DIETARY ASSESSMENT By Lalita Bhattacharjee Nutritionist Training
on Assessment of Nutritional Status 18-22 December 2011 Date : 21
December 2011 Venue: FPMU Meeting Room The Training is organized by
the National National Food Policy Capacity Strengthening Programme
(NFPCSP). The NFPCSP is jointly implemented by the Food Planning
and Monitoring Unit (FPMU), Ministry of Food and Disaster
Management and Food and Agriculture Organization of the United
Nations (FAO) with the financial support of the EU and USAID. Slide
2 Whoever was the father of a disease, an ill diet was the mother!
Slide 3 OUTLINE Introduction Determinants of food intake and
nutritional status National and household food consumption surveys
Assessment of individual food and nutrient intakes and nutrient
adequacy Food frequency questionnaires, Rapid methods of dietary
assessment Validation and Reliability Recommended dietary intake
and evaluating nutrient intakes Conclusion Slide 4 OPTIMAL
NUTRITIONAL STATUS Source: Mahan and Stump, 2000 Slide 5 DIETARY
ASSESSMENT AND NUTRITIONAL ASSESSMENT : KEY TERMS A DIETARY
ASSESMENT : comprehensive evaluation of a person's food intake. It
is one of the established methods of nutritional assessment.
Dietary assessment techniques range from food records to
questionnaires and biological markers. NUTRITIONAL ASSESSMENT :
more comprehensive and includes determining nutritional status by
analyzing the individuals brief socio economic background, medical
history, dietary, anthropometric, biochemical, clinical data and
drug nutrient interactions NUTRITIONAL STATUS : measurement of the
extent to which an individuals physiologic need for nutrients is
being met NUTRIENT INTAKE : depends on actual food consumption
which is influenced by factors such as economic situation, eating
behaviour, emotional climate, cultural influences, effects of
disease states on appetite and the ability to absorb nutrients
NUTRIENT REQUIREMENTS : are determined and influenced by age, sex,
BMR, physiological status, activity patterns, physiologic stressors
(infection, disease) and psychological stress Slide 6 Dimensions
and methods for assessing food security and under nutrition
MethodsAvailability of food Access to food Consumption of food
Utilization of nutrients FAO Method Household income &
expenditure surveys Individual food consumption/ intake surveys
Anthropometry Qualitative measures of food security Slide 7
Development of clinical deficiency with corresponding dietary,
biochemical and clinical evaluation Slide 8 Methods of assessing
dietary intake National food supply data Household data Individual
data (Food records, 24 hr dietary recall, FFQs, diet histories,
food habit questionnaires, combined methods RAP - rapid assessment
procedure ( focus groups to gather information on food behaviours,
beliefs and intakes) Slide 9 National and household food
consumption Food consumption data collected at national, HH or
individual levels Individual intake data required for assessing
nutrient adequacy Food supply and HH data can provide useful
information Food consumption assessment at national level based on
FBS ( per capita availability, no individual variation in food
intake) Food supply data useful Slide 10 SHARE OF FOOD GROUPS AS %
OF DIETARY ENERGY SUPPLIES Source: Adapted from FBS, FAO, 2010
Slide 11 Per capita/d intake of major food items (g) Slide 12
Relative dietary energy contribution (En%) of cereals and rice to
Bangladesh diet Source/YearEnergy intake (kcal) Cereal (g) En %
Rice (g) En % HIES 20052238 452 70% 440 68% HIES 20102318 442 66%
416 64% Slide 13 DIETARY ASSESSMENT PRINCIPLES Adequacy : a diet
that provides enough energy and nutrients to meet the needs
according to the recommended dietary meet the needs according to
the recommended dietary intakes/allowances (for healthy and active
life) intakes/allowances (for healthy and active life) Balance : a
diet that provides enough, but not too much of each type of food (
adequacy of basic food groups) Variety : a diet that includes a
wide selection of foods within each food group (dietary diversity/
includes biodiversity species, varieties, cultivars) food group
(dietary diversity/ includes biodiversity species, varieties,
cultivars) Nutrient Density : a diet that includes foods that
provide the Nutrient Density : a diet that includes foods that
provide the most nutrients for the least number of calories most
nutrients for the least number of calories (nutrient dense foods)
(nutrient dense foods) Moderation : A diet that limits intake of
foods high in sugar Moderation : A diet that limits intake of foods
high in sugar and fat (nutrient intake goals/guidelines) and fat
(nutrient intake goals/guidelines) Slide 14 Methods of obtaining
dietary intake data MethodAdvantagesDisadvantages Nutrient intake
analysisAllows actual observation of food intake May yield
