10.14639/0392-100X-N0766
Objectives. Clinical experience and daily life indicate that the importance of smell, taste and flavour is variable among individuals. Therefore, the aim of this research was to de- velop a questionnaire to investigate the importance attributed to smell, taste and flavour and socio-cultural differences among individuals.Methods. Cross-cultural adaptation of the questionnaire was executed by two professional translators and one bilingual investigator and pre-tested on a pilot group of 25 subjects with&nbsp;normal smell and taste abilities. The final version of the questionnaire was sent by e-mail to 850 healthy subjects. The Google form consisted of three parts: “The importance of olfac- tion” developed by Croy et al. in 2010, “The importance of taste and flavour” developed by our team and a section to collect demographic data. The questions were classified into “as- sociation”, “application”, “consequence” and “aggravation”. Statistical differences were assessed using t-test with p ≤ 0.05. Correlations were calculated using Spearman’s test. Internal consistency was assessed using the Cronbach’s Alpha, while test-retest reliability&nbsp;was analysed by calculating the Intraclass Correlation Coefficients (ICC2k).Results. The questionnaire received a non-response rate of 10.7%. Calculation of Cron- bach’s alpha showed good internal reliability (a = 0.87). Test-retest evaluation was satis- factory for all subscales, with an overall ICC2k = 0.84 (CI 0.79-0.89). Statistical analysis showed that smell, taste and flavour appeared to be more important for women when com- pared to men (p &lt; 0.001). No statistical differences were seen between individuals with various educational background (p &gt; 0.05), and the importance of smell (r = 0.16; p &lt; 0.01), taste and flavour (r = 0.08; p &lt; 0.05) did not decline with age.Conclusions. The development of this original test provides an overview into the impor- tance of smell, taste and flavour among individuals. Although further research is needed, it can help in the evaluation and investigation of aspects that influence people to seek medical&nbsp;attention in the presence of sensory alterations.
text/xml
1827-675X
766
en
Michele Cassano
http://creativecommons.org/licenses/by-nc-nd/4.0
ACTA Otorhinolaryngologica Italica
statistics
Development of a questionnaire to investigate socio-cultural differences in the perception of smell, taste and flavour
Text.Serial.Journal
https://www.actaitalica.it/
41
Rhinology
2021-09-14
2020-03-25
2021-09-15
2021-09-15
336-347
1
Michele Cassano
2021/09/14
10.14639/0392-100X-N0766
336
Department of Otolaryngology, University Hospital of Foggia, Foggia, Italy
1827-675X
statistics
347
Development of a questionnaire to investigate socio-cultural differences in the perception of smell, taste and flavour
https://www.actaitalica.it/article/download/766/653
41
ACTA OTORHINOLARYNGOLOGICA ITALICA 2021;41:336-347; doi: 10.14639/0392-100X-N0766




Rhinology


Development of a questionnaire to investigate
socio-cultural differences in the perception of smell,
taste and flavour
Sviluppo di un questionario per indagare le differenze socio-culturali nella percezione
di olfatto, gusto e sapore
Eleonora M.C. Trecca1,2, Francesca Fortunato3, Matteo Gelardi1, Paolo Petrone4, Michele Cassano1
1
 Department of Otolaryngology, University Hospital of Foggia, Foggia, Italy; 2 Department of Maxillofacial Surgery and
Otolaryngology; IRCCS Casa Sollievo della Sofferenza; San Giovanni Rotondo (FG), Italy; 3 Department of Medical and Surgical
Sciences, University of Foggia, Foggia, Italy; 4 Department of Otolaryngology, Di Venere Hospital, Bari, Italy


SUMMARY
Objectives. Clinical experience and daily life indicate that the importance of smell, taste
and flavour is variable among individuals. Therefore, the aim of this research was to de-
velop a questionnaire to investigate the importance attributed to smell, taste and flavour and
socio-cultural differences among individuals.
Methods. Cross-cultural adaptation of the questionnaire was executed by two professional
translators and one bilingual investigator and pre-tested on a pilot group of 25 subjects with
normal smell and taste abilities. The final version of the questionnaire was sent by e-mail to
850 healthy subjects. The Google form consisted of three parts: “The importance of olfac-
tion” developed by Croy et al. in 2010, “The importance of taste and flavour” developed by
our team and a section to collect demographic data. The questions were classified into “as-      Received: March 25, 2020
sociation”, “application”, “consequence” and “aggravation”. Statistical differences were         Accepted: January 24, 2021
assessed using t-test with p ≤ 0.05. Correlations were calculated using Spearman’s test.
Internal consistency was assessed using the Cronbach’s Alpha, while test-retest reliability      Correspondence
                                                                                                 Eleonora M.C. Trecca
was analysed by calculating the Intraclass Correlation Coefficients (ICC2k).
                                                                                                 University Hospital of Foggia, Department of Oto-
Results. The questionnaire received a non-response rate of 10.7%. Calculation of Cron-
                                                                                                 laryngology, viale Pinto 1, 71122 Foggia, Italy
bach’s alpha showed good internal reliability (a = 0.87). Test-retest evaluation was satis-      E-mail: eleonora.trecca@unifg.it
factory for all subscales, with an overall ICC2k = 0.84 (CI 0.79-0.89). Statistical analysis
showed that smell, taste and flavour appeared to be more important for women when com-           Funding
pared to men (p < 0.001). No statistical differences were seen between individuals with          None.
various educational background (p > 0.05), and the importance of smell (r = 0.16; p < 0.01),
taste and flavour (r = 0.08; p < 0.05) did not decline with age.                                 Conflict of interest
Conclusions. The development of this original test provides an overview into the impor-          The Authors declare no conflict of interest.
tance of smell, taste and flavour among individuals. Although further research is needed, it
can help in the evaluation and investigation of aspects that influence people to seek medical
                                                                                                   How to cite this article: Trecca EMC, Fortunato
attention in the presence of sensory alterations.
                                                                                                   F, Gelardi M, et al. Development of a question-
KEY WORDS: olfaction, taste, olfactory disorders, quality of life, statistics                      naire to investigate socio-cultural differences in
                                                                                                   the perception of smell, taste and flavour. Acta
                                                                                                   Otorhinolaryngol Ital 2021;41:336-347. https://
RIASSUNTO                                                                                          doi.org/10.14639/0392-100X-N0766
Obiettivo. L’esperienza clinica e la vita quotidiana mostrano come l’importanza attribuita
al senso dell’olfatto, del gusto e del sapore siano variabili nella popolazione. L’obiettivo     © Società Italiana di Otorinolaringoiatria
di questo studio è stato, pertanto, quello di sviluppare un questionario per indagare l’im-      e Chirurgia Cervico-Facciale
portanza attribuita a questi sensi e le differenze socioculturali esistenti tra gli individui.
Metodi. L’adattamento interculturale del questionario è stato eseguito da due traduttori                        OPEN ACCESS
professionisti e un ricercatore bilingue e pretestato su un gruppo pilota di 25 soggetti con     This is an open access article distributed in accordance with
normali capacità olfattive e gustative. La versione finale del questionario è stata inviata      the CC-BY-NC-ND (Creative Commons Attribution-Non-
via e-mail a 850 soggetti sani. Il Google form era composto da tre parti: “L’importanza          Commercial-NoDerivatives 4.0 International) license. The
                                                                                                 article can be used by giving appropriate credit and mentio-
dell’olfatto” (Croy et al., 2010), “L’importanza di gusto e sapore” creato dal nostro grup-      ning the license, but only for non-commercial purposes and
po, e un modulo per l’inserimento dei dati demografici. Le domande sono state suddivise          only in the original version. For further information: https://
in 4 classi: “associazione”, “applicazione”, “conseguenza” e “gravità”. Per l’analisi sta-       creativecommons.org/licenses/by-nc-nd/4.0/deed.en




