Attachment 11

ATTACHMENT 11

Formative Research to Assess Public Attitudes and Behaviors

Regarding Fruit and Vegetable Consumption

___________________________________________________________________________

OMB #0925-0046-11

Exp. Date: 10/31/2006

Dear Panel Member,

Today my questions are for the person whose age and sex appears above. This may be you. Please make sure the appropriate person in your household answers my questions. It is very important that only that person answers my questions.

TO THE PERSON ANSWERING THIS QUESTIONNAIRE

This survey about eating behaviors is being sponsored by the National Cancer Institute (NCI), part of the National Institutes of Health. Your feedback is very important. The results of this survey will help make a significant contribution to the goal of helping to make cancer a less common disease.

The questionnaire includes a wide range of questions about you – what you do, think, and feel. It is extremely important that you give honest answers to the survey questions. Please answer carefully and accurately.

Please carefully read the instructions at the beginning of each section. You will find that most of my questions can be answered by placing a circle around a number or an “X” in the box that best expresses your answer.

Your participation in this survey is completely voluntary. Please be assured that your responses will be kept confidential and will not be disclosed to anyone outside of NCI or its contractor, Synovate, except as otherwise required by law. Neither your name nor any other information about your identity will be provided to the sponsors of this survey. Data will be provided to the NCI in aggregate form only, with any potentially identifying information removed. You may skip any questions that you prefer not to answer. This survey should take approximately 25 minutes to complete.

AS A TOKEN OF OUR APPRECIATION, I HAVE ENCLOSED $2.00.

THANK YOU IN ADVANCE FOR COMPLETING THIS QUESTIONNAIRE.

Thank you so much for helping with this important survey. I hope you’ll be able to return the questionnaire to me as soon as possible. I’m looking forward to receiving your answers. A postage-paid envelope is provided for your convenience.

Cordially,

Marie Brighton
Panel Director

OMB #0925-0046-11

NCI 5 A Day Customized Survey Exp. Date: 10/31/2006

SECTION 1 – ATTITUDES AND OPINIONS

1. In this section, there are a number of statements with which you may or may not agree. For each statement listed, please indicate whether you personally agree or disagree. If you don’t understand a statement, please leave that row blank. (circle one number for each)

		strongly disagree						strongly agree
a.	Eating fruits and vegetables will help me live a healthy life	1	2		3		4		5
b.	I eat more fruits and vegetables than other people I know	1	2		3		4		5
c.	I never hesitate to go out of my way to help someone in trouble	1	2		3		4		5
d.	Generally, I like sweet foods	1	2		3		4		5
e.	I take a multivitamin almost every day	1	2		3		4		5
f.	I eat enough fruits and vegetables to keep me healthy	1	2		3		4		5
g.	I have never intensely disliked anyone	1	2		3		4		5
h.	I enjoy trying new foods	1	2		3		4		5
i.	I would volunteer my time to help develop a nutrition program at work or in my community	1	2		3		4		5
j.	There have been times that I was quite jealous of the good fortune of others	1	2		3		4		5
k.	Dinner doesn’t seem right without meat (chicken, pork, beef) as a main course………………………………………………………………………………	1	2		3		4		5
l.	After I eat a meal without meat, I still feel hungry	1	2		3		4		5
m.	Vegetarians are a bit “different”	1	2		3		4		5
n.	I wish restaurants would have healthier food choices	1	2		3		4		5
o.	Lately I have been under a lot of stress	1	2		3		4		5
p.	I would never think of letting someone else be punished for my wrong doings	1	2		3		4		5
q.	Generally, I like salty foods	1	2		3		4		5
r.	I think meals should include some meat	1	2		3		4		5
s.	I sometimes feel resentful when I don’t get my way	1	2		3		4		5
t.	When it comes to food, I’m a creature of habit. I eat the same things all the time	1	2		3		4		5
u.	Generally, I like spicy foods	1	2		3		4		5
v.	I usually like to eat something sweet after dinner	1	2		3		4		5
w.	There have been times when I felt like rebelling against people in authority even though I knew they were right	1	2		3		4		5
x.	I cannot relate to people who are vegetarians	1	2		3		4		5
y.	Low-carb diets, such as Atkins, are a healthy way to lose weight	1	2		3		4		5
z.	I eat enough fruits and vegetables according to the government recommended guidelines	1	2		3		4		5
aa.	I am always courteous, even to people who are disagreeable	1	2		3		4		5
bb.	Generally, I like tart or sour foods (like sauerkraut, pickles, and grapefruit)	1	2		3		4		5
cc.	I believe that eating fruits and vegetables decreases my risk of getting cancer	1	2		3		4		5
dd.	When I don’t know something, I don’t at all mind admitting it	1	2		3		4		5
ee.	What you eat doesn’t really affect your health	1	2		3		4		5
ff.	I trust government health recommendations	1	2		3		4		5
gg.	I can remember “playing sick” to get out of something	1	2		3		4		5
hh.	I don’t pay attention to government health recommendations because they are always changing	1	2		3		4		5
ii.	It is easy for me to purchase good fresh fruits and vegetables in my neighborhood	1	2		3		4		5
jj.	I am sometimes irritated by people who ask favors of me	1	2		3		4		5
kk.	When I eat lunch out, it is easy for me to have fruits and vegetables if I want them	1	2		3		4		5