inconsistent and subjective estimates of food consumption; possible
variation in portion size Daily food record or diaryProvides daily
record of food consumption; can provide information on quantity of
food; how food is prepared; and timing of meals and snacks Variable
literacy skills of participants; requires ability to measure or
judge portion sizes; actual food intake possibly influenced by the
recording process; questionable reliability of records Food
frequencyEasily standardized; can be beneficial when considered in
combination with usual intake; provides overall picture of intake
Requires literacy skills; does not provide meal pattern data;
requires knowledge of portion sizes 24 Hour RecallQuick, easyRelies
on memory Slide 15 Assessment of individual intakes Dietary records
Record all foods and beverages consumed over a specific time period
(3-4 d) Amount consumed determined by weighing with a scale or
measuring volume using standard cups and spoons Specific/special
foods may be recorded (fat, vitamin A, iron rich) Total energy
intake will require all foods to be recorded. Slide 16 Food Diary :
DAY MealFoods ( list )Amount eaten How prepared Where eaten (home,
work, etc) Breakfast Snack Lunch Tea Dinner Food supplements : Name
(cans/d) Vitamins/minerals supplement :. Slide 17 Assessment of
individual intakes Diet history Collection of information on
frequency of intake of various foods and usual meal pattern Entails
detailed listing of foods and beverages consumed at each eating
session 3 d - diet record as an independent check on food intake
Methods of preparation Slide 18 Get an accurate and complete
listing of all food/drink individual consumed within last 24 hrs
Specifically: What food/drink was consumed? How much was consumed?
Time it was consumed? How was it prepared? How was it served?
Details of food (e.g low fat, 1%, whole, milk powder, preparation,
) Assessment of individual intakes : 24 dietary recall Slide 19
Assessment of individual intakes 24 hour recall : Recall all the
foods and beverages consumed the previous day or 24 hours prior to
the interview Interviewers should be knowledgeable about foods
available in the market Regional and ethnic preparations and
methods Interview conducted face to-face, structured w/o probing
questions Estimates of portion size are made using standardized
cups and spoons Record of food amounts converted into nutrient
intakes using food composition tables Slide 20 Assessment of
individual intakes Food frequency questionnaire (FFQ) Report usual
frequency of consumption of each food item from a list of food
items in reference to a specified period (past wk/mo/yr) Face to
face interview, telephone or by self administration Describes
dietary patterns or food habits not nutrient intake Semi quantified
tools can obtain information on portion size using household
measures Slide 21 FFQ - Examples : For each item indicate with a
check mark the category that best describes the frequency with
which you usually eat that particular food; complete questionnaire
might contain more than 100 items Food item> 1/d1/d3-6 times/wk
1-2/wk2/mth or less Never Beef Fish Liver Poultry Eggs Dried beans
Green leafy vegetables Enter other foods not listed that are eaten
regularly 1.------------- 2. ------------- 3. ----------- Slide 22
Example of semi quantitative FFQ FoodMedium serving ServingHow
often ? SMLDWMYN Apples, apple sauce 1 or cup Banana1 medium Papaya
medium Water melon1 slice Orange1 medium Bel juice6 oz glass
Coconut water4 oz glass Boroi bati Slide 23 Relative risk of lung
cancer according to categories of baseline carotenoid and fruit +
vegetable intake Quintile of nutrient or intake/d (n)
MedianRelative risk Carotenoids (mcg) 1 ( < 2770) ( 397)21701.00
2 ( 2770-3786) (364)32810.94 3 (3787 4988) (320)43440.80 4 (4989
6792) (276)57770.70 5 ( > 6792) (287)85770.72 P for trend <
0.0001 Fruits + vegetables (g) 1 ( < 116 ) 407801.00 2 (
116-176) 3621470.88 3 ( 177 241 ) 3262070.79 4 ( 242 332)
2932800.71 5 ( > 332) ( 256)4150.64 Amer J Epidemiol (2002) 156:
536 -547 Slide 24 Estimating average intake of nutrients
Specification of portion size standardized portions (Willet )
Description of portion size small, medium, large (Block)
Information on frequency and serving size allows for estimating
nutrient intakes Food list should contain foods that contribute to
majority of the nutrients/specific in the diet (represent 75% of
the nutrient intake selected nutrients) % adequacy of food groups %
adequacy of RDA for energy and nutrients including micronutrients
Used in epidemiological research to study diet disease
relationships Slide 25 Rapid methods for community dietary
assessment Dietary assessment of HHs with children under 5s Rapid
assessment survey (focus group interviews, selected target group
