OMB Number 0910-0545
Expiration Date: XX/XX/XXXX
2011 HEALTH AND DIET SURVEY (HDS)
DRAFT QUESTIONNAIRE
SCREENER
Hello, I'm (name) with Westat. I’m calling on behalf of the United States Food and Drug Administration, the FDA. We’re doing a study about people’s opinions about nutrition and health to help the FDA design better programs to improve the Nation’s health. May I speak to the member of your household who is aged 18 or over and has had the most RECENT birthday? Would that be you?
Yes 1 [GO TO INTRODUCTION.]
No 2 [READ THE FOLLOWING.]
May I speak with a member of the household who is at least 18 years old and has the most recent birthday?
Yes……………………………………………… 1 [REINTRODUCE.]
No/Not Available 2 [GO TO SMS.]
[IF NOT AVAILABLE, ASK FOR THE FIRST NAME OF THE ELIGIBLE RESPONDENT FOR CALL-BACK PURPOSE.]
[REINTRODUCE AS NECESSARY.]
INTRODUCTION
This call may be monitored for quality control purposes. Your answers to this survey are voluntary and will be kept confidential. The survey will take about 15 minutes.
INTERVIEWER: CODE GENDER WITHOUT ASKING.
Male ……………….. 1
Female …………….. 2
Not Sure …………… 8
A. DIET-DISEASE AWARENESS
A1. Have you heard anything about cancer being related to things people eat or drink?
YES…………………………………1
NO…………………………………..2
[DON’T READ] DK/NS …………. 8
[DON’T READ] RF ………………9
[IF A1 =1]
A2. What things that people eat or drink might make them MORE likely to get cancer? [DON'T READ LIST] [PROBE ONLY ONCE: Are there any other things people eat or drink that make them more likely to get cancer?]
YES ……………………………. 1
NO ……………………………... 0
(suffix in variable name)
Additives/chemicals 1
Alcohol 2
Artificial colors/dyes 3
Artificial Sweetener / Aspartame/Nutrasweet 4
Caffeine/coffee/tea 5
Charcoal/barbecued food/burnt food 6
Equal / Sweet n’ Low 7
Fats 8
Fried food(s) 9
Junk food(s) 10
Meats/specific meats 11
Nitrates/nitrites/nitrosamines 12
Polyunsaturated fat 13
Preservatives 14
Processed foods/Refined foods 15
Saccharin 16
Saturated fat 17
Smoking 18
Trans fat or Trans fatty acids 19
Other [SPECIFY] ______________ …………… 21 - 34, OTH
[DON’T READ] DK/NS DK
[DON’T READ] RF RF
A3. Have you heard about any things people could eat or drink that might help PREVENT cancer?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF A3=1]
A4. What things could people eat or drink that might help PREVENT cancer? [DON'T READ LIST] [PROBE ONLY ONCE: Are there any other things people eat or drink that might help prevent cancer?]
YES ……………………………. 1
NO ……………………………... 0
(suffix in variable name)
Antioxidants 1
Beta-carotene/Vitamin A 2
Dietary supplements 3
Fiber/roughage/whole grain cereals/bran 4
Fish/fish oil/omega 3 oil 5
Fruits/specific fruit 6
Fruit juice(s)/vegetable juice(s) 7
Poultry/chicken 8
Vegetables / specific vegetable(s) 9
Vitamin C/ascorbic acid 10
Vitamin E 11
Other [SPECIFY] _______________ …………. 13 - 27, OTH
[DON’T READ] DK/NS DK
[DON’T READ] RF RF
A5. Have you heard anything about heart disease or heart attacks being related to things people eat or drink?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF A5=1]
.
A6. What things that people eat or drink might be related to heart disease or heart attacks? [DON'T READ LIST] [PROBE ONLY ONCE: Are there any other things people eat or drink that might be related to heart disease or heart attacks?]
YES ……………………………. 1
NO ……………………………... 0
(suffix in variable name)
Alcohol 1
Caffeine/coffee/tea 2
Calories/eating too much/overweight 3
Cholesterol 4
Dairy products/milk/cheese 5
Eggs 6
Fats 7
Fried foods/greasy foods/oily foods 8
Junk food(s) 9
Meat/red meat/specific meat 10
Salt/salty foods/sodium 11
Saturated fat 12
Smoking 13
Sugar/sweet foods 14
Trans fat or trans fatty acids 15
Other [SPECIFY] ___________ ………………. 17 - 24, OTH
[DON’T READ] DK/NS DK
[DON’T READ] RF RF
A7. Have you heard about any things people could eat or drink that might help PREVENT heart disease or heart attacks?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF A7=1]
A8. What things could people eat or drink that might help PREVENT heart disease or heart attacks? [DON'T READ LIST] [PROBE ONLY ONCE: Are there any other things people eat or drink that might help prevent heart disease or heart attacks?]
YES ……………………………. 1
NO ……………………………... 0
(suffix in variable name)
Dietary supplements 1
Fiber/roughage/whole grain cereals/bran 2
Fish 3
Fish oil/omega 3 oil 4
Fruits/specific fruit 5
Olive oil/monounsaturated fat/oils 6
Poultry/chicken 7
Red wine/wine 8
Vegetables/specific vegetable 9
Vegetable oils/polyunsaturated fat/oils 10
Other [SPECIFY] ______________ …………... 12 - 28, OTH
[DON’T READ] DK/NS DK
[DON’T READ] RF RF
A9. Have you heard anything about high blood pressure being related to things people eat or drink?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF A9=1]
A10. What things that people eat or drink might be related to high blood pressure?
[DON'T READ LIST] [PROBE ONLY ONCE: Are there any other things people eat or drink that might be related to high blood pressure?]
