Nutrition

The choice of the appropriate tool for measuring dietary intake depends upon the purpose of the study. Diet is usually described in terms of its nutrient content. Typical food patterns, eating habits, and the use of specific foods and groups of foods can also describe diet. Many different methods can be used for assessing dietary intake; three of the most common are food frequency questionnaires, food records and twenty-four hour diet recalls. Food Frequency Questionnaires Food Records Dietary Recalls

Food Frequency Questionnaires Description A Food Frequency Questionnaire (FFQ) is a limited checklist of foods and beverages with a frequency response section for subjects to report how often each items was consumed over a specified periods of time. Semi-quantitative FFQ collect portion size information as standardized portions or as a choice of portion sizes. Portion size information is not collected in non-quantitative FFQs. Calculations for nutrient intake can be estimated via computerized software programs that multiply the reported frequency of each food by the amount of nutrient in a serving of that food. Pros (Strengths) Representative of usual intake Preferable method of measuring intake for nutrients with very high day-to-day variability Questionnaire processing is significantly less expensive than food records or diet recalls Can be easy for literate subjects to complete as a self-administered form Suitable for very large studies Designed to rank individuals according to intake Cons (Weaknesses) Retrospective method that relies upon the respondents memory Cost may increase dramatically for questionnaires must be intervieweradministered, e.g., low literacy populations

Less sensitive to measures of absolute intake for specific nutrients Arbitrary groupings of foods may not correspond to perception of respondent Exclusion of foods popular to ethnic minority groups that are significant contributors of nutrients Possible response distortion of healthy foods (e.g., fruits, vegetables)

Examples of Food Frequency Questionnaires Harvard FFQ: developed by Walter Willett, M.D. and his colleagues at Harvard University. Portion size information is included as a part of the food item description rather than a separate listing. Block FFQ: a semi-quantitative FFQ originally developed at the National Cancer Institute under the direction of Gladys Block, PhD. Diet History Questionnaire (DHQ): a semi-quantitative FFQ which uses an embedded question approach directed by Fran Thompson and Amy Subar at the National Cancer Institute.

Food Frequency Citations Block G, Thompson FE, Hartman AM, Larkin FA, Guire KE: Comparison of two dietary questionnaires validated against multiple dietary records collected during a 1-year period. J Am Diet Assoc 92: 686-693, 1992. Block G, Woods M, Potosky A, Clifford C: Validation of a self-administered diet history questionnaire using multiple diet records. J Clin Epidemiol 43: 1327-1335,1990. Block G, Patterson B, Subar A: Fruit, vegetables, and cancer prevention: A review of the epidemiologic evidence. Nutr Cancer 18: 1-29, 1992. Field AE, Byers T, Hunter DJ, Laird NM, Manson JE, Williamson DF, Willett WC, Colditz GA: Weight cycling, weight gain, and risk of hypertension in women. Am J Epidemiol 150: 573-579, 1999. Oh K, Hu FB, Cho E, Rexrode KM, Stampfer MJ, Manson JE, Liu S, Willett WC: Carbohydrate intake, glycemic index, glycemic load, and dietary fiber in relation to risk of stroke in women. Am J Epidemiol 161: 161-169, 2005. Subar AF, Thompson FE, Kipnis V, Midthune D, Hurwitz P, McNutt S, McIntosh A, Rosenfeld S: Comparative Validation of the Block, Willett, and National Cancer Institute Food Frequency Questionnaires: The Eating at America's Table Study. Am J Epidemiol 154: 1089-1099, 2001. Thompson FE, Subar AF, Brown CC, Smith AF, Sharbaugh CO, Jobe JB, Mittl B, Gibson JT, Ziegler RG: Cognitive research enhances accuracy of food frequency

questionnaire reports: results of an experimental validation study. J Am Diet Assoc 102: 212-225, 2002. Willett WC, Stampfer MJ, Underwood BA, Speizer FE, Rosner B, Hennekens CH: Validation of a dietary questionnaire with plasma carotenoid and alpha-tocopherol levels. Am J Clin Nutr 38: 631-639, 1983. Food Frequency Websites The current source of the Block FFQ is through NutritionQuest. The company provides several types of diet questionnaires and screeners for both children and adults. In addition to diet questionnaires, NutritionQuest also supplies physical activity questionnaires and Behavior Change Systems for organizations. For more information, visit: http://www.nutritionquest.com/index.htm Dr. Walter Willett and his team at the Harvard School of Public Health have developed several versions of a FFQ used in The Nurses Health Study. To view forms of the questionnaire, visit: http://www.channing.harvard.edu/nhs/questionnaires/index.shtml Questionnaires, and other instruments developed by the Risk Factor Monitoring & Methods Branch of NCI, are used by many researchers. To view documentation, software and other supporting material, visit: http://riskfactor.cancer.gov/tools/instruments

