Research Proposal to Describe Pulse Consumption in Canada

Consumption of pulse dishes by the Canadian population: Analysis of the Canadian Community Health Survey (Nutrition) 2004 and 2015

Rationale and Objectives

Objectives

This research aims to describe pulse consumption by the Canadian population from two national cross-sectional surveys 2004 and 2015.

Specific objectives are:

1. To determine the association of consumption of pulses in different cuisines and food sources at the national level for different ages, BMI, ethnicities, gender, health and other available socio-demographic variables in adults ≥ 19 years.
2. To find out the common characteristics of pulse eating behavior of the Canadian population in terms of eating occasions, types of pulses and food dishes consumed.
3. To examine major trends for pulses consumed between 2004 and 2015 to estimate whether Canadians are increasing, decreasing or changing sources of pulse consumption
4. Based on findings from Objectives 1-3, complete cluster or profile analysis to identify subgroups in the population for targeted marketing and promotion material for producers, processors and health care professionals.

Rationale

Over the past 25 years, Canadian adults have become heavier and increasingly inactive, leading to an increase in related chronic illnesses. Health Canada estimates from 1978/1979 showed that 14 percent of Canadian adults aged 18 and over were considered obese (1) . The majority (61%) of Canadian adults are now overweight, 24% are  obese and 20% suffer from metabolic syndrome (hypertension, dyslipidemia, Type 2 diabetes)(2). Diet quality/eating pattern is one contributing factor.

It is widely assumed that the Canadian diet has contributed to the increase in obesity, even though mechanisms are uncertain (3). The Canadian diet is highly processed, with large portions and emphasis on pre-prepared and processed foods. No one nutrient or food can be blamed, but it is generally acknowledged that portion sizes are too large and the diet is calorically dense. The rapid onset of obesity in the population suggests it can be reversed.  To reverse current trends multiple approaches are needed, both in the population and with individuals, to decrease caloric density and promote more plant-based food  sources ,fruits and vegetables.

Among plant-based foods, the main  protein sources in the diet are legumes, specifically pulses (dried beans, peas and lentils). This proposal focuses on pulses because of the results of our recent lifestyle study in 293 middle-aged adults (4). Diet counselling by registered dietitians promoted a Mediterranean diet pattern, not weight loss, and diet quality was measured 2 ways.  Only a modest shift in legume consumption was achieved; from 7% of participants eating ≥ 3 servings of legumes (including pulses) per week to 15% over the one-year program.  In contrast, participants increased fruit and vegetable intake by one serving per day and substantially decreased sweets and baked goods(4). More targeted work on pulse promotion is needed to identify and test strategies for increasing consumption.

To inform possible interventions, there is a need to better understand who consumes pulses, when and how they consume pulses and what kinds of dishes they are consuming. One approach is to assess recent consumption patterns among Canadians from population-based surveys using validated diet assessment methods.  Based on the purpose of study, the dietary assessment tool would be chosen. Eating behaviors, nutrients measurement or quality of diet are the main purpose.  Many different methods ( including detailed individual weighed records collected over a period of 7 days or more to food frequency questionnaires, national survey methods and simple food lists )are exits in order to achieve the purpose of assessing dietary intake . Each has advantages, related errors and applied difficulties to be considered when choosing one method above another. National  surveys  may  be  required  to  produce  statistics  for  every  city  in  the  country.  A  sample  survey  could  provide  national  statistics  with  small  sampling  error when adjusted for sampling. The researcher can also use information from a community sample of individuals to make  inferences about the wider population, but these samples may be biased.  In a geographically large country with multiethnic makeup like Canada, population-based surveys are more likely to yield representative data.

The only two such national surveys were done as part of the Canadian Community Health Surveys(CCHS) in 2004 and 2015, using 24-hour recall methods.  Our review of previous research on pulse consumption indicates that despite increasing attention to analyses of food consumption, no systematic research has been done to examine pulse consumption by food sources or ethnic background differences among consumers. One previous study of legume consumers was completed on the 2004 data(5). Respondents (N = 20,156) were divided into groups based on pulse consumption and levels of intake and the association between nutrient intakes and pulse consumption was examined. Analysis revealed that 13% of Canadians consumed pulses on any given day, and individuals with higher pulse intakes had higher intakes of macronutrients as well as enhanced micronutrient intake (5).