YES ……………………………. 1
NO ……………………………... 0
(suffix in variable name)
Alcohol 1
Caffeine/coffee 2
Calcium/milk/dairy products 3
Calories/eating too much/overweight 4
Cholesterol/eggs 5
Fats 6
Fried food(s) 7
Junk food(s) 8
Meats/specific meats 9
Salt/salty foods/sodium 10
Saturated fat 11
Smoking 12
Sugar 13
Trans fat or trans fatty acids 14
Other [SPECIFY]_______________ ……………. 16 -22, OTH
[DON’T READ] DK/NS DK
[DON’T READ] RF RF
A11. Have you heard about any health problems that might be related to [READ AND ROTATE LIST]
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
a. Not eating enough calcium
b. Not eating enough antioxidant vitamins
c. Not eating enough fiber
d. Not eating enough folic acid
B. PART GOAL QUESIONS
B1. Next, I am going to ask you about three different kinds of fat in foods we eat. As I read each one, please tell me whether you have ever heard of it.
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
trans fat or trans fatty acid
saturated fat
omega 3 fatty acid
For EACH YES to B1
B2. You just told me you had heard of [NAME OF FAT FROM B1]. As far as you know, does [NAME OF FAT FROM B1] raise the risk of heart disease, lower the risk of heart disease, or have no effect on the risk of heart disease, or don’t you know?
Raise the risk ...………………. 1
Lower the risk …………….… 2
Have no effect …………………. 3
[DON’T READ] DK/NS ……… 8
[DON’T READ] RF ………….. 9
B3. I am going to read three other kinds of fat. For each one, please tell me whether you have
ever heard of it
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
polyunsaturated fat or fatty acid
monounsaturated fat or fatty acid
hydrogenated oil or partially hydrogenated oil
For EACH YES to B3
B4. As far as you know, does [NAME OF FAT from B3] raise the risk of heart disease, lower the risk of heart disease, or have no effect on the risk of heart disease, or don’t you know?
Raise the risk ...………………. 1
Lower the risk …………….… 2
Have no effect …………………. 3
[DON’T READ] DK/NS ……… 8
[DON’T READ] RF ………….. 9
C. FAT/CHOLOSTEROL AWARENESS AND KNOWLEDGE
[IF B1b=1]
C1. Is saturated fat usually found in: [READ]
Vegetables and vegetable oils or …………………… 1
Animal products like meat and dairy products ……… 2
[DON’T READ] DK/NS ………………………….. 8
[DON’T READ] RF ………………………………. 9
[IF B3a=1]
C2. Is polyunsaturated fat usually found in: [READ]
Vegetables and vegetable oils or …………………… 1
Animal products like meat and dairy products ……… 2
[DON’T READ] DK/NS ………………………….. 8
[DON’T READ] RF ………………………………. 9
[IF B1b and B3a =1]
C3. Which kind of fat is more likely to raise people's blood cholesterol level? [READ]
Saturated fat, or ……………………… 1
Polyunsaturated fat or ………………. 2
Both, or ……………………………… 3
Neither ………………………………. 4
[DON’T READ] DK/NS ……………. 8
[DON’T READ] RF ………………… 9
[IF B1a=1]
C4. Do trans fatty acids raise blood cholesterol, lower blood cholesterol or have no effect on blood cholesterol?
Raise cholesterol …………………. 1
Lower cholesterol ………………… 2
Have no effect ……………………. 3
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF …………….. 9
C5. Are trans fatty acids often found in:
YES ……………………… 1
NO ……………………….. 2
[DON'T READ] DK/NS … 8
[DON'T READ] RF …….... 9
Butter
Margarine
vegetable cooking oils
cookies and other baked foods sold in stores
D. EATING PRACTICES
I have a few questions about when and where you eat your meals. By meals, I mean breakfast, lunch, and dinner.
D1. On average, how many days per week do you eat breakfast?
0 days …………………………… 1
1 day …………………………… 2
2 days …………………………… 3
3 days …………………………… 4
4 days …………………………… 5
5 days …………………………… 6
6 days …………………………… 7
7 days …………………………… 8
[DON'T READ] DK/NS ……… 88
[DON’T READ]RF …………… 99
[IF D1 NOT EQUAL 1]
D2. How many of these breakfasts were not prepared at home? (NOTE: Please include breakfasts from both dine-in and carry out restaurants, restaurants that deliver food to your home, cafeterias, fast-food places, food courts, food stands, breakfasts prepared at a grocery store, and breakfasts from vending machines.)
1 ……………………………..2
2……………………………... 3
3…………………………….. 4
4 ……………………………. 5
5…………………………….. 6
6…………………………..… 7
7…………………………..… 8
[DON'T READ] DK/NS …. 88
[DON’T READ]RF ……….. 99
D3. How about lunch? On average, how many days per week do you eat lunch?
0 days …………………………… 1
1 day …………………………… 2
2 days …………………………… 3
3 days …………………………… 4
4 days …………………………… 5
5 days …………………………… 6
6 days …………………………… 7
7 days …………………………… 8
[DON'T READ] DK/NS ……… 88
[DON’T READ]RF …………… 99
[IF D3 NOT EQUAL 1]
D4. How may of these lunches were not prepared at home? (IF NEEDED, “Please include lunches from both dine-in and carry out restaurants, restaurants that deliver food to your home, cafeterias, fast-food places, food courts, food stands, lunches prepared at a grocery store, and lunches from vending machines.”)