336
                                                                                    Socio-cultural differences in the perception of smell, taste and flavour




tistica è stato utilizzato il test t considerando come significative differenze con p ≤ 0,05. Le correlazioni sono state calcolate con il test di Spe-
arman. La coerenza interna è stata valutata utilizzando l’Alpha di Cronbach, mentre l’affidabilità del test-retest è stata analizzata calcolando
i coefficienti di correlazione intra-classe (ICC2k).
Risultati. Il tasso di non risposta del questionario è stato pari al 10,7%. Il calcolo dell’Alpha di Cronbach ha evidenziato una buona affida-
bilità interna (a = 0,87). Inoltre, la valutazione del test-retest è stata soddisfacente per tutte le scale, con un ICC2k complessivo pari a 0,84
(CI 0,79-0,89). L’analisi statistica ha evidenziato che: olfatto, gusto e sapore sono risultati più importanti per le donne rispetto agli uomini
(p < 0,001); non sono state evidenziate differenze statisticamente significative tra individui con diversi titoli di studio (p > 0,05); l’importanza
attribuita all’olfatto (r = 0,16; p < 0,01), così come quella al gusto e al sapore (r = 0,08; p < 0,05), non è diminuita con l’aumentare dell’età
degli intervistati.
Conclusioni. Lo sviluppo di questo nuovo questionario fornisce una panoramica completa sull’importanza attribuita al senso dell’olfatto,
gusto e sapore e sulle differenze socio-culturali esistenti tra gli individui. Sebbene ulteriori studi siano necessari, potrebbe essere di aiuto nel
comprendere quali aspetti influenzano gli individui nel cercare o meno una consulenza medica in presenza di alterazioni sensoriali.
PAROLE CHIAVE: olfatto, gusto, disturbi olfattivi, qualità della vita, statistica



Introduction                                                                 normal cognitive function [mini mental state examination
                                                                             (MMSE) score ≥ 26 for subjects aged between 18 and 64
The use of questionnaires and clinical E-Surveys has be-                     years and ≥ 24 for subjects older than 65 7]. Subjects as-
come increasingly popular in medicine in the last few                        sessed the severity of their nasal symptoms by answering
years, not only for research purposes, but also as diagnostic                the Sino-Nasal Outcome Test (SNOT-22) questionnaire in
instruments. In the field of smell and taste disorders, sub-                 order to limit the possibility of any pre-existing sino-nasal
jective patient-reported olfactory assessment should be un-                  disorder that might influence the chemical senses of the
dertaken as a first level evaluation before proceeding with                  population; subjects with a baseline score ≤ 10 8 were con-
psychophysical olfactory tests 1. Validated questionnaires                   sequently included.
and recognised forms of assessment exist in rhinology; they                  There were no exclusion criteria related to sex, race, gender
predominantly focus on sinonasal symptoms 2, olfactory                       or ethnicity, while subjects meeting any of the following
dysfunction and quality of life 3, while giving more limited                 criteria were excluded:
attention to taste complaints. Another type of questionnaire                 • history of Ear, Nose and Throat (ENT) diseases or pre-
was developed by Croy et al. 4 to provide a gauge of the                        existing smell/taste disorders;
individual importance of olfaction. Clinical experience and                  • previous airway surgery (i.e., septoplasty, turbinoplasty,
daily life show that the consideration of smell, taste and                      sinus surgery etc.);
flavour varies among individuals. Interestingly, the impor-                  • presence of upper respiratory tract infection (URTI);
tance of olfactory and gustatory function seems to vary not                  • history of neuropsychiatric disorders (i.e., Parkinson’s
only within the general population, but also among patients                     disease, Alzheimer’s disease, multiple sclerosis, depres-
with sensory impairment, who may or may not choose to                           sion, eating disorders etc.);
pursue medical counselling 5.                                                • previous major head trauma;
Therefore, the aim of this research was to develop a ques-                   • history of significant comorbidities, such as severe hy-
tionnaire to investigate the importance attributed not only                     pertension, poorly controlled diabetes mellitus, rheu-
to the sense of smell, but also to taste and flavour, and the                   matic or autoimmune disease;
socio-cultural differences among individuals.                                • concurrent treatment or medication that may interfere
                                                                                with olfactory/gustatory function;
Materials and methods                                                        • history of drug or alcohol abuse;
                                                                             • history of smoking 20 or more cigarettes/day 9.
The study was conducted from June 2017 to March 2018 and
was compliant with the Checklist for Reporting Results of                    Development of the questionnaire
Internet E-Surveys (CHERRIES) 6. The Institutional Review                    Cross-cultural adaptation of the questionnaire was executed
Board of the University of Foggia Department of Otolaryn-                    by two professional translators and one bilingual investiga-
gology approved this study. The questionnaire was translated                 tor speaking Italian and English. Three Otolaryngologists,
into Italian and English and uploaded to Google Drive.                       well acquainted with the topic involved, further improved
                                                                             the preliminary version obtained. A new version including
Inclusion and exclusion criteria                                             all the suggestions was forwarded to the translators to ex-
Recruitment was directed to male and female subjects                         ecute the back-translation into Italian. Finally, the expert
aged ≥ 18, with intact reading comprehension abilities and                   group developed a consensus version of the instrument 10.



