Under-reporting of food intake and body fatness in independent older people: a doubly labelled water study

Factors of food choice and nutritional intake of Brazilian older adults according sociodemographic and health characteristics

The rapid demographic transition in developing countries has always posed a challenge for the social and economic policies of these nations. The increase in longevity poses new challenges for understanding dietary consumption among different age groups at the old age population. The aim of this study was to evaluate the reasons for food choice and the composition of nutritional intake of older adults and its relationship to individual characteristics. Community-living older adults aged 60 and older were interviewed in their homes at the southeastern region of Brazil, between December 2021 and February 2022. The Food Choice Questionnaire and a Food Frequency Questionnaire were administered to obtain data on the reasons for food choice and nutritional intake. A structured interview was employed to gather information on individual characteristics. 168 older adults (mean age of 72.6 ± 8.9; 69.6% women) participated. The reasons for food choice differed significantly, with weight control being one of the least important and health being one of the most important. But older adults aged 80 and over valued the health criterion less than younger participants (60-69 years old). The intake of macronutrients and energy were below nutritional recommendations. Carbohydrate consumption was positively correlated with the mood motive. There was a relationship between the reasons for choosing food and/or the components of nutritional intake with: gender, age, living with a partner, self-report of depression/anxiety, self-perception of health and nutritional status anthropometric. The results are important to be considered in prevention policies and clinical-nutritional management, with special attention to the oldest-old.

Evaluating the influence of ultra-processed food intake on associations between dietary indices with systemic inflammation in adulthood and old ages

BACKGROUND & AIMS

Low-grade systemic inflammation (LGSI) is critical to developing many chronic diseases. In turn, it has been shown that the diet can modulate favorably or unfavorably the inflammatory status. Thus, evaluating the diet from appropriate approaches is fundamental; to do so, there are different proposals for dietary indexes. We aimed to: (i) investigate the association between three well-known dietary indexes and LGSI biomarkers; (ii) test these associations individually or in combination with an indicator of ultra-processed foods (UFPs) intake. (iii) as an additional aim, hypothesizing that all the indexes should be capable of identifying the inflammatory potential of diet, we tested the hypothesis that these indexes agree and correlate with each other.

METHODS

Cross-sectional population-based data of adults and older persons (n = 583). Dietary data were obtained through two non-consecutive 24-h dietary recalls (24HDR) and calculated for Dietary Inflammatory Index (DII), Mediterranean-Style Dietary Pattern Score (MSDPS); Brazilian Healthy Eating Index - Revised (BHEI-R) and energy ingested from UPFs (UPFs ratio). An LGSI score was created from some plasma inflammatory biomarkers [C-Reactive Protein (CRP), tumor necrosis factor-alpha (TNF-α), and adiponectin]. Logistic and linear regression models tested the associations between dietary indexes and LGSI score.

RESULTS

The MSDPS and DII were significantly associated with our inflammatory score, but the BHEI-R did not. Including UPFs in regression models did not increase the strength of these associations.

CONCLUSIONS

From the three scores, the dietary inflammatory index and the Mediterranean-style dietary pattern score (MSDPS) were the ones that showed significant association with the inflammatory biomarker. The combination of the indexes with a ratio of UPF intake did not increase the significance of our analyses. The best agreement between the indexes was found between MSDPS and UPFs ratio; the only pair of indexes considered concordant and correlated was the BHEI-R and DII.

Development and validation of age-specific predictive equations for total energy expenditure and physical activity levels for older adults

BACKGROUND

Predicting energy requirements for older adults is compromised by the underpinning data being extrapolated from younger adults.

OBJECTIVES

To generate and validate new total energy expenditure (TEE) predictive equations specifically for older adults using readily available measures (age, weight, height) and to generate and test new physical activity level (PAL) values derived from 1) reference method of indirect calorimetry and 2) predictive equations in adults aged ≥65 y.

METHODS

TEE derived from "gold standard" methods from n = 1657 (n = 1019 females, age range 65-90 y), was used to generate PAL values. PAL ranged 1.28-2.05 for males and 1.26-2.06 for females. Physical activity (PA) coefficients were also estimated and categorized (inactive to very active) from population means. Nonlinear regression was used to develop prediction equations for estimating TEE. Double cross-validation in a randomized, sex-stratified, age-matched 50:50 split, and leave one out cross-validation were performed. Comparisons were made with existing equations.

RESULTS

Equations predicting TEE using the Institute of Medicine method are as follows: For males, TEE = -5680.17 - 17.50 × age (years) + PA coefficient × (6.96 × weight [kilograms] + 44.21 × height [centimeters]) + 1.13 × resting metabolic rate (RMR) (kilojoule/day). For females, TEE = -5290.72 - 8.38 × age (years) + PA coefficient × (9.77 × weight [kilograms] + 41.51 × height [centimeters]) + 1.05 × RMR (kilojoule/day), where PA coefficient values range from 1 (inactive) to 1.51 (highly active) in males and 1 to 1.44 in females respectively. Predictive performance for TEE from anthropometric variables and population mean PA was moderate with limits of agreement approximately ±30%. This improved to ±20% if PA was adjusted for activity category (inactive, low active, active, and very active). Where RMR was included as a predictor variable, the performance improved further to ±10% with a median absolute prediction error of approximately 4%.

CONCLUSIONS

These new TEE prediction equations require only simple anthropometric data and are accurate and reproducible at a group level while performing better than existing equations. Substantial individual variability in PAL in older adults is the major source of variation when applied at an individual level.

The Human Interference Scoring System (HISS): A New Tool for Quantifying Food Quality Based on Its Level of Processing

The Human Interference Scoring System (HISS) is a novel food-based diet-quality-classification system based on the existing NOVA method. HISS involves food and fluid allocation into categories from digital imagery based on food processing levels, followed by meal plan analysis using food-servings quantification. The primary purpose of this work was to evaluate the reliability of HISS. Trained nutrition professionals analyzed digital photographs from five hypothetical 24 h food recalls and categorized foods into one of four HISS categories. A secondary purpose was to assess the nutrient composition of the food recalls and other selected foods from the HISS categories. Participants effectively categorized foods into HISS categories, with only minor discrepancies noted. High inter-rater reliability was observed in the outer HISS categories: unprocessed and ultra-processed foods. Ultra-processed items consistently displayed elevated energy, carbohydrates, and sugar compared to unprocessed foods, while unprocessed foods exhibited notably higher dietary fiber. This study introduces the HISS as a potentially useful tool for quantifying a food-quality-based system using digital-photography-based assessments. Its high inter-rater reliability and ability to capture relationships between food processing levels and nutrient composition make it a promising method for assessing dietary habits and food quality.