0 …………………………..… 1
1 ……………………………..2
2……………………………... 3
3…………………………….. 4
4 ……………………………. 5
5…………………………….. 6
6…………………………..… 7
7…………………………..… 8
[DON'T READ] DK/NS …. 88
[DON’T READ]RF ……….. 99
D5. How about dinner? On average, how many days per week do you eat dinner?
0 days …………………………… 1
1 day …………………………… 2
2 days …………………………… 3
3 days …………………………… 4
4 days …………………………… 5
5 days …………………………… 6
6 days …………………………… 7
7 days …………………………… 8
[DON'T READ] DK/NS ……… 88
[DON’T READ]RF …………… 99
[IF D5 Not Equal to 1]
D6. How may of these dinners were not prepared at home? (IF NEEDED, “Please include dinners from both dine-in and carry out restaurants, restaurants that deliver food to your home, cafeterias, fast-food places, food courts, food stands, dinners prepared at a grocery store, and dinners from vending machines.”)
0 …………………………..… 1
1 ……………………………..2
2……………………………... 3
3…………………………….. 4
4 ……………………………. 5
5…………………………….. 6
6…………………………..… 7
7…………………………..… 8
[DON'T READ] DK/NS …. 88
[DON’T READ]RF ……….. 99
D7. Finally, I have a few questions about snacks? On average how many days per week do you eat snacks? By snacks, I mean any food or drinks besides water, coffee, and tea, which you eat or drink between meals.
0 days …………………………… 1
1 day …………………………… 2
2 days …………………………… 3
3 days …………………………… 4
4 days …………………………… 5
5 days …………………………… 6
6 days …………………………… 7
7 days …………………………… 8
[DON'T READ] DK/NS ……… 88
[DON’T READ]RF …………… 99
[IF D7 NOT EQUAL to 1]
D8. On average, how many snacks do you eat per day?
0 …………………………..… 1
1 ……………………………..2
2……………………………... 3
3…………………………….. 4
4 ……………………………. 5
5…………………………….. 6
6…………………………..… 7
7…………………………..… 8
[DON'T READ] DK/NS …. 88
[DON’T READ]RF ……….. 99
E. FOOD LABEL USE
Version 1 – Use exact same wording as in past.
E1V1. I'd like you to think about the labels on many food products that list ingredients and provide nutrition and other information. When you buy a product for the FIRST TIME, how often do you read this information? Would you say [READ]
OFTEN …………………………………… 1
SOMETIMES, ……………………………. 2
RARELY, OR ……………………………… 3
NEVER …………………………………… 4 [SKIP TO E5V1]
[DON’T READ] DK/NS ………………… 8 [SKIP TO F1]
[DON’T READ] RF ……………………... 9 [SKIP TO F1]
E2V1. People tell us they use food product labels in many different ways. When you look at food labels, either in the store or at home, how often, if at all, do you use the labels in the following ways? Would you say you often, sometimes, rarely or never use the label [READ AND ROTATE LIST]
OFTEN …………………………… 1
SOMETIMES, ……………………. 2
RARELY, OR ……………………… 3
NEVER …………………………… 4
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
a. To help you decide which brand of a particular food item to buy
b. To figure out how much of the food product you or your family should eat
c. To compare different food items with each other
d. To see if something said in advertising or on the package is actually true
e. To get a general idea of the nutritional content of the food
f. To see how high or low the food is in things like calories, salt, vitamins, or fat
g. To help you in meal planning
h. To see if there is an ingredient that you or someone in your family should avoid
E3V1. In the last TWO WEEKS, can you remember an instance where your decision to buy or use a food product was changed because you read the nutrition label?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
E4V1. When you look at the nutrition label on a food product, which information do you use, the gram or milligram amounts, the percent Daily Value amounts, or both?
The gram or milligram amounts…..1
The Percent Daily value amounts…2
Both……………………………….3
NEITHER…………………………4
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF E1V1=4]
E5V1. People have different reasons for not using the nutrition information on the food label. Please say whether you agree, disagree or neither agree or disagree with the following statements:
Agree………………………………1
Disagree…………………………...2
Neither agree or disagree………….3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
a. I’m just not that interested
b. The information is hard to understand
c. It takes too much time
d. I prefer getting nutrition information from other sources
Version 2 – Use specific language and define the Nutrition Facts label.
E1V2. The Nutrition Facts on food labels shows information about nutrients, such as fat, cholesterol, and carbohydrates. When you buy a product for the first time, how often do you read the Nutrition Facts information? [READ]
OFTEN …………………………………… 1
SOMETIMES, ……………………………. 2
RARELY, OR ……………………………… 3
NEVER …………………………………… 4 [SKIP TO E5V2]
[DON’T READ] DK/NS ………………… 8 [SKIP TO F1]
[DON’T READ] RF ……………………... 9 [SKIP TO F1]
E2V2. People tell us they use the Nutrition Facts in many different ways. When you look at the Nutrition Facts labels, either in the store or at home, how often, if at all, do you use the it the following ways? Would you say you often sometimes, rarely or never use the Nutrition Facts label …
OFTEN …………………………… 1
SOMETIMES, ……………………. 2
RARELY, OR ……………………… 3
NEVER …………………………… 4
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
a. To help you decide which brand of a particular food item to buy?
b. To figure out how much of the food product you or your family should eat?
c. To compare different food items with each other?
d. To see if something said in advertising or on the package is actually true?
e. To get a general idea of the nutritional content of the food?
f. To see how high or low the food is in things like calories, salt, vitamins, fat, etc.?
g. To help you in meal planning?
h. To see if there is an ingredient that you or someone in your family should avoid?
E3V2. In the last TWO WEEKS, can you remember an instance where your decision to buy or use a food product was changed because you read the Nutrition Facts label?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
E4V2. When you look at the Nutrition Facts label on a food product, which information do you use, the gram or milligram amounts, the percent Daily Value amounts, or both?
