An evaluation of a colour food photography atlas as a tool for quantifying food portion size in epidemiological dietary surveys

Comprehensive global review and methodological framework for developing food atlases

Introduction

An atlas is a trustworthy resource created from precise data collection that serves as a guide for communities. A food atlas is a useful tool for analyzing dietary data. There is a growing need for a food atlas that is part of the nation's strategy to help the health sector with specific nutritional or dietary assessments of individual consumption and overall wellbeing. Although researchers previously attempted to create a food atlas on a national level, the process of data collection was not well defined.

Methods

This study provides an overview of global food atlases that can be used to develop a procedure manual to guide experts in creating a dependable food atlas.

Results

To date, 27 countries have developed food atlases for various reasons. After examining these countries' experiences, six important steps in the procedure manual that should be considered when developing a food atlas were identified: choosing the most consumed food, using traditional cooking utensils, determining portion sizes, capturing photographs of the food, validating the food atlas, and publishing the food atlas.

Discussion

This procedure manual can be used as a guide until a validation study is conducted.

A Close Relationship Between Ultra-Processed Foods and Adiposity in Adults in Southern Italy

BACKGROUND/OBJECTIVES

One of the main culprits of the obesity epidemic is the obesogenic food environment, which promotes the consumption of ultra-processed foods (UPFs) that are highly palatable, have low nutritional quality and a high caloric impact and are economical and ready to use. This monocentric retrospective study explored the association between UPFs, obesity and adiposity measurements among adults living with obesity in Southern Italy.

METHODS

According to their Body Mass Index (BMI) values, 175 participants (63M) were recruited and stratified into three groups. To evaluate their usual eating habits, PREDIMED and the Nova Food Frequency Questionnaire (NFFQ) were administered to investigate Mediterranean diet (MD) adherence and UPF consumption. Anthropometric and biochemical measurements, body composition, as well as visceral obesity indices were collected.

RESULTS

The data showed an increase in UPF consumption as the BMI increased, with a concomitant decrease in MD adherence. Soft drinks were the most representative UPF in all groups, and we observed a significant increase in such consumption as the BMI increased. In addition, in the highest tertile of UPF consumption, there was an increase in adiposity indices.

CONCLUSIONS

Our data suggest that high UPF consumption correlates with an increased BMI and visceral adiposity, and it is a predictive risk factor for the occurrence of non-communicable diseases.

Exploring dietitians' views on digital nutrition educational tools in Malaysia: a qualitative study

BACKGROUND/OBJECTIVES

Dietitians frequently use nutrition education tools to facilitate dietary counselling sessions. Nevertheless, these tools may require adaptation to keep pace with technological advancements. This study had a 2-fold purpose: first, to identify the types of nutrition education tools currently in use, identify their limitations, and explore dietitians' perspectives on the importance of these tools; second, to investigate the features that dietitians prefer in digital nutrition education tools.

SUBJECTS/METHODS

A semi-structured face-to-face interview was conducted among 15 dietitians from selected public hospitals, primary care clinics, and teaching hospitals in Malaysia. Inductive thematic analysis of the responses was conducted using NVivo version 12 software.

RESULTS

Most dietitians used physical education tools including the healthy plate model, pamphlets, food models, and flip charts. These tools were perceived as important as they facilitate the nutrition assessment process, deliver nutrition intervention, and are time efficient. However, dietitians described the current educational tools as impersonal, outdated, limited in availability due to financial constraints, unhandy, and difficult to visualise. Alternatively, they strongly favoured digital education tools that provided instant feedback, utilised an automated system, included a local food database, were user-friendly, developed by experts in the field, and seamlessly integrated into the healthcare system.

CONCLUSION

Presently, although dietitians have a preference for digital educational tools, they heavily rely on physical nutrition education tools due to their availability despite the perception that these tools are outdated, impersonal, and inconvenient. Transitioning to digital dietary education tools could potentially address these issues.

Estimation of food portion sizes in women of childbearing age and young children in Ouagadougou (Burkina Faso) using a food photography atlas and salted replicas: Comparison with weighed records

Quantitative assessment of foods consumed when using 24-hour dietary recall requires accurate tools to estimate portion sizes. Therefore, we developed a food portion photography atlas with age-appropriate portion sizes for 11 foods frequently consumed by young children (sizes for 6-11-month- and for 12-23-month-old children) and women of childbearing age in Ouagadougou, Burkina Faso capital. We then compared the accuracy and precision of portion estimation with this atlas and with salted replicas relative to weighed records (the reference). After weighing, we randomly assigned food portions to 67 women and their children. The next day, women estimated the served portions and leftovers by recall using the atlas and then salted replicas (n = 1156 measurements, ranging from 19 to 113 for each food). For most food types, the portions estimated with the atlas and salted replicas were positively correlated and showed good concordance with the weighed records. However, accuracy and precision varied in function of the estimation method, food type, and age group. The mean crude differences ranged from -28 to +12g (with errors in absolute values from 24 to 69%) for children, and from -32 to +44g (errors from 17 to 56%) for women. The atlas-based method showed the lowest Lin's concordances (coefficients of 0.1 to 0.2) for the leafy vegetable dish, meat, and fish in 12-23-month-old children. Bland-Altman plots indicated that the salted replicas allowed estimating the consumed portions with fewer errors than the photographic atlas (56 to 91% vs 46 to 79% between the limits of ±50%). Our study highlights that mothers have difficulties in perceiving the quantities of food consumed by their children. Our findings also indicate that the food atlas could be used in food consumption surveys when salted replicas are not available for all food types.

