Is there a place for pixels in our practice? Dietitians' attitudes towards the use of photographic dietary records within the nutrition care process

Photographic records of dietary intake (PhDRs) are an innovative method for the dietary assessment and may alleviate the burden of recording intake compared to traditional methods of recording intake. While the performance of PhDRs has been evaluated, no investigation into the application of this method had occurre within dietetic practice. This study examined the attitudes of dietitians towards the use of PhDRs in the provision of nutrition care. A web-based survey on the practices and beliefs with regards to technology use among Dietitians Association of Australia members was conducted in August 2011. Of the 87 dietitians who responded, 86% assessed the intakes of clients as part of individualised medical nutrition therapy, with the diet history the most common method used. The majority (91%) of dietitians surveyed believed that a PhDR would be of use in their current practice to estimate intake. Information contained in the PhDR would primarily be used to obtain a qualitative evaluation of diet (84%) or to supplement an existing assessment method (69%), as opposed to deriving an absolute measure of nutrient intake (31%). Most (87%) indicated that a PhDR would also be beneficial in both the delivery of the intervention and to evaluate and monitor goals and outcomes, while only 46% felt that a PhDR would assist in determining the nutrition diagnosis. This survey highlights the potential for the use of PhDRs within practice. Future endeavours lie in establishing resources which support the inclusion of PhDRs within the nutrition care process.

Variability in estimation of self-reported dietary intake data from elite athletes resulting from coding by different sports dietitians

A routine activity for a sports dietitian is to estimate energy and nutrient intake from an athlete's self-reported food intake. Decisions made by the dietitian when coding a food record are a source of variability in the data. The aim of the present study was to determine the variability in estimation of the daily energy and key nutrient intakes of elite athletes, when experienced coders analyzed the same food record using the same database and software package. Seven-day food records from a dietary survey of athletes in the 1996 Australian Olympic team were randomly selected to provide 13 sets of records, each set representing the self-reported food intake of an endurance, team, weight restricted, and sprint/power athlete. Each set was coded by 3-5 members of Sports Dietitians Australia, making a total of 52 athletes, 53 dietitians, and 1456 athlete-days of data. We estimated within- and between- athlete and dietitian variances for each dietary nutrient using mixed modeling, and we combined the variances to express variability as a coefficient of variation (typical variation as a percent of the mean). Variability in the mean of 7-day estimates of a nutrient was 2- to 3-fold less than that of a single day. The variability contributed by the coder was less than the true athlete variability for a 1-day record but was of similar magnitude for a 7-day record. The most variable nutrients (e.g., vitamin C, vitamin A, cholesterol) had approximately 3-fold more variability than least variable nutrients (e.g., energy, carbohydrate, magnesium). These athlete and coder variabilities need to be taken into account in dietary assessment of athletes for counseling and research.

Análise da concordância entre o plano dietético Dietary Approaches to Stop Hypertension (DASH) e o padrão alimentar de pacientes hipertensos

