutritional status

Background food choices, including a reduced energy intake where

A number of national strategies and programs focus on appropriate, during a dietary intervention with persona-
improving lifestyle and dietary habits for the prevention lised nutritional advice [13, 14].
of non-communicable chronic diseases [1], especially Development of tools to assess health status has
those related to weight management [2, 3]. However, the played an important role in health behaviour research
perceived benefit of consuming certain foods is influ- [15]. The relationship between wellbeing and healthy
enced by multiple individual factors, which may alter eating is well established, which is the reason why many
eating habits and dietary patterns. Identification of these psychological and public health studies have tried to
factors and dietary patterns is an important challenge develop questionnaires aiming to collect information on
for the promotion of well-being and public health [4, 5]. complex issues like eating behaviour related to the
Identification of barriers to the consumption of healthy development of chronic diseases such as obesity,
foods is imperative to the design of effective behaviour diabetes, and cardiovascular events [16, 17]. These
change interventions and policies [6]. Moreover, infor- questionnaires require the use of representative data
mation on barriers to healthy eating will help identify and sufficient accuracy before being used as early
food-related perceptions that have the potential to nega- detection tools.
tively impact on dietary choices [7]. The current development of worldwide internet-based
Perception of food healthiness is determined by communications has highlighted the need for short and
numerous factors such as conventional and unconven- applicable tools for the screening of large populations
tional beliefs [4, 6], as well as consciousness/knowledge [18]. The use of Internet-based platforms allows contact
of food composition [8]. Such perceptions may affect with large numbers of individuals with a good cost
attitudes towards foods consumption, resulting in under- effectiveness [19], however such questionnaires would
or over-eating and causing unhealthy changes in body need to be tested in different settings and with large and
weight [8]. Previous studies have indicated positive asso- heterogeneous populations. The present study was a
ciations between perception of healthy food intake and cross-sectional and longitudinal analysis intended to
diet quality [9–11]. A preceding study on dietary design and validate a short nutritional perception
patterns in a Spanish cohort showed that participants questionnaire. It is anticipated that this screening tool
who presented with “prudent” or “healthy” dietary may be used by health professionals to assess percep-
patterns reported greater proportions of positive percep- tions of eating behaviour and health status with the aim
tions of healthy eating than those who exhibited a of predicting the optimal level of personalisation in
“Western” or “compensatory” dietary patterns [5]. nutritional advice via the internet.
Similarly, the perception of healthy eating has been pre-
sented by some authors as a plausible predictor of Methods
behavioural intentions regarding food choices [12]. Such Study population and study design
evidence suggests that a maintained positive perception The Food4Me study followed all required ethical standards,
of healthy intake, alongside other perceived values, including the CONSORT guidelines (Additional file 1).
might contribute to the adoption of healthy habits and Participants in the follow-up Nutritional Perception

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San-Cristobal et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:168 Page 3 of 12

Screening Questionnaire-9 (NPSQ9) design were enrolled based on dietary data; Level 2 – personalised advice based
from the Food4Me study, which was a randomised con- on dietary and phenotypic data; and Level 3 – personalised
trolled intervention trial designed to assess the effect of per- advice based on dietary, phenotypic, and genotypic data.
sonalised nutrition advice on health-related behaviours For the analysis of the effects of personalised nutrition ad-
across seven European countries [20]. Participants who vice, volunteers from Levels 1, 2, and 3, were pooled to
signed up on the Food4Me webpage (http://www.food4 evaluate the effects of personalising the nutritional advice,
me.org) and completed the initial screening processes were without taking into account the type of feedback provided.
selected (n = 2369) for inclusion in the NPSQ9 design.
These processes consisted of signing two informed consent
forms if inclusion criteria for taking part in the Food4Me Item selection
study were met [20], and providing information by answer- Data obtained from the questionnaire, specifically
ing the screening questionnaires (Table 1), on aspects re- designed within the Food4Me study, and related to diet-
garding socio-demographics, medical history, lifestyle and ary habits, health perception, eating perception, and
dietary habits, health and eating self-perception, as well as nutrition self-efficacy were used for the analyses. This
responses to a validated Food Frequency Questionnaire questionnaire contained Likert scale questions related to
(FFQ) [21, 22]. Volunteers selected for inclusion in the Nutrition Self-efficacy [23], Health locus of control [24],
intervention and who completed the questionnaires at Self-report Habit Index [25, 26], and Dietary food choice/
baseline and at 6 months (n = 1153), were used for the sub- habits (Additional file 2: Table S1).
sequent validation study and for association analyses with Socio-demographic questions, self-reported height and
different dietary indices (Fig. 1). During the study, the vol- weight [27], the validated Food4Me FFQ [21, 22, 28],
unteers were randomly assigned to one of four intervention and biochemical values of dried blood spots [29], were
groups receiving different types of personalised nutrition analysed for associations with the scores obtained from
advice: Level 0 – control group – conventional non- the screening stage. These questionnaire items were
personalised nutrition advice; Level 1 – personalised advice coded and used to create a reduced aggregate score.

