Accuracy in dietary assessment: on the road to good science

Packed School Lunch Food Consumption: A Childhood Plate Waste Nutrient Analysis

Packed school lunch consumption remains a sparsely studied aspect of childhood nutrition. Most American research focuses on in-school meals provided through the National School Lunch Program (NSLP). The wide variety of available in-home packed lunches are usually nutritionally inferior compared to the highly regulated in-school meals. The purpose of this study was to examine the consumption of home-packed lunches in a sample of elementary-grade children. Through weighing packed school lunches in a 3rd grade class, mean caloric intake was recorded at 67.3% (32.7% plate waste) of solid foods, while sugar-sweetened beverage intake reported a 94.6% intake. This study reported no significant consumption change in the macronutrient ratio. Intake showed significantly reduced levels of calories, sodium, cholesterol, and fiber from the home-packed lunches (p < 0.05). The packed school lunch consumption rates for this class were similar to those reported for the regulated in-school (hot) lunches. Calories, sodium, and cholesterol intake are within childhood meal recommendations. What is encouraging is that the children were not "filling up" on more processed foods at the expense of nutrient dense foods. Of concern is that these meals still fall short on several parameters, especially low fruit/vegetable intake and high simple sugar consumption. Overall, intake moved in a healthier direction compared to the meals packed from home.

Breastfeeding and complementary feeding in fragile settings: the case of Syrian refugees and their host communities in North Lebanon

BACKGROUND

Adequate breastfeeding and complementary feeding practices are paramount in fragile situations where access to food and healthcare is limited. The objectives of this study are to examine breastfeeding and complementary feeding practices among Syrian refugees and their Lebanese host communities and to investigate the correlates of exclusive breastfeeding (EBF) at four and 6 months in these communities.

METHODS

Using two-stage stratified sampling, a cross-sectional survey was conducted in Akkar, a region with a high density of Syrian refugees in Lebanon, between April and November 2019. In one-to-one interviews, mothers of children (6-24 months) completed a questionnaire including specific questions about breastfeeding and complementary feeding practices, a 24-h recall, and socio-demographic characteristics for 189 Syrian refugees and 182 Lebanese host community households. Descriptive statistics, simple and multiple logistic regression were used in data analysis.

RESULTS

Among breastfeeding practices, ever-breastfeeding was most prevalent (90%), followed by early initiation of breastfeeding (64.8%), EBF at four (49.6%), and six (36%) months. One in four children was introduced to solids before 6 months of age, and less than a third was given iron-fortified baby cereals as the first complementary foods. Only 24.4% and 9.2% of children met the minimum dietary diversity and minimum acceptable diet requirements, respectively. Compared to children of the Lebanese host communities, those of Syrian refugees had higher rates of EBF at four and 6 months as well as continued breastfeeding at 1 year, whereas only 17.9% of Syrian refugees' children met minimum dietary diversity compared to 30.9% of Lebanese host community children (p <  0.05). Among refugees, education and spouse's employment status were associated with higher odds of EBF at 4 months. As for Lebanese households, female children were less likely to be exclusively breastfed at 4 months and 6 months, while a natural delivery increased the odds of EBF at 6 months.

CONCLUSION

Breastfeeding and complementary feeding practices are suboptimal among children of Syrian refugees and their Lebanese host communities in North Lebanon. There is a need for intervention strategies to tackle gaps in services and assistance delivery programs to enhance infant and young child feeding practices among both communities.

Dietary Micronutrient Intake of Participants in a "Partners Together in Health" Cardiac Rehabilitation Intervention

PURPOSE

Current guidelines for cardiovascular health emphasize a "dietary pattern" approach that could be expected to increase intakes of micronutrients in addition to altering the macronutrient profile. However, the effect of interventions such as cardiac rehabilitation on the micronutrient quality of the diet has not been evaluated. Therefore, the goal of this study was to investigate changes in micronutrient intake of cardiac rehabilitation participants over time.

METHODS

This was a secondary analysis of data from a randomized clinical trial that assessed the effects of the Partners Together in Health intervention on physical activity and healthy eating behaviors. The intake of 9 micronutrients important in cardiovascular health was assessed using 3-d food records. A micronutrient adequacy score was evaluated at 3 time points (baseline, 3 and 6 mo). Changes over time in micronutrient intake were assessed using a general linear model.

RESULTS

Sixty-eight participants who were enrolled in the Partners Together in Health interventional trial completed the study. There was no significant difference in the mean micronutrient score at any time point. Intake of individual micronutrients did not improve over the 6-mo time frame with the exception of vitamin E, (8.7 mg vs 6.5 mg for at 6 vs 3 mo, P = .02). The proportion of participants with intakes meeting the Dietary Recommended Intake for each nutrient also remained the same over time.

CONCLUSION

Although cardiac rehabilitation programs may be effective in altering the macronutrient composition, improvements to overall diet quality may be tempered by a lack of improvement in intake of micronutrients.

Validation of a novel image-weighed technique for monitoring food intake and estimation of portion size in hospital settings: a pilot study

OBJECTIVE

Optimal nutrition for hospital patients is crucial and routine monitoring of patients' nutrient intake is imperative. However, personalised monitoring and customised intervention using traditional methods is challenging and labour-intensive, consequently it is often neglected in hospital settings. The present pilot study aimed to examine the reliability and validity of the Dietary Intake Monitoring System (DIMS) against the weighed food method (WFM).

DESIGN

The DIMS 2.0 is composed of an integrated digital camera, weighing scale, radio-frequency identification sensor and WIFI connection for real-time image and weight dietary data acquisition and analysis. The DIMS equipment was used to collect data for a paired set of meals both before and after meal consumption at lunchtime.

SETTING

Odense University Hospital, Denmark.

SUBJECTS

Photos and weights of seventeen patient meals were captured.