Development and validation of new predictive equations for the resting metabolic rate of older adults aged ≥65 y

BACKGROUND

The aging process alters the resting metabolic rate (RMR), but it still accounts for 50%-70% of the total energy needs. The rising proportion of older adults, especially those over 80 y of age, underpins the need for a simple, rapid method to estimate the energy needs of older adults.

OBJECTIVES

This research aimed to generate and validate new RMR equations specifically for older adults and to report their performance and accuracy.

METHODS

Data were sourced to form an international dataset of adults aged ≥65 y (n = 1686, 38.5% male) where RMR was measured using the reference method of indirect calorimetry. Multiple regression was used to predict RMR from age (y), sex, weight (kg), and height (cm). Double cross-validation in a randomized, sex-stratified, age-matched 50:50 split and leave one out cross-validation were performed. The newly generated prediction equations were compared with the existing commonly used equations.

RESULTS

The new prediction equation for males and females aged ≥65 y had an overall improved performance, albeit marginally, when compared with the existing equations. It is described as follows: RMR (kJ/d) = 31.524 × W (kg) + 25.851 × H (cm) - 24.432 × Age (y) + 486.268 × Sex (M = 1, F = 0) + 530.557. Equations stratified by age (65-79.9 y and >80 y) and sex are also provided. The newly created equation estimates RMR within a population mean prediction bias of ∼50 kJ/d (∼1%) for those aged ≥65 y. Accuracy was reduced in adults aged ≥80 y (∼100 kJ/d, ∼2%) but was still within the clinically acceptable range for both males and females. Limits of agreement indicated a poorer performance at an individual level with 1.96-SD limits of approximately ±25%.

CONCLUSIONS

The new equations, using simple measures of weight, height, and age, improved the accuracy in the prediction of RMR in populations in clinical practice. However, no equation performs optimally at the individual level.

Feasibility of wearable camera use to improve the accuracy of dietary assessment among adults

Traditional methods of dietary assessment are prone to measurement error, with energy intake often under-reported. The 24-h recall is widely used in dietary assessment, however, its reliance on self-report without verification of consumption can result in inaccuracies in true nutrient intake. Wearable cameras may provide a complementary approach to improve self-report accuracy by providing an objective and passive measure of food consumption. The purpose of the present study was to determine whether a wearable camera improves the accuracy of a 24-h recall compared with a 24-h recall alone in twenty adults aged 18-65 years. The study also explored limitations associated with wearable cameras. Participants wore the camera for 1 d and a 24-h recall was then conducted the following day, before and after viewing the camera images. Dietary data were analysed using Nutritics dietary analysis software, while eating habits were assessed by a self-report questionnaire. Energy and nutrient intakes were compared between the recall alone and the camera-assisted recall. Results showed a significant increase in mean energy intake with the camera-assisted recall compared with the recall alone (9677⋅8 ± 2708⋅0 kJ/d v. 9304⋅6 ± 2588⋅5 kJ/d, respectively, P = 0⋅003). Intakes of carbohydrates, total sugars and saturated fats were also significantly higher with the camera-assisted recall. In terms of challenges, there were occasionally technological issues such as proper positioning of the camera by the participants. In conclusion, reporting of energy and nutrient intake may be enhanced when a traditional method of dietary assessment, the 24-h recall, is assisted by a wearable camera.

Accuracy and cost-effectiveness of the INDDEX24 Dietary Assessment Platform in Viet Nam

Technology-enabled approaches to conducting 24-h dietary recalls (24HR) may reduce dietary assessment bottlenecks in low-resource settings. However, few studies have assessed their performance relative to conventional pen-and-paper interview (PAPI) approaches and none have validated performance against a benchmark (e.g. weighed food record (WFR)) in a low- and middle-income country (LMIC). This study assessed relative accuracy and cost-effectiveness of INDDEX24, a technology-enabled approach to conducting 24HR, compared with a PAPI approach and against an observer WFR. Women aged 18-49 years from northern Viet Nam (n 234) were randomly assigned to be interviewed using INDDEX24 or PAPI 24HR following a WFR. The two one-sided t test approach assessed the equivalence of each recall modality to the benchmark. Difference-in-differences analysis compared the recall-benchmark results across modalities. Cost per percentage point of accuracy for INDDEX24 and PAPI was derived from accuracy results and the cost to conduct the 24HR. The PAPI and INDDEX24 24HR were statistically equivalent to the WFR for all nutrients except vitamin A. INDDEX24 diverged significantly less than PAPI from the WFR for Fe (0·9 v. -1·3 mg) and PAPI diverged less for protein (-3·7 v. 7·9 g). At the individual level, 26 % of PAPI and 32 % of INDDEX24 respondents had energy intakes within +/- 10 % of the WFR. INDDEX24 cost $111 004 and the PAPI cost $120 483 (USD 2019), making INDDEX24 more cost-effective across most indicators. INDDEX24 was an accurate and cost-effective method for assessing dietary intake in the study context and represents a preferred alternative to PAPI 24HR in Viet Nam and other LMIC.

Misreporting of dietary energy intake obtained by 24 h recalls in older adults: a comparison of five previous methods using doubly labeled water

BACKGROUND/OBJECTIVE

To test five different methods to detect misreporting in comparison to doubly labeled water in a sample of older adults.

