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Classroom Activities

Subject: Nutrition Science

Grade: Higher Ed

Topic: Dietary Assessment

Additional Details: Tools and questionnaires to assess dietary needs of patients

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Students maintain a food diary over a week, documenting everything they consume. Analyze the nutritional content and patterns to understand dietary habits.

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Conduct a 24-hour dietary recall exercise with a partner. One student plays the role of a nutritionist, while the other is a patient. Swap roles to ensure everyone gets practice.

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Summary

The 24-hour Dietary Recall (24HR) method provides comprehensive, quantitative information on individual diets by querying respondents about the type and quantity of all food and beverages consumed during the previous 24-hour period ( Gibson & Ferguson, 2008). A standard multiple pass 24HR includes having the respondent iteratively provide increasingly granular data about each food or drink and its preparation method and other attributes, as well as an estimation of the portion size consumed. The multiple pass approach has been validated in many low- and middle-income countries ( Gibson et al., 2017).

Enumerator-administered, rather than self-administered, 24HRs are often used in low- and middle-income countries because they are quick, culturally sensitive, and provide quantitative data on both foods and nutrients ( Gibson et al., 2017). Data from 24HR can be used to assess dietary patterns, food groups, or nutrient intake. In order to analyze the nutrient content, the food data must be matched with nutrient information from a food composition database. Mean intakes of foods and nutrients can be measured using a single 24HR, while assessing the "usual intake" of a population requires that repeat 24HRs are collected from a sub-sample of the study population ( Gibson & Ferguson, 2008).

Individual-level quantitative dietary data can also be used to develop a better understanding of typical household food preparation, cooking methods, and brand names of foods consumed within the household. Furthermore, if individual-level dietary data are collected in conjunction with information on socioeconomic status, education, and health, the data can be used to examine linkages between income levels and dietary choices, as well as dietary patterns and health outcomes.

While 24HRs offer a higher degree of accuracy in assessing food and nutrient intake relative to Food Frequency Questionnaires (FFQ) or estimates derived from Household Consumption and Expenditure Surveys (HCES), they are collected infrequently on nationally representative samples, and when they are collected, these data are typically not publicly available ( Pisa et al., 2018). However, there is increasing interest in, and demand for, individual-level quantitative dietary data, particularly in light of the nutrition transition and rapid food system changes ( Coates et al., 2017). For example, the Food and Agriculture Organization and World Health Organization Global Individual Food consumption data Tool (FAO/WHO GIFT) aims to make publicly available existing quantitative individual food consumption data from countries all over the world. In addition, the Global Dietary Database (GDD) provides information on dietary intakes of foods and nutrients for children and adults by age, sex, pregnancy/nursing status, rural/urban, and level of education.

Strengths:

24HRs provide quantitative estimates of individual food consumption and nutrient intake

Can structure survey-and analyses-to include information on food sources and preparation methods

Can account for foods consumed together that may enhance or inhibit micronutrient absorption

Offer a higher degree of accuracy in assessing food and nutrient intake relative to FFQs or estimates derived from HCES

Weaknesses:

Given relative complexity of 24HR surveys, significant training of enumerators is required to minimize errors in data collection

Accurately recalling the quantity consumed can be challenging for respondents and a relatively large source of error in 24HRs compared to enumerator-administered Weighed Food Records (WFR)

Data are frequently collected from small samples that are not nationally representative

As with other surveys that rely on memory and are administered by an enumerator, there is potential for recall bias and interviewer bias

Like most surveys, to capture seasonal variation data collection must span the entire year or be repeated in multiple seasons

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The 24-hour Dietary Recall (24HR) method provides comprehensive, quantitative information on individual diets by querying respondents about the type and quantity of all food and beverages consumed during the previous 24-hour period ( Gibson & Ferguson, 2008).

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Introduce nutrient analysis software through an instructional video. Follow up with a hands-on activity where students assess dietary intakes using the software.

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NutriSurvey Software for nutrition data analysis | Nutrition Assessment #nutrition

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Explore Food Frequency Questionnaires (FFQ) by reviewing different types and conducting a mock FFQ with classmates to assess dietary patterns over the last month.

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Food Frequency Questionnaire at a Glance

Purpose

To obtain frequency and, in some cases, portion size information about food and beverage consumption over a specified period of time, typically the past month or year.

Description

A food frequency questionnaire (FFQ) consists of a finite list of foods and beverages with response categories to indicate usual frequency of consumption over the time period queried. To assess the total diet, the number of foods and beverages queried typically ranges from 80 to 120.

Usual portion size can be asked separately for each food and beverage. Alternatively, portion size can be combined with frequency information by asking respondents to translate usual consumption amount to number of specified units (e.g., How often do you eat a ½ cup of rice?). Some questionnaires include portion size images in an attempt to enhance reporting [glossary term:] accuracy.

In addition to foods and beverages, FFQs often ask about the frequency of intake and dosages of commonly consumed [glossary term:] dietary supplements.

FFQs are usually self-administered; interviewer-administration is done occasionally, for example, when literacy is low.

Completing a questionnaire aimed at capturing the total dietary intake usually requires 30 to 60 minutes.