RESULTS

The results showed a significant correlation between DIMS and WFM for energy (r=0·99, P&lt;0·01) and protein intake (r=0·98, P&lt;0·01). Intraclass correlation coefficients (ICC) revealed a high degree of agreement among the four non-trained assessors for estimates of portion size of each food item before (0·88, P&lt;0·01) and after consumption (0·99, P&lt;0·01). The ICC for energy and protein intake were 0·99 (P&lt;0·01) and 0·99 (P&lt;0·01), respectively. Bland-Altman plots revealed no systematic bias.

CONCLUSIONS

Considering the huge benefits associated with routine monitoring, technological advances have made it possible to develop a novel, easy-to-use DIMS that, according to the findings, is a valid alternative for use in hospital settings.

ALLN-177, oral enzyme therapy for hyperoxaluria

Purpose

To evaluate the potential of ALLN-177, an orally administered, oxalate-specific enzyme therapy to reduce urine oxalate (UOx) excretion in patients with secondary hyperoxaluria.

Methods

Sixteen male and female subjects with both hyperoxaluria and a kidney stone history were enrolled in an open-label study. Subjects continued their usual diets and therapies. During a 3-day baseline period, two 24-h (24-h) urines were collected, followed by a 4-day treatment period with ALLN-177 (7,500 units/meal, 3 × day) when three 24-h urines were collected. The primary endpoint was the change in mean 24-h UOx from baseline. Safety assessments and 24-h dietary recalls were performed throughout.

Results

The study enrolled 5 subjects with enteric hyperoxaluria and 11 with idiopathic hyperoxaluria. ALLN-177 was well tolerated. Overall mean (SD) UOx decreased from 77.7 (55.9) at baseline to 63.7 (40.1) mg/24 h while on ALLN-177 therapy, with the mean reduction of 14 mg/24 h, (95% CI − 23.71, − 4.13). The calcium oxalate-relative urinary supersaturation ratio in the overall population decreased from a mean of 11.3 (5.7) to 8.8 (3.8) (− 2.8; 95% CI − 4.9, − 0.79). This difference was driven by oxalate reduction alone, but not any other urinary parameters. Mean daily dietary oxalate, calcium, and fluid intake recorded by frequent diet recall did not differ by study periods.

Conclusion

ALLN-177 reduced 24-h UOx excretion, and was well tolerated. The results of this pilot study provided justification for further investigation of ALLN-177 in patients with secondary hyperoxaluria.

Trial registration: Clinicaltrials.gov NCT02289755.

Identifying sources of measurement error in assessing dietary intakes - Results of a multi-country ring-trial

BACKGROUND AND AIMS

Epidemiological investigations include dietary intakes as primary exposures or potential confounders. To reduce bias, data collection protocols include the administration of questionnaires together with measurements of biomarkers. Some error, however, remains and needs to be considered in the analysis and interpretation of results. The European Food Safety Authority supported a ring-trial to compare the precision and reproducibility of dietary assessment methods applied in Europe.

METHODS AND RESULTS

Software applications used to collect 24-hour recalls and food records in six countries (Estonia, Italy, Latvia, Portugal, Spain, and Sweden) were assessed. The intake of 256 foods was identically reported to each method. Experienced interviewers participated and were instructed to repeat national protocols closely. The error in recording quantities, compared with reference values, was variable but in about 60% of recorded quantities was in the range of ±20%. Errors were however unsystematic and independent of the food type or quantification method used - although food pictures performed better. The reproducibility of some tools was limited. The methods generally captured additional ingredients (usually flavoring agents), but not sweetening agents or fortification and failed to record packaging information in about 60% of the cases.

CONCLUSION

In a design that eliminated respondent bias, this study indicates that softwares, supporting databases and interviewers generally introduce random error in dietary assessments. The inclusion of large sample sizes and food pictures to quantify portions, together with enhanced attention on interviewers' training, standardisation of procedures and regular tool upgrades are essential in assuring a study's quality and comparability.

Successful nutrition policy: improvement of vitamin D intake and status in Finnish adults over the last decade

Background

Due to vitamin D intake below recommendation (10 µg/day) and low (<50 nmol/l) serum 25-hydroxycholecalciferol (25(OH)D) concentration in Finnish population, the fortification of liquid dairy products with 0.5 µg vitamin D/100 g and fat spreads with 10 µg/100 g started in Finland in December 2002. In 2010, the fortification recommendation was doubled. The aim of this study was to investigate whether the vitamin D intake and status have improved among Finnish adults as a consequence of these nutrition policy actions. A further aim was to study the impact of vitamin supplement use to the total vitamin D intake.

Methods

A cross-sectional survey was conducted every 5 years. The National FINDIET Survey was conducted in Finland as part of the National FINRISK health monitoring study. Dietary data were collected by using a computer-assisted 48-h dietary recall. In 2002, dietary data comprised 2007, in 2007, 1575 and 2012, 1295 working aged (25-64 years) Finns.

Results

The mean D-vitamin intake increased from 5 µg/day to 17 µg/day in men and from 3 µg/day to 18 µg/day in women from 2002 to 2012. The most important food sources of vitamin D were milk products, fat spreads and fish dishes. The share of milk products was 39% among younger men and 38% among younger women, and 29% among older men and 28% among older women. Fat spreads covered on average 28% of vitamin D intake, except for younger men for which it covered 23%. Fish dishes provided 28% of vitamin D intake for older men and women, and approximately 18% for younger ones. In January-April 2012, the average serum 25-hydroxycholecalciferol (25(OH)D) concentration for men was 63 nmol/l for men and for women 67 nmol/l for women.

Conclusions

The fortification of commonly used foods with vitamin D and vitamin D supplementation seems to be an efficient way to increase the vitamin D intake and the vitamin D status in the adult population.