Better information on consumption patterns is needed as a baseline to any future efforts to increase pulse intake. We will begin to address these gaps by assessing the socio-demographic characteristics, nutrient and food group intakes and other characteristics of consumers and non-consumers of legumes from the 24-hour dietary recall data in both 2004 and 2015.

Analysis of these national nutrition surveys will provide a different approach to identifying key factors to consider in promoting pulses, providing a more complete picture that complements  other marketing research (6).

Literature Review

Definition of Pulses

Dietary pulses, the edible non-oil seeds of plants in the legume family, such as beans, lentils, chickpeas and dry peas, are well positioned to aid in dietary prevention of chronic diseases, especially cardiovascular conditions, diabetes and/or metabolic syndrome because they possess many positive nutritional qualities as well as being low in saturated fat (7).

Pulses are excellent sources of proteins as well as fibre. The bioactive compounds that pulse contain such as resistant starch, α galactoside oligosaccharides, phytate, polyphenols and saponins may act as potential  physiological modulators of metabolism, given that they inhibit the activity of angiotensin-converting enzyme and exhibit prebiotic effects, as well as antioxidant and bile acid-binding properties (8), thus showing promising potential as functional ingredients.

Furthermore, different compounds produce by pulse crops that feed soil microbes and benefit soil health(9). The ability of pulses to feed the soil different compounds has the effect of increasing the number and diversity of soil microbes. Pulses are a source of protein with a very low water requirement (10). The amounts of water for producing meat products including beef, pork and chicken are 18,11 and 5 times respectively higher than water requirement of pulses. .(10)

Pulses in health

Some observational studies have assessed the association between dietary pulse consumption and Metabolic syndrome (Mets) (11, 12).  The WHO has also suggested the consumption of pulse to help reduce risks of Mets and obesity(13).

A  meta-analysis  has been done in order to assess the pulse  consumption on body weight. It was consist of  21 randomized controlled trials (n = 940 participants ) .The results confirmed  that pulses in a diet may have a beneficial effects on losing weight even when diets are not planned to be  calorically restricted. The results showed a significant weight reduction −0.34 kg (95% CI: −0.63, −0.04 kg; P = 0.03) in diets containing dietary pulses compared with diets without a dietary pulse intervention over a median duration of 6 wk. Based on the results from 6 included trials, dietary pulse consumption may reduce body fat percentage also suggested that (14).

Dietary Guidelines

Health Canada, in its publication, “Canada’s Food Guide” recommends that Canadians consume pulses often with three-quarter of a cup being considered one serving.

Canada’s Food Guide promotes legumes by recommending meat alternatives such as beans, lentils and tofu often. The Meat and Alternatives group provides important nutrients such as iron, zinc, magnesium, B vitamins (thiamin, riboflavin, niacin, vitamin B6 and vitamin B12), protein and fat. Diabetes Canada has also suggested regular intake of vegetables, fruits, whole grains and plant-based sources of protein, including legumes.  A legume rich diet, either alone or as part of a low GI or high fiber diet, can lower fasting blood glucose and/or hemoglobin A1C, in people with and without diabetes.

The American Diabetes Association, however, has made no specific recommendations to consume pulses, recommending instead various dietary patterns that may be high in dietary pulses (i.e., Mediterranean, Dietary Approaches to Stop Hypertension (DASH), vegetarian, and vegan).

Similarly, heart-healthy guidelines from the American Heart Association encourage intake of pulses as part of a diet aimed at reducing risk of cardiovascular disease (CVD)(15),whereas the Canadian Cardiovascular Society and the European guidelines for CVD prevention have not made any specific recommendations for the intake of dietary pulses. Obesity prevention is not a focus of any of these guidelines, while weight loss is often mentioned.

Current consumption

Pulse dishes are traditional components of the food cultures in Mediterranean, Latin American, East Indian, East Asian and Middle Eastern countries. This has largely been due to the traditional high cost and limited availability of meat in these countries. In Canadapalatableness and healthiness are the main reasons of pulse consumption. However, lack of preparation skills, inconvenience and  not liking pulses are the fundamental causes of  not eating pulses.(6).

Pulses are not totally excluded from northern countries’ diets. The example of Canada reveals the presence of pulses in developed countries food regimen.