2. How often would you say that you do each of the following? (“X” one for each)

		none of the time	some of the time	most of the time	all of the time
a.	How often do you avoid eating fruits because they are too high in carbohydrates?	O	O	O	O
b.	How often do you avoid eating vegetables because they are too high in carbohydrates?	O	O	O	O

3. When growing up, which BEST describes how often you ate fruit? (“X” one)

More than once a day	O	More than once a week	O	A few times a month	O
About once a day	O	Once a week	O	Less often or never	O

3. When growing up, which BEST describes how often you ate vegetables? (“X” one)

More than once a day	O	More than once a week	O	A few times a month	O
About once a day	O	Once a week	O	Less often or never	O

3. When growing up, which BEST describes your overall physical activity patterns, that is, engaging in activities such as biking, swimming, team sports, brisk walking, etc.? (“X” one)

Not at all active	O	Fairly active	O	Extremely active	O
A little active	O	Very active	O

6. When it comes to choosing the foods you eat and drink each day, how important are the following to you? (circle one number for each)

		not at all important				very important
a.	How good it tastes	1	2	3	4	5
b.	How nutritious it is	1	2	3	4	5
c.	How quick it is to make	1	2	3	4	5
d.	How much it costs	1	2	3	4	5
e.	How much my kids like it	1	2	3	4	5
f.	How it impacts my body weight	1	2	3	4	5
g.	How convenient it is to buy	1	2	3	4	5

6. Which, if any, of the following foods do you generally avoid or restrict? (“X” all that apply)

	Red meat	O	Carbohydrates	O	Eggs	O
	Pork	O	Chicken/poultry	O	Fruits	O
	Fish	O	Sweets or sugar	O	Vegetables	O
	Shellfish	O	Milk products, including cheese	O	None of these	O
	Wheat/gluten	O	Added fat such as butter or oil	O

8. Do you currently consider yourself to be a vegetarian or vegan? (“X” one)

Yes

O

No

O

Don’t know

O

SECTION 2 – YOUR HEALTH

9. In general, would you say your health is… (“X” one)

Excellent

O

Very Good

O

Good

O

Fair

O

Poor

O

9. What is your height and weight without shoes? (write in)

	Height:	______ Feet ______ Inches
	Weight:	_______ Pounds

9. How do you describe your weight? (“X” one)

	very underweight		slightly underweight		about the right weight		slightly overweight		very overweight
	O		O		O		O		O

9. Are you currently trying to gain weight or lose weight? (“X” one)

	gain weight		lose weight			neither of these
	O		O			O

9. Have you EVER been told by a doctor or other health professional that you had any of these health conditions? (“X” all that apply)

High blood pressure	O	Breast cancer	O	Irritable Bowel Syndrome	O
High cholesterol	O	Colorectal cancer	O	Other digestive disorders	O
Heart attack	O	Prostate cancer…….	O	Other health condition	O
Diabetes (Type I or II)	O	Other cancer	O	No health problems	O

9. How often do you worry about getting a serious illness in the future? (“X” one)

	never		rarely		sometimes		often		all of the time
	O		O		O		O		O

9. How much has worrying about getting a serious illness led you to change the way you eat? (“X” one)

	not at all		a little		somewhat		quite a bit		completely
	O		O		O		O		O

9. How much has worrying about getting a serious illness led you to exercise more? (“X” one)

	not at all		a little		somewhat		quite a bit		completely
	O		O		O		O		O

9. 17. Have you smoked at least 100 cigarettes in your entire life? One hundred cigarettes is equal to 5 packs.