Table 1 Characteristics of overall sample and by country

Overall By country
Germany Greece Ireland Netherlands Poland Spain United Kingdom
n (n of females) 2369 (1534) 343 (231) 262 (180) 238 (145) 398 (231) 253 (190) 634 (386) 241 (171)
Age (years) 40 ± 13 44 ± 14 38 ± 12 39 ± 13 48 ± 14 36 ± 13 38 ± 10 37 ± 13
Ethnicity
Asian 11 (0.5%) – – – 3 (0.8%) – – 8 (3.3%)
Black 2 (0.1%) 2 (0.6%) – – – – – –
Mixed 30 (1.3%) 5 (1.5%) – 4 (1.7%) 5 (1.3%) – 8 (1.3%) 8 (3.3%)
Chinese 1 (0.0%) – – – – – – 1 (0.4%)
White 2305 (97.3%) 332 (96.8%) 260 (99.2%) 234 (98.3%) 385 (96.7%) 253 (100.0%) 624 (98.4%) 217 (90.0%)
Other 20 (0.8%) 4 (1.2%) 2 (0.8%) – 5 (1.3%) – 2 (0.3%) 7 (2.9%)
BMI (kg/m2) 25.2 ± 4.7 24.3 ± 3.7 26.6 ± 5.8 25.4 ± 4.7 25.0 ± 4.2 24.6 ± 4.8 25.7 ± 4.8 24.9 ± 4.7
Weight status (by BMI)
Under-weight 56 (2.4%) 8 (2.3%) 5 (1.9%) 8 (3.4%) 10 (2.5%) 11 (4.4%) 11 (1.7%) 3 (1.2%)
Normal weight 1247 (52.6%) 206 (60.1%) 115 (43.9%) 123 (51.7%) 214 (53.8%) 139 (54.9%) 308 (48.6%) 142 (58.9%)
Overweight 743 (30.8%) 97 (28.3%) 90 (34.4%) 65 (27.3%) 128 (32.2%) 68 (26.9%) 213 (33.6%) 71 (29.5%)
Obese 334 (14.1%) 32 (9.3%) 52 (19.9%) 42 (17.7%) 46 (11.6%) 35 (13.8%) 102 (16.1%) 25 (10.4%)
Energy intake reported (kcal) 2633 ± 775 2509 ± 678 2519 ± 744 2779 ± 772 2723 ± 760 2593 ± 779 2674 ± 816 2571 ± 805
Physical activity level (AU) 1.51 ± 0.10 1.50 ± 0.08 1.50 ± 0.11 1.53 ± 0.09 1.54 ± 0.10 1.50 ± 0.11 1.50 ± 0.10 1.54 ± 0.11
Smoke habit
Non-smoker 1411 (59.6%) 201 (58.6%) 132 (50.4%) 164 (68.9%) 202 (50.8%) 197 (77.9%) 328 (51.7%) 187 (77.6%)
Ex-smoker 671 (28.3%) 112 (32.7%) 53 (20.2%) 57 (24.0%) 169 (42.5%) 38 (15.0%) 200 (31.6%) 42 (17.4%)
Current smoker 287 (12.1%) 30 (8.8%) 77 (29.4%) 17 (7.1%) 27 (6.8%) 18 (7.1%) 106 (16.7%) 12 (5.0%)
BMI Body Mass Index, AU Arbitrary Units

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Fig. 1 Flowchart for participant selection in the present study

