Underreporting of Energy Intake in Developing Nations

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.

Development and validation of a photographic atlas of food portions for accurate quantification of dietary intakes in China

Background

Accurate estimation of food portion sizes remains an important challenge in dietary data collection. The present study aimed to develop a food atlas with adequate visual reference to improve the accuracy of dietary surveys in China.

Methods

A food atlas for dietary surveys in China was developed using three visual reference systems, namely, regularly placed food portions, the two‐dimensional background coordinates and common objects known in daily life. The atlas was validated by estimating a meal before and after using the food atlas, and differences in weight estimation were compared using a paired t‐test. In total, 50 college students participated in the study.

Results

After determination of food varieties; design of the food display; purchase, processing, cooking and weighing of food; photographing food; post‐image processing and data processing, a total of 799 pictures of 303 types of food and two types of tableware were produced. The mean value of food weight estimated with the atlas was closer to the actual weight, and the variation range of these values was smaller and more stable than that estimated without the atlas. The differences estimated before and after using the atlas for all foods were significant (P < 0.05). Comparing the differences in weight before using the atlas, the error ranges of food samples were reduced.

Conclusions

A food atlas has been developed for a retrospective dietary survey in China, which can be used to enable a better understanding of nutritional adequacy in the Chinese population.

Effects of food supplementation on cognitive function, cerebral blood flow, and nutritional status in young children at risk of undernutrition: randomized controlled trial

OBJECTIVE

To assess the effects of food supplementation on improving working memory and additional measures including cerebral blood flow in children at risk of undernutrition.

DESIGN

Randomized controlled trial.

SETTING

10 villages in Guinea-Bissau.

PARTICIPANTS

1059 children aged 15 months to 7 years; children younger than 4 were the primary population.

INTERVENTIONS

Supervised isocaloric servings (≈1300 kJ, five mornings each week, 23 weeks) of a new food supplement (NEWSUP, high in plant polyphenols and omega 3 fatty acids, within a wide variety and high fortification of micronutrients, and a high protein content), or a fortified blended food (FBF) used in nutrition programs, or a control meal (traditional rice breakfast).

MAIN OUTCOME MEASUREMENTS

The primary outcome was working memory, a core executive function predicting long term academic achievement. Additional outcomes were hemoglobin concentration, growth, body composition, and index of cerebral blood flow (CBFi). In addition to an intention-to-treat analysis, a predefined per protocol analysis was conducted in children who consumed at least 75% of the supplement (820/925, 89%). The primary outcome was assessed by a multivariable Poisson model; other outcomes were assessed by multivariable linear mixed models.

RESULTS

Among children younger than 4, randomization to NEWSUP increased working memory compared with the control meal (rate ratio 1.20, 95% confidence interval 1.02 to 1.41, P=0.03), with a larger effect in the per protocol population (1.25, 1.06 to 1.47, P=0.009). NEWSUP also increased hemoglobin concentration among children with anemia (adjusted mean difference 0.65 g/dL, 95% confidence interval 0.23 to 1.07, P=0.003) compared with the control meal, decreased body mass index z score gain (-0.23, -0.43 to -0.02, P=0.03), and increased lean tissue accretion (2.98 cm2, 0.04 to 5.92, P=0.046) with less fat (-5.82 cm2, -11.28 to -0.36, P=0.04) compared with FBF. Additionally, NEWSUP increased CBFi compared with the control meal and FBF in both age groups combined (1.14 mm2/s×10-8, 0.10 to 2.23, P=0.04 for both comparisons). Among children aged 4 and older, NEWSUP had no significant effect on working memory or anemia, but increased lean tissue compared with FBF (4.31 cm2, 0.34 to 8.28, P=0.03).

CONCLUSIONS

Childhood undernutrition is associated with long term impairment in cognition. Contrary to current understanding, supplementary feeding for 23 weeks could improve executive function, brain health, and nutritional status in vulnerable young children living in low income countries. Further research is needed to optimize nutritional prescriptions for regenerative improvements in cognitive function, and to test effectiveness in other vulnerable groups.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03017209.

Validation of a digitally displayed photographic food portion-size estimation aid among women in urban and rural Malawi

Objective:

To validate digitally displayed photographic portion-size estimation aids (PSEA) against a weighed meal record and compare findings with an atlas of printed photographic PSEA and actual prepared-food PSEA in a low-income country.