interviews IYCF practices, Social customs and food beliefs,
behaviours & intakes Key informants community leaders, local
shop owners or health personnel Small clusters of women 5-6 women
sufficient for FGD development of culture -specific relevant food
usage list Linking food intake data with weighing /measuring of
children & mother Derive mothers BMI from standard tables Slide
26 Strengths and limitations of dietary assessment methods Relies
on memory; may require trained interviewer ( need for food list
& community based training No literacy needed; Diet history may
rely on memory; may require trained interviewer ( need for food
list; std menu types; community based training) Rapid &low
cost; does not alter intake behaviour Food habit questionnaire
Relies on memory; requires complex calculations to estimate
frequencies; requires literacy, doe not quantify intake ( need for
exhaustive food list; need for manual tally type calculations)
Inexpensive ; preferred for nutrients with high day-to-day
variability; does not alter intake behavior; lower respondent
burden; epidemiological research to study diet-disease
relationships FFQs Relies on memory; requires skilled interviewer;
does not reflect the usual dietary intake ; tendency to over report
low intakes and under report high intakes ( need for food list, std
menu types; need for community based training ) Immediate recall
period, easy to obtain information; since interviewers administer
tool & records the responses, literacy is not a problem,
respondent burden minimal; does not alter intake behavior; wide
range of use 24 hr recall High participation burden; requires
literacy; may alter intake behaviour ( ?? community use ) Does not
rely on memory; open endedFood record LimitationsStrengthsMethod
Slide 27 Validation and Reliability of dietary methods Validity -
how well it measures what it purports to measure (accuracy)
Reliability how well it agrees on retesting under the same
conditions (consistency) Assessment of reliability is feasible,
validity poses a problem Gold standard established dietary
record/direct observation of subjects consumption Reference for
validation Slide 28 SOURCES OF ERROR IN DIETARY ASSESSMENT METHODS
(INDIVIDUAL INTAKES) Source of errorWeighed food records Estimated
food weight records 24 hr recallDietary history and FFQs FCT
/recipe books ++++ Food coding++++ Wrong weight of foods _+++
Reporting error__++ Variation of diet with time +++_ Wrong
frequency___+ Modified eating pattern __ Response bias Sampling
bias++++ Source: Anna Ferro Luzzi in FAO, 2002 Slide 29 Dietary
factorGoal (% of total energy ) Total fat15-30% Saturated fat<
10% PUFA6-10% Trans fatty acids< 1% Total CHO55 -75% Free
sugars10% Protein10-15% Cholesterol Slide 30 Dietary guidelines
:Healthy food pyramid Slide 31 Slide 32 Easy way to count your
calories (Measures providing 100 kcal Cereals : 30 g ( 1/5 cup)
Bread : 40 g ( 2 slices) Pulses : 30 (2 Tbsp) Leafy vegetables
(sak): 250 g ( 2 small bunches) Other vegetables : 400 g (4 cups)
Potato : 100 ( 1 cup) Nuts/oilseeds : 20 g (handful) Fruit : 150 g/
1-2 fruits Milk/Curd :150 ml ( 1 cup) Butter milk (ghol) : 670 ml (
4 cups) Channa/paneer/cheese : 30 g (1 pkt) Egg : 60 g ( 1 medium
size) Chicken : 90 g ( 3 small pieces) Mutton: 85 g Fish (lean) 100
g Fish (fatty) 60 g Shrimp : 30 g Prawn : 100 g Sugar : 25 g ( 5
tsp) Spices : 40 g ( 6 tsp) Oil/ghee : 10 g (2 tsp) Butter : 15 g
(1 Tbsp) Slide 33 Conclusions Need to use core indicators linked to
food security & nutrition outcomes; Identify food and nutrition
vulnerability through information on food consumption patterns Need
to obtain information on intra household distribution of food for
accurate assessment of individual intakes; Differential nutritional
status associated with differences in morbidity or illness or other
factors within HHs provides valuable information on food
distribution Knowledge of HH food allocation patterns and
underlying reasons for food / diet related behaviour, so that
effectiveness of nutrition interventions can be improved. Slide 34
Conclusions Choice of method : Information needed, resources
available Food/nutrients of primary interest, group/vs individual
data, absolute /vs relative intake, population characteristics
Include statistical expertise while designing survey and questions
Can provide qualitative data on dietary intake of HH Can be
combined with other methods to obtain individual quantitative data
When absolute vs relative estimates are required, food record, 24
dietary recall are methods of choice For day to-day variability FFQ
useful DD dietary patterns/habits/semi qualitative can be
quantified Dietary assessment is essential to identify populations
at risk Useful for informing and developing appropriate policies
and programmes to improve nutritional status Slide 35 THANK YOU FOR
YOUR KIND ATTENTION !