Lunch Salad Bars in New Orleans' Middle and High Schools: Student Intake of Fruit and Vegetables

The school lunch salad bar (SB) is a recommended food environmental strategy to increase access to, and consumption of fruit and vegetables (F/V). In a study to examine use of school lunch SBs, middle and high school students provided data via the Automated Self-Administered 24-h dietary recall (24HDR) tool for kids (ASA24-Kids-2012), a web-based data collection platform. Kilocalories were computed, food groups were assigned and F/V sources were obtained. Students (n = 718) from 12 schools with SBs and nine schools without SBs were approximately 87% African American, over 64% female and most were 7th and 8th graders. SB school students had higher median energy consumption at lunch but a higher percent of non-SB students reported eating fruit at lunch compared to SB students. Most students reporting eating F/V at lunch obtained F/V from the cafeteria main line; only 19.6% reported eating F/V exclusively from the SB. In SB schools median intake of cups F/V was higher among students using the SB (0.92) compared to those not using the SB (0.53). Results of this study are mixed, but encouraging. Additional factors, e.g., nutrition education, marketing, and kinds of foods offered on the SB need to be examined for potential influence on SB use.

Improving the Quality of Students’ Dietary Intake in the School Setting

The dramatic increase in our understanding of the brain’s development throughout childhood has increased our knowledge of the significance of micronutrients, such as iron and vitamin B-12, for this development. Deficiencies of these micronutrients have been shown to have an impact on students’ cognitive development. Regardless of this knowledge, students continue to make unhealthy food choices and develop poor dietary habits. School environments are places where there is an opportunity to practice healthy eating habits. Yet many school policies fail to address the sale of foods of minimal nutritional value in the school setting. School nurses can play a vital role in planning policies at the local and national level that support and encourage healthy food environments, performing assessments of the nutritional status of students, and spearheading the implementation of evidence-based health promotion programs. It is time for school nurses to take the lead in efforts aimed at improving the quality of students’ dietary intake in the school setting.

Electronic nutritional intake assessment in patients with urolithiasis: A decision impact analysis

Purpose

To evaluate a physician's impression of a urinary stone patient's dietary intake and whether it was dependent on the medium through which the nutritional data were obtained. Furthermore, we sought to determine if using an electronic food frequency questionnaire (FFQ) impacted dietary recommendations for these patients.

Materials and Methods

Seventy-six patients attended the Stone Clinic over a period of 6 weeks. Seventy-five gave consent for enrollment in our study. Patients completed an office-based interview with a fellowship-trained endourologist, and a FFQ administered on an iPad. The FFQ assessed intake of various dietary components related to stone development, such as oxalate and calcium. The urologists were blinded to the identity of patients' FFQ results. Based on the office-based interview and the FFQ results, the urologists provided separate assessments of the impact of nutrition and hydration on the patient's stone disease (nutrition impact score and hydration impact score, respectively) and treatment recommendations. Multivariate logistic regressions were used to compare pre-FFQ data to post-FFQ data.

Results

Higher FFQ scores for sodium (odds ratio [OR], 1.02; p=0.02) and fluids (OR, 1.03, p=0.04) were associated with a higher nutritional impact score. None of the FFQ parameters impacted hydration impact score. A higher FFQ score for oxalate (OR, 1.07; p=0.02) was associated with the addition of at least one treatment recommendation.

Conclusions

Information derived from a FFQ can yield a significant impact on a physician's assessment of stone risks and decision for management of stone disease.

Effects of partners together in health intervention on physical activity and healthy eating behaviors: a pilot study

BACKGROUND

Despite proven efficacy of cardiac rehabilitation (CR) in helping patients initiate physical activity and healthy eating changes, less than 50% of CR participants maintain changes 6 months later.

OBJECTIVE

The objective of this feasibility study was to test the Partners Together in Health (PaTH) intervention versus usual care in improving physical activity and healthy eating behaviors in coronary artery bypass graft surgery patients and their spouses.

METHODS

An experimental, 2-group (n = 17 couples/group), repeated-measures design was used. Coronary artery bypass surgery patients in both groups participated in phase II outpatient CR. Spouses in the PaTH group attended CR with the patient and were asked to make the same physical activity and healthy eating changes as patients did. Spouses in the usual care attended educational classes with patients. It was theorized that "2 persons would be better than 1" at making changes and sticking with them in the long-term. Physical activity behavior was measured using the Actiheart accelerometer; the activity biomarker was an exercise tolerance test. Eating behavior was measured using 3-day food records; the biomarker was the lipid profile. Data were collected at baseline (entrance in CR), at 3 months (post-CR), and at 6 months. Changes over time were examined using Mann-Whitney U statistics and effect sizes.

RESULTS

The PaTH intervention was successful primarily in demonstrating improved trends in healthy eating behavior for patients and spouses. No differences were found between the PaTH and usual care patients or spouses at 3 or 6 months in the number of minutes per week of physical activity. By 6 months, patients in both groups were, on average, below the national guidelines for PA recommendations (≥150 min/wk at >3 metabolic equivalents).

CONCLUSIONS

The couple-focused PaTH intervention demonstrated promise in offsetting the decline in dietary adherence typically seen 6 months after CR.

Assessment of energy intake in women with chronic obstructive pulmonary disease: a doubly labeled water method study

OBJECTIVES

To maintain energy balance, reliable methods for assessing energy intake and expenditure should be used in patients with chronic obstructive pulmonary disease (COPD). The purpose of this study was to validate the diet history and 7-day food diary methods of assessing energy intake (EI) using total energy expenditure (TEE) with the doubly labeled water (DLW) method (TEEDLW) as the criterion method in outpatient women with COPD.

METHODS

EI was assessed by diet history (EIDH) and a 7-day food diary (EIFD) in 19 women with COPD, using TEEDLW as the criterion method. The three methods were compared using intra-class correlation coefficients (ICC) and Bland-Altman analyses. The participants were classified according to their reporting status (EI/TEE) as valid-reporters 0.79-1.21, under-reporters < 0.79 or over-reporters > 1.21.

RESULTS

Diet history underestimated reported EI by 28%, and 7-day food diary underestimated EI by approximately 20% compared with TEEDLW. The ICC analysis showed weak agreement between TEEDLW and EIDH (ICC=-0.01; 95%CI-0.10 to 0.17) and between TEEDLW and EIFD (ICC=0.11; 95%CI -0.16 to 0.44). The Bland-Altman plots revealed a slight systematic bias for both methods. For diet history, six women (32%) were identified as valid-reporters, and for the 7-day food diary, twelve women (63%) were identified as valid-reporters. The accuracy of reported EI was only related to BMI.