Design:

Participants served themselves water and five prepared foods, which were weighed separately before the meal and again after the meal to measure any leftovers. Participants returned the following day and completed a meal recall. They estimated the quantities of foods consumed three times using the different PSEA in a randomized order.

Setting:

Two urban and two rural communities in southern Malawi.

Participants:

Women (n 300) aged 18–45 years, equally divided by urban/rural residence and years of education (≤4 years and ≥5 years).

Results:

Responses for digital and printed PSEA were highly correlated (>91 % agreement for all foods, Cohen’s κw = 0·78–0·93). Overall, at the individual level, digital and actual-food PSEA had a similar level of agreement with the weighed meal record. At the group level, the proportion of participants who estimated within 20 % of the weighed grams of food consumed ranged by type of food from 30 to 45 % for digital PSEA and 40–56 % for actual-food PSEA. Digital PSEA consistently underestimated grams and nutrients across foods, whereas actual-food PSEA provided a mix of under- and overestimates that balanced each other to produce accurate mean energy and nutrient intake estimates. Results did not differ by urban and rural location or participant education level.

Conclusions:

Digital PSEA require further testing in low-income settings to improve accuracy of estimations.

Lack of negative autocorrelations of daily food intake on successive days challenges the concept of the regulation of body weight in humans

According to most theories, the amount of food consumed on one day should be negatively related to intake on subsequent days. Several studies have observed such a negative correlation between the amount consumed on one day and the amount consumed two to four days later. The present study attempted to replicate this observation by re-examining data from a previous study where all food ingested over a 30-day observation period was measured. Nine male and seven female participants received a vegan diet prepared, dispensed, and measured in a metabolic unit. Autocorrelations were performed on total food intake consume on one day and that consumed one to five days later. A significant positive correlation was detected between the weight of food eaten on one day and on the amount consumed on the following day (r = 0.29, 95% CI [0.37, 0.20]). No correlation was found between weights of food consumed on one day and up to twelve days later (r = 0.09, 95% CI [0.24, -0.06]), (r = 0.11, 95% CI [0.26, -0.0.26]) (r = 0.02, 95% CI [0.15, -0.7]) (r = -0.08, 95% CI [0.11, -0.09]). The same positive correlation with the previous day's intake was observed at the succeeding breakfast but not at either lunch or dinner. However, the participants underestimated their daily energy need resulting in a small, but statistically significant weight loss. Daily food intake increased slightly (13 g/day), but significantly, across the 30-day period. An analysis of the previous studies revealed that the negative correlations observed by others was caused by a statistical artifact resulting from normalizing data before testing for the correlations. These results, when combined with the published literature, indicate that there is little evidence that humans precisely compensate for the previous day's intake by altering the amount consumed on subsequent days. Moreover, the small but persistent increase in food intake suggests that physiological mechanisms that affect food intake operate more subtly and over much longer periods of time than the meal or even total daily intake.

Intake of essential fatty acids in Indonesian children: secondary analysis of data from a nationally representative survey

Essential fatty acids (EFA) such as α-linolenic acid (ALA) and linoleic acid (LA) are needed for healthy growth and development of children. Worldwide, reliable intake data of EFA are often lacking. The objective of this study was to investigate dietary intake of EFA in Indonesian children. Dietary intake data of 4–12-year-old children (n 45 821) from a nationally representative Indonesian survey were used to estimate median intake and distribution of population fatty acid intake. Missing data on individual fatty acids in the Indonesian food composition table were complemented through chemical analyses of national representative food samples and imputation of data from the US nutrient database. Nutrient adequacy ratios were calculated as a percentage of FAO/WHO intake recommendations. The medians of total fat intake of the children was 26·7 (10th–90th percentile 11·2–40·0) percentage of total daily energy (%E). Intakes of fatty acids were 4·05 (10th–90th percentile 1·83–7·22) %E for total PUFA, 3·36 (10th–90th percentile 1·14–6·29) %E for LA and 0·20 (10th–90th percentile 0·07–0·66) %E for ALA. Median intake of PUFA was 67 % and that of ALA 40 % of the minimum amounts recommended by FAO/WHO. These data indicate that a majority of Indonesian children has intakes of PUFA and specifically ALA that are lower than recommended intake levels. Total fat and LA intakes may be suboptimal for a smaller yet considerable proportion of children. Public health initiatives should provide practical guidelines to promote consumption of PUFA-rich foods.