SUBJECTS/METHODS

A cross-sectional study with thirty-eight Brazilian community-dwelling older adults aged 60-84 years, who had their total energy expenditure measured by doubly labeled water (TEE_DLW). Dietary data were collected by two 24 h recalls. Misreporting was compared with estimates obtained by the methods proposed by: Goldberg et al. [1, 2], Black [3], McCrory et al. [4], Huang et al [5], and Rennie et al [6]. Bland-Altman plots with 95% limits of agreement were constructed to assess the agreement between rEI and TEE_DLW. Weighted kappa coefficients, sensitivity and specificity analyses, and area under the receiving operator characteristic curve (AUC) were used to test the performance of each method.

RESULTS

The prevalence of under-reporters (UR) and over-reporters (OR) obtained by the reference (DLW) were 57.9% (n = 22) and 5.3% (n = 2), respectively. Black [3] presented the worst agreement and McCrory et al. [4] the best one to accurately classify individuals in the three categories of energy reporting. McCrory et al. [4] had the best performance in the sensitivity and specificity analyses detecting UR and plausible reporters.

CONCLUSIONS

There was a high prevalence of misreporting, especially underreporting, in this sample of community-dwelling Brazilian older adults. The study showed a wide variation in the accuracy of predictive methods to handle misreporting, with none of the equations showing outstanding agreement with the reference. When DLW is not available, a valid method should be chosen to address energy intake reporting.

Association Between Fish Consumption and Muscle Mass and Function in Middle-Age and Older Adults

Background: Sarcopenia, the age-related loss of skeletal muscle mass and function, represents a crucial risk factor for disability and mortality. Increasing intake of some nutrients, particularly protein and omega-3 fatty acids seems to be a promising strategy to augment muscle mass and function.

Objective: The purpose of this study was to assess the beneficial effects of fish consumption on muscle mass and function among middle-age and older adults.

Methods: Twenty-two adults aged 50–85 years participated in this study. Participants were asked to consume 150–170-g of fish for lunch twice a week for a 10-week period. During that period, participants were asked to maintain their normal diet and physical activity. Outcome measures included anthropometry, muscle mass, and muscle function. All these measures were assessed at baseline, week 5, and week 10. Repeated-measures analysis of variance was used to analyze statistical significance.

Results: Consuming fish twice a week for 10 weeks significantly increased the skeletal muscle mass and appendicular lean mass divided by height squared (ALM/h²) (p < 0.01). Handgrip strength and gait speed <0.8 m/s were also improved (p < 0.01) at week 10 compared with that at baseline.

Discussion: Consuming fish seems to improve muscle mass and function and may slow sarcopenia progression in middle-age and older adults.

Prevalence of Triad-RED-S symptoms in high-level Kenyan male and female distance runners and corresponding control groups

PURPOSE

This study examined and compared select Triad-RED-S components/risk factors in high-level Kenyan male and female distance runners to corresponding control groups; focusing on examining energy intake (EI), bone indices, and hormonal markers.

METHODS

A cross-sectional, observational design was used in which Kenyan male and female (n = 30 and n = 26, respectively) middle- and long-distance runners and corresponding male and female control groups (n = 29 and n = 29, respectively) were examined. The participant's bone mineral density (BMD) at the lumbar spine, right femur, and total body were measured using a dual-energy X-ray absorptiometry analysis. Complete blood counts (CBC) were done on the whole blood specimens and hormonal measurements were performed on plasma specimens. In addition, athletes completed metabolic testing to determine maximal oxygen uptakes and 7-day dietary diaries.

RESULTS

Overall daily EI across runners and controls within each sex were low, but not significantly different (p > 0.05). Prevalence of low BMD values (Z score < - 2.0) was comparable across groups in each sex (p > 0.05). CBC measures suggested that both runners and controls were healthy. Finally, slight hormonal differences between runners and their respective controls existed (p < 0.05), but were not clinically meaningful or observed in typical Triad-RED-S-related parameters.

CONCLUSION

High-level Kenyan male and female runners had low daily EI, but no tendency toward a higher prevalence of low BMD, or Triad-RED-S-related hormonal abnormalities. The occurrence of low EI was not a major risk factor in our athletes; this calls into question whether the current criteria for Triad-RED-S are entirely applicable for athletes of African ethnicity.

Evaluation of energy intake by brief-type self-administered diet history questionnaire among male patients with stable/at risk for chronic obstructive pulmonary disease

Background and objective

Weight loss and reduced fat-free mass are independent risk factors for mortality among patients with chronic obstructive pulmonary disease (COPD). These factors are important for determining diet therapy and examining the validity of assessment for energy intake (EI). We assessed the agreement of EI between a brief-type self-administered diet history questionnaire (BDHQ) and the doubly labelled water (DLW) method among male patients with stable/at risk for COPD.

Method

In this cross-sectional observational study, data for 33 male patients were analysed. At the first visit, EI was estimated using a BDHQ (EI_BDHQ). Total energy expenditure (TEE) was measured during 13–15 days by the DLW method, while corrected EI was calculated using the TEE and weight change during the DLW period (EI_DLW). The difference between EI_BDHQ and EI_DLW was evaluated by the Bland-Altman method. Multiple regression analysis was used to determine the proportion of variance in the difference between EI_BDHQ and EI_DLW, as determined by the patient’s characteristics.

Results

EI_BDHQ was 2100 (95% CI: 1905 to 2295) kcal/day in the total population. A fixed bias was observed between EI_BDHQ and EI_DLW as −186 (95% CI: −422 to 50) kcal/day, while a proportional bias was not detected by the Bland-Altman analysis. Age, weight, anxiety and interleukin 6 were responsible for 61.7% of the variance in the difference between both EIs in a multiple regression model.

Conclusions

The BDHQ underestimated EI among male patients with stable/at risk for COPD, but this estimation error was within an acceptable range compared with previous studies. EI_BDHQ precision might be improved by considering common COPD traits, including inflammatory condition and mental state.

Investigating sex differences in the accuracy of dietary assessment methods to measure energy intake in adults: a systematic review and meta-analysis

BACKGROUND

To inform the interpretation of dietary data in the context of sex differences in diet-disease relations, it is important to understand whether there are any sex differences in accuracy of dietary reporting.

OBJECTIVE

To quantify sex differences in self-reported total energy intake (TEI) compared with a reference measure of total energy expenditure (TEE).

