Nutrition

Elizabeth

epidemiology:

how do we know what they ate?3

Barreti-Connor

ABSTRACT
It is generally
believed
but difficult
to prove
that diet plays a role in the risk of various diseases.
This paper
reviews
strengths
and deficiencies
of select diet-assessment
methods

used

in epidemiologic

studies

with

particular

reference

to their use in the study of osteoporosis.

Direct observation
or
weighed
food records
are useful primarily
as validation
for less
intrusive
methods.
Complete
food history by interview
or food
diary (by self report) is expensive
and time consuming.
A 24-h
diet recall obtained
by a trained
dietitian
can provide accurate,
information

on recent

intake

but does

not represent

usual intake. Food frequency

questionnaires
provide
better
estimates
of usual diet but are less quantitative
and subject
to
problems
ofrecall
and seasonality.
No method
is universally
the
best. Lack of an expected
diet-disease
association
may reflect
exposure
misclassification,
inadequate
statistical
power, or limited

range

ofthe

nutrients

assessment
methods,
studies
fracture
have had surprisingly

studied.

Given

the differences

of dietary
calcium
similar
results.

in diet-

and osteoporotic
Am J Clin Nutr

199 1;54:182S-7S.

KEY WORDS
osteoporosis

Dietary

assessment,

reproducibility,

validity,

Introduction
The association
creasing concern

of behavior
with subsequent
health is of into both the scientific
and the lay communities.

No health-related

behavior

has generated

more

universal

atten-

tion than diet because everyone

eats and has, therefore,
a vested
interest.
Analytic studies ofdiet and current or future disease in human
beings
are the core of nutritional
epidemiology.
In case-control
studies, people with and without
disease are compared
with regard to what they now say was their previous
or usual diet. In
cohort

studies,

at baseline,

diet
and

is determined

is compared

in a population
with

diets

of people

free of disease
who

later

do

or do not develop
the disease.
Minor variations
on these two
themes exist but all are dependent
on the assessment
of diet in
individuals.

In the l980s a great deal was written

about the merits and
demerits
of specific methods
for ascertaining
diet for epidemiologic studies.
Didactic
and often unsubstantiated
claims were
made about the relative value of different
methods.
Grants were
awarded
or denied on the basis of the prejudices
of reviewers
with regard to the proposed
diet-assessment
tool. This paper
reviews selected diet-assessment
methods
and their strengths
and
deficiencies,
with particular
reference
to their use in the study
of diet and osteoporosis.
1 82S

Am iC/in

Nuir

199 l;54:182S-7S.

diet-assessment

Clues to diet-disease

methods
have often been derived
of food-disappearance

associations

cross-cultural
and geographic
comparisons
rates
vs mortality.
Associations
observed

in

such

from

ecological

studies
dividual

must be confirmed
by studies of individual
diet vs indisease. The five main methods
of diet assessment
in
individuals
used for epidemiologic
research
are summarized
in
Table 1. All have serious flaws with regard to cost, representativeness,

quality

behavior

change.

Direct

of quantitive

observation

estimates,

and weighed-food

and/or

study-induced

records

Direct observation
or in-home
weighed-food
records are the
only methods
of diet assessment
applicable
to free-living
populations
that assure the quantitative
and qualitative
validity of
all nutrients

consumed.

Both

are

usually

too

expensive

(in the

context
of the sample size required)
for epidemiologic
studies
ofdiet and disease. If more than 1 d is necessary
to assess usual
diet, direct observation
ofdiet is less likely to be an option
than
are

weighed-food

records.

In-home

weighed-food

records

may

work particularly
well in countries
where participants
are accustomed
to recipe units given by weight rather than by measure.
When direct observation
is used as a gold standard
to validate reported
recent intake, neither the amount
nor the direction
ofthe error is predictable.
Both over- and underestimation
have
been reported.
Two studies comparing
direct observation
with
weighed-food
analysis are shown in Table 2 (1, 2). It can be seen
that, contrary
to popular
expectation,
overweight
women
may
overestimate
their intake (2).
Although

direct

observation

or weighed-food

records

accu-

rately represent
current intake, they may not reflect usual intake.
The need to weigh and record intake may lead to a reducedcalorie or more monotonous
diet. Further,
when studied in the
home, subjects
know their diet is being observed,
directly
or
indirectly,

by record

review.