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E.M.C. Trecca et al.




As a last step, the tool was pre-tested on a pilot group of      sheet (Excel, Microsoft, 2011). In order to prevent multi-
25 subjects with normal smell and taste abilities confirmed      ple entries from the same individual, users were required
by Sniffin’ sticks and taste strips tests (Burghart®) who        to register first. The username was stored together with the
fulfilled the inclusion criteria mentioned in the previous       survey results and later eliminated. The spreadsheet was
section to check for comprehensibility, redundancy and           stored and protected by unique passwords and kept on a
consistency of its items, including technical usability and      secure, restricted network drive. Only the principal investi-
functionality of the electronic platform.                        gator and authorised study personnel had access to the files.
The Google form consisted of three screens presenting the        No incentives were offered to complete the survey.
following questionnaires:
1. “Importance of olfaction” (IO-Q), developed by Croy           Reproducibility of the questionnaire
   et al. 4 to evaluate the subjective importance attributed     The reproducibility of the questionnaire was evaluated us-
   to the sense of smell (Tabs. I, II). For this questionnaire   ing internal consistency and test-retest reliability. Internal
   an Italian version validated by the Italian Academy of        consistency was considered acceptable in case of Cron-
   Rhinology (IAR) already existed and was adopted.              bach’s alpha values between 0.7 and 0.9. Additionally, 50
2. “Importance of taste and flavour” (ITF-Q), created by         patients in the study group were randomly selected for as-
   our group to evaluate the subjective importance attrib-       sessment of test–retest reliability. In this cohort, the ques-
   uted to taste and retronasal smell (Tabs. I, II).             tionnaire was administered twice, after an interval of one
3. “About you”, a section for collecting demographic data        month, without any possibility for participants to look at
   (age, sex, nationality, education).                           the answers given the first time. Test–retest reliability was
Based on the questionnaire by Croy et al. 4, the items in        assessed through Intraclass Correlation Coefficients (IC-
the questionnaire “The importance of taste and flavour”          C2k) and considered acceptable with a minimum test–re-
(ITF-Q), were classified into four groups: “association”         test correlation coefficient of 0.7.
with sensations, “application” of the sense, ability to
draw “consequences” from the olfactory and gustatory             Statistical analysis
perception, and tendency to “aggravate” the importance           Descriptive statistics were performed to characterize re-
of sensory loss. The first and second page consisted of 18       sponses to the survey. Qualitative data were summarised
personal statements referring to one of the four mentioned       as percentages. The assessment of significant differences
subscales. The subjects attributed a score of 1 to 4 to indi-    across the means of continuous variables relied on t-tests
cate how much they agreed with the statement (“I totally         for independent samples, with those values with p ≤ 0.05
agree” to “I totally disagree”). They were unaware of which      were considered significant. To assess the distribution of
scale the items belonged to. The third page consisted of a       the variables, Bartlett’s test was used. The correlations were
simple module in which the subject manually entered his or       calculated using the Spearman test and Spearman’s rho was
her age, country of origin, sex and education level.             also calculated. Internal consistency was assessed using
After a preliminary meeting, during which eligibility of         Cronbach’s alpha, while test-retest reliability was analysed
individuals to participate was established, informed con-        by calculating the ICC2k. All analyses were performed us-
sent was obtained and instructions and purpose of the re-        ing STATA-MP software, version 15 for Mac OS X.
search explained, the link was sent by e-mail to a sample of
850 people. The cohort comprised health workers, univer-
sity and college students including international/exchange
                                                                 Results
students, visitors to our University Hospital or patients’       Overall, 759 of 850 subjects answered the questionnaire
relatives who consented to be enrolled in this study. The        with a non-response rate of 10.7%. Calculation of Cron-
“jellybean flavour experiment” was used to explain the           bach’s alpha showed good internal reliability (a = 0.87).
not intuitive difference between taste and flavour to partici-   Test-retest evaluation was also satisfactory for all the sub-
pants during the preliminary meeting [e.g.: close your eyes,     scales, with an overall ICC2k = 0.84 (CI 0.79-0.89).
pinch your nose with your hand and put a jellybean in your       Of the responders, 460 (60.6%) were female, 299 (30.4%)
mouth. You should be able to perceive the taste (i.e., sweet),   were male, 508 (66.9%) were college graduates, 231
but only if you release your hand, will you be able to dis-      (30.4%) were high-school graduates and 20 (2.7%) were
tinguish the correct flavour (i.e., strawberry)]. Before sub-    secondary school graduates. By country of origin, 653
mitting the questionnaire, a mandatory completeness check        (86%) were Italian and 106 (14%) were non-Italians;
highlighted the missing response items. Answers were             among this group, 64 (8.4%) were from other European
automatically captured and stored in an electronic spread-       countries, 12 (1.6%) were from Africa, 21 (2.7%) from