Dietary assessment considered inadequate, while for those nutrients in which

For participants included in the randomization interven- excessive intake may also be considered inadequate, over-
tion study, diet quality indices were calculated at baseline consumption was also taken into account. The Mean
(t0), 3 months (t3) and 6 months (t6), to assess the effect Adequacy Ratio (MAR) was a measure of overall diet
of personalised nutrition advice on dietary intake. Healthy adequacy including the mean of all the NAR components.
Eating Index-2010 (HEI-2010) was calculated as described For both NAR and MAR a score of 100% represented the
by Guenther et al. [30] according to consumption of food ideal adequacy of intake reported, showing neither
groups estimated using the FFQ. The Mediterranean Diet reduced nor excessive consumption.
Score (MDS) was calculated using the PREDIMED 14-
item screening tool [31]. Finally, Nutrient Adequacy Ratio Chemical validation of intakes of fatty acids and of
(NAR), as described elsewhere [32], was estimated for the carotenoids using analysis of dried blood spots
following nutrients: protein, carbohydrates, total fat, Dietary fatty acid markers were determined via gas liquid
saturated fat, monounsaturated fatty acids (MUFA), poly- chromatography combined with flame ionisation detection
unsaturated fatty acids (PUFA), omega-3 fatty acids, salt, (GLC-FID) by Vitas Ltd. (www.vitas.no) as described
fiber, calcium, iron, vitamin A, folate, thiamine, riboflavin, previously [34]. Carotenoids were determined using high
vitamin B12, and vitamin C, after the personalised performance liquid chromatography with UV detection
nutrition intervention [33]. The NAR was specifically (HPLC-UV) on dried blood spots (DBS) cards with an
calculated for each nutrient, and the recommended intake appropriate stabilizer impregnated onto the DBS paper [35].
values established in the intervention were used as the
reference. Subsequently, the reported intake of each nutri- Statistical analyses
ent was computed as a percentage of the corresponding To determine items for inclusion in the final NPSQ9
reference value, establishing levels of attainment. For scale, the questions previously coded (Additional file 2:
some specific nutrients only under-consumption was Table S1) were analysed through an exploratory factor

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San-Cristobal et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:168 Page 5 of 12

analysis with the “least squares estimation” method and software (Stata IC version 12.0, StataCorp, College
“varimax rotation”, to include the maximum amount of Station, TX, USA), and p values lower than 0.05 were
variance from the categorical variables. considered significant.
Secondly, to test the suitability of the data used for the
factor analysis, the Kaiser-Meyer-Olkin Criterion [36] and Results
Bartlett’s test of sphericity [37] were performed. Scree plot Descriptive statistics among recruiting centres showed dif-
and Eigen values higher than 1 were used for the selection ferences regarding population characteristics (Table 1).
of the factors to be included in the NPSQ9. By this Exploratory factor analysis using an iterative process,
method it was possible to collect the highest proportion of carried out on the 2369 volunteers and including 22
variance. For each factor, a step-wise selection (removing questions from the screening questionnaire (Table S1, in
and rerunning the analysis) of the items was applied. Sub- Additional file 2), revealed a total of nine items with factor
sequently, the items presenting a factor loading greater loadings higher than 0.3 after varimax rotation (Table 2).
than 0.3 for the model were selected and included in the The Kaiser-Meyer-Olkin Criterion was 0.83 and Bartlett’s
aggregate score, which was calculated by summing the test of sphericity was highly significant (p < 0.001), indicat-
coded values of each question, thus providing a plausible ing suitability of the results.
range of scores from 0 to 30 (NPSQ9 score). The nine items were aggregated into two groups (or
The internal reliability of the score items was evaluated factors) that were named “Management” and “Perception
by a Cronbach alpha analysis. Finally, a confirmatory fac- & Habits” respectively, to reflect the items included in
tor analysis (CFA) was performed by means of structural each. The “Management” factor included items reflecting
equation modelling (SEM). To identify correlated unique- the self-reported capacity of the volunteers to select
ness in the obtained factor model, modification of indices healthy foods, and the effort required to achieve healthy
was checked, and goodness-of-fit indices were estimated. eating habits. The “Perception & Habits” factor included
The resulting NPSQ9 score was used in the Food4Me par- items related to the effort of selecting healthy foods, and
ticipants who had been randomised to the personalised one item involving substitution of meals with snacks.
nutrition intervention (Fig. 1), in order to validate the The correlation between the estimated factor scores and
results obtained with the exploratory analysis performed factors (factor determinacies coefficient) were higher
in the screening population. Model robustness was also than 0.978 for both factors. The analysis of internal
tested by applying the model in different subgroups classi- consistency showed an acceptable Cronbach’s alpha of
fied by sex and age (<45 years or ≥45 years) from the 0.792 for overall items, whereas the alpha values for each
randomised volunteers. factor were 0.875 and 0.732, respectively (Table 2).
A linear regression model adjusted for continuous var-
Table 2 Exploratory factor analysis for questionnaire
iables (age, and physical activity) and categorical vari-
item selection
ables (sex, country, socio-economic status and smoking
Factor
habits) was performed to test the association between loadings
the NPSQ9 score and anthropometrical characteristics,
Factor 1: Management
biochemical values, and diet quality indices (MDS and
I Can Manage To Stick To Healthy Foods:
HEI) in the screening population. Furthermore, linear
mixed regression models, adjusted also by age, sex, Even If I Need A Long Time To Develop The 0.775
Necessary Routines
country, physical activity, socio-economic status and
Even If I Have To Try Several Times Until It Works 0.819
smoking habits, were used to analyse potential trends in
variables categorised by tertiles of NSPQ9 score within Even If I Have To Rethink My Entire Way Of Nutrition 0.791
the participants randomised in the Food4Me interven- Even If I Do Not Receive A Great Deal Of Support 0.669
tion. To analyse the effect of personalised nutrition From Others When Making My First Attempts
advice during the intervention on the obtained NPSQ9 Even If I Have To Make A Detailed Plan 0.725
score, time-point and level of personalised advice inter- Cronbach’s alpha = 0.875
actions were included in the previously described mixed Factor 2: Perception & Habits
models for estimating the variation of each dependent
Eating Healthily Is Something I Do Frequently 0.649
variable on each tertile of the NPSQ9 score.
I Eat Healthily Without Having To Consciously Think 0.759
For descriptive analyses, differences between groups About It
were assessed by chi-square for categorical variables,
Eating Healthily Is Something I Don’t Have To Think 0.777
and by analysis of variance (ANOVA) adjusted for age, About Doing
sex, country, physical activity, socio-economic status and
Do You Skip Meals And Replace Them With Snacks? 0.311
smoking habits for continuous variables. All statistical
Cronbach’s alpha = 0.732
analyses were performed using STATA statistical