Food Records Description A food record is a detailed description of the types and amounts of food, beverage and/or supplements documented over a prescribed period, usually 3 to 7 days. Food records are also known as Food Diaries because of the specially designed booklets that subjects use to enter the details of the food and beverages that they consume. Information on food preparation, recipes, brand names and amounts consumed included specific portion sizes is included. In addition, the name of the meal, the time of day and exact location may be required depending upon the nature of the study. Subjects may be asked to weigh and measure foods and should be trained to record intake to the level of detail needed to describe the diet and nutrients in question. At the end of the recording period, a trained interviewer meets with the respondent to clarify food details and to review the foods and portions documented. Pros (Strengths) Open ended design Easy to quantify amounts

Does not rely upon the subjects memory if used correctly Practical method to obtain information about the use of specific foods and frequency Optimal method for validating food frequency questionnaires and diet histories The act of recording dietary intake may alter eating behavior which is useful in dietary intervention programs and as a teaching tool (however, this is considerably a disadvantage in measuring usual intake)

Cons (Weaknesses) Substantial burden upon the subject Very expensive to code and analyze due to the cost of skilled personnel, computer hardware and software Requires literate and motivated individuals so has limited use in many populations Less effective in measuring usual intake due to heightened awareness, may alter behavior Significant decrease in the subjects recording intake as the number of reporting days increase Validation studies indicate usual intake may be seriously underestimated, e.g., underreporting thought to be common in women and obese individuals. Examples of Food Records Weighted Food Record: The subject weighs all food and beverages on a small household scale then records the amount eaten. (Leftover food is subtracted from the original food weight to document the exact amount consumed.) Estimated Food Record: This is the most common example of food records used in research. Study participants estimates the amount consumed by using commond household measures (e.g., spoons, cups, glasses, plates) or by using portion size estimation aides (e.g., three dimensional food models)

Food Record Citations Craig MR, Kristal AR, Cheney CL, Shattuck AL: The prevalence and impact of 'atypical' days in 4-day food records. J Am Diet Assoc 100: 421-427, 2000. Freudenheim JL, Johnson NE, Wardrop RL: Misclassification of nutrient intake of individuals and groups using one-, two-, three-, and seven-day food records. Am J Epidemiol 126: 703-713, 1987. Kristal AR, Feng Z, Coates RJ, Oberman A, George V: Associations of race/ethnicity, education, and dietary intervention with the validity and reliability of a food frequency

questionnaire: The Women's Health Trial Feasibility Study in Minority Populations. Am J Epidemiol 146: 856-869, 1997. Erratum in: Am J Epidemiol 148: 820, 1998. Millen BE, Quatromoni PA, Franz MM, Epstein BE, Cupples LA, Copenhafer DL: Population nutrient intake approaches dietary recommendations: 1991 to 1995 Framingham Nutrition Studies. J Am Diet Assoc 97: 742-749, 1997. Reeves RS, McPherson RS, Nichaman MZ, Harrist RB, Foreyt JP, Goodrick GK: Nutrient intake of obese female binge eaters. J Am Diet Assoc 101:209-215, 2001. Wilson AM, Lewis RD: Disagreement of energy and macronutrient intakes estimated from a food frequency questionnaire and 3-day diet record in girls 4 to 9 years of age. J Am Diet Assoc 104:373-378, 2004. Food Record Websites Lafene Health Center of Kansas State University includes a sample food record with instructions. To view, go to: http://www.k-state.edu/lafene/foodrecordsample.htm Dennis Gage, M.D., F.A.C.P. discusses the importance of recording food intake in his book The Thinderella Syndrome: A Practical Guide to Individualized Permanent Weight Loss. His website includes a sample food record: http://www.thethinderellasyndrome.com/food_record_the_thinderella_syndrome. html The University of Texas at Austin Health Promotion and Education Services provides their students with services to keep them healthy. Included on their web site is information on Computerized Dietary Analysis which includes a food record form and instructions. To view, visit: http://www.utexas.edu/student/health/pdfs/dailyfoodrecordform.pdf

Dietary Recalls Description The twenty-four hour dietary recall is the most widely used diet assessment method. As the name implies, the subject is asked to report all of the food, beverages and/or supplements that he has consumed for the past 24 hours or the previous day. Usually, the recall is conducted by personal interview and can be completed by using a