In a marketing study commissioned by Alberta Agriculture, Ipsos Reid has analyzed the factors influencing pulse consumption in Canada .Five groups of consumers identified by  segmentation analysis including ;Informed Champions, Disinterested Unreachables, Unexposed Reachables, Forgetful Proponents and Health Driven Persuadables .They were  based on the consumers attitude to pulse ,food and health.(6).

Current levels of dietary pulse consumption remain low in Canada (16). Knowledge of consumption is based on disappearance data and reports from some surveys (6). It was reported that only 13% of Canadians and 7.9% of Americans consume pulses on any given day, based on national 24-h recalls (5). The average intakes ranged from 13 to 294  g/day among Canadian consumers, and 23 to 277 g/day among American consumers (approximately less than  0.25–1.75  cups/day or less than 0.5– 2.5 servings/day of cooked pulses based on Health Canada’s Food Guide serving size)(5). European data show a similar pattern of low consumption (17, 18).

 Among Canadians, It is estimated that 1.3 cups of cooked pulse is average weekly consumption. However, the estimated  average consumption is among people who consumed pulses in the past six months. When all Canadians are considered ,this number  drops to an average of 1.0 cups(5)In order to understand current and future consumption of pulses, it is vital to understand the associations of consumption and other factors, such as attitudes and socioeconomic background. Understanding of relationship between many different factors, such as attitudes and socioeconomic circumstances and pulse consumption   are essential .It would help to realized current and future consumption. In this regards, there are many studies that  have explored the motives to eat or not to eat plant proteins. A qualitative study  showed that in spite of health benefits of soy ,tastiness, convenience  and cost were the main obstacles  of soy consumption (19). Having adversely unattractive image  is the major barrier to soy consumption  (19). Ethnicity and cultural background are the factors could effect on pulse consumption. In a study those factors were comparing among  French and Vietnamese consumers. It showed that  in France soy was unfavorable  product, whereas in Vietnam it was a product of memories, sensation and desire (20). In the UK and the Netherlands, users of meat-substitutes were highly educated. In the UK, heavy users were women and younger age groups. This study confirmed that socioeconomic background and gender are associated with the consumption of plant proteins (21) .A Canadian study displayed that pulse consumption associated  with education . Moreover, heavy pulse users were generally young (6).

Methods

In the present study, we will investigate pulse consumer in a large population sample, from two population-based surveys (CCHS 2004 and 2015) with a specific focus on socio-demographic and health characteristics of pulse consumers and non-consumers; and analysis of the composition of the meals that feature pulses and analysis of any changes between the surveys.  We are particularly interested in the meals/snacks of younger consumers who do not identify as vegan or from traditional ethnic backgrounds that consume pulses.

In addition, we will investigate to what extent the identified segments differed regarding their demographical variables, consumption of a number of pulse foods, and liking and health perception of certain foods (variable list).

Basic descriptive approaches and exploration of factors associated with consumption are common methods. Studies on the segmentation of consumers based on their food or nutrition consumption of information are still very rare (22). In developing targeted communication materials to stimulate healthy eating, it would be very helpful to know more about the characteristics of consumers, and what they are eating as context for developing new interventions. This line of thinking follows from the advisor’s previous work on vegetable consumption, and has not been applied to pulse consumption.  Therefore, the segmentation work will be exploratory.

Canadian Community Health Survey

The CCHS consists of a series of cross-sectional surveys that was initiated in the year 2000.  The main purpose of the CCHS was to provide timely information on health determinants, health status and health system utilization. It was based on collaborations of the Health Canada, the Canadian Institute for Health Information, and Statistics Canada. The CCHS consists of two distinct surveys through two years data collection cycle. The first year (cycle X.1) is a general health survey that including130,000 Canadian subjects, which is large enough to allow data to be presented at the level of  health regions  within each province. The second year (cycle X.2) approximately has a total sample of 35,000 Canadian subjects allows provincial-level estimates as it focuses on a specific content area.