Contribution of Food Groups to Energy and Nutrient Intakes in Five Developed Countries

Economic growth in developing countries and globalization of the food sector is leading to increasingly similar food consumption patterns worldwide. The aim of this study was to describe similarities and differences in the contributions of main food groups to energy and nutrient intakes in five developed countries across three continents. We obtained summary reports of national food consumption survey data from Australia, France, Denmark, the Netherlands, and the United States. Survey years spanned 2003-2012; sample size ranged from 1444 to 17,386. To mitigate heterogeneity of food groups across countries, we recategorized each survey's reported food groups and subgroups into eight main food groups and, for three countries, a ninth "mixed dishes" group. We determined the percent contribution of each food group to mean daily intakes of energy, saturated fat, sodium, fiber, and ten vitamins and minerals that are commonly under-consumed. Differences in findings from surveys utilizing a foods-as-consumed versus a disaggregated or ingredients approach to food group composition and contributions from the milk and milk products group, a source of several under-consumed nutrients, were explored. Patterns of food group contributions to energy and nutrient intakes were generally similar across countries. Some differences were attributable to the analytical approach used by the surveys. For the meat/protein, milk and milk products, vegetables, and fruit groups, percent contributions to key nutrient intakes exceeded percent contributions to energy intake. The mixed dishes group provided 10%-20% of total daily energy and a similar 10%-25% of the daily intake of several nutrients. This descriptive study contributes to an understanding of food group consumption patterns in developed countries.

Under-reporting of dietary energy intake in five populations of the African diaspora

Studies on the role of diet in the development of chronic diseases often rely on self-report surveys of dietary intake. Unfortunately, many validity studies have demonstrated that self-reported dietary intake is subject to systematic under-reporting, although the vast majority of such studies have been conducted in industrialised countries. The aim of the present study was to investigate whether or not systematic reporting error exists among the individuals of African ancestry (n 324) in five countries distributed across the Human Development Index (HDI) scale, a UN statistic devised to rank countries on non-income factors plus economic indicators. Using two 24 h dietary recalls to assess energy intake and the doubly labelled water method to assess total energy expenditure, we calculated the difference between these two values ((self-report - expenditure/expenditure) × 100) to identify under-reporting of habitual energy intake in selected communities in Ghana, South Africa, Seychelles, Jamaica and the USA. Under-reporting of habitual energy intake was observed in all the five countries. The South African cohort exhibited the highest mean under-reporting ( - 52·1% of energy) compared with the cohorts of Ghana ( - 22·5%), Jamaica ( - 17·9%), Seychelles ( - 25·0%) and the USA ( - 18·5%). BMI was the most consistent predictor of under-reporting compared with other predictors. In conclusion, there is substantial under-reporting of dietary energy intake in populations across the whole range of the HDI, and this systematic reporting error increases according to the BMI of an individual.

Measurement of breastfeeding initiation: Ethiopian mothers' perception about survey questions assessing early initiation of breastfeeding

BACKGROUND

Although breastfeeding is almost universal in Ethiopia, only 52% newborns benefited from early initiation in 2011. Early initiation is one of the recommended interventions for saving newborn lives but its potential seems not yet realized for Ethiopian newborns and there is a need for continued efforts to increase coverage. To do so, it is also relevant to focus on consistent and accurate reporting of coverage in early initiation. WHO recommends the question "how long after birth did you first put [name] to the breast?" in order to assess coverage in early initiation. It is designed to measure the time after birth when the mother attempted to initiate breastfeeding regardless of whether breast milk had arrived or not. However, it is unclear how mothers perceive this question and what their responses of time refer to. In this study, we assessed Ethiopian mothers' perception about the question assessing early initiation.

METHODS

Cognitive interviews were conducted between April and May 2013 with eligible mothers in Basona and Debrebirhan woredas (districts), 120 km away from Addis Ababa, Ethiopia.

RESULTS

A total of 49 mothers, most from Basona (n = 36) and the rest from Debrebirhan woredas (n = 13) were interviewed. No probes or follow on questions were required for mothers to understand what the WHO recommended question was about. However, further probing was needed to ascertain what maternal responses of time refer to. Accordingly, mothers' response about the timing of early initiation was related to the first time the newborn received breast milk rather than their first attempt to initiate breastfeeding. In addition, considerable probing was required to approximate and code responses of time based on the WHO coding format because some mothers were unable to assess time in minutes or hours.