Being

observed

is liable

to induce

behavior
change.
Nearly everyone
in Westernized
cultures
has
some knowledge
of how they should eat and could be tempted
to have a better diet to impress the observer.
Few of us would
allow

anyone

ence

to monitor

cloaked

in the

our feeding

aura

and

of hotdogs

authority

of medical

and

to our children.

chips

sci-

From the Department

of Community
and Family Medicine,
University of California,
San Diego, La Jolla, CA.
2SupportedbyNlH/NIA
1 R37AG07181.
3Address
reprint requests to E Barrett-Connor,
Department
of Community
and Family
Medicine,
University
of California,
San Diego,
M-007, La Jolla, CA 92093-0607.
Printed

in USA.

1991 American

Society

for Clinical

Nutrition

Downloaded from ajcn.nutrition.org by guest on October 11, 2015

quantitative

Individual

NUTRITIONAL
TABLE
1
Individual
diet-assessment

methods

for epidemiologic

Method

research

Expensive

Observation
Diet history
Diet diary or record
24-h diet recall
Food frequency questionnaire

Behavior

change

Quantitative

Representative

Yes, very
Yes, very
Yes
Yes

Yes
No
Yes
No

Yes
Yes
Semiquantitative
Yes

No

No

Semiquantitative

?
Yes
?
No
Yes

Usual.

Food

history

The

association

This
usual

(4).

approach,
and

foods,

interview

which includes
data on food

by a specially

trained

on the quality
of the interviewer
plication.
Concordance
of other

TABLE
2
Mean percentage
intake

error in reported

a 24-h

diet recall,

preparation,

a history

requires

estimate

of quantity

vs observed

Percentage

group*

Combined

main dishes

-29.2

Dairy products
Vegetables
Fruits
Salads
Cereals
Breads
Starches
Soups
Desserts

-5.7
-22.5
-2.4
-53.0
+11.9

Foodt
Cottage cheese
Roast turkey
Green beans
Boiled ham
Cooked spaghetti

different

estimates

derived

from

of which resembled
is used as the gold

methods

validated

records
Food

not

by observation

record

women

(2).

or a 4 d food

or multiple

the
other

weighed

diet

d, can

theo-

or diary
This is a false savings,

in that

when

the

food

record

is most

accurate

for 3-7

participants

are

trained

by dietitians
in how to estimate
quantity
and record
intakes.
As shown in Table 4, intake from a 7-d food record
does not always parallel
the intake based on a food history (6).
One problem
with the food record
is compliance.
Writing
down everything
soon gets tedious
and the characteristics
(dietary
and otherwise)
of people who will do so are apt to differ from
those ofpeople
who will not. One could argue that only the most
compulsive
would actually
complete
a 7-d diary and that conwith

another

diet

method

might

be much

greater

in

such individuals
than that for a total study population.
Another
problem
is a training
effect, a change in food intake due to participation.
Recording
all food consumed
for > 1 or 2 consecutive
days is a well-known
behavior-modification
method
to reduce
intake. Snacks and condiments,
high in calories,
fat, and sugar,
mayjust
not be worth the trouble when keeping a 7-cl diet record.
Nevertheless,
the food record
is often used as the gold standard
for validating
other methods
when neither
a food history nor
observation
is possible.
diet recall

intake

quantitatively

TABLE
Average
method

3
daily joule intake

The

24-h

diet

recall

was designed
(5-8).

When

of 400 women

Method

+6.0

by 30 overweight

recall

each other. Nevertheless,

standard
against
which

A food record or diary, usually

obtained
retically avoid the costs ofan interviewer.

to assess
correctly

recent

based on diet-assessment

Energy

24-h recall

6760

Current

9084

diet history

Past diet history

4-drecord

(1).
*

Reference

5.

nutrient

performed

kJ/d

+260.0
+ 10.0
+ 120.0
+7.5
postpartum

a 24-h

(5),
was

are measured.

+85.0
+70.0

women

from

record,
both
food history

-17.8
-51.8
-30.8

+95.0
+25.0

3 in a study by Morgan
past and current
food history

in Table

from

Twenty-four-hour

+23.3

Potato chips
Blueberries
Slice of bread
Orange juice
by 86 healthy

error

As shown

estimated

-19.9

Cola drink

t As reported

variable.

intake

cordance

As reported

of

nutritionist.
It is very dependent
and is too costly for wide apmethods
with the diet history