CONCLUSION

The diet history and 7-day food diary methods underestimated energy intake in women with COPD compared with the DLW method. Individuals with higher BMIs are prone to underreporting. Seven-day food diaries should be used with caution in assessing EI in women with COPD.

Influence of food intake on the predictive value of the gestational diabetes mellitus screening test

OBJECTIVE

To investigate the influence of prior food ingestion on the predictive value of a screening test for gestational diabetes mellitus.

METHODS

This prospective, nonrandomized study enrolled 1,387 pregnant women who underwent the 50-g glucose challenge test. Gestational diabetes mellitus was diagnosed according to the National Diabetes Data Group criteria. A nutritional survey of dietary information before the glucose challenge test was conducted. The patients were stratified into three groups based on the time of last food ingestion (fasting interval): 1 hour or less, 1-2 hours, and more than 2 hours. The more than 2-hours fasting interval group was defined as the "fasting" group, and the combined 1 hour or less and 1-2 hours fasting interval groups were defined as the "fed" group. We calculated the positivity rate and the positive predictive value to detect the predictive value.

RESULTS

Among women who fasted 1 hour or less, 1-2 hours, and more than 2 hours before a glucose challenge test, 2.5%, 3.1%, and 6.9% were diagnosed with gestational diabetes mellitus, respectively. The positive predictive value of the glucose challenge test was greater in the fasting group than in the fed group (27.1% compared with 13.7%, P=.003). A multinomial logistic analysis showed that gestational diabetes mellitus was more prevalent in the fasting group than in the fed group (adjusted odds ratio 2.86, 95% confidence interval 1.65-4.95).

CONCLUSION

Our findings suggest that food intake influences the predictive value of the gestational diabetes screening test.

LEVEL OF EVIDENCE

II.

Repeatability of Food Frequency Assessment Tools in Relation to the Number of Items and Response Categories Included

Background

Accuracy of measurement is a cornerstone of research in order to make robust conclusions about the research hypothesis.

Objective

To examine whether the number of items (questions) and the number of consumption responses (the coding used to measure the frequency of consumption) included in nutritional assessment tools influence their repeatability.

Methods

During 2009, 400 participants (250 from Greece, mean age 37 ± 13 years, 34% males, and 150 from Spain, mean age 39 ± 17 years, 41% males) completed a diet index with 11 items and binary (yes/no) responses, a diet index with 11 items and 6-scale responses, and 36-item and 76-item food frequency questionnaires (FFQs) with 6-scale responses. The participants completed these tools twice, with 15 days between the two administrations of the tools. The Spearman-Brown coefficient ( rsb), Kendall's tau coefficients, and the Bland-Altman method were applied to answer the research hypothesis.

Results

The highest repeatability coefficient was observed for the diet index with 11 items and binary (yes/no) responses ( rsb = 0.948, p < .001), followed by the diet index with 11 items and 6-scale responses ( rsb = 0.943, p < .001), the 36-item FFQ with 6-scale responses ( rsb = 0.936, p < .001), and the 76-item FFQ with 6-scale responses ( rsb = 0.878, p < .001). Statistical comparisons revealed no significant differences between repeatability coefficients of the first three tools ( p > .23), whereas these three tools had significantly higher repeatability coefficients than the 76-item FFQ ( p = .002). Subgroup analyses by sex, education, smoking, and clinical status confirmed these results.

Conclusions

Repeatability was found for all food frequency assessment tools used, irrespective of the number of items or the number of responses included.

Dietary intake and nutrition-related knowledge in a sample of Lebanese adolescents of contrasting socioeconomic status

BACKGROUND

Socioeconomic status (SES) is postulated to be a major predictor of dietary intake and nutrition-related knowledge in adults. To date, very few studies have addressed this effect among adolescents.

OBJECTIVE

To explore differences in nutrient intake and nutrition-related knowledge among adolescents of contrasting SES in Lebanon.

METHODS

In a cross-sectional survey, 209 males and females, aged 17 to 19 years, were recruited from a private university with high tuition and a free public university in Beirut. The participants completed a multicomponent, self-administered questionnaire that inquired about demographic characteristics and nutrition-related knowledge. Three nonconsecutive 24-hour dietary recalls were obtained through interviews. Energy-adjusted means of dietary intake and age-adjusted nutrition-related knowledge were compared between groups using a general linear model.

RESULTS

Adolescents in the high-SES group consumed more vegetables, meats, and fats and oils (p < .05). Energy and nutrient intake analysis showed that adolescents in the high-SES group consumed significantly higher amounts of calories, protein, fat, vitamin A, vitamin C, and iron (p < .001) and significantly lower amounts of carbohydrates (p < .05). Nutritional knowledge, although high among all participants, was higher in the high-SES group (p < .05).

CONCLUSIONS

Although both groups showed good nutrition-related knowledge, SES significantly affected dietary intake in a sample of Lebanese adolescents. This warrants consideration of other factors, such as cost and environment, that may modulate eating behavior among adolescents from different socioeconomic strata.

Shortening the retention interval of 24-hour dietary recalls increases fourth-grade children's accuracy for reporting energy and macronutrient intake at school meals

BACKGROUND

Accurate information about children's intake is crucial for national nutrition policy and for research and clinical activities. To analyze accuracy for reporting energy and nutrients, most validation studies utilize the "conventional approach," which was not designed to capture errors of reported foods and amounts. The "reporting-error-sensitive approach" captures errors of reported foods and amounts.

OBJECTIVE

To extend results to energy and macronutrients for a validation study concerning retention interval (elapsed time between to-be-reported meals and the interview) and accuracy for reporting school-meal intake, the conventional and reporting-error-sensitive approaches were compared. DESIGN AND PARTICIPANTS/SETTING: Fourth-grade children (n=374) were observed eating two school meals, and interviewed to obtain a 24-hour recall using one of six interview conditions from crossing two target periods (prior 24 hours and previous day) with three interview times (morning, afternoon, and evening). Data were collected in one district during three school years (2004-2005, 2005-2006, and 2006-2007).