(“X” one)

	Yes	O  (continue to next question)
	No	O	(skip to question 19)
	Don’t know/Not sure	O

9. Do you now smoke cigarettes every day, some days, or not at all? (“X” one)

	Everyday	O
	Some days	O
	Not at all	O

9. These next questions are about drinking alcoholic beverages.

A drink of alcohol is 1 can or bottle of beer, 1 glass of wine, 1 can or bottle of wine cooler, 1 cocktail, or 1 shot of liquor. During the past 30 days, how many days per month did you have at least one drink of any alcoholic beverage? (write in a number from 1 to 30. if you do not drink at all or did not drink any alcohol at all in the past month, “X” the appropriate circle below and skip to section 3)

_________ Number of days in past month (continue to next question)

	I do not drink alcohol	O	 (skip to section 3)
	I did not drink any alcohol in the past 30 days	O	 (skip to section 3)
	Don’t know/Not sure	O	 (skip to section 3)

9. On the days when you drank alcohol, about how many drinks did you drink on average? (write in)

_________ Number of drinks per day (continue to next question)

9. Considering all types of alcoholic beverages, how many times during the past 30 days did you have 5 or more drinks on an occasion? (write in)

_________ Number of times

	None	O
	Don’t know/Not sure	O

(Please continue on next page)

SECTION 3 – PHYSICAL ACTIVITY

9. This question is about the physical activities you did last week. Physical activity includes the things that you do that make you breathe harder and/or make your heart beat faster. We are interested in the physical activities you did for at least 10 minutes at a time.

Thinking of the physical activities you did in the last week that made you breathe harder and/or made your heart beat faster for at least 10 minutes at a time, please write down how many hours and/or minutes you spent doing physical activities each day in the last 7 days. There are some examples below of the types of activities you should include. (write in hours and/or minutes for each day. if you did not do any activities for at least 10 minutes on a given day, write “0”)

Examples of activities you might do for at least 10 minutes at a time (not a complete list):

Brisk walking: Count brisk walking as physical activity if it makes you breathe harder. This might include walking around the neighborhood, walking back and forth to work, or walking as part of your job (if you are walking at a brisk pace most of the time). Do not count leisurely walking.

Exercise/Sport: Count things like aerobics, working out at the gym, jogging, running, swimming, kickboxing, dancing, playing active sports like basketball, or any other activities that make your heart beat faster.

Physical activity at work: Count things like heavy labor or lifting or anything thing else that makes you breathe harder for at least 10 minutes at a time.

Home and yard work: Count things like gardening, scrubbing floors, or mowing the lawn with a push mower. Make sure to count only the things that made your heart beat faster for at least 10 minutes.

Other: Count other activities that you do that make you breathe harder and/or make your heart beat faster for at least 10 minutes at a time.

DAY	Time you spent being physically active each day LAST week
Sunday……….	_______Hours	_______Min
Monday………	_______Hours	_______Min
Tuesday……...	_______Hours	_______Min
Wednesday….	_______Hours	_______Min
Thursday…….	_______Hours	_______Min
Friday…………	_______Hours	_______Min
Saturday……..	_______Hours	_______Min

SECTION 4 – SHOPPING

9. How often do you typically go food shopping? (“X” one)

	More than once a week	O	Every other week	O	Less often than once a month…	O
	Once a week	O	Once a month	O

9. Where do you usually do your food shopping? (“X” all that apply)

Large chain grocery store or supermarket……………...	O	Discount superstore (such as Wal-Mart)…………..	O
Natural or organic supermarket..…………………………	O	Online delivery (such as Peapod or Fresh Direct)..	O
Small local store or corner store….………………………	O	Ethnic market…………………………………………	O
Convenience store (such as 7-Eleven or mini market)..	O	Farmer’s market/co-op………………………………	O
Warehouse club store (such as Sam’s club or Costco).	O	Other (Please specify:______________________)	O

9. When it comes to fruit, what type of fruit do you buy most often? (“X” one)

	Fresh fruit	O	Canned or jarred fruit	O
	Frozen fruit	O	Do not buy fruit	O

9. When it comes to vegetables, what type of vegetables do you buy most often? (“X” one)

	Fresh vegetables	O	Canned or jarred vegetables…	O
	Frozen vegetables	O	Do not buy vegetables………...	O

9. How often do you buy pre-washed and pre-packaged fresh fruits and vegetables such as bags of salad, baby carrots, or cut up fruit? (“X” one. do not count frozen or canned fruits and vegetables)

	More than once a week	O	Every other week	O	Every other month	O	Yearly	O
	Once a week	O	Once a month	O	2-3 times a year	O	Not at all	O