The 2004 and 2015 CCHS consists of both a nutritional as well as general health component. According to Health Canada, the nutrition component estimated the distribution of usual dietary intake based on foods, food groups, dietary supplements, nutrients and eating patterns among a representative sample of Canadians at national and provincial levels using a 24-hour dietary recall. Two 24-hour recalls have been done in subsets to estimate day-to-day variances. It also measured the prevalence of household food insecurity among a variety of Canadian population groups, collected anthropometric measurements (body height and weight) as well as information on physical activity, selected health conditions and socio-demographic characteristics. What follows is a brief overview of the CCHS 2.2. The survey methods were intentionally kept similar to allow for comparison. Further details on the methods used in the CCHS 2.2 and CCHS 2015 are available on the Statistics Canada Website.

Data Analysis

Statistical Methodology

The statistical package for social sciences (SPSS) (version 24; a subsidiary of IBM, based in Chicago, Illinois) and the Statistical Analysis Software (SAS) (version 9.4; SAS Institute Inc., Cary, NC, USA) will be used for statistical anlaysis. An initial descriptive analysis of data will be performed to determine the prevalence of specific pulse consumption in food dishes. Pulse consumers will be defined as respondents who consume pulses or a pulse-containing product for dietary intakes. Consumers will be further divided into different segments  based on analysis by food sources or ethnic background.

Currently, for accounting the complex multistage survey design in estimation of  variances and Confidence Intervals (CI) bootstrap balanced repeated replication (BBR) method will be used (23, 24). Bootstrapping is an approach to estimate distribution from a sample’s statistics. It also can be defined as ‘sampling within a sample’ and involves the selection of random samples known as replicates, and the calculation of the variation in the estimates from replicate to replicate(23, 24) .

All analyses will be adjusted for the complex sampling design using appropriate sample weights based on respondent classes with similar socio-demographic characteristics, to maintain a nationally representative sample. Due to the representative nature of the data, the analysis will utilize the weights included in the CCHS. The weighting strategy considers the area and telephone sampling frames independently to determine separate household-level weights for each of the frames; those weights are integrated and further adjusted to become the final person-level weight. The territories are weighted differently than the provinces due to different sampling methods.. Group comparison with Tukey post-hoc adjustment will be used to evaluate the characteristics of participants classified within categories (ex. Age categories).Statisitical consultation will be sought as needed from an analyst familiar with the surveys.

Cross-tabulations and tests will be used to compare the proportions of consumers and non-consumers based on sex, age categories, and other categorical variables. Logistic regression will be used to determine whether any demographic variables (sex, age, culture, ethnicity, province of residence, BMI, health conditions, food security, household size, rural/urban, working out of home,  income adequacy and education level) increased the likelihood of being classified as a pulse consumer and Odds Ratio will be calculated. We will aim to identify key variables for higher consumption of pulse foods. The significance level will be set at α=0·05 and results with a two-tailed p-value < 0.05 will be considered statistically significant.

Depending on results of the basic analyses,  segmentation latent class analysis (LCA) technique will applied  will be applied to identify consumer segments.

The National Survey  like CCHS provides a rich source of data. However, the nonresponse rates might be  high. To handle the missing data   a variety of methods exist such as  pairwise deletion, listwise deletion , and multiple imputation. Based on type of missing data we will decide on the method for handling the missing.Data Requirements

Data Access

I am requesting access to the confidential Master Data File for the Canadian Community Health Survey (CCHS). I will analyze both the 2004 and 2015 CCHS national diet surveys for associations with socio-demographic factors and other variables as outlined

The primary objective of the study is to examine consumption of pulses by the Canadian population. I aim to conduct a cross-sectional analysis. I will consult with the staff at the University of Guelph and University of Waterloo RDC .They will confirm  that acceptable sample sizes can be derived from each variable and that appropriate weighting and bootstrapping procedures are applied to the data. Data from the CCHS 2.2 (2004) and 2015 master files will be used for this analysis. Data are  housed in a secure satellite center at the library of the University of Guelph. Access will be gained by following Statistics Canada’s application process and guidelines including the submission of this project proposal, completion of an online application as well as the security screening process. Access to the confidential data is needed as the censoring of sensitive data in the public files will affect the validity of the regression models. Variables such as NSP_Q01, MSH_R1 and MSW_R1 are not included in the public data and are needed for this research, thus access to confidential data is imperative.