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Furthermore, results obtained in the exploratory ana- positive association with β-values of 0.2 (p < 0.001) and
lyses were confirmed by the CFA with the corresponding 0.16 (p < 0.001) for total carotenoids and omega acid-3
items (Figure S1, in Additional file 3). The goodness-of- fatty index, respectively, as well as 0.3 (p < 0.001) and
fit values for the two factors model after the inclusion of 0.28 (p < 0.001) for HEI and MDS, respectively.
four pairwise correlated errors showed acceptable ranges The trends during the intervention study (Table 4)
over the whole screening sample: RMSEA (0.037; 90% showed significant reduction in BMI, waist circumference,
CI: 0.029–0.044), CFI (0.992). When the resulting model plasma concentrations of glucose, cholesterol, total carot-
was applied to the sample of randomised volunteers, the enoids, and MAR, whereas omega-3 fatty acid index, HEI
results exhibited a satisfactory value for goodness of fit: and MDS were enhanced during the intervention. Differ-
RMSEA (0.031; 90% CI: 0.018–0.043), CFI (0.994). These ences in trends between tertiles 1 and 2 were observed in
results were also consistent when the model was carried waist circumference and plasma glucose, whereas total
out in categorised subsamples for sex and age: RMSEA carotenoids showed significant differences between tertiles
(0.028; 90% CI: 0.012–0.040), CFI (0.994) and RMSEA 1 and 3. Furthermore, HEI and MAR exhibited differences
(0.032; 90% CI: 0.019–0.044), CFI (0.992), respectively. in trends between the higher and lower tertile (Table 4).
Differences in the screening sample characteristics Despite the differences in trends during the intervention,
were observed when volunteers were categorised into the participants in tertile 3 maintained lower BMI and
tertiles of NPSQ9 score (Table 3). Lower BMI values waist circumference, and higher levels of carotenoids and
were observed in volunteers with a high NPSQ9 score, of omega-3 fatty acid index in blood, along with higher
and physical activity level was lower for the volunteers scores for HEI and MDS.
in the first tertile. Regarding food consumption, the indi- The effect of personalised nutrition advice on anthropo-
viduals ranked in the first tertile reported greater energy metrical and dietary quality is shown in Fig. 3. Interestingly,
intake and higher intake of sweets & snacks, whereas a significant reduction in BMI was found for participants
there was an increased intake of cereal, egg, fruit, and with low NPSQ9 scores receiving personalised advice as
vegetables in the upper tertiles. An association study compared to the control group (only receiving general
within the randomised participants was carried out to advice) at t3 (Δt0-t3: β = −0.23, 95%CI = −0.43 to
evaluate previous results obtained at baseline on the −0.03, ρ = 0.025) and t6 (Δt0-t6: β = −0.27, 95%CI =
anthropometrical, biochemical and diet quality indices −0.52 to −0.02, ρ = 0.038). Furthermore, significant
(Fig. 2). Negative relationships were found for anthropo- effects were observed for the diet quality indices: an
metrical variables, showing β-values of −0.18 for BMI (p increase for HEI at short-term, 3 months (Δt0-t3: β =
< 0.001) and −0.16 (p < 0.001) for waist circumference, 2.81, 95%CI = 1.06 to 4.66, ρ = 0.002), and also for
whereas biochemical and dietary indices showed a MDS at both short and long-term, 6 months (Δt0-t3:

Table 3 Dietary characteristics of screening sample by Nutritional Perception Screening Questionnaire-9 (NPSQ9) tertiles
Tertile 1 (Low) Tertile 2 (Medium) Tertile 3 (High) ρ† ρ‡
(Score 4–19) (Score 20–23) (Score 24–30)
n (n of women) 934 (478) 805 (546) 630 (506) 0.005§
Age (years) 40 ± 12 41 ± 14 40 ± 13 0.069 0.408
Physical activity level (AU) 1.49 ± 0.10a 1.52 ± 0.10b 1.53 ± 0.10b <0.001 <0.001
2 a b c
BMI (kg/m ) 26.4 ± 5.2 25.0 ± 4.5 23.9 ± 3.8 <0.001 <0.001
Energy intake reported (kcal/day) 2723 ± 801a 2571 ± 733b 2577 ± 775b <0.001 <0.001
a b b
Cereal (g/day) 42.9 ± 72.4 58.4 ± 104.4 64.9 ± 91.6 <0.001 <0.001
Dairy products (g/day) 360.9 ± 254.6 374.2 ± 285.4 385.2 ± 284.3 0.540 0.303
a a b
Eggs (g/day) 32.3 ± 37.9 30.9 ± 32.4 37.5 ± 49.2 0.012 0.013
Fats & Spreads (g/day) 21.2 ± 17.3 19.8 ± 14.9 20.3 ± 18.8 0.236 0.636
Fruit (g/day) 257.2 ± 237.6a 320.1 ± 248.6b 380.3 ± 301.4c <0.001 <0.001
Meat & Fish (g/day) 201.9 ± 119.4 187.0 ± 116.2 199.6 ± 139.8 0.358 0.476
Soups & sauces (g/day) 94.7 ± 76.4 97.8 ± 79.3 97.6 ± 88.1 0.082 0.051
Sweets & snacks (g/day) 121.3 ± 93.9a 100.1 ± 83.1b 82.0 ± 69.7c <0.001 <0.001
Vegetables (g/day) 188.1 ± 117.4a 229.1 ± 163.6b 282.6 ± 186.5c <0.001 <0.001
†
BMI Body Mass Index, AU Arbitrary Units. ANOVA for least squared values adjusted by age, sex, country, smoking habits, and physical activity with Bonferroni
post-hoc expressed by superscript letters; differences in letters show differences between groups with p-value < 0.05. §p-value for Chi-square test of distribution.
‡
p-value for linear trend

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Fig. 2 Association between Nutritional Perception Screening Questionnaire-9 (NPSQ9) Score with BMI, HEI score, total carotenoids in blood and
Omega-3 fatty acid index in blood. All associations were highly significant (p < 0.001)

β = 0.33, 95%CI = 0.01 to 0.65, ρ = 0.045; Δt0-t6: β = self-perception questions. Despite the numerous question-
0.47, 95%CI = 0.13 to 0.81, ρ = 0.007; respectively). naires developed in the last years, the combination of aware-
ness items with the capacity of predicting health and dietary
Discussion outcomes has not been properly addressed so far [38–40].
The main novelty of this study was the development of a This tool used items from the Food4Me screening
screening tool based on health and eating status, through questionnaire, which was validated to collect