METHODS

Six electronic databases were systematically searched for published original research articles between 1980 and April 2020. Studies were included if they were conducted in adult populations with measures for both females and males of self-reported TEI and TEE from doubly labeled water (DLW). Studies were screened and quality assessed independently by 2 authors. Random-effects meta-analyses were conducted to pool the mean differences between TEI and TEE for, and between, females and males, by method of dietary assessment.

RESULTS

From 1313 identified studies, 31 met the inclusion criteria. The studies collectively included information on 4518 individuals (54% females). Dietary assessment methods included 24-h recalls (n = 12, 2 with supplemental photos of food items consumed), estimated food records (EFRs; n = 11), FFQs (n = 10), weighed food records (WFRs, n = 5), and diet histories (n = 2). Meta-analyses identified underestimation of TEI by females and males, ranging from -1318 kJ/d (95% CI: -1967, -669) for FFQ to -2650 kJ/d (95% CI: -3492, -1807) for 24-h recalls for females, and from -1764 kJ/d (95% CI: -2285, -1242) for FFQ to -3438 kJ/d (95% CI: -5382, -1494) for WFR for males. There was no difference in the level of underestimation by sex, except when using EFR, for which males underestimated energy intake more than females (by 590 kJ/d, 95% CI: 35, 1,146).

CONCLUSION

Substantial underestimation of TEI across a range of dietary assessment methods was identified, similar by sex. These underestimations should be considered when assessing TEI and interpreting diet-disease relations.

Mis-reporting of energy intake among older Australian adults: Prevalence, characteristics, and associations with quality of life

OBJECTIVES

Mis-reporting is common in dietary assessment, leading to misinterpretation of disease risk and could be important in older adults with increased chronic disease risk. This study investigated the prevalence and characteristics of mis-reporting among older adults and its association with health outcomes including quality of life (QoL).

METHODS

The study was conducted in 335 community-dwelling older adults at increased risk for cardiovascular disease, participating in the SCReening Evaluation of the Evolution of New Heart Failure Study dietary substudy. Diet was assessed using 4-day weighed food diaries, QoL measured through Short Form 36, and physical activity assessed using the European Prospective Investigation into Cancer and Nutrition physical activity questionnaire. Dietary mis-reporting was defined based on Goldberg cutoffs, using individual physical activity levels. Odds ratios were determined to establish associations between mis-reporting and health outcomes.

RESULTS

The prevalence of mis-reporting among older adults was 49.3%, with 44.5% of women mis-reporting their energy intake. The study found under-reporting of energy to be associated with body mass index, specifically being overweight (odds ratio: 3.08; 95% confidence interval [CI], 1.54-6.15) and obese (odds ratio: 6.60; 95% CI, 3.05-4.26), as well as physical inactivity (odds ratio: 0.24; 95% CI, 0.14-0.43). Only physical inactivity predicted over-reporting of dietary intake (odds ratio: 7.52; 95% CI, 1.57-36.0).

CONCLUSIONS

Dietary under-reporting was associated with being overweight, obese, and physically inactive in addition to the absence of comorbidities, reinforcing the need for further research in older adults to factor in dietary mis-reporting for meaningful diet-disease relationship analyses.

Validation of saliva and urine use and sampling time on the doubly labelled water method to measure energy expenditure, body composition and water turnover in male and female cats

Less invasive protocols are necessary to study energy expenditure (EE) of cats living in homes for expressing their normal living conditions. The present study compared sampling times and the use of saliva, urine and blood to measure 2H and 18O to apply the doubly labelled water method. In the first study, four cats were used to evaluate the enrichment (2, 4, 6, 7 and 8 h) and elimination (2, 4, 6, 8, 10, 12, 14, 16, 18 and 20 d) of 2H and 18O (subcutaneously injected). The maximum enrichment was after 5 h (R2 0·82) of injection, with an Ln linear elimination of both isotopes (P < 0·001; R2 0·99). The results of EE were similar, regardless of the sampling time used (P = 0·999). In the second study, seven male cats and seven female cats were used. Before and after isotope injection (5 h, 7 d, 10 d and 14 d), blood, saliva and urine were collected. Isotope enrichment was lower in urine (P < 0·05) and at the similar level in blood and saliva. Isotope elimination was similar for all fluids (P < 0·473). The EE calculated with blood and saliva was similar but higher for urine (P = 0·015). According to Bland-Altman statistics, blood and saliva presented low bias and high correlation (P < 0·001), but this was not observed for urine (P = 0·096). Higher EE was observed for male cats (384 (se 39) kJ/kg0·67 per d) than for female cats (337 (se 34) kJ/kg0·67 per d; P < 0·05). The sampling time for the method is flexible, and saliva can be used as a substitute for blood.

Estimating total daily energy requirements in community-dwelling older adults: validity of previous predictive equations and modeling of a new approach

BACKGROUND/OBJECTIVES

Accurate estimation of energy requirements is crucial for health maintenance and prevention of malnutrition in older adults. This study aimed to assess the accuracy of predictive equations for estimating energy requirements in older adults and to test the validity of new predictive equations for this age group.

SUBJECTS/METHODS

This is a cross-sectional study including 38 Brazilian community-dwelling older adults aged 60-84 years, who had their total energy expenditure measured by doubly labeled water (TEE_DLW). The energy expenditure was compared to the Institute of Medicine (Dietary Reference Intake (DRI)) and Vinken et al. previous predictive equations and three predictive models developed in a modeling sample. The agreement was assessed using intra-class correlation coefficient, Bland-Altman plots, and Lin's concordance correlation. Accuracy was evaluated considering ±10% of the ratio between estimated and measured energy expenditure.

RESULTS

The mean (standard deviation) TEE_DLW was 2656.7 (405.6) kcal/day for men and 2168.9 (376.9) for women. Vinken et al. and both DRI equations presented moderate to good degree of agreement, while the developed models vary from fair to very good agreement in comparison to DLW. The accuracy rate was the same for both DRI equations and Vinken et al. equation (60.53%). The new equations developed in this study had accuracy in predicting TEE for Brazilian older adults varying from 43.11% to 73.68%.