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Table I. (A) “Importance of olfaction” questionnaire (IO-Q, Croy et al., 2010 4); (B) “Importance of taste and flavour” questionnaire (ITF-Q) by our group in the
English language with reference to the subscales.
 (A) Importance of olfaction
 This questionnaire refers to the role your sense of smell plays in your daily life. Please answer all of the questions spontaneously, there are no
 right or wrong answers.
 Scale                                                                                                     4              3               2               1
                                                                                                       I totally       I mostly       I mostly         I totally
                                                                                                        agree            agree        disagree        disagree
 Ass        The smell of a person plays a role in the decision whether I like him/her.
 App        I smell foods to find out whether it is spoiled or not.
 App        I sniff food before eating.
 Con        Please imagine you visit a museum. There is an offer to get additionally smell-
            presentations to underline the overall impression for the price of 2. Would you take
            this offer?
 Con        When I don’t like the smell of a shampoo, I don’t buy it.
 Ass        When I smell delicious food, I’m getting hungry.
 Agg        Without my sense of smell, life would be worthless.
 Con        I try to locate the odour, when I smell something.
 Ass        I feel rather quickly disturbed by odours in my environment.
 Ass        Certain smells immediately activate numerous memories.
 App        Before drinking coffee/tee, I intentionally smell it.
 App        When I buy tomatoes, I pay attention to their odour.
 Con        If my partner has a nasty smell, I avoid kissing him.
 Ass        Certain smells immediately activate strong feelings.
 App        I smell my clothes to judge whether I have to wash them or not.
 Con        When there is a nasty smell in the office/apartment of a colleague, I leave the room
            as soon as possible.
 Ass        Certain odours can stimulate my fantasy.
 Agg        To me it is more important to be able to smell than to be able to see or hear.
 App        Sometimes I smell a person (e.g., my partner or my child) to judge, if he/she has
            drunken alcohol or smoked.
 Con        I cannot pass good smelling candles in a store without buying one.

 B) Importance of taste and flavour
 The questionnaire refers to the role your sense of taste plays in your daily life. Please answer all of the questions spontaneously. There are no
 right or wrong answers.
 Scale                                                                                                    4               3               2               1
                                                                                                       I totally      I mostly        I mostly        I mostly
                                                                                                        agree           agree           agree         disagree
 App        I taste a food to find out whether it is spoiled or not.
 Ass        Kissing a partner with a bad breath does not please me.
 Con        Please imagine you go to a restaurant. There is the chance to participate in a tasting
            session at an additional cast of 10€. Would you take this offer?
 Agg        To me it is more important to be able to taste than to be able to see or hear.
 App        I taste a food before buying.
 Ass        After taking a first bite of a delicious food, my appetite to eat gets stronger.
 Con        When I don’t like the taste of a toothpaste, I don’t buy it.
 Agg        Without my sense of taste, life would be worthless.
 App        When I kiss my partner, I am able to understand whether he/she drank or smoked.
 Ass        I feel rather quickly disturbed by a food that I don’t like.

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E.M.C. Trecca et al.




Table I. (B) follows.
 B) Importance of taste and flavour
 The questionnaire refers to the role your sense of taste plays in your daily life. Please answer all of the questions spontaneously. There are no
 right or wrong answers.
 Scale                                                                                                        4               3               2           1
                                                                                                          I totally        I mostly        I mostly   I mostly
                                                                                                           agree             agree           agree    disagree
 Con        If my partner has a bad breath, I don’t kiss him/her.
 App        After cooking/before serving pasta, I taste it to find out whether it is salty or not.
 Ass        Certain tastes/flavours evoke a lot of memories.
 Con        If I don’t like the food I tasted in a restaurant, I do not go back a second time.
 App        I taste food with my eyes closed and I am able to understand what it is.
 Ass        Certain tastes/flavours immediately activate strong feelings.
 Con        I absolutely have to buy a food I enjoy after tasting it.
 App        I often taste first only a little piece of a food to judge whether I want to eat more of it
            or not.
 Ass        Certain tastes/flavours can stimulate my imagination.
 Con        If I taste a food I don’t like, I feel the need to spit it as soon as possible.



Table II. (A) “Importance of olfaction” questionnaire (IO-Q, Croy et al., 2010 4); (B) “Importance of taste and flavour” questionnaire (ITF-Q) by our group in the
Italian language with reference to the subscales.
  A) Importanza dell’olfatto
  Questo questionario si pone l’obiettivo di comprendere il ruolo che il senso dell’olfatto gioca nelle nostre vite quotidiane. Si prega di rispondere a
  tutte le domande con la massima sincerità tenendo presente che non esistono risposte giuste o sbagliate.
 Scala                                                                   4                           3                        2                       1
                                                             Sono completamente                  Sono                        Sono            Sono completamente
                                                                  d’accordo                 tendenzialmente           tendenzialmente in        in disaccordo
                                                                                               d’accordo                  disaccordo
 Ass        L’odore di una persona gioca un ruolo
            fondamentale nel decidere se mi piaccia
            o meno.
 App        Annuso il cibo per capire se sia avariato
            o meno.
 App        Annuso il cibo prima di mangiarlo.
 Con        Immagini di visitare un museo. Con una
            spesa aggiuntiva di 2 € c’è la possibilità di
            partecipare a un’esperienza sensoriale di
            tipo olfattivo. Accetterebbe l’offerta?
 Con        Quando non mi piace l’odore di uno
            shampoo non lo compro.
 Ass        Quando percepisco l’odore di buon cibo mi
            viene fame.
 Grav       La mia vita perderebbe di valore senza il
            senso dell’olfatto.
 Con        Quando percepisco un odore, cerco di
            capire da dove provenga.
 Ass        Mi sento disturbato molto rapidamente da
            odori nel mio ambiente.
 Ass        Alcuni odori mi evocano nella mente
            numerosi ricordi.
 App        Annuso the o caffè prima di berli.