9. How often do you go out of your way or make a special effort to go to a particular store to buy fresh or high quality fruits or vegetables? (“X” one)

	More than once a week	O	Every other week	O	Every other month	O	Yearly	O
	Once a week	O	Once a month	O	2-3 times a year	O	Not at all	O

9. In the summer, how often do you buy fresh fruits and vegetables from an outdoor farmer’s market, roadside stand, or pick-your-own produce farm? (“X” one)

	More than once a week	O	Every other week	O	Less than once a month	O
	Once a week	O	Once a month	O	Not at all	O

9. Did you grow any of your own fruits or vegetables in the past year? (“X” one)

Yes

O

No

O

SECTION 5 – NUTRITION

9. O

   Some examples of how much one cup equals:

   
   

   1 cup	=	1 small apple
   of fruit		1 large banana
   		1 large orange
   		8 large strawberries
   		1 medium pear
   		2 large plums
   		32 seedless grapes
   		1 cup of 100% juice
   		½ cup of dried fruit
   		1 small wedge of watermelon (1 inch thick)
   1 cup of
   vegetables	=	3 broccoli spears, 5 in. long
   		1 cup of cooked leafy greens 2 cups of lettuce or raw greens
   		12 baby carrots
   		1 large potato
   		1 large sweet potato
   		1 large ear of corn
   		1 large raw tomato
   		2 large celery stalks

   n average, how many cups of FRUIT (including

100% fruit juice) do you eat/drink each day?

(“X” one)

	0 cups	O	3 ½ cups	O
	½ cup	O	4 cups	O
	1 cup	O	4 ½ cups	O
	1 ½ cups	O	5 cups	O
	2 cups	O	5 ½ cups	O
	2 ½ cups	O	6 cups	O
	3 cups	O	More than 6 cups	O

9. On average, how many cups of VEGETABLES (including

100% vegetable juice) do you eat/drink each day?

(“X” one)

	0 cups	O	3 ½ cups	O
	½ cup	O	4 cups	O
	1 cup	O	4 ½ cups	O
	1 ½ cups	O	5 cups	O
	2 cups	O	5 ½ cups	O
	2 ½ cups	O	6 cups	O
	3 cups	O	More than 6 cups	O

9. On average, about how many cups of water do you drink each day? (8oz. of water is equal to one cup. One standard 16oz. bottle of water equals 2 cups.) (“X” one)

0 cups

O

1-3 cups

O

4-7 cups

O

8 or more cups

O

9. In this section, there are a number of statements with which you may or may not agree. For each statement listed, please indicate whether you personally agree or disagree. If you don’t understand a statement, please leave that row blank. (circle one number for each)

		strongly disagree					strongly agree
a.	I don’t eat fruits and vegetables as much as I’d like to because they cost too much	1	2		3	4		5
b.	I don’t eat fresh fruits and vegetables as much as I’d like to because they often spoil before I get a chance to eat them	1	2		3	4		5
c.	I don’t eat fruits and vegetables as often as I should because they take too much time to prepare (clean, cut up, and cook)	1	2		3	4		5
d.	I don’t eat fruits and vegetables as often as I should because they are not filling enough	1	2		3	4		5
e.	I don’t eat fruits and vegetables as much as I’d like to because my family doesn’t like to eat them	1	2		3	4		5
f.	I don’t eat fruits and vegetables as much as I’d like to because I can’t get good fresh produce at my local store	1	2		3	4		5
g.	It’s hard for me to eat more fruits and vegetables because you have to buy fresh ones every few days	1	2		3	4		5
h.	I don’t eat as much fruit as I’d like to because the restaurants I go to don’t serve fruit	1	2		3	4		5
i.	I don’t eat as many vegetables as I’d like to because the restaurants I go to don’t serve vegetables	1	2		3	4		5
j.	It is hard for me to eat more fruits and vegetables because I don’t have time to plan how to work them into my diet	1	2		3	4		5
k.	I don’t eat fruits and vegetables as much as I’d like to because I don’t know how to choose fresh fruits and vegetables	1	2		3	4		5
l.	I don’t eat fruits and vegetables as much as I’d like to because I have trouble digesting them	1	2		3	4		5
m.	I don’t eat as many fruits and vegetables as I’d like to because my family eats them up too fast	1	2		3	4		5
n.	I don’t eat fruits and vegetables as often as I should because they are hard to take with me when I am “on the go”	1	2		3	4		5
o.	It’s hard for me to eat more vegetables because I don’t know how to prepare them	1	2		3	4		5
p.	I don’t eat fruits and vegetables as often as I should because I just don’t think of them when I’m looking for something to eat……………	1	2		3	4		5
q.	I often forget to eat fruits and vegetables because they are stored out of sight……………………………………………...	1	2		3	4		5
r.	I don’t eat fruits and vegetables as often as I should because they are too messy…………………………………………...	1	2		3	4		5