CONCLUSIONS

The results corroborate the use of previous predictive equations for estimating energy requirements in Brazilian older adults. Further studies have the potential to explore the use of the developed models to assess energy needs in this population.

Under-reporting of the energy intake in patients with type 2 diabetes

BACKGROUND

In patients with type 2 diabetes mellitus (DM), an accurate assessment of food intake is essential for clinical nutritional management. Tools such as the food frequency questionnaire (FFQ) and 24-h food record (24HR) identify dietary habits in support of dietary planning. However, it is possible that these tools have reporting errors with respect to assessing food intake, particularly energy intake (EI).

METHODS

A cross-sectional study was conducted in patients with type 2 DM. EI was assessed by the FFQ and 24HR tools. Resting energy expenditure (REE) was measured by indirect calorimetry. Data were analysed using a kappa test, t-test and Spearman's correlation coefficients. Under-reporting was assessed using the EI/REE ratio. Patients with values <1.18 and <1.10 for FFQ and 24HR, respectively, were considered as under-reporting.

RESULTS

We evaluated 55 patients [mean (SD) 62.7 (5.3) years old, duration of diabetes 11.2 (7.3) years, 52.7% female]. The mean (SD) EI assessed by FFQ was 1797.7 (641.3) and as assessed by 24HR was 1624 (484.8) kcal day^-1 . The mean (SD) REE was 1641.3 (322.3) kcal day^-1 . The mean (SD) ratios FFQ/REE and 24HR/REE were 1.11 (0.38) and 1.01 (0.30), respectively. The tools showed a moderate agreement for under-reporting of EI (kappa = 0.404; P = 0.003). Moderate and positive correlations between REE were observed with FFQ (r = 0.321; P = 0.017) and 24HR (r = 0.364; P = 0.006). According to the tools, the under-reporting was observed in approximately 65% of patients.

CONCLUSIONS

The majority of patients with type 2 DM under-reported their calorie intake, as assessed by FFQ and 24HR. REE showed a positive correlation with both tools.

Issues in Measuring and Interpreting Diet and Its Contribution to Obesity

PURPOSE OF REVIEW

This review summarises the issues related to the measurement and interpretation of dietary intake in individuals with overweight and obesity, as well as identifies future research priorities.

RECENT FINDINGS

Some aspects of the assessment of dietary intake have improved through the application of technology-based methods and the use of dietary biomarkers. In populations with overweight and obesity, misreporting bias related to social desirability is a prominent issue. Future efforts should focus on combining technology-based dietary methods with the use of dietary biomarkers to help reduce and account for the impact of these biases. Future research will be important in terms of strengthening methods used in the assessment and interpretation of dietary intake data in the context of overweight and obesity.

Validity of Dietary Assessment Methods When Compared to the Method of Doubly Labeled Water: A Systematic Review in Adults

Accuracy in quantifying energy intake (EI) using common dietary assessment methods is crucial for interpreting the relationship between diet and chronic disease. The aim of this systematic review was to evaluate the validity of dietary assessment methods used to estimate the EI of adults in comparison to total energy expenditure (TEE) measured by doubly labeled water (DLW). Articles in English across nine electronic databases, published between 1973 and February 2019 were retrieved. Studies were included if participants were adults (≥18 years) and used the DLW technique to measure TEE compared to self-reported EI. A total of 59 studies were included, with a total of 6,298 free living adults and a mean of 107 participants per study. The majority of studies including 16 studies that included a technology based method reported significant (P < 0.05) under-reporting of EI when compared to TEE, with few over-reporting EI. Misreporting was more frequent among females compared to males within recall based dietary assessment methods. The degree of under-reporting was highly variable within studies using the same method, with 24 h recalls having less variation and degree of under-reporting compared to other methods.

Food Insecurity is Associated with Maladaptive Eating Behaviors and Objectively Measured Overeating

OBJECTIVE

The association between food insecurity and obesity may be partially explained by overeating in response to unpredictable food availability cycles. The aim of this study was to measure objective food intake in food-insecure individuals.

METHODS

Eighty-two volunteers (53 m; BMI 29 ± 7; 38 ± 12 years) were admitted to our inpatient Clinical Research Unit and completed the Food Security Short Form, Three-Factor Eating Questionnaire, Gormally Binge Eating Scale, and body composition assessment (dual-energy x-ray absorptiometry). After 5 days of a weight-maintaining diet, participants self-selected food from an ad libitum vending machine paradigm for 3 days. Mean daily intake (kilocalories), macronutrient intake, and percentage of weight-maintaining energy needs (%WMEN) were calculated.

RESULTS

Based on Food Security Short Form cutoffs, food-insecure participants (n = 46; 56%) had higher body weight (P = 0.04), fat-free mass (P = 0.05), disinhibition (P = 0.008), hunger (P = 0.02), and binge-eating scores (P = 0.02) but not cognitive restraint (P = 0.37) compared with food-secure individuals. They overate more kilocalories (P = 0.001), %WMEN (P = 0.003), fat (P = 0.003), and carbohydrates (P = 0.004) during the vending machine paradigm, continued to increase their hourly rate of kilocalories (group × time; β = 37.7 cumulative kcal/h; P < 0.0001), and ate more total kilocalories across the 72 hours (β = 47.09 kcal/h; P = 0.003).

CONCLUSIONS

Food insecurity may amplify susceptibility to weight gain via overeating during times of unlimited food access.

Dietary intake and adequacy of energy and nutrients in Mexican older adults: results from two National Health and Nutrition Surveys

Objective:

To describe energy and nutrient intakes and their adequacies in older Mexican adults participating in the National Health and Nutrition Survey (Ensanut) 2006 and 2012.

Materials and methods:

Dietary information was obtained through a semiquantitative food frequency questionnaire (SFFQ) from 526 adults 60 y and older participating in Ensanut 2012 and 3 326 in Ensanut 2006 in Mexico. Quantile and logistic regression models were used to obtain medians and marginal effects of each nutrient, adjusting by confounders and survey design.