MAIN OUTCOME MEASURES

Report rates (reported/observed), correspondence rates (correctly reported/observed), and inflation ratios (intruded/observed) were calculated for energy and macronutrients.

STATISTICAL ANALYSES PERFORMED

For each outcome measure, mixed-model analysis of variance was conducted with target period, interview time, their interaction, and sex in the model; results were adjusted for school year and interviewer.

RESULTS

With the conventional approach, report rates for energy and macronutrients did not differ by target period, interview time, their interaction, or sex. With the reporting-error-sensitive approach, correspondence rates for energy and macronutrients differed by target period (four P values <0.0001) and the target period by interview-time interaction (four P values <0.0001); inflation ratios for energy and macronutrients differed by target period (four P values <0.0001), and inflation ratios for energy and carbohydrate differed by the target period by interview-time interaction (both P values <0.005).

CONCLUSIONS

Shortening the retention interval of dietary recalls increases accuracy for reporting energy and macronutrients. For validation studies, it is best to obtain reference information from a method that provides details about foods and amounts consumed and to use an analytic approach that captures errors of reported foods and amounts.

Fourth graders' reports of fruit and vegetable intake at school lunch: does treatment assignment affect accuracy?

OBJECTIVE

Dietary interventions with children often use self-reported data to assess efficacy despite that objective methods rarely support self-report findings in validation studies. This study compared fourth graders' self-reported to observed lunch fruit and vegetable intake to determine if the accuracy of self-reported intake varied by treatment condition.

DESIGN

Matched randomized follow-up design examined three treatment groups (high and low intensity interventions and control) post-intervention.

SUBJECTS/SETTING

Three hundred seventy-nine middle-school children participating in a randomized controlled trial of a school-based fruit and vegetable intervention were observed during school lunch one day and asked to recall intake the following day.

MAIN OUTCOME MEASURES

Food items were coded as: "match," "omission," or "intrusion." Students were classified as accurate if all food items matched, otherwise inaccurate. Matched foods' portions were compared for accuracy. Servings were computed for total fruit and vegetable intake.

ANALYSES

Accuracy for fruits and vegetables were compared in separate analyses and tested for multiple potential associates: treatment condition, sex, race, body mass index, subsidized meal eligibility, school district, fruit/vegetable availability, age, and test scores. Fitted multivariable regression models included variables found to be significant in univariate or chi(2) analyses.

RESULTS

Variables found to be significant for fruit item accuracy were availability at lunch, body mass index, and subsidized lunch eligibility. For vegetable item accuracy, availability at lunch was significant. No differences were found for food portions or for efficacy of the intervention between the two methods of dietary data collection: observation and self-report.

CONCLUSIONS

Condition assignment did not bias recalled fruit and vegetable intakes among fourth graders.

Validation of dietary intake data in black women with type 2 diabetes

The validity of baseline dietary intake data in women participating in a culturally competent intervention study for black women with type 2 diabetes was assessed. The relationship of sociodemographic and physiologic factors with underreporting of dietary intake was determined. Criterion validity of dietary intake, which had been assessed using the Nutritionist Five Collection Form, a combination of a standard 2-day dietary recall and a modified, culturally appropriate food frequency questionnaire, was determined. Data were analyzed using First Data Bank Nutritionist Five (version 2.3, 2000, First Data Bank, San Bruno, CA) software. Validation of baseline dietary data in 109 women was performed by calculating the ratio of energy intake to resting metabolic rate. Chi(2) and t tests were used to assess relationships between underreporting and sociodemographic and physiologic factors. Mean ratio of energy intake to resting metabolic rate was 1.46 (+/-0.4). Using a lower limit of 1.35, the prevalence of underreporting was 46.8%. Underreporting was significantly associated with body mass index (P< or =0.001) and waist circumference (P<0.001). Use of this combined dietary recall and modified food frequency questionnaire might, therefore, provide more accurate dietary assessment in this population. Additional modification and validity testing is warranted in this and other populations.

Obesity in HIV-infection: dietary correlates

OBJECTIVE

To describe the prevalence of obesity among a cohort of individuals living with HIV infection, and to determine differences in dietary intake among those subjects who are normal weight, overweight, and obese.

DESIGN

A cross-sectional study among participants enrolled in the Nutrition for Healthy Living (NFHL) study.

SETTING

Eligible participants included HIV-positive adults living in the greater Boston, MA and Providence, RI, areas. Subjects and Measures of Outcome: In total, 321 (265 males, 56 females) subjects were studied. Body composition measurements, demographic and health data, and fasting blood samples were analyzed. Dietary intake was assessed by three-day food records. Statistical analyses were performed using Statistical Package for Social Science (SPSS).

RESULTS

13% of males and 29% females were found to be obese. Energy intake per kilogram decreased by body mass index (BMI) category for both men and women (p <0.05). Although not different between groups, mean total fat and saturated fat intakes were above recommendations for both men and women in all BMI categories, while total grams dietary fiber decreased as BMI increased. Individuals in all BMI groups had micronutrient intakes below the Dietary Reference Intakes. Serum markers of insulin resistance were significantly different by BMI category among men and women, as well as triglycerides and total cholesterol for the males.

CONCLUSIONS

Obesity and diet in individuals living with HIV-infection needs to be addressed, as quality of dietary intake may have future implications regarding cardiovascular disease, metabolic syndrome, and other health risks associated with overweight and obesity.

A New Portion Size Estimation Aid for Wedge-Shaped Foods

Dietary surveys are important for understanding food consumption patterns in national studies, clinical research, and patient counseling. Portion size estimation aids usually increase accuracy of consumers' reports of the amount of food they ate in dietary surveys. However, wedge-shaped foods (eg, pie, cake, and pizza) pose special problems; this shape is not easily estimated by previously available portion size estimation aids. In focus groups, respondents indicate they need a portion size estimation aid that is easier to use than a ruler for portion estimation of wedge-shaped foods. An adjustable wedge was developed and tested with 320 respondents, ages 18 to 65 years, of various races and education levels, and both sexes, in four states using multiple sizes and types of wedge-shaped foods. The accuracy of portion size estimation with the two portion size estimation aids was assessed. The adjustable wedge gave similar results to the ruler for most portions tested, but was more accurate (P<0.05) than the ruler in approximately one third of comparisons. Both aids resulted in substantial misestimation, indicating that regardless of aid some people have difficulty estimating portions of wedge-shaped foods. The adjustable wedge was easy for people to use and can be recommended as an option for estimating portion size of wedge-shaped foods.