9. Assuming that you would want to, how confident are you that you could do each of the following?

(circle one number for each)

	How confident are you that you could…	not at all confident					very confident
a.	Prepare good tasting recipes that contain fruits or vegetables	1	2		3	4		5
b.	Order fruits or vegetables when eating at a restaurant	1	2		3	4		5
c.	Eat fruits and vegetables when eating away from home	1	2		3	4		5
d.	Choose fruits and vegetables instead of higher fat foods	1	2		3	4		5
e.	Eat a healthy snack, like a fruit or a vegetable when you’re really hungry	1	2		3	4		5
f.	Eat healthy foods, like fruits or vegetables, when you are depressed or in a bad mood	1	2		3	4		5
g.	Eat healthy foods, like fruits or vegetables, when you are tired	1	2		3	4		5
h.	Eat healthy foods, like fruits or vegetables, when there are junk foods in your house like chips, cookies, or candy	1	2		3	4		5
i.	Eat healthy foods like fruits and vegetables when you eat out with friends	1	2		3	4		5
j.	For dessert, eat fruit instead of cake, cookies, candy, ice cream, or other sweets	1	2		3	4		5

9. 36. On a scale from 1 to 5 where 1 = strongly disagree and 5 = strongly agree, please tell me how much you agree or disagree with the following statements. (circle one number for each)

		strongly disagree						strongly agree
a.	I receive support from others (such as spouse, family, friends, etc.) to eat fruits and vegetables	1	2		3		4		5
b.	Other people give me a hard time if I eat a lot of fruits and vegetables	1	2		3		4		5
c.	Eating fruits and vegetables is not really important to my family or friends	1	2		3		4		5
d.	I would feel out of place eating only a salad when everyone else I’m with is eating other foods (such as steak, fried chicken, hamburgers, etc.)	1	2		3		4		5
e.	I rarely eat fruits and vegetables unless someone provides or cooks them for me	1	2		3		4		5
f.	My family or friends make it easier for me to eat fruits and vegetables	1	2		3		4		5
g.	My family or friends do not really care whether or not I eat fruits and vegetables	1	2		3		4		5
h.	I often encourage my family or friends to eat fruits and vegetables	1	2		3		4		5
i.	I would seriously consider eating more fruits and vegetables if my family or friends asked me to	1	2		3		4		5
j.	My family or friends would be concerned if I did not eat enough fruits and vegetables	1	2		3		4		5
k.	My family or friends would not be willing to eat a vegetarian or vegetable-based meal	1	2		3		4		5

9. The following questions relate to reasons why you eat fruits and vegetables. Different people have different reasons for doing it, and we want to know how true the following reasons are for you. Please indicate the extent to which each reason is true for you, using the following 5-point scale.

(circle one number for each)

	The reason I eat fruits and vegetables is…	not true at all					very true
a.	Because I want to feel in control of my health	1	2		3	4	5
b.	Because I would feel guilty or ashamed of myself if I did not	1	2		3	4	5
c.	Because my family wants me to	1	2		3	4	5
d.	Because I personally believe it is a good thing for my health	1	2		3	4	5
e.	Because others would be upset with me if I did not	1	2		3	4	5
f.	Because I have carefully thought about it and believe it is very important for me	1	2		3	4	5
g.	Because I would feel bad about myself if I didn’t	1	2		3	4	5
h.	Because my friends want me to	1	2		3	4	5
i.	Because it is an important choice I really want to make	1	2		3	4	5
j.	Because I feel pressure from others to eat more fruits and vegetables	1	2		3	4	5
k.	Because it is easier to do what I am told than think about it	1	2		3	4	5
l.	Because it is consistent with my life goals	1	2		3	4	5
m.	Because my doctor wants me to	1	2		3	4	5
n.	Because I want others to approve of me	1	2		3	4	5
o.	Because it is important for being as healthy as possible	1	2		3	4	5
p.	Because I want others to see I can do it	1	2		3	4	5
q.	Because not doing so puts me at great health risk	1	2		3	4	5
r.	Because I want to set a good example for my family	1	2		3	4	5
s.	Because it is important to treat my body with respect	1	2		3	4	5
t.	Because I want to set a good example for my community	1	2		3	4	5