Results:

Dietary intake of energy and nutrients was similar in both surveys. Most common micronutrients at risk of dietary deficiency were, for vitamins: A, B-12, C, D and folate, and for minerals: calcium, iron and zinc, in both surveys. Excessive intake of sugar and saturated fat and low fiber intake were common.

Conclusions:

Diet in older Mexican adults is low in micronutrient essentials, and excessive in fat and sugar. Attention to the diet in this age group through targeted interventions is necessary to promote a healthy diet.

High Fat and Sugar Consumption During Ad Libitum Intake Predicts Weight Gain

OBJECTIVE

To determine how macronutrients accompanying foods with high energy density (EnDen) affect energy intake and weight gain.

METHODS

A total of 214 subjects (130 males, BMI: 32 ± 7 kg/m² ) ate ad libitum for 3 days. Food intake was expressed as the mean daily intake (in kilocalories) and the percentage of weight-maintaining energy needs (%WMEN). EnDen was expressed as the ratio of intake (in kilocalories) to food weight (in grams). Food choices were expressed as absolute and percent intake (kilocalories), categorized as high in fat (HF; ≥ 45% kcal) or low in fat (LF; < 20% kcal), and further categorized as high in complex carbohydrates (≥ 30% kcal), high in simple sugars (HSS; ≥ 30% kcal), or high in protein (HP; ≥ 13% kcal). Follow-up weights were available from 99 subjects (65 males, range: 6 months to 11 years).

RESULTS

EnDen was associated with BMI (r = 0.28, P < 0.0001), percent body fat (r = 0.18, P = 0.007), and percent intake from HF/HP (r = 0.34, P < 0.0001), HF/HSS (r = 0.31, P < 0.0001), LF/HP (r = -0.37, P < 0.0001) and LF/HSS (r = -0.68, P < 0.0001). The %WMEN was associated with EnDen (r = 0.16, P = 0.01), HF/HSS (r = 0.33, P < 0.0001), and LF/HP intake (r = -0.25, P = 0.0002). In a multivariate model, only HF/HSS intake remained a significant predictor of %WMEN (β = 1.4% per 1% change, P < 0.0001). The percent intake from HF/HSS (r = 0.23, P = 0.02), not EnDen (P = 0.54), was associated with weight gain, even after adjusting for follow-up time (in years) and covariates.

CONCLUSIONS

Relatively greater consumption of HF/HSS foods independently predicted overeating and weight gain. Nutrient compositions of high-EnDen foods may be important for weight management.

Total energy expenditure in adults aged 65 years and over measured using doubly-labelled water: international data availability and opportunities for data sharing

BACKGROUND

Increasing population lifespan necessitates a greater understanding of nutritional needs in older adults (65 year and over). A synthesis of total energy expenditure in the older population has not been undertaken and is needed to inform nutritional requirements. We aimed to establish the extent of the international evidence for total energy expenditure (TEE) using doubly-labelled water (DLW) in older adults (65 years and over), report challenges in obtaining primary data, and make recommendations for future data sharing.

METHODS

Four databases were searched to identify eligible studies; original research of any study design where participant level TEE was measured using DLW in participants aged ≥65 years. Once studies were identified for inclusion, authors were contacted where data were not publicly available.

RESULTS

Screening was undertaken of 1223 records; the review of 317 full text papers excluded 170 records. Corresponding or first authors of 147 eligible studies were contacted electronically. Participant level data were publicly available or provided by authors for 45 publications (890 participants aged ≥65 years, with 248 aged ≥80 years). Sixty-seven percent of the DLW data in this population were unavailable due to authors unable to be contacted or declining to participate, or data being irretrievable.

CONCLUSIONS

The lack of data access limits the value of the original research and its contribution to nutrition science. Openly accessible DLW data available through publications or a new international data repository would facilitate greater integration of current research with previous findings and ensure evidence is available to support the needs of the ageing population.

TRIAL REGISTRATION

The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO), registration number CRD42016047549 .

Validity of the Self- Mini Nutritional Assessment (Self- MNA) for the Evaluation of Nutritional Risk. A Cross- Sectional Study Conducted in General Practice

INTRODUCTION

Malnutrition is a frequent condition in the elderly especially in hospitals and in nursing homes, and even among the free-living elders the prevalence is not negligible (5-10%). Awareness towards malnutrition is still limited. The lack of time for nutritional assessment by the overcommitted healthcare personnel, including the general practitioners (GPs), may represent one possible explanation for limited recognition of malnutrition. Therefore, a self-administered instrument could be useful in raising alert on the GPs and allow early detection of malnutrition and early care provision. The aim of the present study was to analyze the validity of the Self-MNA that takes cue from the Mini Nutritional Assessment- Short Form (MNA-SF) and has been adapted to be self-administered by free-living elderly subjects.

METHODS

Participants were recruited from patients referring to the GP offices in Italy. Nutritional evaluation was performed through the administration of Full-MNA, MNA-SF and Self-MNA. The comorbidity level was assessed through the Cumulative Illness Rating Scale (CIRS). The level of difficulty in filling out the test was reported by the participants, and the time spent to complete the Self-MNA was also registered.

RESULTS

A total of 226 subjects, 125 women and 101 men (75.1 ±8 and 75.3 ± 8 years old, respectively; p=0.89) were enrolled, and 214 (94.7%) of them completed the Self-MNA. According with the Full-MNA test score, 8.4% of women and 3.5% of men were classified as malnourished, whereas 32.7% of women and 31.4% of men were at risk of malnutrition. Agreement between Self-MNA and Full-MNA, and Self-MNA vs. MNA-SF was classified as "moderate" (k = 0.476 and 0.496 respectively; p < 0.001). Self-MNA showed a fair predictive value compared to the Full-MNA and MNA-SF tests (76.6 and 79.9%, respectively) with a barely adequate sensitivity (70.9 and 75.4%, respectively). The analysis of the characteristics of FN (false negative: subjects who were considered at risk of malnutrition or malnourished at Full-MNA but not at Self-MNA) showed that the clinical and functional aspects of these subjects (age, comorbidity and severity, time necessary to complete the Self-MNA, decrease in food intake, severe illness in the past 3 months, dementia and depression, fluid intake, need for feeding assistance, arm and calf circumferences) were very similar to the characteristics of true positive subjects. Patients required 6.7 ± 4.5 minutes to complete the test and 25 subjects (11.7%) needed more than 10 minutes, up to a maximum of 30 minutes. Patients who stated a greater difficulty were older (79.8 ± 7 vs. 73.5 ± 7 years; p<0.001), they were more «malnourished» at Full-MNA (10.7 vs. 1,7%; p= 0.006) and clinical status was characterized by a higher severity index (1.72 ± 0.6 vs. 1.41 ± 0.4; p= 0.008).