Development and validation of a food frequency questionnaire

Regular diet monitoring requires a tool validated in the target population. A 73-item, semiquantitative, self-administered food frequency questionnaire (FFQ), was adapted in French and English from the Block National Cancer Institute Health Habits and History Questionnaire. The FFQ was used to capture usual long-term food consumption among adults living in Quebec. A representative sample of adults aged 18 to 82 (57% female) was recruited by random digit dialling in the Montreal region. Approximately 64% of recruits completed and returned the instrument by mail (n=248). The FFQ was validated in a subsample (n=94, 61% female) using four nonconsecutive food records (FRs). Median energy intakes (in kcal) for men and women, respectively, were FFQ (total sample) 2,112 and 1,823, FFQ (subsample) 2,137 and 1,752, and FR (subsample) 2,510 and 1,830. Spearman correlation analyses between FFQ and FR nutrients were positive (with r ranging from 0.32 for folate to 0.58 for saturated fatty acids) and statistically significant (p<0.001), with better results among women. On average, cross-classification of energy and 24 nutrients from the FFQ and means of four FRs placed 39% into identical quartiles and 78% into identical and contiguous quartiles, with only 4% frankly misclassified. These results suggest that the FFQ is a relatively valid instrument for determining usual diet in Quebec adults.

Dietary intake in human immunodeficiency virus-infected adults: a comparison of dietary assessment methods

OBJECTIVE

The objective of this study was to compare estimated nutrient intakes from 3-day food records vs Food Frequency Questionnaire (FFQ) in a large cohort of individuals living with human immunodeficiency virus (HIV) infection.

DESIGN

Dietary data from 315 HIV-positive participants enrolled in a longitudinal cohort study were collected. Nutrient intake data estimated from the Block FFQ were compared with multiple 3-day food records done over the same time period.

SUBJECTS/SETTING

Participants enrolled in Nutrition for Healthy Living, an ongoing cohort study based in Boston, MA, were studied.

STATISTICAL ANALYSES PERFORMED

Using 3-day food records as the gold standard, we compared estimated nutrient intakes between the two assessment methods by (a) median of individual differences in intake, (b) correlation coefficients, (c) quintile ranking, and (d) intakes less than the Dietary Reference Intakes. Nutrient intake estimates between the two methods were compared using Spearman, Pearson, and deattenuated correlation coefficients.

RESULTS

Median reported intakes of all macronutrients and most micronutrients were significantly less on the FFQ for both men and women. Deattenuated correlations were less than 0.5 for 86% of the men and for 68% of the women. Mean percent agreement for quintile ranking was 30%.

CONCLUSIONS

In this large cohort of HIV-infected adults, we found significant differences between FFQs and food records in estimates of absolute dietary intakes, correlation coefficients, quintile rankings, and proportions of subjects consuming less than the Dietary Reference Intakes. These findings have implications for the interpretation and application of dietary intake data from FFQs in specialized populations.

Accuracy of reporting dietary intake using various portion-size aids in-person and via telephone

OBJECTIVE

This study compared the accuracy with which respondents reported food intake using different portion-size estimation aids (PSEAs) and determined whether the interview technique affected the accuracy of reporting.

DESIGN

Participants chose preweighed foods from a buffet line, leftovers were weighed, and actual amounts eaten were calculated. The next day during dietary interviews, participants estimated amounts eaten using one of four procedures, including telephone or in-person interviews, two-dimensional or three-dimensional PSEAs, and guiding or not guiding participants to certain aids.

SUBJECTS

A total of 120 persons, ages 18 to 65 years, representing both genders were recruited through advertisements, local churches, and universities.

STATISTICAL ANALYSIS

Analysis of variance and least significant differences were calculated for mean percentage estimation error. Frequencies and Pearson correlation coefficients were used to determine percentage misestimations and relationships between estimations and perceived healthfulness of the food and confidence in the estimate made.

RESULTS

In general, accuracy of reporting food amounts was not significantly different for the different types of aids or for the interview technique. Participants frequently overestimated the intake by more than 20% for solids (four overestimations and zero underestimations) and liquids (13 overestimations and one underestimation), and both over- and underestimated amorphous (mounding) foods by more than 20% (six underestimations and seven overestimations). Misestimation was unrelated to perceived healthfulness of the food or respondent confidence in the estimate.

CONCLUSIONS

In this study, portion-size data, based on PSEAs used in dietary recalls for estimating amounts eaten, were useful for measuring dietary intake for population-based studies. Individual respondent data, however, may be inaccurate and should be supplemented with additional information to improve assessment of individual nutritional status. Techniques such as telephone interviewing and guiding respondents to certain aids seem useful for reducing the burden of dietary assessment.

Fermentable and Nonfermentable Fiber Supplements Did Not Alter Hunger, Satiety or Body Weight in a Pilot Study of Men and Women Consuming Self-Selected Diets

Little is known about the relative effects of fermentable fiber (FF) vs. nonfermentable fiber (NFF) on energy regulation in humans. We compared 27 +/- 0.6 g/d supplements of FF (pectin, beta-glucan) and NFF (methylcellulose) for their ability to decrease ad libitum energy intake (EI) and hunger, increase satiety and cause spontaneous body weight and fat losses. Men and women (n = 11) aged 23-46 y, BMI 20.0-34.4 kg/m2, consumed first NFF and then FF for 3 wk each, with a 4-wk washout period between phases. Daily satiety assessed with analog scales was higher with NFF than FF (60.7 +/- 1.0 vs. 57.7 +/- 0.8 mm, P = 0.01). However, there were no differences in reported EI (NFF < FF by 7%, P = 0.31, NFF < baseline by 9.5%, P = 0.11), body weight (NFF 0.13 kg, P = 0.73; FF 0.13 kg, P = 0.60) or fat percentage (NFF -0.3%, P = 0.56; FF -0.1%, P = 0.66) within either phase. In contrast to findings in animals, NFF was more, rather than less satiating than FF, and use of neither NFF nor FF preparations was associated with body weight or fat loss. These pilot results suggest no role for short-term use of FF and NFF supplements in promoting weight loss in humans consuming a diet ad libitum.