Table 4 Linear trend prediction through follow-up (0, 3 and 6 months) for changes by NPSQ9 tertiles of randomised volunteers
Tertile 1 (Low) Tertile 2 (Medium) Tertile 3 (High) ρ† ρ‡
Score 7–19 20–23 24–30 – –
n (women) 443 (258) 402 (237) 308 (174) 0.799§ –
BMI (kg/m2) −0.16 ± 0.02*** −0.15 ± 0.02*** −0.12 ± 0.02*** 0.934 0.340
Waist circumference (m) −0.004 ± 0.001 ***
−0.007 ± 0.001 ***
−0.006 ± 0.001*** 0.024 0.197
Glucose (mmol/L) −0.10 ± 0.02 ***
−0.16 ± 0.02 ***
−0.12 ± 0.02 ***
0.046 0.472
Total colesterol (mmol/L) −0.08 ± 0.02*** −0.09 ± 0.02*** −0.05 ± 0.02* 0.658 0.351
Total carotenoids (μmol/L) −0.01 ± 0.01 −0.02 ± 0.01 *
−0.05 ± 0.02 **
0.257 0.030
Omega3 index (AU) 0.09 ± 0.02*** 0.12 ± 0.02*** 0.10 ± 0.03*** 0.289 0.713
*** *** ***
HEI score (AU) 1.75 ± 0.18 1.13 ± 0.16 1.05 ± 0.19 0.012 0.008
MDS (AU) 0.21 ± 0.03*** 0.15 ± 0.03*** 0.12 ± 0.04** 0.201 0.070
MAR (%) −1.84 ± 0.18 ***
−1.10 ± 0.16 ***
−1.12 ± 0.18 ***
0.003 0.006
BMI Body Mass Index, AU Arbitrary Units, HEI Healthy Eating Index, MDS Mediterranean Diet Score, MAR Mean Adequacy Ratio. p-values for linear trend
represented by * for p-value <0.05; ** for p-value < 0.01; *** for p-value < 0.001
†
p-value for contrast of linear trend between Tertile1 and Tertile2; ‡p-value for contrast of linear trend between Tertile1 and Tertile3; §p-value for Chi-square test
of distribution

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Fig. 3 Effect of Personalised nutrition advice on each tertile of Nutritional Perception Screening Questionnaire-9 (NPSQ9) Score on the predicted
change on BMI, HEI and Mediterranean diet score. Effects expressed in adjusted means with standard errors. Estimated p-values comparing the
effect of personalised advice at follow-ups by NPSQ9 tertile. * p-value < 0.05; ** p-value < 0.01; *** p-value < 0.005

information relating to personalised nutrition [13]. Simi- to the development of obesity, such as the frequency of
larly, previous studies have sought to capture the infor- eating fried foods, or the frequency of skipping meals
mation collected by validated questionnaires through with snacks [45–47], which form part of the NPSQ9’s
reduced factor structure providing new reliable scales “Perception & habits” factor.
[40, 41] or validating this new factor structure in other Our findings support the usefulness of emerging statis-
populations or subsamples [42–44]. tical tools, such as factor structure analysis and criterion
Indeed, a previous study using the Spanish screening validity, to reduce the number of questions related to
cohort of the Food4Me study has indicated that some of perceptions of healthy eating habits. The questionnaires
the items present in the questionnaires were related to used for the development of the present screening tool
specific dietary patterns [5]. In that study, significant were selected and adapted for the Food4Me study to
ifferences were observed in the perceptions of healthy evaluate the psychological determinants of acceptance of
eating habits between participants who were character- personalised nutrition [13], self-reported dietary intake
ized by “Western” and “Compensatory” dietary patterns [21, 22, 28], and self-reported anthropometrical mea-
compared to participants reporting “Prudent” and surements [27]. In this context, these statistical tools
“Healthy” dietary patterns. Differences were also found have been used to analyse the dimensions of new ques-
in habits that have previously been found to be related tionnaires [41, 48], and for validation in other

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San-Cristobal et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:168 Page 9 of 12