CONCLUSION

In the present study we investigated the validity of the Self-MNA in a sample of free-living elderly subjects. The results obtained confirm the validity of the test that may represent a useful tool for the GPs, although some important limitations need to be considered, limiting its use in clinical practice.

Measurement Errors in Dietary Assessment Using Self-Reported 24-Hour Recalls in Low-Income Countries and Strategies for Their Prevention

Securing accurate measurements of dietary intake across populations is challenging. Of the methods, self-reported 24-h recalls are often used in low-income countries (LICs) because they are quick, culturally sensitive, do not require high cognitive ability, and provide quantitative data on both foods and nutrients. Measuring intakes via 24-h recalls involves 1) collecting data on food intakes, 2) the appropriate use of relevant food-composition data for calculating nutrient intakes, and 3) statistically converting observed intakes to "usual intakes" for evaluating nutrient adequacy or relations between foods and nutrients and health outcomes. Like all dietary methods, 24-h recalls are subject to random errors that lower the precision and systematic errors that can reduce accuracy at each stage of the measurement protocol. Research has identified the potential sources of measurement errors in 24-h recall protocols and emphasized that sources of random error can be reduced by incorporating standardized quality-control procedures and collecting more than one 24-h recall per person, with the number depending on the study objective. Careful design of the initial 24-h recall protocol can take into account potential sources of systematic error, such as day of the week, season, age, etc. Other sources of systematic error (e.g., energy underreporting) can best be detected by including a reference measure (e.g., doubly labeled water to measure energy expenditure). Alternatively, 24-h recall intakes of energy can be compared with same-day weighed intakes. Nevertheless, very few studies in LICs have assessed the validity of 24-h recalls in their study settings or adopted recommended standardized protocols to mitigate random errors. Hence, efforts should be made to improve the assessment, analysis, and interpretation of self-reported 24-h recall data for population studies in LICs. Accurate and precise dietary intake data at the national level can play an essential role in informing food, nutrition, and agricultural policies; food fortification planning; and compliance to food-based dietary guidelines.

Doubly Labeled Water Method and Accelerometer for the Measurement of Energy Expenditure in Human Immunodeficiency Virus-Infected Patients

BACKGROUND

Several studies have reported increased resting energy expenditure (REE) in human immunodeficiency virus (HIV)-infected patients with HIV-associated lipodystrophy syndrome (HALS). However, limited data exist on the total energy expenditure (TEE). This study was aimed at evaluating the REE and TEE of HIV-infected patients with and without HALS by using the doubly labeled water (DLW) technique and the activity monitor based on accelerometry system (AM), and comparing the results obtained using both methods.

METHODS

Evaluated total of 45 HIV+ men undergoing antiretroviral therapy, including 18 LIPO- (without lipodystrophy) and 27 LIPO+ (with lipodystrophy) individuals were evaluated. Habitual physical activity patterns were measured by using the ActivPAL™ AM system, REE by indirect calorimetry, and TEE by DLW and AM.

RESULTS

No significant differences were found between LIPO- and LIPO+ in REE (1,433 ± 196 vs. 1,510 ± 203 kcal), TEE-DLW (2,691 ± 856 vs. 2,618 ± 415 kcal) and TEE-AM (2,560 ± 458 vs. 2,594 ± 456 kcal), respectively. RQ was a predictor of REE in LIPO+. TEE estimated by the AM had a moderate correlation with DLW, but there was a wide variance in the intra-subject results.

CONCLUSIONS

TEE is not increased in HIV-infected patients with HALS. AM should be used with caution for TEE evaluation during clinical practice.

Misreport of energy intake assessed with food records and 24-h recalls compared with total energy expenditure estimated with DLW

BACKGROUND/OBJECTIVES

The accuracy of dietary assessment methods has rarely been validated using precise techniques. The objective of this work was to evaluate the validity of energy intake (EI) estimated with food records (FRs) and 24-h recalls (24hRs) against total energy expenditure (EE) estimated by the doubly labeled water (DLW) method. In addition, the magnitude of EI under-reporting was assessed along with its associated characteristics.

SUBJECTS/METHODS

The studied group included 83 adults between 20 and 60 years of age who were recruited from a population-based sample. Within-person variation-adjusted means of EI estimated from two FRs and three 24hRs were compared with EE estimated using the DLW method multiple-point protocol. The Wilcoxon signed-rank test was used to assess the differences between EI and EE, whereas Bland-Altman and survival-agreement plots assessed the agreement between the estimates.

RESULTS

The mean EE (2540 kcal) was greater than the mean reported EI for both dietary assessment methods (FR: 1774 kcal; 24hR: 1658 kcal, P<0.01). The frequency of under-reporting was lower (20%) for EI estimated with the 24hR than that estimated with the FR (32%). Men presented lower magnitude of under-reported EI than women did. For women, differences between EI and EE were lower with FR than with 24hR. Overall, FR and 24hR showed similar performance. The mean under-reported EI was ~30% for both methods.

CONCLUSIONS

Irregular meal habits, smoking and low education were associated with the under-report of EI. Both FR and 24hR are subjected to bias suggesting the need of refining the procedures applied in dietary assessment methods.

Reproducibility of the Online Food4Me Food-Frequency Questionnaire for Estimating Dietary Intakes across Europe

BACKGROUND

Accurate dietary assessment is key to understanding nutrition-related outcomes and is essential for estimating dietary change in nutrition-based interventions.

OBJECTIVE

The objective of this study was to assess the pan-European reproducibility of the Food4Me food-frequency questionnaire (FFQ) in assessing the habitual diet of adults.