Food group*

Food

a 1-2

is quite

caloric

9561
7451

by

Downloaded from ajcn.nutrition.org by guest on October 11, 2015

next-best-thing
in epidemiologic
diet assessment
is
the food history,
usually practiced
as a refinement
of
the method
described
by Burke (3) in the 1940s. The quality of
food-history
data was considered
to be one of the reasons why
an association
between
dietary fat and cholesterol
and coronary
heart disease
could be shown within a population
in the Chicago
Western
Electric
study, where most other within-population
studies
using less extensive
dietary
data have failed to show an
probably

l83S

EPIDEMIOLOGY

184S

BARRETT-CONNOR

TABLE 4
Comparison
of percentage
24-hour
recall and between

The degree
differences
between
Burke history
24-hour
recall and 74 record*

and

the

study

used
in two

Massachusetts
(n = 28)

Rhode

(n

Island
87)

Burke

Also,

+23.3
+20.1
+21.5
+20.9
+17.3

+6.5
+1.9
+2.5
+ 1.3
+1.7

Reference

quency
offood

are

estimates
be almost

that

most

ate

than

they

people

The

diet recall
participant,
recall

that

memory

that

major

usually

eat.

details

without

people

diet

history

in a third.

reproducible

than

Bernardo
study,
adults
continued

those who
to drink

who

tend

drink

milk

observations,

to do

1988).

questionnaires

representative
food

picture

ofchronic

frequency

become

of diet
disease

would

than

questionnaire

to obtain
of usual

be expected

would

to

a single

days

many

years

was devised

a self-administered,
inexpensive,
intake (13-16).
Initially,
food fre-

were very short,

with a limited
selected
to test a single hypothesis.

considerably

longer

for use in cohort

number
They

studies,

where

disadvantage

change

diet
could

of the 24-h

recall

of a psybe asked.

of

a single days intake

to describe
usual diet. This lack of representativeness
has led many investigators
to conclude
that a single
24-h diet recall is worthless
for epidemiologic
research
(8-12).
Twenty-four-hour

recalls

are certainly

not

recommended

when

forms

entry,

eliminating

are

As noted

above,

typically

asked

years,

is more

to de-

Costs

designed

(such

greatly

reduced

to be scanned

the need

the other
for

are

because

the

directly

to computer

for manual
coding and keypunching.
major advantage
is that food frequency,

past

year,

representative

sometimes

of usual

be expected

by increasing
as placing

the

for

intake

more

than

to be. This tends

chances

in quintiles

address

remote

a short

1- or

to reduce

of correctly

by usual

ranking

intake),

more likely to reflect a diet-disease

association
(17,
The food frequency
method
is not without
problems,
The order ofthe listing is arbitrary
but may influence
Completion
questionnaire

the

by a self-administered
questionnaire,
interviewers.
Costs are further reduced

or recall could

tionnaire

be excluded.)

is the inability

representativeness.

data are usually obtained

without
need for trained

subjects

by notifying

would
not

associations

misclassification

and qualor remote

is more

diet-disease

3-d record

It is assumed,

be improved

of yesterdays

behavior

better

only once from

effect.
(Some

warning

would

short-

of food
an axiom

yesterday

is usually
obtained
there
is no training

a diet

protocol,

they

they

the

is both quantitatively
is the remembered
usual

that

this

what

what

test and

participant

Under

remember

remember

the

argued

the

can

that the information

more accurate
than

chological

may be more

with

method

remarkable

and

concordance

unpublished

questionnaires
items that were

have

to assess
this method
interviewer-

term
memory
required
and the quantitative
intake.
As noted by Balogh
et al (7) it should

have

and

the

shows
recall

remarkable

foods

with

may be sought. Currently

popular
food frequency
questionnaires
include well over 100 food items
and may be self- or interviewer-administered.
The major advantages
of the food frequency
method
are cost

than is the traditional

diet history.
biggest
advantages
of the 24-h recall

diet. Because
an unprepared

older

predictor

The

by 24-h

in the Rancho
intake
as young

ago in an attempt
and rapid estimate

and

can

and

(E Barrett-Connor,

A more

+0.9
+4.3
+11.9
+8.2
+3.4

trained
dietitian
using
food models
and containers
quantity,
the interview
takes 30-60
mm. Therefore,
is relatively
expensive,
although
less so, and less

therefore,
itatively

of some

be a better

6.

dependent,
The two

the intake

Foodfrequency

many

areas

as they grew

diet.
+2.4
+1.1
+13.1
+3.1
+7.7

geographic

so daily

+9.7
-7.2
+0.1
-3.7
-10.9

intake

varies

and

4, for example,

dietary

others.
For example,
had moderate
milk

milk
+21.1
+23.8
+20.6
+23.8
+32.2

Table

in the

of diet

which

is

18).
however.

responses.

of even a short
nonquantitative
self-administered
requires
a certain
level of literacy.
If the quesis very

short,

the

limited

only one or two specific

number

hypotheses,

of food
which

items

can

is not efficient

study.
The need to list specific
foods also tends to
make the questionnaire
fairly culture
specific. Food frequency
questionnaires
for Japanese-American
men include mochi-gashi,
duri-manju,
and monaka
whereas
the Oxford
(England)
quesfor a cohort

tionnaire

asks

about

spotted

dog.