Population of Interest

The population of interest for this research are the individuals that were randomly selected to participate in the 24-hour recall interview. This interview used an automated multiple-pass method consisting of one or two interviews. The first was to represent one-day (“daily”) intake while the second interview allowed for assessment of  “usual” intake. As well the first 24 hour recall was used for point estimates (mean) while the 2nd recall was important to make conclusions related to distributions. This research will focus on  adults who are 19 years of age and older. Individuals younger than 19 years of age are excluded from these analyses, and  they are not included in data sets for many key variables of interest including adult health and marketing.

Personnel

The second year Ph.D student complete the analysis with support from the advisor (Ph.D in epidemiology) with statistical help  from the local RDC analyst. A statistical consultant (Michelle Edwards) is a co-investigator, as is Sunghwan Yi, from Consumer Studies, who has done LPA.

Timeline

Preliminary data analysis is expected to begin May 2018, and the post graduate student will finish his analysis by Sep 2018. The Ph.D thesis will be completed by 2019.

Ethics

No additional ethical approvals are needed.

Expected Products

The result of this research is expected to be a graduate level thesis  and seminar presentation of the findings. A peer-review paper is planned. As per the RDC Microdata Research Contract, the final paper will be submitted to Statistics Canada as the product derived from the research project at the RDC.

Variables of Interest

CCHS contains numerous relevant variables. Those of interest are: household characteristics, general health, level of physical activity/sedentary activities, measured height and weight (BMI), intake of vitamin/mineral supplements, prevalence of chronic conditions, smoking, alcohol use, food security and socio-demographic characteristics. A broad view has been taken to identify all possible variables that may be associated with food intake, in keeping with descriptive epidemiological principles.  The study is exploratory and may be hypothesis generating.

 