METHODS

Participants from the Food4Me study, a 6-mo, Internet-based, randomized controlled trial of personalized nutrition conducted in the United Kingdom, Ireland, Spain, Netherlands, Germany, Greece, and Poland, were included. Screening and baseline data (both collected before commencement of the intervention) were used in the present analyses, and participants were included only if they completed FFQs at screening and at baseline within a 1-mo timeframe before the commencement of the intervention. Sociodemographic (e.g., sex and country) and lifestyle [e.g., body mass index (BMI, in kg/m(2)) and physical activity] characteristics were collected. Linear regression, correlation coefficients, concordance (percentage) in quartile classification, and Bland-Altman plots for daily intakes were used to assess reproducibility.

RESULTS

In total, 567 participants (59% female), with a mean ± SD age of 38.7 ± 13.4 y and BMI of 25.4 ± 4.8, completed both FFQs within 1 mo (mean ± SD: 19.2 ± 6.2 d). Exact plus adjacent classification of total energy intake in participants was highest in Ireland (94%) and lowest in Poland (81%). Spearman correlation coefficients (ρ) in total energy intake between FFQs ranged from 0.50 for obese participants to 0.68 and 0.60 in normal-weight and overweight participants, respectively. Bland-Altman plots showed a mean difference between FFQs of 210 kcal/d, with the agreement deteriorating as energy intakes increased. There was little variation in reproducibility of total energy intakes between sex and age groups.

CONCLUSIONS

The online Food4Me FFQ was shown to be reproducible across 7 European countries when administered within a 1-mo period to a large number of participants. The results support the utility of the online Food4Me FFQ as a reproducible tool across multiple European populations. This trial was registered at clinicaltrials.gov as NCT01530139.

A Lebanese dietary pattern promotes better diet quality among older adults: findings from a national cross-sectional study

Background

Proper nutrition is critical for healthy aging and maintaining functional independence. Limited research has been done on the assessment of dietary patterns of older adults and their association with diet quality indices. This study was conducted to identify, characterize, and evaluate the dietary patterns and diet quality of older adults in Lebanon, a middle-income country undergoing nutrition transition.

Methods

A cross-sectional population-based study was conducted on a nationally representative sample of community-dwelling older adults aged >50 years (n = 525). Socio-demographic, anthropometric, and lifestyle variables were collected through interviews, and dietary intake was assessed using a semi-quantitative food frequency questionnaire (FFQ). Five commonly used diet quality indices (DQIs) were calculated, including the Alternative Healthy Eating Index (AHEI), the alternate Mediterranean diet score (aMed), the Dietary Approach to Stop Hypertension (DASH) style diet score, and the Lebanese Mediterranean Diet index. Dietary patterns (DPs) were derived using exploratory factor analysis. Associations of identified DPs with energy, energy-adjusted nutrients, and DQIs were evaluated by Pearson’s correlations. Multiple linear regression analyses were used to examine correlates of DPs.

Results

Three DPs were derived: Lebanese, Western, and High Protein/Alcohol patterns. The Lebanese pattern had highest correlations with fiber, folate, vitamin C, and all five DQIs. The Western was positively associated with energy and sodium and was inversely correlated with fiber, most vitamins, and a number of DQIs, namely AHEI, aMED, and DASH-style diet score. Highest correlations with intakes of proteins and fat were observed for the High Protein/Alcohol pattern. The Lebanese pattern was associated with female gender, education, nonsmoking and physical activity, whereas the Western pattern was associated with adverse health behaviors, including smoking, skipping breakfast, and physical inactivity.

Conclusions

Of the three identified patterns, the Lebanese DP was associated with better diet quality and healthier lifestyle behaviors while the Western pattern implicated a lower quality diet. Public health programs promoting prudent diets, including the Mediterranean and Lebanese DPs, are needed to improve the diet quality of middle-aged and older adults in an attempt to improve their functionality and quality of life.

Energy Intake in Socially Vulnerable Women Living in Brazil: Assessment of the Accuracy of Two Methods of Dietary Intake Recording Using Doubly Labeled Water

BACKGROUND

Diet is related to the prevention of chronic diseases, but assessing dietary intake is a complex task, especially in socially vulnerable populations.

OBJECTIVES

To assess the accuracy of the 24-hour food recall (24HFR) and the food frequency questionnaire (FFQ) methods in socially vulnerable women in Brazil and compare these methods against doubly labeled water (DLW).

DESIGN

Cross-sectional study. Energy intake (EI) was measured using 3 24HFRs and 1 FFQ. Total energy expenditure (TEE) was measured using DLW. Cutoff points were calculated to assess underreporting and overreporting using both the difference and the ratio between the EI and TEE.

PARTICIPANTS/SETTING

Sixty-seven socially vulnerable, nondieting adult women with stable body weight and mothers of malnourished children.

MAIN OUTCOME MEASURES

EI, in kilocalories, derived from 24HFR and FFQ.

STATISTICAL ANALYSES

Repeated measures analysis of variance was used to compare EI and TEE and Bland-Altman graphs were plotted to assess the agreement between these variables. Spearman correlation coefficient between the ratio of EI to TEE and socioeconomic or anthropometric variables was calculated.

RESULTS

Mean TEE was 2,186 kcal (95% CI 2,063 to 2,309 kcal). EI obtained through 24HFR (mean=1,848.6 kcal [95% CI 1,737.5 to 1,959.7 kcal]) was significantly lower than TEE (P=0.01), and significantly lower than the EI obtained through FFQ (mean=2,084.5 [95% CI 1,929.0 to 2,240.0 kcal]; P<0.01). There were no statistically significant differences between the EI values of FFQ and TEE (P=0.89). The distribution of underreporters, nonunderreporters, and overreporters were more homogenous in the FFQ method. There was a positive correlation between body fat percentage and underreporting in the FFQ method (r=0.245; P=0.046).

CONCLUSIONS

The methods of assessing dietary intake in our study showed poor agreement with TEE obtained by DLW. These may, therefore, not be the most suitable methods for assessing EI in this population.