CONCLUSION

The existing question is not adequate to identify intended attempts of mothers to initiate breastfeeding. We recommend revising the question as "how long after birth did you first put [name] to the breast even if your breast milk did not arrive yet?" Standard probes or follow on questions are required to avoid subjective interpretation of the indicator.

Sleep duration in elderly obese patients correlated negatively with intake fatty

STUDY OBJECTIVES

The purpose of the present study was to evaluate the relationship between sleep duration and dietary habits in elderly obese patients treated at an institute of cardiology.

METHODS

The fifty-eight volunteers were elderly patients with obesity (classified as obese according to BMI) of both genders, between 60 and 80 years of age. All participants were subjected to assessments of food intake, anthropometry, level of physical activity, and duration of sleep.

RESULTS

The men had significantly greater weight, height, and waist circumference than women. Sleep durations were correlated with dietary nutrient compositions only in men. We found a negative association between short sleep and protein intake (r = -0.43; p = 0.02), short sleep and monounsaturated fatty acids intake (r = -0.40; p = 0.03), and short sleep and cholesterol dietary intake (r = -0.50; p = 0.01).

CONCLUSIONS

We conclude that mainly in men, volunteers that had short sleep duration showed a preference for high energy-density as fatty food, at least in part, may explain the relationship between short sleep duration and the development of metabolic abnormalities.

Dietary trends in the Middle East and North Africa: an ecological study (1961 to 2007)

Objective

Middle Eastern and North African countries are undergoing nutrition transition, a transition which is associated with an increased burden of non-communicable diseases. This necessitates the evaluation of dietary patterns in these regions. The present study aimed to assess changes in dietary patterns in Middle Eastern and North African countries between 1961 and 2007.

Design

Availability of energy and fifteen main food items during 1961–2007 was examined using FAO food balance sheets from the FAOSTAT database.

Setting

Fifteen countries including nine in the Middle East and six in North Africa were selected and the average availability of total energy and different food items in these regions were compared.

Results

Over the 47 years studied, energy and food availability (apart from animal fats and alcoholic beverages) has increased in the Middle East and North Africa. In both regions the proportion of energy derived from meat and vegetable oils has increased significantly while that from cereals decreased significantly. In addition, the proportion of energy from milk and dairy products and vegetables has shown an ascending trend in North Africa while the proportion of energy from fruits has shown a descending trend in the Middle East.

Conclusions

The study results reveal an unfavourable trend towards a Westernized diet in the Middle East and, to a certain extent, in North Africa. Tailored nutritional education encouraging healthy eating for prevention of the burden of chronic diseases in these countries seems essential.

Under-reporting of food intake is frequent among Brazilian free-living older persons: a doubly labelled water study

The assessment of food intake is essential for the development of dietetic interventions. Accuracy is low when intake is assessed by questionnaires, the under-reporting of food intake being frequent. Most such studies, however, were performed in developed countries and there is little data about the older population of developing nations. This study aimed to verify the total energy expenditure (TEE) of independent older Brazilians living in an urban area, through the doubly labelled water (DLW) method and to compare it with the reported energy intake obtained through the application of a food frequency questionnaire (FFQ). Initially, 100 volunteers aged from 60 to 75 years had their body composition determined by dual-energy X-ray absorptiometry (DEXA). Five volunteers of each quartile of body fat percentage had their energy expenditure determined by DLW. The mean age of the subjects included in this phase of the study was 66.4 +/- 3.5 years, and ten of the subjects were men. The mean TEE was 2565 +/- 614 and 2154 +/- 339 kcal.day(-1) for men and women, respectively. The Physical Activity Level (PAL) was 1.58 +/- 0.31 and 1.52 +/- 0.22, respectively. Under-reporting of food intake was highly prevalent, with a mean percentage of reported intake in relation to measured TEE of -17.7%. Thus, under-reporting of food intake is highly prevalent among Brazilian independent older persons. The DLW method is an important tool in nutritional studies and its use is to be recommended in developing countries.

Characteristics of women who frequently under report their energy intake: a doubly labelled water study

BACKGROUND/OBJECTIVES

We applied three dietary assessment methods and aimed at obtaining a set of physical, social and psychological variables that can discriminate those individuals who did not underreport ('never under-reporters'), those who underreported in one dietary assessment method ('occasional under-reporters') and those who underreported in two or three dietary assessment methods ('frequent under-reporters').

