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Choice of methods to assess dietary intakes Rosalind S Gibson, University of Otago,

Dunedin, NZ

Choice of methods to assess dietary What will you learn from this session?
intakes of individuals or populations
• Factors influencing choice of dietary methods
• How to achieve four levels of study objectives
• What objectives can be met at each level of
objectives?
Rosalind S Gibson, • Sources of uncertainty in true usual intakes
Emeritus Professor, o measurement errors
Department of Human Nutrition, o true variation in usual intakes
University of Otago, Dunedin, New Zealand • Other factors to consider

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Factors influencing choice of methods to assess Four levels of objectives


dietary intakes of individuals or populations
Level 1: Average intake of a population group
• Level of study objectives Level 2: Proportion of population ‘at risk’ to
• Sources of uncertainty in true usual intakes inadequate intakes
• Characteristics of study group: age, degree Level 3: Usual’ intakes of individuals for ranking*
of literacy
Level 4: ‘Usual’ intakes of individuals for
• Respondent burden correlation* or diet counseling
• Available resources
• Validity and reproducibility of the methods * Requires repeated assessment. The number of
repeats depends on within-subject variation. The greater
the within-subject relative to between-subject variation
the more repeats needed
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How to achieve Level 1 Objective How to achieve Level 2 Objective

Level 1: Average intake of a population group Level 2: Proportion of the population ‘at risk’

Single 24-hr recall/record per person Measure 24-hr recalls/records on two non-
Ensure all days of the week proportionately consecutive days or three consecutive days
represented
Size of study group: depends on the precision Measure 24-hr recalls/records for two days on at
required and the between-subject variation least a subsample (40-50 per stratum) of the
participants

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Choice of methods to assess dietary intakes Rosalind S Gibson, University of Otago,
Dunedin, NZ

How to achieve Level 3 Objective How to achieve Level 4 Objective

Level 4: Usual intakes of individuals for


Level 3: Rank “usual” intakes of individuals
correlation or regression and for counselling

Multiple-replicates of 24-hr recalls/records


Multiple-replicates of 24-hr recalls/records
Number of replicates depends on within-subject
Alternatively, a semi-quantitative FFQ or diet history
variation
Note: Number of repeats depends on within-subject variation.
Alternatively, a semi-quantitative FFQ Greater the within-subject relative to between-subject variation,
the more replicates will be needed

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What objectives can be met with Level 1 data? Median (IQR) nutrient intakes of Ethiopian
children from complementary foods
Describe usual mean or median nutrient intake for a
group with a certain precision Nutrient Age 9-11 months Age 12–23 months
Demonstrate a significant difference in mean or median Energy (kcal) 169 (80, 291) 292 (193, 402)
intakes between two groups Protein (g) 3.6 (1.6, 7.3) 7.3 (4.8, 9.7)
Demonstrate a significant change in group mean Calcium (mg) 7.6 (3.6,14.2) 22.4 (10.7,112.6)
intakes based on paired measurements (eg: before
Iron (mg) 2.1 (0.9, 3.9) 4.5 (3.0,6.6)
and after intervention)
Zinc (mg) 0.9 (0.3, 1.9) 1.8 (1.4, 2.3)
Demonstrate a significant change in group mean
Niacin (mg) 0.64 (0.26, 1.35) 1.37 (0.90, 2.15)
intakes based on unpaired measurements
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From Abebe et al. (2008)

Median (IQR) nutrient intakes of two groups of Change in mean intakes (95th CI) over time in NZ
Malawian children: post-intervention toddlers based on paired measurements