Because

there

is a limit

to the

tect actual deficiency

states in individuals,
because
most vitamins
and trace minerals
can vary from day to day and still be adequate
overall.
Similarly,
a 24-h recall is quite misleading
ifone
wishes
to examine
a particular
food, such as fish, that is not eaten daily.
Estimates
aging.
24-h

of reliability

Both
recalls

Beaton
were

analyzed
to evaluate

habitual

major

nutrients

are

Liu et al (9) found

to reliably

place

subjects

also

discour-

that

multiple

in the

for some
nutrients;
for calcium
the
d. VanStaveren
et al (12) used tissue

for the ratio

the extent

of the number
between
3 and
the

et al (8) and
required

quintile
of intake
was 1 7-19
recall

for

ofpolyunsaturated
ofdietary-fat

of 24-h recalls
7 recalls
were

fat intake

to saturated
misclassification

same

number
biopsies
fatty

TABLE

5
Estimates
of probabilities
observations
used

of misclassification

Number
of dietary
measurements
averaged
(n = 57)

Adjacent

acids

1
3
7

as a function

per subject.
They concluded
that
necessary
to adequately
estimate

of an individual

(Table

5).

Reference

12.

category

for specified

number

Opposite

of

category

(p)

(q)

0.382
0.316
0.237

0.184
0.132
0.132

Downloaded from ajcn.nutrition.org by guest on October 11, 2015

history and 24-h

recall (%)
Energy
Protein
Calcium
Phosphorus
Iron
7-Day record and 24-h
recall (%)
Energy
Protein
Calcium
Phosphorus
Iron

New York
(n = 51)

or representativeness

monotony

for validation.

differences

Difference

Nutrient

of reproducibility

populations

NUTRITIONAL

EPIDEMIOLOGY

30% clearly

TABLE
6
Intraclass
correlation
coefficients,
measuring
within individual
agreement
of daily nutrient
estimates
by two different
methods
in 40 young women *
Comparison
nutrient

14 vs 74
record

34

onstrate

Reference

0.45
0.42f
0.46
0.58
0.63

0.79
0.76t
0.74
0.90f
0.89f

0.09
0.02
0.04
0.19
0.24

t FFQ, food frequency

questionnaire.

number

offoods

that

completeness

be listed,

some

Although
some
diet items not

of such

surprising

dietary

of the questionnaires
included
in the food

responses

habits

provide
list, the

is unknown.

Self-administered
food frequency
methods
are at best semiquantitative
because only fixed or subjective
definitions
of small,
medium,
or large portions
are possible.
The combination
of
missing

foods

and

semiquantitative

methods

limits

assays

for

selected

vitamins

and

antioxidants,

there

is no

easy

way to confirm
the usual food intake of most nutrients.
Concordance
of results based on small groups of more extensively
studied subjects raises questions
about the representativeness
of
such compliant
individuals(15).
Comparison
with other methods
provides
divergent
results, and does not indicate
which of these
results

are correct.

As shown

in Table

6, from

a study

by Stuff

et al (19), correlation
coefficients
with a 7-d diet record
were
better for 1- or 3-d records
(obtained
from
the same
7-d diet
record) than for a food frequency
questionnaire.
It is important
to note that reproducibility,
also called reliability,

is not

the

same

as validity.

There

is no question

that

the

frequency
questionnaires is higher than for the 24-h recall, but a part ofthe improved
reliability
is an artifact.
Because reproducibility
is in part a funcrepresentativeness

of intake

tion of the precision

recalls
increase
with

example,
reported
to vary less from
Similarly,
tion size

a more

by using

food

of the data,
differences
decreasing
simplicity

between
repeated
of the question.
For

consumption
of green vegetables
day to day than is consumption

any instrument
has less variability

quantitative

calcium

and

sorption

and excretion

and

the

protein,

Other

kinds

that affords
and more

is expected
of broccoli.

tabank

assessment

and the coders.

and

metabolism.

supports

the study
there

are

phosphate,

In the United

for major

this

drink
drinks,

resulting

States

vitamin

when

single

etc.