Comparison of digital photography to weighed and visual estimation of portion sizes

OBJECTIVE

The primary goal was to test the validity of digital photography for measuring food portion sizes compared with weighed foods and with direct visual estimation.

SAMPLES

A total of 60 test meals consisting of 10 different portion sizes from six different university cafeteria menus were prepared and weighed.

DESIGN

Food selections and plate waste, as estimated by digital photography and direct visual estimation, were compared with weighed foods. For each method, three observers independently estimated portion sizes of each food. Observers expressed the portion sizes as a percentage of a standard serving. These percentages were multiplied by the weight of the standard portion to yield estimated weights. Statistical analyses To test validity, the estimates of food weights derived from both methods were compared with weighed foods using correlations and were compared with each other using Bland-Altman regression analysis.

RESULTS

For the digital photography and direct visual estimation methods, estimates of the portion sizes for food selections, plate waste, and food intake were highly correlated with weighed foods. Both methods tended to yield small overestimates or underestimates. Bland-Altman regression found the two estimation methods to yield comparable results (bias less than 1.5 g).

APPLICATIONS/CONCLUSIONS

These findings support the validity of the digital photography method for measuring portion sizes. Digital photography may be most useful for measuring food intake in settings that allow for the direct observation of food selections and plate waste but require minimum disruption of the eating environment, and allow unhurried estimates of portion sizes.

Accuracy of fourth-graders' dietary recalls of school breakfast and school lunch validated with observations: in-person versus telephone interviews

OBJECTIVE

To investigate the accuracy of children's dietary recalls of school breakfast and school lunch validated with observations and obtained during in-person versus telephone interviews.

DESIGN

Each child was observed eating school breakfast and school lunch and was interviewed that evening about that day's intake.

SETTING

Ten elementary schools.

PARTICIPANTS

A sample of fourth-graders was randomly selected within race (black, white) and gender strata, observed, and interviewed in person (n = 33) or by telephone (n = 36).

MAIN OUTCOMES MEASURED

Rates for omissions (items observed but not reported) and intrusions (items reported but not observed) were calculated to determine accuracy for reporting items. A measure of total inaccuracy was calculated to determine inaccuracy for reporting items and amounts combined.

ANALYSIS

Analysis of variance; chi-square.

RESULTS

Interview type (in person, telephone) did not significantly affect recall accuracy. For omission rate, intrusion rate, and total inaccuracy, means were 34%, 19%, and 4.6 servings for in-person recalls and 32%, 16%, and 4.3 servings for telephone recalls of school breakfast and school lunch.

CONCLUSIONS AND IMPLICATIONS

The accuracy of children's recalls of school breakfast and school lunch is not significantly different whether obtained in person or by telephone. Whether interviewed in person or by telephone, children reported only 67% of items observed; furthermore, 17% of items reported were not observed.

Reproducibility and validity of the secondary level School-Based Nutrition Monitoring student questionnaire

OBJECTIVE

To evaluate the reproducibility and validity of the School-Based Nutrition Monitoring (SBNM) secondary level student questionnaire.

DESIGN

Reproducibility was evaluated using a test-retest study design by administering the questionnaire on the same day (morning and afternoon, n=254) and, when appropriate, 9 to 14 days apart (n=259). Validity was assessed by comparing foods selected on the questionnaire with foods reported from a single 24-hour recall covering the same referent period (yesterday) in 209 students.

SUBJECTS/SETTING

Eighth grade students in middle schools from central Texas were used: male and female, approximately 75% white, for the reproducibility study, with 15% Hispanic, 6% African American; for the validation study, approximately 38% white, 41% Hispanic, and 17% African American.

STATISTICAL ANALYSIS

Spearman rank order correlation, kappa statistic, and percentage agreement were used for both reproducibility and the validation.

RESULTS

For the reproducibility study, agreement for questions about food intake "yesterday" were 70% to 98%, with kappa statistics ranging from 0.54 to 0.93 and correlations between 0.66 and 0.97. Questions on recent physical activity had high agreement (66% to 89%) as did "usual" physical activity items, weight loss, and food selection behaviors. Nutrition knowledge items showed relatively weaker reliability: agreements ranged from 47% to 92%, with kappa statistics between 0.30 and 0.56. Attitude questions had weaker agreement (50% to 87%), kappa statistics (0.27 to 0.52), and correlations (0.33 to 0.63). For the validation study, correlation coefficients ranged from 0.32 for breads to 0.68 for milk and beans. Percentage agreement ranged from 38% for breads to 89% for gravy.

APPLICATIONS/CONCLUSIONS

Most questions on the SBNM secondary questionnaire were found to have acceptable reproducibility, whereas validation of food choice behaviors showed results similar to or better than other dietary assessment instruments for this age group. This questionnaire is a useful epidemiologic tool for surveillance, assessing broad intervention effects among groups or providing needs assessment data on selected nutrition and physical activity-related constructs.

Vitamin E and depressive symptoms are not related. The Rotterdam Study

OBJECTIVE

To investigate the reported association between low vitamin E levels and depressive symptoms in a population-based study.

METHODS

The study is based on a cohort of 3884 adults aged 60 years and over who participated in the third survey of the Rotterdam Study, were screened for depressive symptoms with the Center of Epidemiological Studies Depression Scale and from whom blood was drawn. All screen-positive subjects had a psychiatric work-up. Blood levels of vitamin E were compared between 262 cases with depressive symptoms and 459 randomly selected reference subjects. All analyses were stratified by sex, and adjusted for age, cholesterol, cognitive score, smoking, dietary supplement use, marital status, living alone, and functional disability score.