Dietary quality Intervention Control


indicator (n=200) (n=81) Nutrient Baseline Post-intervention

Utilizable protein (g) 26 (20, 32) 204, 28)** Energy (kJ) 4126 (3917, 4334) 4093 (3864, 4322)
Animal protein (g) 8.9 (5.1, 12.7) 5.1 (14. 28)**
Protein (g) 41.1 (38.4, 44.1) 40.5 (37.9, 43.3)
Animal source (% energy) 5 3**
Fat (% energy) 11 (8. 15) 9 (2.9, 9.0)** Calcium (mg) 898 (821, 975) 782 (703, 861)
Heme iron (mg) 0.51 ( 0.33** Vitamin C (mg) 33.7 (27.9, 40.7) 39.0 (32.8, 46.5)
[Phy]:[Zn]* molar ratio 16 (12, 20) 20 (15, 23)**
Iron (mg) 4.7 (4.1, 5.3) 5.4 (4.7, 6.1)
[Phy]: [Zn]* < 15 (%) 23 12**
Meat / fish /
Analysis via Mann-Whitney-U-test; ** p<0.05 4.1 ( 3.1, 5.3) 10.0 (8.1, 12.4)
poultry (g)
From Yeudall et al. (2005) RSG From Szymlek Gay et al.(2009) RSG

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Choice of methods to assess dietary intakes Rosalind S Gibson, University of Otago,
Dunedin, NZ

What objectives can be met with Level 2 data? Assessing prevalence of inadequate intakes after
adjusting distribution of observed to usual intakes
Determine distribution of intakes within the group to
assess proportion at risk of inadequate intakes Adjust 1-d intakes to usual intakes
to remove effects of within-
Determine a significant change in proportion at risk of
subject day-to-day variation
inadequate intakes before and after an intervention
Select appropriate EAR
Determine a significant difference in proportion at risk Use cutpoint method for Zn to
to inadequate intakes between two groups asses percent with inadequate
intakes
Assess risk of inadequate intakes of a nutrient in
Results in a reduction in likelihood
specific sub-groups defined by variables such as
of over- or under-estimating
age, sex, geographic region (urban vs. rural), prevalence of inadequate intakes
household composition, SES, etc
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See IZiNCG Brief No. 3

Risk of inadequate intakes of iron


Proportion at risk to inadequate intakes (as %) in for urban vs. rural subjects
two groups of Malawian children
Number of Number of
Risk of inadequate
urban rural
Nutrient Intervention** Control intake of dietary Fe
subjects subjects
Low risk of inadequate
intake of iron; intakes 58 (35.8%)a 35 (23.6%)
Protein 1 7* >RNI
Vitamin A 15 17 Moderate risk of in-
adequate intakes of iron; 11 (6.8%) 25 (15.4%)
Vitamin B-12 23 41* intakes >EAR but < RNI

Calcium 34 54* High risk of inadequate


intakes of iron: intakes 10 (6.2%) 23 (14.2 %)
Available iron 19 20 <EAR
Total 79 (48.8%) 83 (51.2%)
Available zinc 26 44*
a=percentageof the total number of subjects in each category
Sig. *p<0.01 From Yeudall et al. (2005) RSG Chi-square p<0.0=0.0003 RSG

What objectives can be met with Level 3 data? Median daily intake of dairy products by decile
versus mean (SEM) PDA in adipose tissue
Assess relationship between frequency of daily
• Pentadecanoic acid (PDA) level
intake of food groups (e.g. deciles (times/d) of in adipose tissue correlates with
dairy products) versus mean level of a intake of dairy products via decile
biomarker (eg. adipose pentadecanoic acid (r= 0.31; p<0.01) based on a FFQ
(PDA)) in adults (n=503) in Costa Rica
where intake of dairy products is
rather low
Divide individuals into terciles of nutrient intake
(eg. cholesterol) and calculate the • Age, sex, BMI, smoking status
corresponding average biomarker level (eg. taken into account in analysis
plasma cholesterol) for each tercile
RSG From Baylin et al. (2002) RSG

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Choice of methods to assess dietary intakes Rosalind S Gibson, University of Otago,
Dunedin, NZ

What objectives can be met with Level 4 data? IYCF & sentinel food indicators at 9 mos in relation to
LAZ scores of Sumedang, W Java infants at 12 mos
Assess inter-relationships between nutrient intakes of
individuals to other indices of nutritional status in same persons IYCF indicators
ᵝ 95%Confidence I p-value