The

the

Even

it is difficult

D, because

is fortified

the

with

come

have

striking

a good

as for

differences

in ab-

in the

vehicle

diet.

and discordant,
nutrients

are

is high

7) (20). Suppose
that
bones.
Is it the calcium
that

prevent

to study
major

Vitamin

bio-

nutrient,

on the calcium

concordant
(Table

Nutrients

putative

oxalate,

correlation

raise the question

may

that are dependent

adiposity)

and

of itemized

which
ofa

of associations,

dietary

source

in all

people
or the

osteoporosis?

calcium

separate

of calcium

D. Conversely,

is milk

people

very little milk may drink

considerably
more
or alcohol.
This could
lead to the mistaken

who

coffee,
soft
impression

that one of these beverages

increases
the risk of osteoporosis,
when, in fact, the critical variable
is the low milk intake.
these

and

covariances.

terpretation

confounding

are

Sophisticated

are lacking.

sophisticated

solutions

for

For example,

tribution,
adjusting

data.
than

or whether
one makes
any
for the other.
This technique

When one item is more

another,
it may assume

Because

so many

nutrients

for

and

in-

the relative

by putting
makes
the

contribution
is only

accurately
an artificial

terms

analysis

sometimes

contribution
of two nutrients
is assessed
in a multivariate
model
to see which
one

them
larger

both
con-

to risk after
as good as the

recalled or quantitated
priority.

can be derived

(the simplest

outputs

usually give at least protein,

simple and complex
carbohydrate,
saturated
and unsaturated
fatty acids, and several vitamins
and
minerals)

and

because

the complexity

diverse
associations
biologically
with multiple
testing. Unless

gested
based

by other

data

in animals

on an a priori

association

will

out

ofbiologic

plausible,

there

by chance.

real association
should be sought,
relationship
between
the amount

processes

there

the diet-disease
or humans,

hypothesis,

fall

is also

association
or in other

is always

the

Additional

eg, showing
of a nutrient

makes

a problem

risk

evidence

is sugwords,
that

an

for

a dose-response
and the risk of

disease.

The converse
be missed,

risk, that a clinically

probably

TABLE
7
Intercorrelations
Lipid Research

is even

Nutrient

greater.

important
This

association

is because

of major nutrients
for men aged 20-59
Clinics 24-h diet recall*
pairs

the qualitative

y,

Protein X carbohydrate
Protein X fat
Protein X alcohol
Carbohydrate
X fat
Carbohydrate
X alcohol

0.48
0.72
0.05
0.58
0.05

Fat

0.02

alcohol

as good

Reports

foods,

calories

few or no options
for porreproducibility
than does

as the food-composition
daof intracoder
variation
of up to

other

better

recall.

is only

should
be studied.

with

osteoporosis,

ignored.

from

to dem-

Computerized

is an advantage

should

but extreme
diet patterns
who love ice cream
have

Discussion
Diet

mechanism

Multicollinearity

the accuracy

of the estimated
caloric intake. Because calories
may be an independent
risk factor and are often used in the analysis
to correct
for individual
variation
and for exercise,
the lack of accurately
assessed
calories
is not inconsequential.
Perhaps
the most significant
problem
with a food frequency
questionnaire
is uncertain
validity.
For many nutrients
of interest, such as calcium,
which is under homeostatic
control,
no
biochemical
assay of serum
is useful. Aside from biochemical

and

disease.

Reference

20.

will

Downloaded from ajcn.nutrition.org by guest on October 11, 2015

may be missed.
space to include

can

are eaten

(or

for the ability

and

databanks

or foods

on absorption

often

P<0.005.

variation

of nutrient

nutrients
and

diet

methods.

Any mention
ofwhether

implications

between
coder

frequency

effects
logical

19.

important

eliminates

food

in foods
Energy(kJ)
Protein (g)
Fat (g)
Carbohydrate(g)
Calcium
(mg)

have

associations

coding

FFQ vs 74
recordt

vs 74
record

185S

1 86S

BARRETT-CONNOR

TABLE
8
Odds ratio for calcium inta ke quintile
used for classifying
diet in 106 women

True

14 record

3.0
2.5
2.0
1.5
1.0
*

34

1.93
1.69
1.61
1.40
1.00
Reference

record

74

2.17
1.83
1.60
1.32
1.00

record
2.31
2.04
1.57
1.31
1.00

of exposure
this reason

in the reported
diet
Randomly
distributed

relative

risk (Table

Misclassification

also

that

very

inconsistent

results

such

such

remote

a long

data

follow-up

(for

case-control

(for cohort

studies)

studies)

For
the
can

or con-

is rarely

pos-

sible.