computer or by recording the intake on paper. The interview may be face-to-face or occur via telephone. The interviewer must be very well-trained as they are crucial in collecting accurate information through the use of probing questions. The ideal interviewer is a registered dietitian; although, non-nutritionists who have been trained in the use of a standardized instrument can be very effective. Interviewers should be very knowledgeable about foods available in the marketplace, how foods are prepared and know about regional or ethnic food habits. The interview is very structured with specific probes to help the respondent remember all of the foods eaten. Probing is useful in collecting details on how foods were prepared. It is also useful in recovering foods that are forgotten (e.g., butter on toast) or in retrieving eating occasions not originally reported by the subject such as snacks or coffee breaks. Pros (Strengths) Least amount of burden to the participant No literacy requirements of the participants Does not alter the food intake behavior Relatively rapid method of data collection; usually 30 minutes for a trained interviewer to complete a 24-hour recall Provides estimates of the average intake of large samples sizes that are comparable to other methods such as food records Cons (Weaknesses) Very expensive because it requires trained and skilled interviewers Estimation of portion sizes may be very difficult; precision may be improved through the use of food models and photographs There may be a reporting effect because individuals may wish to please the interviewer by overestimating perceived healthy foods and underreporting alcohol, high calorie and high fat foods. Detail about intake relies upon the respondents memory Examples of Dietary Recalls Three-pass recall method: The interviewer employs three distinct probing sessions (or passes) during the interview. The first pass obtains a list of foods, the second pass adds detailed descriptions, and the third pass was reviews for missing items. Automated Multiple-Pass Method (AMPM): The AMPM is a computerized dietary intake instrument that offers a guided interview of five distinct research-based steps. It is designed to elicit accurate food recall descriptions and the amount consumed by respondents. The method includes standardized questions and

possible response options for foods in the U.S.; each response option is programmed to proceed to subsequent appropriate questions. The AMPM is used for collecting dietary recalls of 5,000 Americans yearly in a national federal nutrition survey, What We Eat in America, NHANES. Data from the survey is used to assess the nutritional health of Americans and is the basis of Federal nutrition policy and regulatory decisions. Five-step Multiple Pass Approach: The Obesity Nutrition Research Center (ONRC) of the University of Pittsburgh routinely uses this type of food recall. The interviewer is thoroughly trained to use an interactive, computerized software program, the Nutrition Data System for Research (NDSR), developed by the University of Minnesota Nutrition Coordinating Center. Steps for this example of recall include: 1) Use of a Quick List where individuals are asked to briefly outline foods consumed. 2) Review of the quick list, where an interviewer uses memory prompts to help individuals recall forgotten foods. 3) Recall of time and occasion of food consumption. 4) Food details: individuals are asked to describe foods and beverages by brand name, ingredients and preparation, portion size, and quantity eaten. 5) Final review of the list to make sure that nothing was omitted.

Dietary Recall Citations Bialostosky K, Wright JD, Kennedy-Stephenson J, McDowell M, Johnson CL: Dietary intake of macronutrients, micronutrients, and other dietary constituents: United States 1988-94. Vital Health Stat 11(245): 1-158, Jul. 2002. Block G, Wakimoto P, Metz D, Fujii ML, Feldman N, Mandel R, Sutherland B: A randomized trial of the Little by Little CD-ROM: demonstrated effectiveness in increasing fruit and vegetable intake in a low-income population. Prev Chronic Dis 1: A08, 2004. Epub 2004 Jun 15. Conway JM, Ingwersen LA, Moshfegh AJ: Accuracy of dietary recall using the USDA five-step multiple-pass method in men: an observational validation study. J Am Diet Assoc 104: 595-603, 2004. Schatzkin A, Kipnis V, Carroll RJ, Midthune D, Subar AF, Bingham S, Schoeller DA, Troiano RP, Freedman LS: A comparison of a food frequency questionnaire with a 24hour recall for use in an epidemiological cohort study: results from the biomarker-based Observing Protein and Energy Nutrition (OPEN) study. Int J Epidemiol 32: 1054-1062, 2003. Shai I, Rosner BA, Shahar DR, Vardi H, Azrad AB, Kanfi A, Schwarzfuchs D, Fraser D: DEARR study. Dietary evaluation and attenuation of relative risk: multiple comparisons between blood and urinary biomarkers, food frequency, and 24-hour recall questionnaires: the DEARR study. J Nutr 135: 573-579, 2005.

Dietary Recall Websites The University of Tennessee Family and Consumer Sciences Expanded Food and Nutrition Education Program has instructions posted to their website for completing the Homemakers 24-Hour Food Recall Form. http://fcs.tennessee.edu/efnep/recallinstruc.htm A videotape on the 24-Hour Recall is available from the Oklahoma Cooperative Extension Service, Oklahoma State University for $35. For more information, go to: http://www.fcs.okstate.edu/cnep/tools/food-recall.htm The Virginia Polytechnic Institute and State University digital library and archives allows unrestricted access to a theses which includes detailed descriptions on the procedure. http://scholar.lib.vt.edu/theses/available/etd-1010976128/unrestricted/AppendixH.pdf An excellent source for detailed twenty-four hour recall information is the United States Department of Agriculture (USDA). http://www.csrees.usda.gov/nea/food/efnep/ers/documentation/24hour-recall.pdf