PARTICIPANTS/METHODS

Sixty-five women aged 18-57 years were recruited for this study. Total energy expenditure was determined by doubly labelled water, and energy intake was estimated by three 24-h diet recalls, 3-day food records and a food frequency questionnaire. A multiple discriminant analysis was used to identify which of those variables better discriminated the three groups: body mass index (BMI), income, education, social desirability, nutritional knowledge, dietary restraint, physical activity practice, body dissatisfaction and binge-eating symptoms.

RESULTS

Twenty-three participants were 'never under-reporters'. Twenty-four participants were 'occasional under-reporters' and 18 were 'frequent under-reporters'. Four variables entered the discriminant model: income, BMI, social desirability and body dissatisfaction. According to potency indices, income contributed the most to the total discriminant power, followed in decreasing order by social desirability score, BMI and body dissatisfaction. Income, social desirability and BMI were the characteristics that mainly separated the 'never under-reporters' from the under-reporters (occasional or frequent). Body dissatisfaction better discriminated the 'occasional under-reporters' from the 'frequent under-reporters'.

CONCLUSIONS

'Frequent under-reporters' have a greater BMI, social desirability score, body dissatisfaction score and lower income. These four variables seemed to be able to discriminate individuals who are more prone to systematic under reporting.

Assessing individual dietary intake from common-plate meals: a new tool for an enduring practice

Objective

The purposes of the present study were to estimate individual intake from common-plate meals among Bedouin Arabs using a modified 24 h recall questionnaire, and to evaluate reported energy intake (EI) by comparison with estimated energy requirement (EER).

Design

Weighed records were used to develop a method of quantifying intake from common plates. Reported EI and nutrient intakes were obtained from administration of the modified 24 h recall. The relative standard error (RSE) was used to evaluate the reliability of reported nutrient intakes. The FAO/WHO/United Nations University and Oxford equations and reported physical activity levels were used to compute ratios of reported EI to BMR and EER.

Setting

Population centres of traditionally semi-nomadic Bedouin Arabs undergoing sedentarization/urbanization in southern Israel.

Subjects

A convenience sample of 451 adults (aged 19–82 years).

Results

Mean (se) energy intake was 9648 (276) kJ/d (2306 (66) kcal/d) for men and 8230 (172) kJ/d (1967 (41) kcal/d) for women, of which carbohydrates accounted for 63–64 %. The nutrient intakes evaluated had RSE ratios of less than 25 %. EI:EER ratios ranged from 0·86 to 0·89, and from 0·87 to 0·93 among non-dieters who ate the usual amount on the recall day.

Conclusions

The modified 24 h recall produced plausible estimates of energy and nutrient intakes, comparable to those obtained with the 24 h recall in other populations. The modified questionnaire makes an important contribution to facilitating large-scale nutritional surveillance in the Bedouin population, and may serve as a model for modifying dietary instruments to quantify individual intake in other populations that practise common-plate eating.

A comparison of weighed and recalled intakes for schoolchildren and mothers in rural Kenya

OBJECTIVE

To evaluate the relative validity of recalled intake among schoolchildren and mothers in rural Kenya.

DESIGN

Cross-sectional study. Mothers' recall of both the schoolchild's intake and her own intake on the previous day were compared with intakes that were weighed by an interviewer in the home.

SETTING

Karurumo location of Embu District in Kenya.

SUBJECTS

A total of forty-two sets of grade 1 students and their mothers.

RESULTS

Between 08.00 and 17.00 hours, when foods were both weighed and recalled, approximately 70 % of weighed food items were recalled the next day. Under-reporting of food amounts was seen across most food categories for the recall, with added sugars, sweets and fats being most affected. The recall underestimated energy intakes by approximately 6-9 % during this period. Correlation coefficients between nutrient intakes ranged from 0.43 to 0.65, while weighted kappa values ranged from 0.22 to 0.50. Higher levels of agreement were noted for nutrient densities, with correlation coefficients between 0.46 and 0.82 and weighted kappa values between 0.30 and 0.73.

CONCLUSIONS

Although the recall method provides an acceptable alternative to the more labour-intensive and expensive food-weighing method, there is need to further improve its performance in this population through more accurate recall of single foods, especially fruits, as well as added sugars, fats, dairy products and meats, which are often added in small amounts to mixed dishes.