populations [40, 49]. However, the use of these tools also A possible reason for the relationship between NPSQ9
enables the reduction of dimensions within question- score and healthy body weight could be that individuals
naires, accounting for the maximum variance in the low- with better scores showed more frequent consumption
est number of factors [25, 40]. Previous studies have of fish, vegetables and fruit as observed in the analysis of
validated shortened questionnaires by relating responses MDS components (Additional file 2: Table S2). Reported
to eating behaviour [19], emphasising the importance of intake of fish was associated with higher NPSQ9 scores,
perceptions of healthy eating and providing valuable and the results were validated by the omega-3 fatty acid
tools to screen large populations [18, 50]. Furthermore, index in blood [58, 59].
one of the most common limitations of questionnaires Fruit and vegetable consumption was confirmed by
developed Ad Hoc is the uncertainty of reproducibility, the measure of total carotenoid concentration in blood
and it is important that the new screening tool is repro- at baseline [60, 61]. Preceding studies have shown that
ducible when used across different population groups. people with healthy eating perceptions show increased
For these reasons, we tested the robustness of the model consumption of vegetables and fruit and higher diet
in different subgroups in our own population. quality indices, independently of socio-economic status,
Regarding the selection of questions to be included in suggesting that healthy perception is representative of
the NPSQ9, some comments are needed, as during the good nutrition [9]. Estimation of fruit and vegetable
factor analysis and selection work, some potentially con- intake by short questionnaires has been widely studied
troversial issues arose. Regarding Factor 2, two appar- by numerous researchers [62–64], also using the tele-
ently similar questions were included: “I Eat Healthily phone [54, 65] or Internet [66]. In the present study, we
Without Having to Consciously Think About It” and used on-line contact, an approach in which the possibil-
“Eating Healthily is Something I Don’t Have To Think ity of reaching large populations to promote healthier
About Doing”. However, the correlation was not strong behaviours is notably increased, given the feasibility of
between them, which may be explained through the ana- using the internet worldwide [67], and the benefits and
lysis of acquired habits and habit acquisition [26]. In this reliability of this approach [27, 29].
sense, “Conscious thinking” would refer to an acquired Analysis of the results from the intervention study
habit, where active intention is not involved, while in the showed high improvement in HEI for participants with
second question, the “thinking of doing” implies an low NPSQ9 scores. These individuals with a good
active intention from the subjects’ side on changing or perception of healthy eating showed greater capacity for,
acquiring a new habit [26], assuming that the partici- and willingness to, improve their diet [68]. Our results
pant’s intention, when registering in the Food4Me study, suggest that a score of 20 or less may be used as a cut-
was to improve health through dietary change. off to identify individuals with high risk of nutritional
Regarding another question included in the Factor 2 imbalance, although further analysis would be required.
group (“Healthy Factor”), related to Meal skipping and Results from the Food4Me study [64–66] demonstrated
snacking (“Do You Skip Meals and Replace Them With that personalised nutritional advice, based on self-
Snacks?”), it must be noted that meal skipping and reported information, led to improvement in partici-
replacing meals by snacks is not a healthy behaviour. pants’ dietary quality indices [69–71].
Indeed, not doing these actions is associated with health- In the current investigation, participants’ reported
ier dietary habits, and relates to energy balance and intakes of fish, fruit and vegetables were validated by the
micronutrient adequacy [51, 52]. Thus this item was biochemical measurements of omega-3 fatty acid index
included but with the score inversely coded, giving the and total carotenoids in blood. The main limitation of
highest score in this item to those subjects who never or the present work is the absence of repeated measures for
almost never skip meals. the screening questionnaire, which would have allowed
In the present research, an association was found us to carry out a test/ re-test analysis to ensure repeat-
between high NPSQ9 scores and anthropometric measure- ability of the results amongst the participants. Further
ments, biochemical values and diet quality indices, in line research in this knowledge area is still needed, in order
with previous information [41, 53, 54]. Other studies also to demonstrate the efficacy and reproducibility of
reported a relationship between body weight and percep- NPSQ9 as a screening tool and to determine robust cut-
tions related to appetite [49]. Some authors found associa- off values. Furthermore, it will also be necessary to de-
tions between body weight and behavioural questionnaires termine whether online nutritional advice achieves
linked with the presence of specific gene variants related to dietary changes that are sustainable in the long-term.
appetite regulation in adults [55] as well as children [56].
Heritability of satiety and responsiveness to food suggest Conclusions
that genetics may influence some aspects related to eating The aggregated score obtained from the NPSQ9 was
behaviours and may also alter metabolic pathways [57]. associated with healthy body weight and diet quality,

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San-Cristobal et al. International Journal of Behavioral Nutrition and Physical Activity (2017) 14:168 Page 10 of 12

which could be used in health evaluation for early participating centres, and with the 1964 Helsinki declaration and its later
adaptation to healthy eating. Moreover, individuals with amendments or comparable ethical standards.
Informed consent was obtained from all individual participants included in
a low NPSQ9 score made greater improvements to their the study.
diet during the intervention with personalised The Research Ethics Committees evaluating the study protocol were those
nutritional advice provided on-line. Our results suggest with the appropriate authority in each study site: University College Dublin,
Ireland; University of Maastricht, Netherlands; Universidad de Navarra, Spain;
that scores on the NPSQ9, with nine questionnaire items Harokopio University, Greece; The University of Reading, United Kingdom;
related to perception of healthy eating, could be used as National Food and Nutrition Institute, Poland; Technische Universitaet
a screening tool by dieticians and other health Muenchen, German.
Being the study coordinator Ireland, the relevant Health Authority in
professionals to quickly estimate nutritional status and Food4Me study was the Research Ethics Committee of Ireland.
predict the appropriate level of personalisation in the
nutritional advice. Consent for publication
Not applicable