The gram or milligram amounts…..1
The Percent Daily value amounts…2
Both……………………………….3
NEITHER…………………………4
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF E1V2=4]
E5V2. People have different reasons for not using the Nutrition Facts label. Please say whether you agree, disagree or neither agree or disagree with the following statements:
Agree………………………………1
Disagree…………………………...2
Neither agree or disagree………….3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
a. I’m just not that interested
b. The information is hard to understand
c. It takes too much time
d. I prefer getting nutrition information from other sources
****Stop Versioning *****
E6. Now, I would like for you to think about information about serving sizes which is also found on the food label. How often do you use serving size information, when it is available? Would you say you often, sometimes, rarely or never use serving size information?
OFTEN …………………………… 1
SOMETIMES, ……………………. 2
RARELY, OR ……………………… 3
NEVER …………………………… 4
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
[IF E6=1, 2, 3]
E7. When you use serving size information on the package, what is your main purpose for using this information?
To see how many people it will serve………………………………..1
To see how much I/we should eat……………………………………2
To tell which size/how many packages to buy/use…………………..3
To help me understand nutrient information (e.g., calories per
serving, fat per serving)……………………………………...4
To check the amount needed for a recipe…………………………….5
To help me compare the nutrient characteristics of different products…6
[DON’T READ] DK/NS ………… ……………………………… 8
[DON’T READ] RF ……………... ……………………………… 9
[IF E6=1, 2, 3]
E8. Based on your experience, are the number of servings listed on the food label usually about right or do you usually find you get more or fewer servings than the package says?
About right…………………………………………………………1
I usually get more servings per package……………………………2
I usually get fewer servings per package…………………………..3
[DON’T READ] DK/NS ………… ………………………… 8
[DON’T READ] RF ……………... ………………………… 9
E9. To the best of your knowledge, are serving sizes determined by manufacturers or by government rules?
By manufacturers…………………………………………………1
By government rules……………………………………………....2
[DON’T READ] DK/NS ………… ………………………… 8
[DON’T READ] RF ……………... ………………………… 9
E10. Food packages sometimes have statements on the front of the package that describe the amount of certain nutrients in the product, such as “low fat,” “high fiber” or “cholesterol-free.” When it is available, how often do you use this information on certain nutrients when deciding to buy a food product? Would you say often, sometimes, rarely, or never?
OFTEN …………………………… 1
SOMETIMES, ……………………. 2
RARELY, OR ……………………… 3
NEVER …………………………… 4
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
E11. About how many of the food labels which use these terms to describe the amount of certain nutrients, do you believe are accurate—just about all of them, most of them, only some of them or almost none of them?
All of them……………………………1
Most of them………………………….2
Some of them…………………………3
None of them…………………………4
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
E12. Food packages sometimes have symbols or icons on the front of the package that describe the product as being a healthier option and meeting certain nutrient requirements. Have you seen products with this type of healthy symbol or icon?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF E12=1]
E13. When it is available, how often do you use healthy symbols or icons when deciding to buy a food? Would you say often, sometimes, rarely or never?
OFTEN …………………………… 1
SOMETIMES, ……………………. 2
RARELY, OR ……………………… 3
NEVER …………………………… 4
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
E14. Food packages sometimes have statements on the front that describe the product as being “light,” “reduced,” or “healthy.” When it is available, would you say you use these statements that describe the product often, sometimes, rarely or never?
OFTEN …………………………… 1
SOMETIMES, ……………………. 2
RARELY, OR ……………………… 3
NEVER …………………………… 4
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
E15. About how many of the food labels which use these terms [light, reduced, health] do you believe are accurate—just about all of them, most of them, only some of them or almost none of them?
All of them……………………………..1
Most of them…………………………..2
Some of them……………………….…3
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
E16. Have you seen food packages that have statements on the front that describe possible health benefits of the food, such as saying you may reduce your chances of getting a serious health problem, like heart disease or cancer, by eating that food? [example: Eating a diet high in fiber may reduce the risk of certain types of cancer?]
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF E16=1]
E17. How often do you use this information about health benefits when deciding to buy a food, when it is available? Would you say often, sometimes, rarely or never?
OFTEN …………………………… 1
SOMETIMES, ……………………. 2
RARELY, OR ……………………… 3
NEVER …………………………… 4
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
[IF E16=1]
E18. About how many of the food labels that describe health benefits of the food do you believe are accurate—just about all of them, most of them, only some of them or almost none of them?
All of them……………………………..1
Most of them…………………………..2
Some of them……………………….…3
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
[IF B1a=1]
E19. Food packages sometimes have statements on the front of the package that duct as being “trans fat free” or having “0 grams of trans fat.” When it is available, would you say you use these statements about trans fat, often, sometimes, rarely or never?
OFTEN …………………………… 1
SOMETIMES, ……………………. 2
RARELY, OR ……………………… 3
NEVER …………………………… 4
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
[IF E19=1, 2, 3]
E20. About how many of the food labels which use these claims do you believe are accurate—just about all of them, most of them, only some of them or almost none of them?
All of them……………………………..1
Most of them…………………………..2
Some of them……………………….…3
[DON’T READ] DK/NS ………… 8
[DON’T READ] RF ……………... 9
F. SPECIFIC DIETS AND WEIGHT LOSS PRACTICES
F1. Are you on a low-salt or low-sodium diet recommended by a doctor or other health professional?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
F2. Are you on a diet to lower blood cholesterol recommended by a doctor or other health professional?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
F3. Do you consider yourself to be overweight, underweight, or about the right weight? [IF THE RESPONDENT MENTIONS OTHERS’ OPINIONS, E.G., “MY DOCTOR SAYS I’M OVERWEIGHT,” READ: “what we really want to know is how YOU yourself think about your weight.”]