9. If you were to eat more fruits and vegetables than you do now, how likely do you think you would be to…

(circle one number for each)

		not at all likely				very likely
a.	Eat less junk food	1	2	3	4	5
b.	Have more energy	1	2	3	4	5
c.	Feel more in control of your life	1	2	3	4	5
d.	Set a good example for others	1	2	3	4	5
e.	Live a long life	1	2	3	4	5
f.	Control your weight	1	2	3	4	5
g.	Look better (appearance)	1	2	3	4	5
h.	Be “regular” (cleanse the body)	1	2	3	4	5
i.	Feel good about yourself	1	2	3	4	5

9. 39. About how many cups of fruits AND vegetables does the government recommend adults should eat each day for good health? (“X” one)

	Don’t know……	O	1 ½ cups	O	3 ½ cups	O	5 ½ cups	O
	0 cups	O	2 cups	O	4 cups	O	6 cups	O
	½ cup	O	2 ½ cups	O	4 ½ cups	O	More than 6 cups	O
	1 cup	O	3 cups	O	5 cups	O

9. What is the name of the national campaign to eat more fruits and vegetables? (“X” one)

I am not aware of this campaign	O	“3 to 4 a day”	O	“12 a day”	O
“1 a day”	O	“5 a day”	O	None of these	O
“3 a day”	O	“5 to 9 a day”	O

9. What is the main message of this national campaign to eat more fruits and vegetables? (“X” one)

Have not heard of this campaign ……………………………	O
Eat more fruits and vegetables to build strong bones…….	O
Eat more fruits and vegetables for better health…………..	O
Eat more fruits and vegetables for strength and power…..	O
Eat more fruits and vegetables because “fresh is best”…..	O

9. Where have you heard about this campaign to eat more fruits and vegetables? (“X” all that apply)

Have not heard of this campaign	O	At work or through work activities………………………..	O
On the radio	O	At a church or other place of worship…………………...	O
On TV	O	From friends or family members…………………………	O
In a magazine	O	From your doctor or other health care professional…...	O
In the newspaper………………….	O	From materials in the grocery store or supermarket…..	O
On the Internet…………………….	O	Other (Please specify:_________________________)	O

9. On a scale from 1-5 where 1 means “Not at all likely” and 5 means “Very likely”, please tell me how likely you would be to eat more fruits and vegetables … (circle one number for each statement)

		not at all likely						very likely
a.	If your employer offered free or low-cost fruits and vegetables at work	1	2		3		4	5
b.	If there were more vending machines that offered 100% fruit juice	1	2		3		4	5
c.	If someone sponsored you/checked your progress	1	2		3		4	5
d.	If you could get a free pamphlet on how to prepare fruits and vegetables	1	2		3		4	5
e.	If your health insurance rewarded you with lower premiums	1	2		3		4	5
f.	If you could earn coupons or vouchers for free fruits or vegetables	1	2		3		4	5
g.	If every time you ate fruits and vegetables you would earn points toward free things like magazines, clothes, and travel	1	2		3		4	5
h.	If fruits and vegetables came in more convenient packages (pre-washed, cut up, with dip)	1	2		3		4	5
i.	If you could call a toll-free number to get advice from an expert	1	2		3		4	5

SECTION 6 – WHAT YOU EAT

These questions are about the different kinds of foods you ate or drank during the PAST MONTH, that is, the past 30 days. When answering, please include meals and snacks eaten at home, at work or school, in restaurants, or anyplace else.

You can use the examples in the box below to help you remember how much equals one cup.

Some examples of how much one cup equals:

1 cup	=	1 small apple		1 cup of	=	3 broccoli spears, 5 in. long
of fruit		1 large banana		vegetables		1 cup of cooked leafy greens
		1 large orange				2 cups of lettuce or raw greens
		8 large strawberries				12 baby carrots
		1 medium pear				1 large potato
		2 large plums				1 large sweet potato
		32 seedless grapes				1 large ear of corn
		1 cup of 100% juice				1 large raw tomato
		½ cup of dried fruit				2 large celery stalks
		1 small wedge of watermelon (1 inch thick)

44a. During the past month, how often did you drink 100% FRUIT JUICE, such as orange, apple, and grape juices? Do NOT count fruit drinks. (include only 100% pure juices. do NOT include fruit drinks with added sugar, like cranberry cocktail, hi-c, lemonade, kool-aid, gatorade, tampico, and sunny delight.) (“X” one)