A adoção do plano dietético Dietary Approaches to Stop Hypertension (DASH) tem sido enfatizado na população hipertensa como uma importante estratégia no controle dos níveis pressóricos elevados. O objetivo deste estudo foi analisar o consumo alimentar de macro e micronutrientes em pacientes hipertensos, em especial do sódio, cálcio, potássio e magnésio, e comparar com as recomendações dietéticas contidas no plano DASH. Estudo transversal envolvendo uma amostra de conveniência composta por 113 hipertensos entre 40 e 69 anos. A medida da pressão arterial (PA) foi determinada com aparelho eletrônico devidamente calibrado e a avaliação dietética obtida pelo questionário de freqüência do consumo alimentar. Os alimentos ingeridos foram convertidos em porções e distribuídos em diferentes grupos alimentares. A faixa de porções recomendadas pelo plano DASH foi determinada com base na média das necessidades energéticas desta amostra permitindo assim uma posterior comparação com o hábito alimentar dos hipertensos, utilizando um escore de pontos com pontuação máxima de 9 pontos. A amostra foi dividida em três grupos: grupo B que obteve 2,5 a 4,0 pontos (n=34; 30%), grupo M entre 4,5 a 5,0 pontos (n=43; 38%) e grupo A que obteve 5,5 a 8,0 pontos (n=36; 32%). Não foram observadas diferenças significativas na média da PA sistólica (14024 vs 13823 vs 13515 mmHg) e diastólica (8617 vs 8813 vs 8410 mmHg). Apesar do grupo A consumir mais proteínas e gordura monoinsaturada, foi detectado um excesso pronunciado na ingestão de gordura saturada, colesterol e das calorias totais, por este grupo de pacientes. No que tange a ingestão dos micronutrientes, o grupo A apresentou consumo significativamente maior de cálcio, potássio e magnésio, refletido pela maior ingestão de vegetais e frutas em comparação aos grupos B e M. A média de ingestão do sódio intrínseco foi significativamente maior no grupo A (4,12,0 vs 3,11,1 vs 2,71,1 g/dia). Foram detectadas, apenas no grupo A, correlações entre PA sistólica e o percentual de proteína (r = -0,5; p=0,002) e PA sistólica e o percentual de carboidrato (r = 0,4; p=0,02). Apenas um terço dos hipertensos avaliados apresentaram padrão alimentar mais concordante com o plano DASH e com maior ingestão de proteínas, gordura monoinsaturada, fibras, cálcio, potássio e magnésio. Entretanto, o consumo mais elevado de sódio, gordura saturada, colesterol e das calorias totais por este grupo de pacientes poderia restringir uma maior queda dos níveis pressóricos elevados.

Comparison of dietary fat and fatty acid intake estimated by the duplicate diet collection technique and estimated dietary records

Introduction A high saturated fatty acid intake is a well recognized risk factor for coronary heart disease development. More recently a high intake of n-6 polyunsaturated fatty acids (PUFA) in combination with a low intake of the long chain n-3 PUFA, eicosapentaenoic acid and docosahexaenoic acid has also been implicated as an important risk factor. Aim To compare total dietary fat and fatty acid intake measured by chemical analysis of duplicate diets with nutritional database analysis of estimated dietary records, collected over the same 3-day study period. Methods Total fat was analysed using soxhlet extraction and subsequently the individual fatty acid content of the diet was determined by gas chromatography. Estimated dietary records were analysed using a nutrient database which was supplemented with a selection of dishes commonly consumed by study participants. Results Bland & Altman statistical analysis demonstrated a lack of agreement between the two dietary assessment techniques for determining dietary fat and fatty acid intake. Conclusion The lack of agreement observed between dietary evaluation techniques may be attributed to inadequacies in either or both assessment techniques. This study highlights the difficulties that may be encountered when attempting to accurately evaluate dietary fat intake among the population.

NANA: Novel assessment of nutrition and ageing

Purpose NANA is a 3-year project using sensitively-designed technology to improve data collection and integrate information on nutrition, physical and cognitive function and mental health to identify individuals at risk of under-nourishment and improve targeting of interventions. This research will also improve our understanding of the interactions between these factors, in order to better medical treatment and social provision. The toolkit has potential for commercial development for additional segments of the population. Method This is a multi-disciplinary program involving psychology, nutrition, engineering and software engineering. The first phase is a user needs analysis and will involve consulting with a broad cross-section of older people, caregivers, and health professionals, to establish what technical approaches would be useful and acceptable. The second phase focuses on the development of an integrated measurement toolkit. There are three inter-related subsections: (i) an iterative program to develop the assessment technology, (ii) techniques for dietary assessment in older people, and (iii) a parallel investigation of measures of cognition and mental health in older people. It includes a full validation of the assessment toolkit and will comprise a comparison of the new, integrated assessment with traditional 'pen and paper' methods with volunteers having the equipment installed in their homes.