Overweight……………………….1
Underweight ……………………..2
About the right weight…………...3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF F3 NOT EQUAL to 2]
F4. Did a doctor or other health professional advise you to lose weight?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
F5. During the past 12 month, have your tried to lose weight?
YES …………………………… 1
NO ……………………………. 2
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
F6. Do you try to keep track on a daily basis of how much sodium, fat, or other nutrients, including vitamins or minerals, you eat?
YES …………………………… 1
NO ……………………………. 2
SOMETIMES……………………..3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF F6=1]
F7. Which nutrients do you try to keep track of?
YES …………………………… 1
NO ……………………………. 2
SOMETIMES……………………..3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
Calories
Carbohydrates
Cholesterol
Fat/Total Fat
Saturated Fat
Tran Fat
Fiber
Protein
Sodium/Salt
Specific vitamin/mineral
Other
F8. How do you keep track of how much of this nutrient/these nutrients you eat each day?
YES …………………………… 1
NO ……………………………. 2
SOMETIMES……………………..3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
a. Record amounts eaten at each meal/each day
b. Follow specific diet/eating plan
c. Read the nutrition label
d. Avoid certain foods
e. Include certain foods
f. Practice strict portion control
G. PHYSICAL ACTIVITY
G1. About how many days per week do you engage in moderate or vigorous activity (such as brisk walking, jogging, biking, aerobics, or yard work) in addition to your normal daily routine?
0 days …………………………… 1
1 day …………………………… 2
2 days …………………………… 3
3 days …………………………… 4
4 days …………………………… 5
5 days …………………………… 6
6 days …………………………… 7
7 days …………………………… 8
[DON'T READ] DK/NS ……… 88
[DON’T READ]RF …………… 99
[IF G1 NOT EQUAL 1]
G2. How long do you usually engage in moderate or vigorous activity on these days? Would you say less than 30 minutes, between 30 and 60 minutes, or more than 60 minutes.
Less than 30 minutes……………1
Between 30 and 60 minutes……..2
More than 60 minutes…………..3
[DON'T READ] DK/NS ……… 88
[DON’T READ]RF …………… 99
H. DIETARY SUPPLEMENTS
I would like to ask you a few questions about products called dietary supplements. Dietary supplements are powders, liquids, or capsules that are not foods or medicines that people may take to get nutrients that they can’t get from their diets alone. These include multi-vitamins, vitamin c, iron, calcium, Echinacea, St. John's Wort, amino acids or protein drinks, and fish oil.
H1. I am going to read a number of statements about these products. Please indicate how strongly you agree or disagree with each statement.
Strongly agree……………………………..1
Agree……………………………………...2
Neither agree nor disagree………………...3
Disagree…………………………………..4
Strongly disagree………………………….5
[DON'T READ] DK/NS ………………… 8
[DON’T READ]RF …………… ………..9
a. Taking dietary supplements without a doctor’s recommendation is harmful
b. Taking dietary supplements could improve my health.
c. A good reason for a person to take a dietary supplement is to prevent illnesses.
d. A good reason for a person to take a dietary supplement is to treat illnesses.
e. It is important to educate myself about new products, like dietary supplements, before I try them myself.
f. Dietary supplements have negative side effects.
g. Manufacturers test dietary supplements for effectiveness.
h. Dietary supplements give people greater control over their health, when compared to receiving a prescription from a doctor.
i. The government tests dietary supplements for safety.
k. I can get everything I need from the foods I eat.
l. Dietary supplements cost too much.
m. I am not sure what dietary supplements can do for me.
n. I am concerned about the safety of dietary supplements.
H2. First, have you taken a multi-vitamin or multi-mineral supplement in the past 12 months, that is, since (month) 2010? [IF NECESSARY, EXPLAIN THESE PRODUCTS ARE THINGS LIKE ONE-A-DAY, MEGA-VITAMIN, CENTRUM A-TO-ZINC, AND OTHER PRODUCTS THAT CONTAIN A VARIETY OF DIFFERENT VITAMINS, MINERALS, AND MAY ALSO CONTAIN OTHER THINGS AS WELL.]
YES …………………………… 1
NO ……………………………. 2
SOMETIMES……………………..3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
H3. And in the past 12 months, have you taken a specialized or single-ingredient vitamin or mineral supplement such as Vitamin C, Vitamin E, iron, or calcium? [EXCLUDE: VITAMINS AND MINERALS ADDED TO FOODS OR BEVERAGES—EXAMPLE: VITAMIN-D FORTIFIED MILK AND VITAMIN-C FORTIFIED ORANGE JUICE. INCLUDE: (1) SINGLE-INGREDIENT PRODUCTS THAT COME WITH AUXILIARY INGREDIENTS--EXAMPLE: A SUPPLEMENT SOLD AS A CALCIUM BUT ALSO INCLUDES MAGNESIUM, COPPER, AND A FEW OTHER THINGS; (2) PRODUCTS LIKE “CALCIUM-MAGNESIUM-ZINK” WHICH ALSO CONTAINS A FEW OTHER THINGS; (3) VITAMIN B-COMPLEX; (4) CALCIUM ANTACID, IF TAKEN FOR THE CALCIUM. IF RESPONDENT IS NOT SURE WHETHER THE PRODUCT(S) HE OR SHE TOOK IS CONSIDERED A VITAMIN OR MINERAL SUPPLEMENT, USE THE CHECKLIST, APPENDIX A, TO HELP HIM OR HER IDENTIFY THE KIND OF SUPPLEMENT.]