Table of Proposed Variables

Group		Question	Coding
	SEX_Q01	Is [respondent name] male or female?	categorized
	ANC_Q03	What is [respondent name]’s age?	continuous
	MSNC_Q01	What is [respondent name]’s marital status?	categorized
	ED_Q04	What is the highest degree, certificate or diploma [respondent name] has obtained?	categorized
General Health
	GEN_Q01	In general, would you say [your/his/her] health is:	Likert
	GEN_Q02A	How satisfied are you with your life in general?	Likert
	GEN_Q02B	In general, would you say your mental health is:	Likert
	GEN_Q07	Thinking about the amount of stress in [your/his/her] life, would you say that most days are:	Likert
	PAC_Q2	In the past 3 months, how many times did you participate in physical activity?	categorized
	PAC_Q3	About how much time did you spend on each occasion?	continuous
	NSP_Q01	In the past month, that is, from one month ago to yesterday, did you take any vitamins or minerals?	Dichotomous
	MSH_R1	Measured Height	continuous
	MSW_R1	Measured Weight	continuous
Prevalence of chronic conditions
	CCC_Q071	[Do/Does] [you/FNAME] have high blood pressure?	Dichotomous
	CCC_Q101	[Do/Does] [you/FNAME] have diabetes?	Dichotomous
	CCC_Q121	[Do/Does] [you/FNAME] have heart disease?	Dichotomous
	CCC_Q131	[Do/Does] [you/FNAME] have cancer?	Dichotomous
	CCC_Q401	[Do/Does] [you/FNAME] have osteoporosis?	Dichotomous
	SMK_Q202	At the present time, [do/does] [you/FNAME] smoke cigarettes daily, occasionally or not at all?	categorized
	SMK_Q206A	When did [you/he/she] stop smoking? Was it:	categorized
	ALC_Q2	During the past 12 months, how often did [you/he/she] drink alcoholic beverages?	categorized
	ALC_Q3	How often in the past 12 months [have/has] [you/he/she] had 5 or more drinks on one occasion?	categorized
	FSC_Q010	Which of the following statements best describes the food eaten in your household in the past 12 months?	categorized
	SDE_Q7B	Are you aboriginal?	Dichotomous
INCOME
	INC_Q3	What was the main source of income?	categorized
	INC_Q4	What is your best estimate of the total household income, before taxes and deductions	Continuous
	INC_Q5	What is your best estimate of [your/FNAME’s] total personal income,	Continuous
Socio-demographic characteristics (SDC)
	SDC_Q005	In what country [were/was] [you/he/she] born?	categorized
	SDC_Q006	In which province or territory were you born?	categorized
	SDC_Q007	Are you now, or have you ever been a landed immigrant in Canada?
	SDC_Q008	In what year did you first become a landed immigrant in Canada?	categorized
	SDC_Q010	To which ethnic or cultural groups did your ancestors belong? (For example: French, Scottish, Chinese, East Indian)	categorized
	SDC_Q015	Are you an Aboriginal person, that is, First Nations, Métis or Inuk (Inuit)? First Nations includes Status and Non-Status Indians.	categorized
	SDC_Q016	Are you First Nations, Métis or Inuk (Inuit)?	categorized
	SDC_Q020	You may belong to one or more racial or cultural groups on the following list. Are you… ?	categorized
	SDC_Q030	Is this dwelling…?	categorized
	Neighbourhood environment (NBE)
	NBE_Q010	Many shops, stores, markets or other places to buy things I need are within easy walking distance of my home.	categorized
	NBE_Q035	The crime rate in my neighbourhood makes it unsafe to go on walks at night	categorized
	FRUIT AND VEGETABLE CONSUMPTION
	FVC_Q1A	How often do you usually drink fruit juices such as orange, grapefruit or tomato?	categorized
	FVC_Q2A	How often do you usually eat fruit?	categorized
	FVC_Q3A	How often do you usually eat green salad?	categorized
	FVC_Q6A	How many servings of other vegetables do you usually eat?	categorized
	FVC_Q015	In the last month, how many times did you eat dark green vegetables such as broccoli, green beans, peas	categorized
	Food choices (FDC)
	FDC_Q005	Do you choose certain foods or avoid others: because you are concerned about your body weight?	categorized
	FDC_Q010	because you are concerned about heart disease?	categorized
	FDC_Q015	because you are concerned about cancer?	categorized
	FDC_Q020	because you are concerned about osteoporosis ?	categorized
	FDC_Q025	the lower fat content?	categorized
	FDC_Q030	the fiber content?	categorized
	FDC_Q035	the calcium content?	categorized
	FDC_Q040	the fat content?	categorized
	FDC_Q045	the type of fat they contain?	categorized
	FDC_Q050	the salt content?	categorized
	FDC_Q055	the cholesterol content?	categorized
	FDC_Q060	the calorie content?	categorized
	Canada’s Food Guide use (FGU)
	FGU_Q005	Have you ever seen or heard of Canada’s Food Guide?	categorized
	FGU_Q010	Have you ever used information from Canada’s Food Guide?	categorized
	FGU_Q015	What did you use the information for?	categorized
	Satisfaction with life (SWL)
	SWL_Q005	How satisfied are you with your job or main activity?	Likert
	SWL_Q010	How satisfied are you with your leisure activities?	Likert
	SWL_Q015	(How satisfied are you) with your financial situation?	Likert
	SWL_Q020	(How satisfied are you) with yourself?	Likert
	SWL_Q025	How satisfied are you with the way your body looks?	Likert
	SWL_Q030	(How satisfied are you) with your relationships with family members?	Likert
	SWL_Q035	(How satisfied are you) with your relationships with friends?	Likert
	SWL_Q040	How satisfied are you with your housing?	Likert
	SWL_Q045	(How satisfied are you) with your neighbourhood?	Likert