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Table II. (A) follows.
 A) Importanza dell’olfatto
 Questo questionario si pone l’obiettivo di comprendere il ruolo che il senso dell’olfatto gioca nelle nostre vite quotidiane. Si prega di rispondere a
 tutte le domande con la massima sincerità tenendo presente che non esistono risposte giuste o sbagliate.
 Scala                                                            4                       3                          2                         1
                                                          Sono completamente           Sono                       Sono              Sono completamente
                                                               d’accordo          tendenzialmente          tendenzialmente in          in disaccordo
                                                                                     d’accordo                 disaccordo
 App       Quando acquisto dei pomodori presto
           attenzione al loro odore.
 Con       Se il mio/la mia partner ha un cattivo
           odore evito di baciarlo/a.
 Ass       Alcuni odori mi scatenano
           immediatamente forti emozioni.
 App       Annuso i miei vestiti per decider se lavarli
           o meno.
 Con       Quando c’è un cattivo odore
           nell’appartamento/ufficio di un collega,
           lascio la stanza il più velocemente
           possibile.
 Ass       Alcuni odori possono stimolare la mia
           fantasia.
 Grav      Per me è più importante avere il senso
           dell’olfatto che quello della vista o
           dell’udito.
 App       A volte annuso una persona (es. il mio
           partner o mio figlio) per capire se abbia
           fumato o bevuto alcolici.
 Con       Ogni volta che in un supermercato sento la
           fragranza di una candela profumata devo
           acquistarla.

 B) Importanza del gusto/sapore
 Questo questionario si pone l’obiettivo di comprendere il ruolo che il senso del gusto gioca nelle nostre vite quotidiane. Si prega di rispondere a
 tutte le domande con la massima sincerità tenendo presente che non esistono risposte giuste o sbagliate.
 Scala                                                            4                       3                          2                         1
                                                          Sono completamente           Sono                       Sono              Sono completamente
                                                               d’accordo          tendenzialmente          tendenzialmente in          in disaccordo
                                                                                     d’accordo                 disaccordo
 App       Assaggio un cibo per capire se è avariato
           o meno.
 Ass       Non trovo piacevole baciare un partner con
           un cattivo alito.
 Con       Parteciperei ad una degustazione in un
           ristorante con una spesa aggiuntiva di
           10 €.
 Grav      Ritengo più importante il senso del gusto
           che la vista o l’udito.
 App       Assaggio un cibo prima di comprarlo.
 Ass       Dopo aver assaggiato un pezzetto di un
           cibo delizioso il mio appetito cresce.
 Con       Se il gusto/sapore di un dentifricio non mi
           piace, non lo compro.
 Grav      Senza il senso del gusto la mia vita
           sarebbe priva di senso.
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E.M.C. Trecca et al.




Table II. (B) follows.
 B) Importanza del gusto/sapore
 Questo questionario si pone l’obiettivo di comprendere il ruolo che il senso del gusto gioca nelle nostre vite quotidiane. Si prega di rispondere a
 tutte le domande con la massima sincerità tenendo presente che non esistono risposte giuste o sbagliate.
  Scala                                                           4                      3                       2                        1
                                                          Sono completamente          Sono                     Sono             Sono completamente
                                                               d’accordo         tendenzialmente        tendenzialmente in         in disaccordo
                                                                                    d’accordo               disaccordo
 App        Nel baciare il mio/la mia partner, sono in
            grado di capire se ha bevuto o fumato.
 Ass        Mi sento disturbato molto rapidamente da
            un cibo che non mi piace.
 Con        Se il mio/la mio/a partner ha un cattivo
            alito, non mi viene voglia di baciarlo/a.
 App        Prima di servire la pasta, la assaggio per
            capire se è salata o meno.
 Ass        Alcuni gusti/sapori rievocano in me
            numerosi ricordi.
 Con        Se il cibo mangiato in un ristorante non mi
            piace, non ci torno.
 App         Assaggio il cibo ad occhi chiusi e capisco
            di cosa si tratta.
 Ass        Alcuni gusti/sapori suscitano in me forti
            emozioni.
 Con        Devo assolutamente comprare un cibo che
            mi piace dopo averlo assaggiato.
 App        Mi capita spesso di assaggiare prima un
            pezzetto di un cibo per capire se voglio
            mangiarne di più o no.
 Ass        Alcuni gusti/sapori possono stimolare la
            mia fantasia.
 Con        Se assaggio un cibo che non mi piace,
            sento l’esigenza di sputarlo il prima
            possibile.



Asia, 7 (0.9%) from North America and 2 (0.3%) from                            Discussion
South America. The average age was 35.4 years, while the
                                                                               This study constitutes a preliminary investigation into
median was 29 (range: 18-80 years).                                            socio-cultural differences in the importance attributed to
Figure 1 shows the results on the comparison between                           sensory perception in the general population, not only re-
average scores. The results revealed that women re-                            garding olfaction as in previous literature 4,11, but also with
ported significantly higher scores (p < 0.05) than men                         respect to gustatory function.
in all subscales (association, application, consequence,                       There appears to be wide variability in the importance that
aggravation) of both questionnaires (IO-Q, ITF-Q). Col-                        olfactory sensations play in individuals’ lives. This vari-
lege graduates showed higher scores than high school                           ability must be viewed and understood by otolaryngolo-
graduates in every subscale, but the difference between                        gists and others both in the context of the everyday lives
                                                                               of individuals and in society as a whole. Odours can ac-
the variables reached significance (p < 0.05) only in two
                                                                               tivate memories, affect social relationships and arouse
subscales (association in the IO-Q and consequence in
                                                                               sexual drive, purchasing decisions and dietary behaviours,
the ITF-Q). Lastly, there was a positive and significant                       and influence our mood and attitude towards being and ob-
correlation (Fig. 2) between age and importance of smell                       jects 12 14. While these findings have scientific support, they
(r = 0.16; p < 0.01) and between age and importance of                         are not universally true; nor do they affect all individuals
taste (r = 0.08; p < 0.05).                                                    with equal intensity. Clinically, the condition of anosmia