[IF ANSWER IS NOT CLEARLY A SUPPLEMENT AND SOUNDS LIKE IT MAY BE AN INGREDIENT IN FOOD, ASK “IS THAT IN YOUR FOOD OR IS IT TAKEN SEPARATELY AS A SUPPLEMENT?”]
YES …………………………… 1
NO ……………………………. 2
SOMETIMES……………………..3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
H4. Have you taken any kind of herbs, botanicals, or other dietary supplements in the past 12 months, that is, since (month) 2010? We are talking about things such as garlic pills, echinacea, ginkgo, glucosamine, St. John's wort, amino acids, or fish oil. [INCLUDE: SINGLE-INGREDIENT PRODUCTS AND PRODUCTS WITH MORE THAN ONE KIND OF SUPPLEMENT MIXED TOGETHER. INCLUDE: GINSENG TEA AND OTHER HERBAL TEAS TAKEN MAINLY FOR HEALTH PURPOSES. EXCLUDE: FRESH GARLIC, FRESH GINSENG, GINSENG ROOT, AND HERBS USED TO FLAVOR FOODS IN COOKING SUCH AS GARLIC FOR SPAGHETTI SAUCE OR PEPPERMINT FOR TEA. EXCLUDE: SUPPLEMENTS THAT ARE NOT TAKEN BY MOUTH, SUCH AS VITAMIN E OR ALOE USED ON SKIN. PRODUCTS MAY BE IN THE FORM OF TABLET, CAPSULE, PILL, EXTRACT, GRANULE, LOZENGE, SYRUP, TEA, TINCTURE, OR IN THEIR NATURAL FORM SUCH AS ROOT AND LEAF. IF RESPONDENT IS NOT SURE WHETHER THE PRODUCT(S) HE OR SHE TOOK IS CONSIDERED A HERBAL SUPPLEMENT, USE THE CHECKLIST, APPENDIX A, TO HELP HIM OR HER IDENTIFY THE KIND OF SUPPLEMENT.]
[IF ANSWER IS NOT CLEARLY A SUPPLEMENT AND SOUNDS LIKE IT MAY BE AN INGREDIENT IN FOOD, ASK “IS THAT IN YOUR FOOD OR IS IT TAKEN SEPARATELY AS A SUPPLEMENT?”]
YES …………………………… 1
NO ……………………………. 2
SOMETIMES……………………..3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
FOR EACH YES FOR H2-H4 ASK
H5a-c. How frequently do you take [multivitamins/ specialized or single-ingredient vitamin or mineral supplement/ herbs, botanicals]?
Daily………………………………………1
On a regular basis, but not every day……..2
Occasionally or as needed ………………..3
[DON'T READ] DK/NS ……… ……….. 8
[DON'T READ] RF ………….. ……… 9
H6. Did a doctor or other health care professional recommend that you take the dietary supplement?
YES …………………………… 1
NO ……………………………. 2
SOMETIMES……………………..3
[DON'T READ] DK/NS ……… 8
[DON'T READ] RF ………….. 9
[IF H2, H3, OR H4 = YES]
H7. On a slightly different subject, have you taken any prescription drug in the past 12 months?
Yes ………………………….. 1
No ………………………….. 2
[DON’T READ] DK/NS ……. 8
[DON’T READ] RF ………… 9
[IF H7=1]
H8. While you took the prescription drug, did you also take a dietary supplement?
Yes ………………………….. 1
No ………………………….. 2
[DON’T READ] DK/NS ……. 8
[DON’T READ] RF ………… 9
[IF H8=1]
H9. Did you discuss taking both products with your doctor or other healthcare professional?
Yes ………………………….. 1
No ………………………….. 2
[DON’T READ] DK/NS ……. 8
[DON’T READ] RF ………… 9
[IF H2, H3, OR H4 = YES]
H10. In the past 12 months, have you taken a dietary supplement to treat or prevent a health problem or condition instead of taking a prescription drug?
Yes ………………………….. 1
No ………………………….. 2
[DON’T READ] DK/NS ……. 8
[DON’T READ] RF ………… 9
[IF H10=1]
H11. Did you discuss the substitution with your doctor or healthcare professional? [IF NECESSARY, EXPLAIN "HEALTHCARE PROFESSIONAL ARE PEOPLE LIKE A MEDICAL DOCTOR, A PHYSICIAN’S ASSISTANT, A DENTIST, A PSYCHIATRIST, A PHARMIST, OR A REGISTERED NURSE.]
Yes ………………………….. 1
No ………………………….. 2
[DON’T READ] DK/NS ……. 8
[DON’T READ] RF ………… 9
(All Supplement Users: H1, H2 OR H3=1)
I. ADVERSE EXPERIENCE WITH DIETARY SUPPLEMENTS
I1. In the past 12 months, that is, since (month) 2007, have you experienced any health problem that you thought might be related to any dietary supplements you took?
Yes ………………………….. 1
No ………………………….. 2
[DON’T READ] DK/NS ……. 8
[DON’T READ] RF ………… 9
[If I1=1]
I2. The last time you had such a problem, what were the major symptoms of the problem? [ACCEPT UP TO THREE ANSWERS.]
(Specify) _____________, ________________, ______________
[DON’T READ] DK/NS
[DON’T READ] RF
I3. What supplements did you think were related to your problem? [ACCEPT UP TO THREE ANSWERS.]
(Specify) _____________ , _______________ , ______________
[DON’T READ] DK/NS
[DON’T READ] RF
I4. What did you do about your problem? Did you [READ AND ROTATE LIST.]