	Health insurance coverage (INS)
	INS_Q005	[Do you] have insurance that covers all or part of the cost of [your] prescription medications?	categorized
	INS_Q010	Is it…?	categorized
	INS_Q015	[Do you] have insurance that covers all or part of [your] long-term care costs, including home care?	categorized
	Food security (FSC)
	FSC_Q010	The first statement is: [You and other household members] worried that food would run out before you got money to	Likert1-5
	FSC_Q015	The food that [you and other household members] bought just didn’t last, and there wasn’t any money to get more.	Likert1-5
	FSC_Q020	[You and other household members] couldn’t afford to eat balanced meals.	Likert1-5
	FSC_Q025	[You or other adults in your household] relied on only a few kinds of low-cost food to feed [the children].	Likert1-5
	FSC_Q030	[You or other adults in your household] couldn’t feed [the children] a balanced meal, because you couldn’t afford it.	Likert1-5
	FSC_Q035	[The children were] not eating enough because [you or other adults in your household] just couldn’t	Likert1-5
	FSC_Q040	In the past 12 months, since last ^CURRENTMONTH, did [you or other adults in your household] ever cut	Likert1-5
	FSC_Q045	How often did this happen? Was it…?	Likert1-5
	FSC_Q050	In the past 12 months, did you (personally) ever eat less than you felt you should because there wasn’t enough money to	Likert1-5
	FSC_Q055	in the past 12 months, were you (personally) ever hungry but didn’t eat	Likert1-5
	FSC_Q060	In the past 12 months, did you (personally) ever lose weight because you didn’t have enough money for food?	Likert1-5
	FSC_Q065	In the past 12 months, did [you or other adults in your household] ever not eat for a whole day	Likert1-5
	FSC_Q075	In the past 12 months, did [you or other adults in your household] ever cut the size of [any of the children’s] meals	Likert1-5
	FSC_Q080	In the past 12 months, did [any of the children] ever skip meals because there wasn’t enough money for food?	Likert1-5
	FSC_Q085	How often did this happen? Was it…?	Likert1-5
	FSC_Q090	In the past 12 months, [were any of the children] ever hungry but you just couldn’t afford more food?	Likert1-5
	FSC_Q095	In the past 12 months, did [any of the children] ever not eat for a whole day	Likert1-5
Primary health care (PHC)
	PHC_Q005	Is there a place that you usually [go] to when you [need] immediate care for a minor health problem?	Likert
	PHC_Q010	What kind of place is it?	Likert
	PHC_Q015	Is this…?	Likert
	PHC_Q020	Do you have a regular health care provider?	Likert
	PHC_Q025	What are the reasons why you do not have a regular health care provider?	Likert
	PHC_Q030	Is that regular health care provider a…?	Likert
	PHC_Q035	When you [need] immediate care for a minor health problem	Likert
	PHC_Q040	Do you usually speak in English, in French or in another language with th	Likert
	PHC_Q045	Is there one or more nurses working with your [family physician/specialist/nurse practitioner/regular	Likert
	PHC_Q050	Other than doctors and nurses, are there other health professionals like nutritionists	Likert
	PHC_Q055	Other than from your [family physician/specialist/nurse	Likert
	PHC_Q060	In general, how would you rate the level of coordination between your	Likert
Self-esteem (SFE)
	SFE_Q005	You feel that you have a number of good qualities.	Likert
	SFE_Q010	You feel that you’re a person of worth at least equal to others.	Likert
	SFE_Q015	You are able to do things as well as most other people.	Likert
	SFE_Q020	You take a positive attitude toward yourself.	Likert
	SFE_Q025	Overall, you are satisfied with yourself.	Likert
	SFE_Q030	All in all, you’re inclined to feel you’re a failure.	Likert
Oral health (OHT)
	OHT_Q005	In general, would you say the health of your mouth is…?	Likert
	OHT_Q010	How satisfied are you with the appearance of your teeth and/or dentures?	Likert
	OHT_Q015	In the past 12 months, how often have you found it uncomfortable to eat any food because of problems with your mouth?	Likert
	OHT_Q020	(In the past 12 months,) how often have you avoided eating particular foods because of problems with your mouth?	Likert
	OHT_Q025	In the past 12 months, how often have you had any other persistent or on-going pain anywhere in your mouth?	Likert
	OHT_Q030	Do you have at least one of your own teeth?	Likert
	OHT_Q035	Do you wear dentures, dental prosthesis or false teeth?	Likert
	OHT_Q040	In the past 12 months, how often have you had bleeding gums, including while brushing or flossing your teeth?	Likert
	OHT_Q045	(In the past 12 months,) how often have you had persistent dry mouth?	Likert
	OHT_Q050	(In the past 12 months,) how often have you had persistent bad breath?	Likert
Activities of daily living (ADL)
	ADL_Q005	Because of any physical condition, mental condition or health problem, do you have any difficulty:   with preparing meals?	Likert
	ADL_Q010	with running errands such as shopping for groceries?	Likert
	ADL_Q015	with doing everyday housework?	Likert
	ADL_Q020	with personal care such as bathing, dressing, eating or taking medication?	Likert
	ADL_Q025	with moving about inside the house?	Likert
	ADL_Q030	with looking after your personal finances such as making bank transactions or paying bills?	Likert

 

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