342
                                                                                         Socio-cultural differences in the perception of smell, taste and flavour




Figure 1. Importance of olfaction (A), taste and flavour (B) in male vs female subjects (upper figure), and in tertiary educated vs high school educated (lower
figure).


can be kept private 4 in contrast with other sensory disor-                       validated, internationally used questionnaire focusing on
ders such as hearing impairment 15. According to Merko-                           management of smell impairments is the “Questionnaire
nidis et al. 16 who published the results from a survey about                     of Olfactory Disorders” (QOD) 3, while the only question-
the characteristics of chemosensory disorders, the greatest                       naires analysing the individual significance of olfaction are
number of complaints related to a decrease in eating en-                          the “Odor Awareness Scale” (OAS) 17 and the “Importance
joyment followed by a decrease in overall quality of life.                        of Olfaction Questionnaire” (IO-Q) 4. In our opinion, the
According to Murr et al. 11, the assessment of the subjective                     IO-Q has the advantage of taking only limited clinical time
importance of olfaction is useful to examine the adaptation                       both for patients, who have to answer only 20 items com-
to olfactory disorders. Questionnaires enable systematic                          pared to 34 on the OAS, and for consultants who can easily
and time efficient collection of medical history. Subjective                      draw conclusions by calculating the scores of the different
olfactory assessment should not be undertaken in isolation,                       subscales. Moreover, the changing answer format within
but can be completed prior to psychophysical assessment                           the OAS may generate confusion in some participants. The
of olfactory function (e.g. “Sniffin’ Sticks”, “University of                     greater comprehensibility and lower redundancy of the IO-
Pennsylvania Smell Identification Test, UPSIT”) or during                         Q ensure that respondents answer the entire questionnaire
the waiting time between clinical examinations 1,5.                               appropriately.
However, according to the literature, tests about subjective                      For the reasons noted above, our group preferred to make
olfactory importance and coping are still rare and are often                      use of this currently available validated questionnaire. The
performed using visual analogue scales, Likert question-                          “ITF-Q”, a novel extension of the “IO-Q”, is intended to
naires, or as part of other outcome assessments 1. The only                       provide a wide gauge of the importance of taste and fla-



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E.M.C. Trecca et al.




Figure 2. Correlation between total score of the IO-Q and age (upper figure) and between total score of the ITF-Q and age (lower figure).



344
                                                                        Socio-cultural differences in the perception of smell, taste and flavour




vour. To the best of our knowledge, questionnaires on the          subscale (p = 0.013), while in 2011 21 normosmic control
individual importance of olfaction are rare, but even fewer        female individuals presented higher scores on the applica-
questionnaires on taste have been published. Thus, follow-         tion (p = 0.003) and consequence (p < 0.001) subscales
ing a comprehensive review, we decided to propose the first        than males. Murr et al. 11 demonstrated that the importance
questionnaire on the importance of taste and flavour. Since        of olfaction was highest in the group of young normosmic
specific exams evaluating taste and retronasal smell have          women aged < 26 years, while there were no sex related
been validated (e.g., taste strips, retronasal assessment),        significant differences in the other age groups. In our study,
tests on the subjective importance of gustatory function           we showed an enhanced importance of olfaction in female
should also be performed in combination with psychophys-           individuals in each subscale (p < 0.001). These results are
ical testing.                                                      in accordance with the current literature. The assessment
Designing and pre-testing a questionnaire on taste and fla-        of male physical desirability is highly correlated with the
vour immediately revealed a controversial issue. For non-          assessment of male body odour attractiveness in women 22.
specialists, the words “taste” and “flavour” are essentially       While olfactory detection thresholds of pregnant women do
equivalent, while the term retronasal smell may be unfa-           not seem to be different from those of controls, many wom-
miliar. According to the French physical chemist Hervé             en report heightened smell sensitivity during pregnancy 23.
This, an expert in molecular gastronomy 18, taste should be        As demonstrated by Minovi et al. 24, on a clinical level, sex
considered as a global, synthetic perception, made up of all       was a predictor of the outcome of nasal surgery in terms
sensations that a food transmits to us, and which we use to        of olfactory function with women reporting a significantly
make a judgment. His theory stated that food should stimu-         higher benefit from surgery (p < 0.03).
late the various sensory receptors involved in vision, odour,      Investigating the effects of age, we detected a positive and
taste, trigeminal system and temperature and showed the            significant correlation (Fig. 2) between age and the indi-
multisensory experience deriving from our perception of            vidual importance of olfaction (r = 0.16; p < 0.01). Croy et
food and drink. Zampini et al. 19 studied the multisensory         al. 4 noticed the absence of significant correlation between
perception of flavour, specifically analysing its interaction      age and the importance of olfaction in the main score and
with visual and auditory stimuli. The authors noted that the       in any of the subscales (r = 0.0-0.1). The same group 21
average individual believes that the flavour of food primar-       showed no effect of age on IO-Q scores in normosmic con-
ily comes through the taste buds, ignoring the important           trol individuals or patients. As previously noted, Murr et
“nasal” component in the perception of flavour. For the rea-       al. 11 found enhanced importance of olfaction in the group
sons noted above, we preferred to refer to “taste” and the         of young women, but detected no differences in the other
entire eating experience in our questionnaire, rather than         age groups. On the other hand, men did not present any var-
speaking of taste, flavour or retronasal smell in scientific       iability in importance of olfaction across the different age
terms 20.                                                          groups. These findings appear to fit well with Croy’s the-
Analysis of our results indicated that smells, tastes and          ory 4 according to which the importance of olfactory func-
flavours are more important for women compared to men.             tion is independent of age. Decreased olfactory function is
This is consistent with a greater sensitivity of women in          very common in the elderly, with the > 50% of individuals
these areas 4,11. Secondly, there were no statistically signifi-   aged 65 and 80 years suffering from it. However, the indi-
cant differences in importance in these areas between peo-         vidual importance of olfaction does not appear to decrease
ple with different levels of education. Third, the perception      throughout life, probably because of the notable effects of
of smells, tastes and flavours tends to deteriorate with age;      age-related olfactory sensory loss on physical well-being,
however, their importance does not seem to decrease 4.             quality of life, nutritional status and everyday safety 25.
The individual significance of olfaction was investigated by       Education-related variability in the individual importance
using the IO-Q by Croy et al. who first presented the survey       of olfaction was not investigated in the previous study by
to 123 individuals attending a scientific conference at the        Croy et al. 4 in which the IO-Q was used. The conclusions
University of Dresden 4 and then compared the importance           drawn should be interpreted within the limitations of the
of olfaction between patients with smell impairment and            sample, presenting a high percentage of college graduates
healthy normosmic subjects. Murr et al. 11 also used the           (66.9%) compared to individuals with lower levels of edu-
IO-Q to capture the differences between normosmic and              cation. In fact, the participating group presented the usual
dysosmic individuals. Analysis of our results and those            attributes of such voluntary samples, including higher edu-
of previous studies reveals that women place higher im-            cation level 4 and better awareness of the topic being inves-
portance on olfaction than men. Croy et al. in 2010 4 de-          tigated. However, our results demonstrate that the impor-
tected this sex-related difference only in the consequence         tance of smell, taste and flavour is the same regardless of