Yes ………………………….. 1
No ………………………….. 2
[DON’T READ] DK/NS ……. 8
[DON’T READ] RF ………… 9
a. Stop taking the supplements
b. See a doctor
c. Complain to the manufacturer or the store where you bought the supplements
d. Report to any health authorities [IF YES, ASK I5; OTHERWISE, SKIP TO I6]
e. Go to an emergency room
I5. Did you report your problem to [READ AND ROTATE LIST.]
Yes …………………………………. 1
No …………………………………. 2 [DON’T READ] DK/NS ………….. 8
[DON’T READ] RF ………………. 9
a. the Food and Drug Administration
the CDC, Centers for Disease Control and Prevention
a health department or poison control center
your doctor
16. Please tell me whether you yourself get a lot, a little, or no information about herbs, botanicals, or other dietary supplements from each of the following.
A lot …………………………… 1
A little …..……………………. 2
No information ………………… 3
[DON’T READ] DK/NS ……... 8
[DON’T READ] RF ………….. 9
a. a medical doctor, physician's assistant, registered nurse, or dietitian
b. an alternative medicine practitioner like an herbal or chiropractic therapist [ALSO INCLUDES: PRACTITIONER/THERAPIST OF ACUPUNCTURE, BIOFEEDBACK, CHELATION THERAPY, ENERGY HEALING/REIKI, FOLK MEDICINE, HEPNOSIS, HOMEOPATHY, MASSAGE, NATUROPATHY, NUTRITION THERAPY, OSTEOPATHY.]
c. family or friends
d. a sales person at a store
e. newspapers, magazines, books, or medical articles
f. television or radio
g. the Internet
h. product labels
J. DIETARY SUPPLEMENT LABEL USE
J1. Now, let's talk about the labels on herbs, botanicals, and other dietary supplement products. Do you yourself use these labels to find out [READ AND ROTATE LIST. RECORD START.]
Yes ………………………………..……………………. 1
No …………………………………………………..…. 2
[DON’T READ]The information is not on the labels …... 3
[DON’T READ] DK/NS …….…………………………. 8
[DON’T READ] RF ……………………………………. 9
a. what ingredients are in the product
b. the amounts of specific ingredients in the product
c. what the product is for
d. if there are side effects or drug interactions from using the product
e. if anyone should avoid the product
f. how different brands of a supplement compare to each other
[IF NO TO ALL J1 SKIP TO SECTION K]
J2. Thinking about the information you see on these labels. How easy is it to understand the label information about ingredients. Would you say very easy, somewhat easy, somewhat difficult, or very difficult?
Very easy ……………………….. 1
Somewhat easy …………………. 2
Somewhat difficult ……………… 3
Very difficult …………………… 4
[DON'T READ] DK/NS ……….. 8
[DON'T READ] RF ……………. 9
J3. How useful is the label information about ingredients to you? Would you say very useful, somewhat useful, not too useful, or not at all useful?
Very useful ……………………… 1
Somewhat useful .………………. 2
Not too useful …………………… 3
Not at all useful ………………… 4
[DON'T READ] DK/NS ….…….. 8
[DON'T READ] RF ……….…….. 9
J4. In addition to ingredients, the labels on herbs, botanicals, and other dietary supplements may have information about health benefits. Have you ever seen any information about health benefits on these labels?
Yes ……………………………… 1
No ……………………………… 2
[DON’T READ] DK/NS …….…. 8
[DON’T READ] RF ……………. 9
J5. How easy is it to understand the label information about health benefits? Would you say very easy, somewhat easy, somewhat difficult, or very difficult?
Very easy ……………………… 1
Somewhat easy …………………. 2
Somewhat difficult ……………… 3
Very difficult …………………… 4
[DON'T READ] DK/NS ……….. 8
[DON'T READ] RF ……………. 9
[IF J5=1]
J6. How useful is the label information about health benefits? Would you say very useful, somewhat useful, not too useful, or not at all useful?
Very useful ……………………… 1
Somewhat useful .………………. 2
Not too useful …………………… 3
Not at all useful ………………… 4
[DON'T READ] DK/NS ……….. 8
[DON'T READ] RF …………….. 9
J7. Have you ever seen any information on labels of herbs, botanicals, and other dietary supplements about health risks such as side effects, adverse reactions, interactions with medications, or who should be careful about taking a product?
Yes ……………………………… 1
No ……………………………… 2
[DON’T READ] DK/NS …….…. 8
[DON’T READ] RF ……………. 9
[IF J7=1]
J8. How easy is it to understand the label information about health risks? Would you say very easy, somewhat easy, somewhat difficult, or very difficult?
Very easy ……………………….. 1
Somewhat easy …………………. 2
Somewhat difficult ……………… 3
Very difficult …………………… 4
[DON'T READ] DK/NS ……….. 8
[DON'T READ] RF ……………. 9
[IF J7=1]
J9. How useful is the label information about health risks? Would you say very useful, somewhat useful, not too useful, or not at all useful?
Very useful ……………………… 1
Somewhat useful .………………. 2
Not too useful …………………… 3
Not at all useful ………………… 4
[DON'T READ] DK/NS ……….. 8
[DON'T READ] RF …………….. 9
J10. Now compare the labels on herbs, botanicals, and other dietary supplements with the labels on foods. In general, which labels are easier to understand, [ROTATE: dietary supplements labels, food labels], or are they the same?
Dietary supplement labels are easier to understand …………… 1
food labels are easier to understand ……………………………. 2
they are the same ……………………………………………… 3
[DON'T READ] both are easy to understand …………………. 4
[DON'T READ] both are difficult to understand ……………... 5
[DON'T READ] DK/NS ……………..…...…………………… 8
[DON'T READ] RF ………………….…..…………………..… 9
J11. Now compare the labels on herbs, botanicals, and other dietary supplements with the labels on over-the-counter drugs. In general, which labels are easier to understand, [ROTATE: dietary supplements labels, over-the-counter drug labels], or are they the same?