Another
issue is the sample size and the power of the study.
Grant reviewers
like to see sample-size
estimates
and power calculations
for studies of diet and disease, yet rarely are the necessary data available
to make these calculations
in advance.
The
validity of the data, the range or distribution
of the data, and
the strength
of the association
are seldom
known.
Because
a
much larger sample is required
for a cohort study (to yield the
necessary
number
of events in a reasonable
period
of time),
there are typically
fewer resources
for repeated
or detailed
diet
assessments.
Increasing
the size ofthe study sample reduces
some
of the effects of misclassification
but increasing
the sample size
may not increase
the power sufficiently
to compensate
for a
limited

range

of the

relevant

nutrient.

Often

the

range

tions

lack

of consistency

does

not

exclude

one

a causal

calcium

study

bone

Kong

density)

intakes.

concluded

did not.

Prospective
rates

(25)

and

In both

that

Although

calcium

and

one

in

were of different
had

very

studies,

different

exercise

was

in the highest
to incur a fracture
those

prevented

fractures

the calcium-fracture

and

association

was

as-

( 1 1 ). The reader can discern many possible explanafor the divergent

results in diet studies ofhip fracture.
Two

studies

by calcium

allow

intake.

an

estimate

Comparisons

of fracture-incidence
between

populations

can

be made when the diet-assessment

tool and nutrition
database
are prepared
and standardized
for planned
comparisons.
The
different
study design, diet-assessment
methods,
and range of
calcium
intake could each explain the lack of a statistically
significant (P > 0.05) association
ofdietary
calcium
with hip fracture in a recent population-based
prospective
study in the United
Kingdom
(P

(27) and

0.008)

(28)

the significant

Kingdom

study

independent

in a US study,

risk (for the lowest

tertile

had

ofcalcium

confidence

inverse

association

in Table

shown

intake)

limits

10. The relative

ofO.7 in the United

ofO.l-3.9,

which

include

the statistically
significant
lower risk ofO.4 for the highest tertile
ofcalcium
intake in Rancho
Bernardo.
Exactly comparable
relative risks cannot
be calculated
with the data provided
in the
United

Kingdom

study,

but

these

data

could

be interpreted

as

showing
rather similar results, given the study differences.
In conclusion,
the answer to the question,
How do we know
what they ate? is that we dont, exactly,
and that no widely
applicable
method
is a priori better at making
an estimate.
Recent
excellent,
concise
reviews
and entire
books dealing
with the
methods
and limitations
of nutritional
assessment
(see refs 2932) demonstrate

and Trulson

TABLE

that

little

(33) wrote,

has changed

In general

since

one must

when

conclude

intake and risk of hip fracture

Britain*
Calcium

quintile

1 (low)
2
3
4
5 (high)
Mean calcium intake of
control subjects (mg)
Interquartilerange
*

1960,

Young

that,

on

Case-control
studies of calcium
Britain and Hong Kong

of the

nutrients
of interest
within the study population
is not known
until the diet data are collected.
For example,
a paper reporting
no association
of dietary
fat with breast cancer
in > 85 000
women
(23) was criticized
because
nearly all of the women
in
this very large cohort were in a narrow range of high fat intake.
On the basis of ecologic
studies, within this range only a small
increment
in relative risk would have been expected
(24).
Consistency
of results is usually
an important
criterion
for
causality
in epidemiologic
studies ofassociations.
In nutritional
epidemiology,
sociation

to affect

dietary

in Hong

Reference

26. n

in

Hong Kongt

Men

Women

Men

Women

6.2f
5.8
3.3
6.2
1.0

1.2
1.4
1.1
1.2
1.0

2.1
1.4
1.7
1.5
1.0

1.9
1.9
1.1
1.2
1.0

651
467-799

177
75-226

168
75-176

843
560-1042

300 cases and 600 control

subjects.

t Reference 25. n 400 cases and 800 control subjects.

f Odds ratio based on setting the highest calcium quintile
=

erence

risk at 1.0.