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E.M.C. Trecca et al.




the cultural background. It is worth noting that our sample      those of psychophysical testing of olfactory and gustatory
scored significantly highest the association scale, which        function and to improve the accuracy of our data. Lastly, an
is related to memories, feelings and judgments guided by         interesting point for future research would be to evaluate
the sensory perception 4. These findings are consistent with     the types of diets and feeding behaviours of the population
the finding that the olfactory pathway is a portion of the       and investigate if they have any relationships with the im-
palaeocortex, the oldest part of the brain, which generates      portance attributed to smell and taste.
emotions and accounts for memory. Perception of olfactory
sensations is emotionally influenced 26; it is ancestral and     Conclusions
deeper than the educational and cultural levels of individu-
als. Moreover, other parameters (i.e., work conditions, hob-     We propose a novel test that provides insight into the im-
bies, environments) may modify individual olfactory sensi-       portance of smell, taste and flavour among individuals as
tivity, especially in an era in which great attention is given   well as socio-cultural differences. Although further re-
by media to odour and food culture. For example, perfum-         search is needed, this new tool revealed preliminary useful
ers tend to respond more sensitive to odours 27 and working      information about the importance of smell, taste and fla-
in perfume retail shops is associated with increased odour       vour. In a wider context, it could help in the evaluation and
discrimination 28. The present study is limited by not hav-      investigation of the aspects that influence patients to seek
ing investigated the odour expertise of the subjects includ-     medical attention in the presence of sensory alterations 29.
ed, while behavioural studies on this topic are warranted.
Even though Croy et al. 4 encouraged the use of the IO-Q to      Acknowledgements
study cross-cultural variability in the perception in greater
depth, the current and previous literature has not analysed      This work was presented as a scientific poster presentation
country-related differences in the importance of chem-           at the 64th Annual Meeting of the American Rhinologic So-
osensation. Our sample had more Italians than individu-          ciety (ARS), Atlanta (Georgia), on October 5-6, 2018.
als from other countries (Italians: 653; non-Italians 106).      We thank Prof. Thomas Hummel and Dr. Saul Strieb for
As a result, it should be noted that a response bias might       their constant support and their comments, which greatly
be present, and this limitation prevented us from studying       improved this manuscript.
country-related variability. However, this remains a very
interesting topic and further studies by Otolaryngology so-      References
cieties worldwide should be undertaken in order to better        1
                                                                     Hummel T, Whitcroft KL, Andrews P, et al. Position paper on olfac-
understand the factors behind socio-cultural variability in          tory dysfunction. Rhinology 2017;54:1-30. https://doi.org/10.4193/
perception. The individual significance attributed to taste          Rhino16.248
and flavour has not been widely discussed in the existing        2
                                                                     Erskine SE, Hopkins C, Clark A, et al. SNOT-22 in a control popu-
                                                                     lation. Clin Otolaryngol 2017;42:81-85. https://doi.org/10.1111/
literature; consequently, we encourage the use of the ITF-
                                                                     coa.12667
Q, in order to confirm or invalidate our results.                3
                                                                     Frasnelli J, Hummel T. Olfactory dysfunction and daily life. Eur Arch
Regarding the strengths and limitations of our study, we             Oto-Rhino-Laryngology 2005;262:231-235. https://doi.org/10.1007/
introduced a new tool to investigate the subjective impor-           s00405-004-0796-y
tance of sensory importance and used it on a rather large        4
                                                                     Croy I, Buschhüter D, Seo H-S, et al. Individual significance of olfac-
sample of 759 subjects with heterogeneous characteristics.           tion: development of a questionnaire. Eur Arch Oto-Rhino-Laryngol-
                                                                     ogy 2010;267:67-71. https://doi.org/10.1007/s00405-009-1054-0
However, our research may be limited by issues of valid-         5
                                                                     Nordin S, Brämerson A, Murphy C, et al. A Scandinavian adaptation
ity associated with email surveys, which can be subject to           of the multi-clinic smell and taste questionnaire: evaluation of ques-
considerable bias 6. Although such criticism may be ap-              tions about olfaction. Acta Otolaryngol 2003;123:536-542. https://
propriate, Internet and Web-based research may be useful             doi.org/10.1080/00016480310001411
to get pilot data. Another limitation of the present study       6
                                                                     Eysenbach G. Improving the quality of web surveys: the Checklist for
                                                                     Reporting Results of Internet E-Surveys (CHERRIES). J Med Inter-
is the lack of correlation of subjective results with objec-         net Res 2004;6:e34. https://doi.org/10.2196/jmir.6.3.e34
tive measurements. The next step in this research would          7
                                                                     Crum RM, Anthony JC, Bassett SS, et al. Population-based norms
be to perform an investigation using questionnaires in pa-           for the Mini-Mental State Examination by age and educational
tients with olfactory or gustatory disorders, while describ-         level. JAMA 1993;269:2386-2391. http://www.ncbi.nlm.nih.gov/
ing their causes of sensory impairment and comparing the             pubmed/8479064
results with those of a control group. Moreover, in a further
                                                                 8
                                                                     Gallo S, Russo F, Mozzanica F, et al. Prognostic value of the
                                                                     Sinonasal Outcome Test 22 (SNOT-22) in chronic rhinosinusi-
experiment, we plan to establish the relationships that ex-          tis. Acta Otorhinolaryngol Ital 2020;40:113-121. https://doi.
ist between the subjective results of the questionnaire with         org/10.14639/0392-100X-N0364