Dietary supplement labels are easier to understand ……. 1
Over-the-counter drug labels are easier to understand .….. 2
They are the same ……………………………………….. 3
[DON'T READ] both are easy to understand ……………. 4
[DON'T READ] both are difficult to understand ……….. 5
[DON'T READ] DK/NS …………………...…………… 8
[DON'T READ] RF ………………….…..……………… 9
V. DEMOGRAPHICS AND HEALTH STATUS
Finally, I have a few more questions for statistical purposes.
V1. Are there any telephone numbers in addition to (the telephone number being called) in your home that you receive calls on? [EXCLUDING NUMBERS USED ONLY FOR FAX OR COMPUTER, OR CELLULAR PHONE NUMBERS.]
Yes ……………………………………… 1
No ………………………………………. 2 [SKIP TO V3]
[DON’T READ] RF …………………… 8 [SKIP TO V3]
[DON’T READ] DK/NS ………………. 9 [SKIP TO V3]
V2. Is this/Are these number(s) for …
Home use ……………………………….. 1
Business and home use ………………….. 2
Business use only ………………………. 3
[DON’T READ] DK/NS ……………….. 8
[DON’T READ] RF …………………….. 9
V3. How many adults, age 18 and older, including yourself live in your household?
NUMBER: ____________ (RANGE: 1-15)
[DON’T READ] DK/NS ……………. 88
[DON’T READ] RF …………………. 99
V4. And how many children under 19 years of age, including infants and newborns, live in your household?
NUMBER: ____________ (RANGE: 0-15)
[DON’T READ] DK/NS ……………. 88
[DON’T READ] RF …………………. 99
[VALIDATED HOUSEHOLD SIZE, INCLUDING V3 AND V4]
ADULTS 1 2 3 4 5 6 7 8
V5. What is the last grade or year of school that you have completed? [DO NOT READ LIST.]
0-11 YEARS ……………………………………………………... 1
12 YEARS/HIGH SCHOOL GRADUATE ………………………. 2
1-3 YEARS OF COLLEGE ………………………………………. 3
4 YEARS OF COLLEGE/COLLEGE GRADUATE ……………... 4
POSTGRADUATE/MASTERS/DOCTORATE/LAW/MD ……… 5
[DON’T READ] DK/NS ………………………………………… 8
[DON’T READ] RF …………………………………………….. 9
V6. Are you of Hispanic or Latino origin?
YES ………………………………….. 1
NO …………………………………… 2
[DON’T READ] DK/NS …………….. 8
[DON’T READ] RF ………………… 9
V7. What is your race? Please select one or more. [ACCEPT MULTIPLE ANSWERS.]
Yes ………………………….. 1
No ………………………….. 2
[DON’T READ] DK/NS ……. 8
[DON’T READ] RF ………… 9
White
Black or African American
Asian
Native Hawaiian or other Pacific Islander
American Indian or Alaskan Native
V8. What year were you born?
19 ________ (RANGE: 1900-1984)
[DON’T READ] DK/NS …………….. 8
[DON’T READ] RF …………………. 9
[RESPONDENT AGE = 2011 – V8.]
“The next few questions may seem a bit personal. But we need this information because this survey is about nutrition and health.”
V9. How tall are you without shoes? [WHEN THE RESPONDENT REPORTS FRACTIONS, ROUND UP TO THE NEXT WHOLE NUMBER. FOR EXAMPLE, 3.5 INCHES SHOULD BE CODED AS 4 INCHES. DON’T PROBE.]
( ) feet and ( ) inches
OR
( ) meter(s) and/or ( ) centimeters
V10. How much do you weigh without shoes? [WHEN THE RESPONDENT REPORTS FRACTIONS ROUND UP TO THE NEXT WHOLE NUMBER. FOR EXAMPLE, 122.5 POUNDS SHOULD BE CODED AS 123 POUNDS. DON’T PROBE.]
( ) pounds
OR
( ) kilograms
V11. Have you ever been told by a doctor or other healthcare professional that you have any of the following health conditions? I don’t need to know which condition, just whether you have ANY of them. [READ: “high blood pressure, diabetes, high cholesterol, heart disease, obesity, overweight, or cancer.”]
Yes ………………………….. 1
No ………………………….. 2
[DON’T READ] RF…………… 9
V12. I am going to read you a list of categories of income. Please stop me when I read the category that includes your total household income before taxes for year 2006.
Less than twenty-five thousand dollars ………………………...1
From twenty-five to less than fifty thousand dollars …………...2
From fifty to less than seventy-five thousand dollars…………..3
From seventy-five to less than one-hundred thousand dollars …4
One hundred thousand dollars or more ………………………..5
[DON’T READ] DK/NS …………………………………. 8
[DON’T READ] RF…………… …………………………… 9
Thank you. Those are all the questions I have at this time.
Public Disclosure Burden Statement
Public reporting burden for this collection of information is estimated to average 1.2 minutes per response for the screener and 15 minutes per response for the survey, including the time for reviewing instructions, searching existing data sources, gathering and maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing burden to:
Food and Drug Administration
Center for Food Safety and Applied Nutrition
5100 Paint Branch Parkway, HFS-024
College Park, Maryland 20740
| File Type | application/msword |
| File Title | Tracking Questions |
| Author | Brenda Derby |
| Last Modified By | DPresley |
| File Modified | 2011-05-26 |
| File Created | 2011-05-26 |