Online dietary intake estimation: The Food4Me food frequency questionnaire

Background: Dietary assessment methods are important tools for nutrition research. Online dietary assessment tools have the potential to become invaluable methods of assessing dietary intake because, compared with traditional methods, they have many advantages including the automatic storage of input data and the immediate generation of nutritional outputs. Objective: The aim of this study was to develop an online food frequency questionnaire (FFQ) for dietary data collection in the “Food4Me” study and to compare this with the validated European Prospective Investigation of Cancer (EPIC) Norfolk printed FFQ. Methods: The Food4Me FFQ used in this analysis was developed to consist of 157 food items. Standardized color photographs were incorporated in the development of the Food4Me FFQ to facilitate accurate quantification of the portion size of each food item. Participants were recruited in two centers (Dublin, Ireland and Reading, United Kingdom) and each received the online Food4Me FFQ and the printed EPIC-Norfolk FFQ in random order. Participants completed the Food4Me FFQ online and, for most food items, participants were requested to choose their usual serving size among seven possibilities from a range of portion size pictures. The level of agreement between the two methods was evaluated for both nutrient and food group intakes using the Bland and Altman method and classification into quartiles of daily intake. Correlations were calculated for nutrient and food group intakes. Results: A total of 113 participants were recruited with a mean age of 30 (SD 10) years (40.7% male, 46/113; 59.3%, 67/113 female). Cross-classification into exact plus adjacent quartiles ranged from 77% to 97% at the nutrient level and 77% to 99% at the food group level. Agreement at the nutrient level was highest for alcohol (97%) and lowest for percent energy from polyunsaturated fatty acids (77%). Crude unadjusted correlations for nutrients ranged between .43 and .86. Agreement at the food group level was highest for “other fruits” (eg, apples, pears, oranges) and lowest for “cakes, pastries, and buns”. For food groups, correlations ranged between .41 and .90. Conclusions: The results demonstrate that the online Food4Me FFQ has good agreement with the validated printed EPIC-Norfolk FFQ for assessing both nutrient and food group intakes, rendering it a useful tool for ranking individuals based on nutrient and food group intakes.

The validation of a computer-based food record for older adults: the Novel Assessment of Nutrition and Ageing (NANA) method

Dietary assessment in older adults can be challenging. The Novel Assessment of Nutrition and Ageing (NANA) method is a touch-screen computer-based food record that enables older adults to record their dietary intakes. The objective of the present study was to assess the relative validity of the NANA method for dietary assessment in older adults. For this purpose, three studies were conducted in which a total of ninety-four older adults (aged 65–89 years) used the NANA method of dietary assessment. On a separate occasion, participants completed a 4 d estimated food diary. Blood and 24 h urine samples were also collected from seventy-six of the volunteers for the analysis of biomarkers of nutrient intake. The results from all the three studies were combined, and nutrient intake data collected using the NANA method were compared against the 4 d estimated food diary and biomarkers of nutrient intake. Bland–Altman analysis showed a reasonable agreement between the dietary assessment methods for energy and macronutrient intake; however, there were small, but significant, differences for energy and protein intake, reflecting the tendency for the NANA method to record marginally lower energy intakes. Significant positive correlations were observed between urinary urea and dietary protein intake using both the NANA and the 4 d estimated food diary methods, and between plasma ascorbic acid and dietary vitamin C intake using the NANA method. The results demonstrate the feasibility of computer-based dietary assessment in older adults, and suggest that the NANA method is comparable to the 4 d estimated food diary, and could be used as an alternative to the food diary for the short-term assessment of an individual’s dietary intake.