as the ref-

Downloaded from ajcn.nutrition.org by guest on October 11, 2015

ducting

one

in Table 9. Study subjects

not consistent
and stepwise,
it should be noted that the dietary
calcium
in Hong Kong was ascertained
entirely
from a nineitem food frequency
questionnaire
whereas
that from Britain
used a six-item
questionnaire.
(A cross-cultural
comparison
to
determine
if the Chinese
had higher fracture
rates in the face of
such limited dietary calcium
cannot
be obtained
with the casecontrol design, which ascertains
neither incidence
nor prevalence
of disease.)

be obtained
from study to study, particularly
in case-control
studies where exposure
misclassification
may not be randomly
distributed
and where other biases may exist. Persons
with diseases prevented
or modified
by diet often assume
a better diet
after diagnosis,
but recall of the remote
(prediagnosis)
diet is
colored by current diet (22). Hospital
control subjects may have
changed
their diets as a result of the condition
for which they
were hospitalized.
There is frequent
failure to obtain diet data
for the age or interval
of interest,
when this is known.
In the
cohort
model, the diet is ascertained
before disease onset but
the method
rarely allows assessment
of interim
diet or other
behavior
changes that may be relevant.
For studies of osteoporosis, diet in young adult life may be the critical
period
but
collecting

(known

average

the other

8) (21).
means

studies,

are shown

ethnicity

but

lead to misclassifimisclassification

tends to bias all associations

towards
the null.
any observed
association
usually
underestimates

case-control

Britain(26),

more protective
than was diet. In both studies,
quartile
of calcium
intake were least likely

21.

and quantitative
errors
cation of the exposure.

true

recent
and by number
off ood records
vs true odds ratio*

NUTRITIONAL
TABLE

EPIDEMIOLOGY

10

Two prospective

studies of dietary calcium

and the risk of hip

fracture*
Rancho

Bernardo,
Diet method
Design
Number
in study

Number

References

t Relative
Relative

United

24-h recall
Cohort
957

of fractures

Age(y)
Lowest-tertile
(mg/d)
Relative
risk

CA

74 record
Nested case control
141

33

42

50-79
<416 women
<544 men
O.4t

calcium

Kingdom

<694

65+
women

<588 men
0.7f

27 and 28.
risk for highest tertile of calcium intake.
risk for lowest tertile of calcium
intake.

187S

10. Block G. A review of validations

of dietary
assessment
methods.
Am J Epidemiol
1982;l 15:492-505.
1 1. Willett W. Nutritional
epidemiology:
issues and challenges.
Int J
Epidemiol
1987; 16(suppl):3
12-7.
12. VanStaveren
WA, Burema
J, Deurenberg
P, Katan MB. Weak associations
in nutritional
epidemiology:
the importance
of replication
of observations
on individuals.
Int J Epidemiol
l988;l7:964-69.
13. Hankin JH, Stallones
RA, Messinger
HB. A short dietary method
for epidemiologic
studies. III. Development
ofquestionnaire.
Am J
Epidemiol
1968;87:285-98.
14. Samet JM, Humble CG, Skipper BE. Alternatives
in the collection
and analysis of food frequency
interview
data. Am J of Epidemiol
1984; 120:572-8
1.
15. Mullen BJ, Krantzler
NJ, Grivetti
LE, Schutz HG, Meiselman
HL.
Validity ofa food frequency
questionnaire
for the determination
of
individual
food intake. Am J Gin Nutr l984;39:136-43.
16. Sampson
LS. Food frequency
questionnaires
as a research
instrument. Clin Nutr l985;4: 164-70.
17. Sempos CT, Johnson
NE, Smith EL, Gilligan
C. Effects of intraindividual
and interindividual
variation
in repeated dietary records.

Am J Epidemiol

References
1. Linusson

25. Lau E, Donnan

EEl, Sanjur

method

as a dietary

2. Lansky

D, Brownell

errors in self-report

D, Erickson

survey tool. Latinoam

KD.

98.
6. Young
dietary

Estimates

Nutr

the 24-hour

calcium

recall

of food quantity
and calories:
Am J Clin Nuts l982;35:

history

in epidemiologic

as a tool in research.

J Am Diet Assoc

AM, Paul 0, Lepper M, et al. Diet, serum

from coronary
heart disease.
The Western
J Med 198 1;304:2:65-70.
Miller AB, et al. A comparison
of dietary

studies.