Additional files Competing interests

CAD is cofounder, board member, stock-owner and consultant for Vitas Ltd.
(www.vitas.no) performing the dried blood spot (DBS) analyses. TEG is
Additional file 1: CONSORT CHECKLIST. (DOC 217 kb) cofounder, stock-owner and CEO of Vitas.
Additional file 2: Table S1. Set of all the questions included in the
Item selection analysis. Table S2. Analysis of differences in MDS
components by tertiles of NPSQ9 at baseline. (DOCX 25 kb) Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in
Additional file 3: Figure S1. Flow diagram of the confirmatory factor published maps and institutional affiliations.
analysis of selected items of Nutritional Perception Screening
Questionnaire (NPSQ9) in the randomised sample. (PPTX 188 kb) Author details
1
Centre for Nutrition Research, Department of Nutrition, Food Science and
Abbreviations Physiology, University of Navarra, C/Irunlarrea, 1, 31008 Pamplona, Spain.
2
ANOVA: Analysis of variance; BMI: Body Mass Index; CFA: Confirmatory factor CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto de Salud
analysis; CFI: Comparative Fit Index; FFQ: Food Frequency Questionnaire; Carlos III, 28023 Madrid, Spain. 3Human Nutrition Research Centre, Institute of
HEI: Healthy Eating Index; MAR: Mean Adequacy Ratio; MDS: Mediterranean Cellular Medicine, Newcastle University, Newcastle Upon Tyne NE1 7RU, UK.
4
Diet Score; MUFA: Monounsaturated fatty acids; NAR: Nutrient Adequacy School of Psychology, University of Bradford, West Yorkshire BD71DP, UK.
5
Ratio; NPSQ: Nutritional Perception Screening Questionnaire; Northern Ireland Centre for Food and Health, University of Ulster, Coleraine
PUFA: Polyunsaturated fatty acids; RMSEA: Root Mean Square of BT52 1SA, UK. 6Hugh Sinclair Unit of Human Nutrition and Institute for
Approximation; SEM: Structural equation modelling Cardiovascular and Metabolic Research, University of Reading, Reading RG6
6AA, UK. 7UCD Institute of Food and Health, UCD School of Agriculture and
Food Science, University College Dublin, Belfield, Dublin 4, Republic of
Acknowledgements
Ireland. 8Department of Nutrition and Dietetics, Harokopio University of
Sharron Kuznesof, Arnout R.H. Fischer, Aleksandra Berezowska, Ivo vander
Athens, 17671 Athens, Greece. 9Institute of Food and Nutrition (IZZ), 02-903
Lans, Maria Daniel Vaz de Almeida, Bruno Oliveira, Rui Poínhos, Marian Raley,
Warsaw, Poland. 10ZIEL Research Center of Nutrition and Food Sciences,
Maresa Duffy, Karen Orr, Jenny Robinson are gratefully acknowledged for
Biochemistry Unit, Technische Universität München, 85354 Munich, Germany.
developing the questionnaires included in the Food4Me Study. 11
Vitas Ltd., Oslo Science Park, Gaustadalléen 21, 0349 Oslo, Norway.
Paul Miller from the Department of Modern Language (University of Navarra) 12
Department of Nutrition, Institute of Basic Medical Sciences, Faculty of
is also acknowledged for the English revision of the manuscript.
Medicine, University of Oslo, 0317 Oslo, Norway. 13Department of Human
Biology, NUTRIM School for Nutrition and Translational Research in
Funding Metabolism, Maastricht University Medical Centre, Maastricht 6200 MD, The
The Food4Me project has received funding from the European Union’s Netherlands. 14Food and Society Group, Newcastle University, Newcastle
Seventh Framework Programme for research, technological development Upon Tyne NE1 7RU, UK. 15Instituto de Investigaciones Sanitarias de Navarra
and demonstration (grant agreement no. 265494). (IDisNa), 31008 Pamplona, Spain. 16Instituto Madrileño de Estudios Avanzados
The research leading to these results has received funding from “la Caixa” (IMDEA) Alimentacion, Madrid, Spain.
Banking Foundation through a grant for the PhD work of Rodrigo San-Cristobal.
Received: 30 June 2017 Accepted: 23 October 2017
Availability of data and materials
Requests for data and material should be directed to the study director
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