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: Participantsfromthe Food4Me study, a 6-mo,Internet-based, randomizedcontrolled 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 includedonly iftheycompleted FFQs at screeningand at baselinewithin a 1-mo timeframebeforethe commencement oftheintervention. Sociodemographic (e.g., sex andcountry) andlifestyle[e.g.,bodymass index(BMI,inkg/m2)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 6 SD age of 38.7 6 13.4 y and BMI of 25.4 6 4.8, completed bothFFQswithin 1 mo(mean 6 SD: 19.26 6.2d).Exact plus adjacent classification oftotal energy intakeinparticipants was highest in Ireland (94%) and lowest in Poland (81%). Spearman correlation coefficients (r) 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.

Validation of a food-frequency questionnaire assessment of carotenoid and vitamin E intake using weighed food records and plasma biomarkers: the method of triads model.

Background: Reliability or validity studies are important for the evaluation of measurement error in dietary assessment methods. An approach to validation known as the method of triads uses triangulation techniques to calculate the validity coefficient of a food-frequency questionnaire (FFQ).

Objective: To assess the validity of an FFQ estimates of carotenoid and vitamin E intake against serum biomarker measurements and weighed food records (WFRs), by applying the method of triads. Design: The study population was a sub-sample of adult participants in a randomised controlled trial of b-carotene and sunscreen in the prevention of skin cancer. Dietary intake was assessed by a self-administered FFQ and a WFR. Nonfasting blood samples were collected and plasma analysed for five carotenoids (a-carotene, b-carotene, b-cryptoxanthin, lutein, lycopene) and vitamin E. Correlation coefficients were calculated between each of the dietary methods and the validity coefficient was calculated using
the method of triads. The 95% confidence intervals for the validity coefficients were estimated using bootstrap sampling.

Results: The validity coefficients of the FFQ were highest for a-carotene (0.85) and lycopene (0.62), followed by b-carotene (0.55) and total carotenoids (0.55), while the lowest validity coefficient was for lutein (0.19). The method of triads could not be used for b-cryptoxanthin and vitamin E, as one of the three underlying correlations was negative.

Conclusions: Results were similar to other studies of validity using biomarkers and the method of triads. For many dietary factors, the upper limit of the validity coefficients was less than 0.5 and therefore only strong relationships between dietary exposure and disease will be detected.

24-Hour national dietary survey data : how do we interpret them most effectively?

Objective To illustrate the effect of common mistakes when using 24-hour national dietary survey data to estimate the prevalence of inadequate nutrient intakes.

Design Raw data on nutrient intake from the Australian 1995 National Nutrition Survey were adjusted for within-person variance using standard techniques and corrected for underreporting using the criteria of Goldberg et al. The distributions for six nutrients were compared with current dietary reference values from the UK, USA and Australia.

Setting A national sample of the Australian population with a 61.4% response rate.

Results Adjusting for within-person variance reduced the range of nutrient intakes to 66–80% of the raw data range and the proportion with intakes below the estimated average requirement (EAR) by up to 20%. Excluding underreporters further reduced the proportion below the EAR by up to 10%. Using the dietary reference values from different countries also resulted in some markedly different estimates. For example, the prevalence of low folate intakes ranged from <1 to 92% for adult women depending on the reference used. Except for vitamin A and protein, the prevalence of low intakes was invariably higher for women than for men.

Conclusions Estimates of the prevalence of low nutrient intakes based on raw 24-hour survey data are invariably misleading. However, even after adjustment for within-person variance and underreporting, estimates of the prevalence of low nutrient intakes may still be misleading unless interpreted in the light of the reference criteria used and supported by relevant biochemical and physiological measures of nutritional status.

Dietary patterns, assessed from a weighed food record, and survival among elderly participants from the United Kingdom

Background/Objectives: There is variability in the association between dietary intake and health outcomes across different countries, especially among the elderly. We used the gold standard dietary assessment method, a weighed food record, to examine the association between dietary pattern and mortality in a representative sample of community dwelling participants from Great Britain aged 65 years and older.