346
                                                                                       Socio-cultural differences in the perception of smell, taste and flavour




9
     Vennemann MM, Hummel T, Berger K. The association between                 19
                                                                                    Zampini M, Spence C. Assessing the role of visual and auditory cues
     smoking and smell and taste impairment in the general popula-                  in multisensory perception of flavor. In: Murray MM, Wallace MT,
     tion. J Neurol 2008;255:1121-1126. https://doi.org/10.1007/                    editors. The Neural Bases of Multisensory Processes. Boca Raton
     s00415-008-0807-9                                                              (FL): CRC Press/Taylor & Francis; 2012. Chapter 37.
10
     Beaton DE, Bombardier C, Guillemin F, et al. Guide-                       20
                                                                                    Pandurangan M, Hwang I. Systemic mechanism of taste, flavour and
     lines for the process of cross-cultural adaptation of self-                    palatability in brain. Appl Biochem Biotechnol 2015;175:3133-3147.
     report     measures.      Spine     2000;25:3186-3191.     https://doi.        https://doi.org/10.1007/s12010-015-1488-3
     org/10.1097/00007632-200012150-00014                                      21
                                                                                    Croy I, Landis BN, Meusel T, et al. Patient adjustment to reduced
11
     Murr J, Hummel T, Ritschel G, et al. Individual significance of                olfactory function. Arch Otolaryngol Head Neck Surg 2011;137:377-
     olfaction: a comparison between normosmic and dysosmic peo-                    382. https://doi.org/10.1001/archoto.2011.32
     ple. Psychosomatics 2018;59:283-292. https://doi.org/10.1016/j.           22
                                                                                    Craig Roberts S, Little AC, Lyndon A, et al. Manipulation of body
     psym.2017.11.009                                                               odour alters men’s self-confidence and judgements of their visual at-
12
     Gudziol V, Wolff-Stephan S, Aschenbrenner K, et al. Depression re-             tractiveness by women. Int J Cosmet Sci 2009;31:47-54. https://doi.
     sulting from olfactory dysfunction is associated with reduced sexual           org/10.1111/j.1468-2494.2008.00477.x
     appetite - a cross-sectional cohort study. J Sex Med 2009;6:1924-         23
                                                                                    Cameron EL. Pregnancy and olfaction: a review. Front Psychol
     1929. https://doi.org/10.1111/j.1743-6109.2009.01266.x                         2014;5:1-11. https://doi.org/10.3389/fpsyg.2014.00067
13
     Aschenbrenner K, Hummel C, Teszmer K, et al. The influence of ol-         24
                                                                                    Minovi A, Hummel T, Ural A, et al. Predictors of the outcome of na-
     factory loss on dietary behaviors. Laryngoscope 2008;118:135-144.              sal surgery in terms of olfactory function. Eur Arch Otorhinolaryngol
     https://doi.org/10.1097/MLG.0b013e318155a4b9                                   2008;265:57-61. https://doi.org/10.1007/s00405-007-0409-7
14
     Croy I, Nordin S, Hummel T. Olfactory disorders and quality of            25
                                                                                    Attems J, Walker L, Jellinger KA. Olfaction and aging: a mini-review.
     life-an updated review. Chem Senses 2014;39:185-194. https://doi.              Gerontology 2015;61:485-490. https://doi.org/10.1159/000381619
     org/10.1093/chemse/bjt072                                                 26
                                                                                    Walliczek-Dworschak U, Hummel T. The human sense of ol-
15
     Mick P, Kawachi I, Lin FR. The association between hearing loss and            faction. Facial Plast Surg 2017;33:396-404. https://doi.
     social isolation in older adults. Otolaryngol Neck Surg 2014;150:378-          org/10.1055/s-0037-1603828
     384. https://doi.org/10.1177/0194599813518021                             27
                                                                                    Royet J-P, Plailly J, Saive A-L, et al. The impact of expertise in
16
     Merkonidis C, Grosse F, Ninh T, et al. Characteristics of chemosen-            olfaction. Front Psychol 2013;4:928. https://doi.org/10.3389/
     sory disorders - results from a survey. Eur Arch Otorhinolaryngol              fpsyg.2013.00928
     2015;272:1403-1416. https://doi.org/10.1007/s00405-014-3210-4             28
                                                                                    Hummel T. Olfactory sensitivity of subjects working in odorous en-
17
     Smeets MAM, Schifferstein HNJ, Boelema SR, et al. The odor aware-              vironments. Chem Senses 2004;29:533-536. https://doi.org/10.1093/
     ness scale: A new scale for measuring positive and negative odor               chemse/bjh058
     awareness. Chem Senses 2008;33:725-734. https://doi.org/10.1093/          29
                                                                                    Marchese-Ragona R, Restivo DA, De Corso E, et al. Loss of smell
     chemse/bjn038                                                                  in COVID-19 patients: a critical review with emphasis on the use of
18
     This H. Food for tomorrow? EMBO Rep 2006;7:1062-1066.                          olfactory tests. Acta Otorhinolaryngol Ital 2020;40:241-247. https://
     doi:10.1038/sj.embor.7400850                                                   doi.org/10.14639/0392-100X-N0862




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