Minimum dietary diversity 0.01 -0.18, 0.20 0.91


Minimum acceptable diet 0.01 -0.18, 0.20 0.91
Iron-rich/iron fortified foods 0.22 0.01, 0.44 0.04*
Sentinel food indicators
Flesh foods 0.07 -0.12,0.26 0.45
Eggs 0.02 -0.18, 0.21 0.88
Animal-source foods 0.10 -0.10, 0.30 0.32
Correlations between fatty acid composition of adipose tissue Fortified infant foods 0.29 0.09, 0.48 0.04*
and fatty acid content of dietary intakes for 86 subjects
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From TjØnneland et al. (1993) * Also significant for WAZ at 12 mos Diana et al. (2017)

Measurement errors during collection of


Other factors to consider when selecting food and nutrient intake data
a method for measuring dietary intakes
• Non-response bias
• Interviewer and/or respondent biases
Sources of uncertainty in true usual intakes • Respondent memory lapses: for recalls, FFQ, DH only
• measurement errors • Incorrect estimation of portion sizes: for recalls, FQ, DH
• Omission of supplements: all methods
• true variation in usual intakes
• Errors in converting portion sizes to weight equivalents:
Characteristics of the study group for recalls, FFQ, DH
Respondent burden • Errors in handling of mixed dishes: all methods
• Coding and computation errors: all methods
Available resources • Errors in food composition databases: all methods
Validity and reproducibility of method in study setting
NB Errors may be random or systematic
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Sources of true variation in usual intakes Other factors to consider when selecting a
method for measuring dietary intakes
Between-subject variation: Depends on study group & nutrient. Characteristics of the study group and setting: Level of
Reduce by increasing number of subjects literacy and numeracy; Age group:(elderly problems with
Within-subject variation: Reduce with multiple days of intake per memory)
subject
Respondent burden: Weighed intakes in home: high respondent
Day-of-the-week effects: weekends: market days. Avoid by burden
proportionately including these days in study design
Available resources: Experience of research assistants?
Seasonal effects: Greater for intakes of foods than nutrients
Availability of dietary scales; Availability of local food
(except Vit A). Accounted for by using random days
representative of all seasons composition data
Training effect: May be severe if recalls/records on consecutive Validity and reproducibility of the proposed method: Must be
days. Avoid by completing on randomly selected non- confirmed for population group and study setting before
consecutive days adopting any method
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Choice of methods to assess dietary intakes Rosalind S Gibson, University of Otago,
Dunedin, NZ

Validity and reproducibility of dietary method Conclusions


Validity: degree to which the dietary method measures
what it is intended to measure:
Selection of a dietary method depends on :
• actual, usual, or past intake
Study objectives: 4 levels of objectives
• intake of foods and/or nutrients
Sources of uncertainty in true usual intakes
• intakes at group or individual level Characteristics of the study group
Reproducibility: degree to which a dietary method Respondent burden
yields very similar results when used repeatedly in Available resources
the same situation
Validity and reproducibility of method in study setting
NOTE: Dietary method can have good reproducibility but poor
validity. e.g: consistently over- or under-estimates of portion sizes
BUT a method with good validity cannot have poor reproducibility
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Key References

Gibson RS. Ferguson EL. An interactive 24-hour recall for


assessing the adequacy of iron and zinc intakes in developing
countries. Chapter 3. HarvestPlus Technical Monograph
Series 8. Washington. DC and Cali: International Food Policy
Research Institute (IFPRI) and International Center for
Tropical Agriculture (CIAT), 2008.
Gibson RS. Principles of Nutritional Assessment. Chapters 2
and 5. Oxford University Press, 2nd Edition, New York, 2005.
National Institute of Health NCI (2015). Dietary assessment
primer. http://dietassessmentprimer.cancer.gov/
Subar AF, Freedman LS, et al. (2015) Addressing current
criticism regarding the value of self-report dietary data. J Nutr
doi:10.3945/jn.115.219634.
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