	Never	O	1 time per day	O
	1-3 times last month	O	2 times per day …	O
	1-2 times per week	O	3 times per day	O
	3-4 times per week	O	4 times per day	O
	5-6 times per week	O	5 or more times per day	O

44b. About how much did you have each time you drank 100% fruit juice? (“X” one)

	Did not drink 100% fruit juice in the past month	O	1 ¼ to 2 cups (10 to 16 ounces)	O
	Less than ¾ cup (less than 6 ounces)	O	More than 2 cups (more than 16 ounces)	O
	¾ to 1 ¼ cup (6 to 10 ounces)	O

45a. During the past month, how often did you eat FRUIT? Count fresh, frozen, or canned fruit. Do NOT count juices. (“X” one)

	Never	O	1 time per day	O
	1-3 times last month	O	2 times per day	O
	1-2 times per week	O	3 times per day	O
	3-4 times per week	O	4 times per day	O
	5-6 times per week	O	5 or more times per day	O

45b. About how much did you have each time you ate fruit? (“X” one)

	Did not eat fruit in the past month	O	About 1 cup	O
	Less than ½ cup	O	More than 1 cup	O
	About ½ cup	O

46a. During the past month, how often did you eat lettuce or green leafy SALAD, with or without other vegetables? (include spinach salads) (“X” one)

	Never	O	1 time per day	O
	1-3 times last month	O	2 times per day	O
	1-2 times per week	O	3 times per day	O
	3-4 times per week	O	4 times per day	O
	5-6 times per week	O	5 or more times per day	O

46b. About how much did you have each time you ate salad? (“X” one)

	Did not eat salad in the past month	O	About 2 cups	O
	About ½ cup	O	More than 2 cups	O
	About 1 cup	O

47a. During the past month, how often did you eat FRENCH FRIES, home fries, or hash brown potatoes?

(“X” one)

	Never	O	1 time per day	O
	1-3 times last month	O	2 times per day	O
	1-2 times per week	O	3 times per day	O
	3-4 times per week	O	4 times per day	O
	5-6 times per week	O	5 or more times per day	O

47b. About how much did you have each time you ate French fries or fried potatoes? (“X” one)

	Did not eat fried potatoes in the past month	O	About 2 cups (large order)…………………………	O
	About 1 cup or less (small order or less)	O	About 3 cups or more (Super Size order or more)	O
	About 1 ½ cups (medium order)	O

48a. During the past month, how often did you have other WHITE POTATOES? Count baked potatoes, boiled potatoes, mashed potatoes, and potato salad. (do NOT include yams or sweet potatoes. INCLUDE red-skinned and yukon gold potatoes) (“X” one)

	Never	O	1 time per day	O
	1-3 times last month	O	2 times per day	O
	1-2 times per week	O	3 times per day	O
	3-4 times per week	O	4 times per day	O
	5-6 times per week	O	5 or more times per day	O

48b. About how much did you have each time you ate other potatoes? (“X” one)

	Did not eat other potatoes in the past month	O	1 to 1 ½ cups (1 large potato)	O
	½ cup or less (1 small potato or less)	O	1 ½ cups or more (2 medium potatoes or more)	O
	½ to 1 cup (1 medium potato)	O

49a. During the past month, how often did you eat COOKED DRIED BEANS, such as refried beans, baked beans, bean soup, and pork and beans? Do NOT include green beans. (“X” one)

	Never	O	1 time per day	O
	1-3 times last month	O	2 times per day	O
	1-2 times per week	O	3 times per day	O
	3-4 times per week	O	4 times per day	O
	5-6 times per week	O	5 or more times per day	O

49b. About how much did you have each time you ate beans? (“X” one)

	Did not eat beans in the past month	O	1 to 1 ½ cup	O
	Less than ½ cup	O	More than 1 ½ cups	O
	½ to 1 cup	O

50a. NOT counting lettuce salads, white potatoes, cooked dried beans, and NOT counting rice, how often did you eat OTHER VEGETABLES? (examples of other vegetables include tomatoes, string beans, carrots, corn, sweet potatoes, bean sprouts, collard greens, and broccoli.) (“X” one)

	Never	O	1 time per day	O
	1-3 times last month	O	2 times per day	O
	1-2 times per week	O	3 times per day	O
	3-4 times per week	O	4 times per day	O
	5-6 times per week	O	5 or more times per day	O

50b. About how much did you have each time you ate other vegetables? (“X” one)

	Did not eat other vegetables in the past month	O	1 to 2 cups	O
	Less than ½ cup	O	More than 2 cups	O
	½ to 1 cup	O