RESULTS

Vitamin E levels in men with depressive symptoms were lower than in non-depressed men after adjusting for age, whereas no such difference was found in women. This association in men was substantially weakened after controlling for biological factors, and disappeared with additional adjustment for nutritional behaviour and social factors. No differences were observed when the analyses were restricted to cases with depression as defined in the Diagnostic and Statistical Manual of Mental Disorders IV.

CONCLUSIONS

After control for several biological and behavioural factors relating to health we found no association between low vitamin E levels and depressive symptoms or depression in the elderly.

Nutrient intake of first generation Gujarati Asian Indian immigrants in the U.S

OBJECTIVE

To examine the nutrient intake of Gujarati Asian Indian immigrants in the U.S. and the influence of length of residence in the U.S. and socioeconomic status (SES) on their macronutrient intake.

METHODS

Subjects were male (n = 90) and female (n = 99) Gujarati Asian Indian immigrants over the age of 45. Each participant completed a 24-hour dietary recall. Dietary recalls were analyzed using Food Processor nutrient analysis software. Participants were classified into recent immigrants (<10 years length of residence in the U.S.) and long-term immigrants (>10 years length of residence in the U.S.) and into low, medium and high education groups, based on highest level of education achieved, to examine the influence of these variables on their macronutrient intake.

RESULTS

The macronutrient contributions to the total energy intake of these Gujarati Asian Indian immigrants were as follows: carbohydrate 57%, protein 12% and total fat 33%. The diets were low in cholesterol (<100 mg/day) and high in dietary fiber (>/=25 g/day). Reported intakes of vitamin D, calcium (women only), potassium (women only), copper and zinc were less than two-thirds of the recommendations. Significant differences (p < 0.05) in macronutrient intake were observed based on length of residence in the U.S. and SES. Regression analysis indicates age, total energy intake, length of residence in the U.S. and SES to have a significant influence on the nutrient intake of these Gujarati Asian Indian immigrants.

CONCLUSION

The nutrient intakes of these Gujarati Asian Indian immigrants indicate both inadequacies and excesses of select macro and micronutrients. These nutrient inadequacies and excesses can impact overall health and risk of chronic diseases of these individuals. Further investigation of the influence of the diets of these immigrants on their health is warranted.

Effects of habitual physical activity on the resting metabolic rates and body compositions of women aged 35 to 50 years

OBJECTIVE

To examine the effect habitual physical activity has on resting metabolic rate (RMR) and body composition (fat-free mass[FFM], fat mass, and percent body fat) in active compared to sedentary adult women.

DESIGN

RMR was measured (by indirect calorimetry) twice after a 12-hour fast at the same point of the menstrual cycle and 48 hours after exercise. FFM, fat mass and percent body fat were measured using whole body air displacement plethysmography. Energy intake and expenditure were determined using 7-day weighed-food records and activity logs.

SUBJECTS

Healthy, weight-stable premenopausal women aged 35 to 50 years classified as either active (approximately 9 hours per week of physical activity for 10 or more years) (n= 18) or sedentary (approximately 1 hour per week of physical activity) (n= 14).

STATISTICAL ANALYSES

Analysis of covariance was used to investigate differences in mean RMR (kcal/day) between the groups adjusted for FFM, and independent t tests were used to determine differences in demographic, energy expenditure, and diet variables.

RESULTS

Percent body fat and fat mass were lower (P<.0005) and RMR (adjusted for FFM) was significantly higher in the active women (P=.045) compared with sedentary controls. In the active and sedentary groups respectively, mean adjusted RMR was 1,510 kcal/day and 1,443 kcal/day, body fat was 18.9% and 28.8%, and fat mass was 11.1 kg and 18.8 kg. Groups were similar in body mass, FFM, body mass index, and age. Mean energy balance appeared to be more negative in the active group (P=.0059) due to significantly higher mean self-reported energy expenditures (P=.0001) and similar mean self-reported energy intakes (P=.52) compared with sedentary controls. These data indicate that active women who participate in habitual physical activity can maintain lower body fat and a higher RMR than sedentary controls with similar body mass, FFM, and body mass index.

APPLICATIONS/CONCLUSIONS

This research supports and emphasizes the benefits of habitual physical activity in maintaining RMR and lower body fat levels in middle-aged women.

Diet interviews of subject pairs: how different persons recall eating the same foods

OBJECTIVE

To compare qualitative descriptions of the same food items eaten by different persons using 24-hour dietary recall interviews.

DESIGN

Eleven pairs of subjects were interviewed twice using 24-hour dietary recalls such that each member of the pair described the same day's foods. Each pair shared a home and ate at least 2 meals together daily. After each interview, subjects were asked to identify the foods reported during the interview that they observed the other member of their pair consuming and to note when a particular food was the only item of that type available in the house. Qualitative descriptions of the foods were compared, differences in descriptions were noted, and calculations were made of the potential energy error produced if a subject erred in reporting a food item.

SUBJECTS/SETTING

Subjects were randomly selected from a database of persons who have participated in other studies at the Beltsville Human Nutrition Research Center. Ten pairs were husbands and wives and 1 pair was sisters. Each pair reported eating at least 2 meals per day together. Dietary recall interviews were done at the Research Center and were conducted by a trained dietitian in a quiet room free of distractions.

RESULTS

Discrepancies in qualitative food descriptions were identified for every subject pair interviewed. Men were found to be more likely to omit food items than women, snack items were more likely to be omitted than meal items, meat items were likely to be described inaccurately, and first interviews were likely to contain more errors than second interviews.

APPLICATIONS/CONCLUSIONS

This analysis shows which types of food items are most likely to be omitted or inaccurately described, and that dietetics professionals may improve the accuracy of dietary intake interviews by asking questions related to meat, milk, and snacks very carefully. The analysis also showed reductions in recall inconsistencies from the first recall to the second recall, suggesting that the learning associated with repeated interviews may be helpful in accurately identifying what a person consumes.