Am J Epidemiol

1978;107:488-

CM, Hagan GC, Tucker RE, Foster WD. A comparison

of
study methods.
II. Diet history vs seven-day
record vs 24hour record. J Am Diet Assoc 1952;28:218-21.
7. Balogh M, Kahn H, Medalie JH. Random
repeat 24-hour
dietary
recalls. Am J Clin Nutr 197 1;24:304-lO.
8. Beaton GH, Mimer J, Corey P, et al. Sources of variance in 24-hour
dietary recall data: implications
for nutrition
study design and interpretation.
Am J Gin Nutr l979;32:2456-559.
9. Liu K. Measurement
error and its impact on partial correlations
and multiple
linear regression
analyses.
Am J Epidemiol
l988;127:
864-74.

intake

S, Barker
in fracture

DJP, Cooper
ofthe

proximal

C. Physical
femur

activity

in Hong

Kong.

and
Br

Med J 1988;297:144l-3.

l974;24:277-94.
26.

among obese patients.

727-32.
3. Burke BS. The dietary
l947;23: 1041-6.
4. Shekelle RB, Shryock
cholesterol,
and death
Electric Study. N EngI
5. Morgan
RW, Jam M,

methods

EC. Validating

1985;12l:l20-30.

18. Rhoads CG. Reliability

ofdiet measures
as chronic disease risk factors. Am J Clin Nutr l987;45:1073-9.
19. StuffJE,
Garza C, OBrian Smith E, Nichols BL, Montandon
CM.
A comparison
ofdietary
methods
in nutritional
studies. Am J Gin
Nutr 1983;37:300-6.
20. Gordon
T, Fisher M, Rifkind BM. Some difficulties
inherent
in the
interpretation
of dietary data from free-living
populations.
Am J
Gin Nutr l984;39:152-6.
21. Freudenheim
JL, Johnson
NE, Wardrop
RL. Nutrient
misclassification: bias in the odds ratio and loss of power in the Mantel test
for trend. Int J Epidemiol
l989;18:232-8.
22. Wu ML, Whittemore
AS, Jung DL. Errors in reported dietary intakes.
II.Long-term recall.Am J of Epidemiol l988;l28: 1137-45.
23. Willett WC, Stampfer
Mi, Colditz GA, Rosner BA, et al. Dietary
fat and the risk ofbreast
cancer. N EngI J Med 1987;316:22-8.
24. Goodwin
PJ, Boyd NE Critical appraisal ofthe evidence that dietary
fat intake is related to breast cancer risk in humans.
J Natl Cancer
Int l987;79:473-85.

27.

28.

29.

30.
31.

32.
33.

Cooper C, Barker DJP, Wickham

C. Physical activity and calcium
intake in fracture
of the proximal
femur in Britain.
Br Med J
1988;297: 1443-6.
Wickham
CAC, Walsh K, Cooper C, et al. Dietary calcium,
physical
activity,
and risk of hip fracture:
a prospective
study. Br Med J
l989;299:889-92.
Holbrook
TL, Barrett-Connor
E, Wingard
DL. Dietary calcium and
risk of hip fracture:
14-year prospective
population
study. Lancet
l988;2: 1046-9.
Lee-Han
H, McGuire
V, Boyd NF. A review of the methods
used
by studies ofdietary
measurement.
J Clin Epidemiol
l989;42:26979.
Block G, Hartman
A. Issues in reproducibility
and validity of dietary
studies. Am J Clin Nutr 1989;50:1 133-8.
Moon TE, Micozzi MS. eds. Nutrition
and cancer prevention.
Investigating
the role of micronutrients.
New York: Marcel Dekker,
Inc, 1989.
Willett, Walter. Nutritional
epidemiology.
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Am J Public Health 1960;50:803-14.

Downloaded from ajcn.nutrition.org by guest on October 11, 2015

an individual
basis, results to be obtained
from one method
cannot be predicted
by another
method.
With different
methods
one is measuring
different
things. Though
comparisons
of one
method
with another
have been made, these comparisons
are
between
methods
whose accuracy
and reliability
are not known;
therefore
no conclusions
may be reached
regarding
which
method
is the more accurate
or reliable.
It is fortunate
that
neither
complete
accuracy
nor reproducibility
is essential
to
produce
useful research
on any behavior,
including
diet and
disease. Excessive
certainty
about the value or nonvalue
of any
method
of diet assessment,
or the truth of any diet-disease
association
or its absence,
should be avoided.
Thoughtful
comparisons ofthe results ofdifferent
studies are necessary
and often
demonstrate
considerable
consistency
despite the limits of dietary
assessment.