51a. During the past month, how often did you have TOMATO SAUCE such as spaghetti sauce or pizza with tomato sauce? (“X” one)

	Never	O	1 time per day	O
	1-3 times last month	O	2 times per day	O
	1-2 times per week	O	3 times per day	O
	3-4 times per week	O	4 times per day	O
	5-6 times per week	O	5 or more times per day	O

51b. About how much did you have each time you ate tomato sauce? (“X” one)

	Did not eat tomato sauce in the past month	O	About 1 cup	O
	About ¼ cup	O	More than 1 cup	O
	About ½ cup	O

52. Think about the TYPES of fruits and vegetable you eat. Do you tend to eat the same types of fruits and vegetables all year round, or do you tend to eat different types of fruits and vegetables depending on what is “in season”? (“X” one)

	I tend to eat the same types of fruits and vegetables all year round	O
	I tend to eat different types of fruits and vegetables depending on what is in season	O

52. Think about the AMOUNT of fruits and vegetables you eat. Compared to the winter, would you say you eat more, fewer, or about the same amount of fruits and vegetables than in the summer? (“X” one)

	I eat more fruits and vegetables in the summer than I do in the winter	O
	I eat fewer fruits and vegetables in the summer than I do in the winter	O
	I eat about the same amount of fruits and vegetables in the summer and in the winter….	O

52. Thinking of the fruits you eat most often, how would you describe them? (“X” all that apply)

	Crunchy	O	Cool	O	Soft	O	Warm	O
	Sweet	O	Colorful	O	Tart	O	Juicy	O
	Raw	O	Cooked	O	Smooth	O	Mild	O
	Flavorful	O	Bitter	O	Crisp	O	Ripe	O
	Hearty	O	Grainy	O	Chewy	O	Firm	O

52. Thinking of the vegetables you eat most often, how would you describe them? (“X” all that apply)

	Crunchy	O	Cool	O	Soft	O	Warm	O
	Sweet	O	Colorful	O	Tart	O	Juicy	O
	Raw	O	Cooked	O	Smooth	O	Mild	O
	Flavorful	O	Bitter	O	Crisp	O	Ripe	O
	Hearty	O	Grainy	O	Chewy	O	Firm	O

N

SECTION 7 – GENERAL

ow that you’ve answered my questions about fruits and vegetables, please tell me a little more about yourself and the other things you do.

56. Do you have any children or grandchildren under 18 years old living at home with you? (“X” all that apply)

	Yes, children	O
	Yes, grandchildren	O
	No	O  (skip to question 58)

56. Starting with the YOUNGEST child, please list the ages of the 3 youngest children and/or grandchildren who live at home with you.

	Child #1:		Child #2:		Child #3:

56. On average, how many hours of sleep do you usually get…

On a typical weeknight (Sunday - Thursday)? _______ (write in number)

On a typical weekend night (Friday or Saturday)? _______ (write in number)

56. On average, how many hours of sleep would you like to get each night? _______ (write in number)

56. About how often do you attend church or another place of worship for services or other activities (like choir, bible class, or community service)? (“X” one)

	More than once a week	O	Every other week	O	Every other month	O	Yearly	O
	Once a week	O	Once a month	O	2-3 times a year	O	Not at all	O

61. Please tell me which of the following products you currently own. (“X” all that apply)

Cable or digital TV	O	DVD player	O	Personal digital assistant (such as a Palm Pilot)	O
VCR	O	Home computer	O	High speed Internet connection	O

61. How often do you use the Internet for personal reasons (not for work)? (“X one)

	Every day	O	Once a month	O
	A few times a week	O	A few times a year	O
	Several times a month	O	Rarely/never	O

61. IN THE PAST WEEK, how many hours total did you spend using the Internet for personal reasons (not for work)? Write in the number of hours in the space provided below. (if you did not use the internet in the past week, write in “0”)

_________ # of hours last week

61. What is the total number of hours of television you watch…

During an average week (add up Monday through Friday)? _______ (write in number)

During an average weekend (add up Saturday and Sunday)? _______ (write in number)

61. Do you do yoga or pilates at least once a week?

Yes

O

No

O

How many times a week do you usually eat a meal from a fast food restaurant like McDonalds, Burger King, Wendy’s, Taco Bell, pizza, etc.? Consider breakfast, lunch, and dinner.

_______ (write in)

How many times a week do you eat a meal while watching television? Consider breakfast, lunch, and dinner.

_______ (write in)

61. FOR WOMEN ONLY: Are you currently pregnant? (“X one)

Yes



No