Subjects/Methods: Dietary intake was recorded at baseline in 1017 elderly participants (520 men, 497 women, mean age 76.3±7.4 years). Exploratory factor analysis was performed to examine dietary patterns and participants were followed up over an average of 9.2 years for mortality.

Results: The factor analysis revealed four interpretable principal components accounting for approximately 9.8% of the total variance, with similar patterns across sex. A ‘Mediterranean-style’ dietary pattern explained the greatest proportion of the variance (3.7%), followed by ‘health-aware’ (2.2%), ‘traditional’ (2.0%) and ‘sweet and fat’ (1.9%) factors. There were a total of 683 deaths through follow-up. After adjustment for potential confounders, only the Mediterranean-style dietary pattern remained associated with mortality (highest vs lowest tertile; hazard ratio¼0.82, 95% CI, 0.68–1.00). The benefits of the Mediterranean-style diet were only observed among women (hazard ratio¼0.71, 95% CI 0.52–0.96) although in men the traditional diet was a risk factor for mortality (hazard ratio¼1.30, 95% CI 1.00–1.71).

Conclusions: Using a gold standard approach, our results confirm previous evidence that dietary patterns are important in longevity among the elderly.

Enhancing the dietary management of general practice patients through collaborative care: perspectives of general practitioners and dietitians

Aim:  To describe how general practitioners and dietitians view their role in the dietary management of cardiac patients and to provide insights on how to facilitate collaborative care.
Methods:  Two studies were conducted in Victoria (Australia) 2005–2006. Study One: semi-structured interviews with general practitioners. Study Two: cross-sectional quantitative surveys of general practitioners and dietitians. Study One: texts were analysed using the grounded theory approach. Study Two: frequency analysis was conducted and chi-squared test for independence was used to explore the impact of age, sex and consultation time on the role and reporting scales.
Results:  Study One: Themes arising from the interviews with 30 general practitioners showed their involvement in dietary management fell into three broad roles: ‘Influencing’, ‘Coordinator’ of referrals and dietary ‘Educator’. They described dietetic education as a process that included dietary assessment, education, application of behavioural change techniques and reporting back to general practitioners. Study Two: Respondents were 248 general practitioners (30% response) and 180 dietitians (60% response). General practitioners' counselling consisted mostly of advocating for dietary change, coordinating dietetic referrals and reinforcing dietitians' recommendations. General practitioners considered dietary education as the role of dietitians. Dietitians reported a much broader role in the management of patients with some overlap with general practitioners' roles.
Conclusions:   The findings indicate the need: (i) for more structured reporting to ensure general practitioners receive appropriate information to enable them to reinforce dietetic counselling and recommendations; and (ii) to streamline the communication process in order to expedite dietitians' reports to general practitioners.

Assessing dietary intake in children and adolescents : considerations and recommendations for obesity research

Dietary intake and food habits are important contributors to the obesity epidemic. They are highly modifi able components of energy balance and are usually targeted in both obesity prevention and treatment programs. However, measurement of total diet creates challenges and can convey a large burden in terms of cost, technical expertise, impact on respondents and time. It is not surprising therefore that comprehensive reports of dietary intake in children are uncommon and, when reported, have limitations. The aim of this paper is to guide researchers and practitioners in selecting the most appropriate dietary assessment method for situations involving children and adolescents. This paper presents a summary of the issues to consider when choosing a method, a description of some of the more commonly used dietary assessment methods for young people and a series of case-studies to illustrate the range of circumstances faced when measuring dietary intake. We recommend that researchers consider the specifi c components of dietary intake addressed in their research and practice, and whether diet should be reported comprehensively or as targeted components. Other considerations include age, cognitive ability, weight status, physical activity level, respondent burden, and reliability and validity in the context of program goals and research questions. A checklist for selecting the appropriate dietary methodology is provided. This guide aims to facilitate the reporting of dietary intake and food habits in the context of obesity using valid and reliable measures, thus contributing to the evidence-base for nutrition policies and programs relating to obesity.