An FFQ is sometimes loosely referred to as a [glossary term:] diet history. However, the term diet history can refer generally to any instrument that asks about diet in the past ( Learn More about Diet History). It also is used to refer specifically to a meal-based FFQ or the Burke diet history, which includes a food frequency cross-check component, and its various adaptations.

To learn more about brief frequency questionnaires aimed at capturing particular aspects of the diet, see Screener Profile.

The National Cancer Institute's Diet History Questionnaire is a freely available FFQ.

Utility of Data

FFQs provide information on consumption of queried foods and beverages over the specified period.

Depending on the breadth of items queried, data can be used to assess total dietary intake and/or particular aspects of diet.

Depending on whether portion size is determined, information may represent either usual frequency of consumption only or total amount usually consumed. The term "food propensity questionnaire" is sometimes used to define an FFQ that does not include portion size.

FFQs may be better than [glossary term:] short-term instruments (e.g., 24-hour dietary recall [24HR]) at assessing intake of [glossary term:] episodically consumed foods because they attempt to directly capture usual intake over a period of time.

Data can be linked to a database to yield information about total dietary intake.

If data are linked to a nutrient composition database, nutrient intake can be determined (Learn More about Food Composition Databases for Food Frequency Questionnaires and Screeners). However, [glossary term:] total nutrient intakes cannot be estimated unless dietary supplement intake data also are included. If not linked to a nutrient composition database, frequency data can be used as a qualitative indicator of diet (Learn More about Dietary Supplements and Estimating Total Nutrient Intakes).

If data are linked to a database that translates foods and beverages into food group equivalents, such as the Food Patterns Equivalents Database, food and beverages reported can be disaggregated into their component ingredients, which can then be converted to equivalent amounts of relevant guidance-based food groups (For more information, read a factsheet on FPED products and associated data files or its application to dietary analysis .). This provides information about the consumption of food groups of particular interest, such as the total amount of fruits, vegetables, or added sugars. The frequency of food groups consumed or pattern of food groups consumed can be used as indicators of particular aspects of diet.

FFQs are sometimes used to describe a population's intake in [glossary term:] cross-sectional studies, although this is not recommended because of their large [glossary term:] systematic error, or [glossary term:] bias (a type of [glossary term:] measurement error) (see Choosing an Approach for Dietary Assessment and Key Concepts about Measurement Error).

FFQs can be used to examine [glossary term:] associations between diet and health or other variables (see Choosing an Approach for Dietary Assessment).

FFQs and screeners are the only practical methods for capturing diet in [glossary term:] retrospective case-control studies.

FFQs are sometimes used to evaluate the effectiveness of interventions to change diet (see Choosing an Approach for Dietary Assessment). However, because of concern about potential [glossary term:] differential response bias due to the tendency of the intervention group to [glossary term:] misreport their diets to a greater extent than the control group, use of an FFQ (or any self-report dietary instrument) as the sole evaluation method should be carefully considered.

Limitations of Data

Contains systematic error (see Key Concept about Measurement Error). This error can be at least partially mitigated through appropriate statistical modeling, using a less biased dietary assessment method as a [glossary term:] reference instrument, and through [glossary term:] energy adjustment.

Detailed information about food preparation, specific food and beverages consumed, and brands, and contextual information about intake (e.g., which foods and beverages are consumed at the same meal) is lacking.

Because an FFQ is composed of a pre-specified food list, any single FFQ may not reflect the eating patterns of a given population. Thus, the performance of a particular FFQ in a particular population may not reflect its performance in a different population.

Salient Features Compared to Other Self-Report Instruments

For an at-a-glance comparison of the major features of self-report instruments for assessing diet, including FFQs, see the Comparing Dietary Assessment Instruments table.

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To obtain frequency and, in some cases, portion size information about food and beverage consumption over a specified period of time, typically the past month or year. A food frequency questionnaire (FFQ) consists of a finite list of foods and beverages with response categories to indicate usual frequency of consumption over the time period queried.

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Split the class into groups, each analyzing a case study involving dietary assessment of a hypothetical patient. Present findings and recommendations.

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Organize a workshop where students bring packaged foods and practice reading and interpreting the nutritional labels. Discuss the implications of findings.

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Compare dietary guidelines from different countries. Analyze the differences and discuss how cultural factors influence dietary recommendations.

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Introduce the concept of diet diversity score. Have students calculate their own or a hypothetical patient’s diet diversity score and discuss its implications on health.

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Household Dietary Diversity Score (HDDS) for Measurement of Household Food Access: Indicator Guide | Food and Nutrition Technical Assistance III Project (FANTA)

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This guide provides an approach to collecting and measuring household dietary diversity as a proxy measure of household food access.

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Engage the class with a fun game where they estimate the portion sizes of various foods and compare their estimations to actual measurements.

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Using Your Hand to Estimate Portion Sizes

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Critical Analysis of Dietary Interventions

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Critical Analysis of Dietary Interventions

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Students choose a dietary intervention strategy and critically reflect on its efficacy, challenges, and implications for patient care in a written report.