Estimation of Plate and Bowl Dimensions for Food Portion Size Assessment in a Wearable Sensor System

Automatic food portion size estimation (FPSE) with minimal user burden is a challenging task. Most of the existing FPSE methods use fiducial markers and/or virtual models as dimensional references. An alternative approach is to estimate the dimensions of the eating containers prior to estimating the portion size. In this article, we propose a wearable sensor system (the automatic ingestion monitor integrated with a ranging sensor) and a related method for the estimation of dimensions of plates and bowls. The contributions of this study are: 1) the model eliminates the need for fiducial markers; 2) the camera system [automatic ingestion monitor version 2 (AIM-2)] is not restricted in terms of positioning relative to the food item; 3) our model accounts for radial lens distortion caused due to lens aberrations; 4) a ranging sensor directly gives the distance between the sensor and the eating surface; 5) the model is not restricted to circular plates; and 6) the proposed system implements a passive method that can be used for assessment of container dimensions with minimum user interaction. The error rates (mean ± std. dev) for dimension estimation were 2.01% ± 4.10% for plate widths/diameters, 2.75% ± 38.11% for bowl heights, and 4.58% ± 6.78% for bowl diameters.

Development and validation of a photographic food atlas of Middle Eastern Mediterranean diet: Toward improved understanding of traditional healthy and sustainable diets

Background

Middle Eastern Mediterranean diet (MEMD) is a traditional plant-based diet that is commonly consumed and increasingly popular, but not well studied in nutrition research. To facilitate the dietary assessment of MEMD, we developed and validated a photographic food atlas depicting a variety of foods and dishes consumed in the MEM region.

Methods

The photographic food atlas included 1,002 photos of 400 types of foods and traditional dishes photographed characterizing MEMD. Foods and dishes were prepared by a professional cook and were subsequently photographed as a series of photos depicting portion size options. In a validation study, 45 individuals aged 20-50 years were recruited to assess portion size estimation of 25 representative food-photo series for each item. The validity of portion size estimation was assessed by comparing actual and reported estimates using Pearson or Spearman correlation tests. Sizes of the differences between estimated portions and the actual served portion sizes were calculate as mean differences and standard deviations.

Results

In the validation study, there was a strong correlation (r > 0.7) between estimated portion size of actual foods for 7 food items, such as pita bread, milk, labneh, and tomatoes, a moderate correlation (< 0.5 | r | < 0.7) for 12 items, such as meat, chicken, and grapes, and weak correlation (r < 0.3) for 6 items, such as seeds. Underestimation of portion sizes was more commonly observed for food items quantified when using "grams" or "milliliters" as a unit of measurement. In contrast, when household measurements were used, the participants tended to overestimate the portion sizes of respective foods and dishes.

Conclusion

We developed and validated a photographic food atlas depicting a wide variety of foods and dishes typical for the MEMD. The application of the photographic food atlas may facilitate the accurate assessment of adherence to MEMD and support the understanding of its health and sustainability aspects. Further methodological work is warranted to extend the list of food items and to evaluate the validity of the food atlas among larger and more heterogeneous groups of participants.

Assessment of Dietary Intake in Three Cohorts of Advanced Age in Two Countries: Methodology Challenges

OBJECTIVES

Dietary intake information is key to understanding nutrition-related outcomes. Intake changes with age and some older people are at increased risk of malnutrition. Application, difficulties, and advantages of the 24-hour multiple pass recall (24hr-MPR) dietary assessment method in three cohorts of advanced age in the United Kingdom (UK) and New Zealand (NZ) is described.

PARTICIPANTS

The Newcastle 85+ study (UK) recruited a single year birth cohort of people aged 85 years during 2006-7. LiLACS NZ recruited a 10-year birth cohort of Māori (indigenous New Zealanders) aged 80-90 years and a single year birth cohort of non-Māori aged 85 years in 2010.

MEASUREMENTS

Two 24hr-MPR were conducted on non-consecutive days by trained assessors. Pictorial resources and language were adapted for the New Zealand and Māori contexts. Detailed methods are described.

RESULTS

In the Newcastle 85+ study, 805 (93%) participants consented to the 24-MPR, 95% of whom completed two 24hr-MPR; in LiLACS NZ, 218 (82%) consented and 203 (76%) Māori and 353 (90%) non-Māori completed two 24hr-MPR. Mean time to complete each 24hr-MPR was 22 minutes in the Newcastle 85+ study, and 45 minutes for Māori and 39 minutes for non-Māori in LiLACS NZ. Dietary assessment of participants residing in residential care and those requiring proxy respondents were successfully included in both studies. Most participants (83-94%) felt that data captured by the 24hr-MPR reflected their usual dietary intake.

CONCLUSIONS

Dietary assessment using 24hr-MPR was successful in capturing detailed dietary data including information on portion size and time of eating for over 1300 octogenarians in the UK and New Zealand (Māori and non- Māori). The 24hr-MPR is an acceptable method of dietary assessment in this age group.

Development of a Digital Photographic Food Atlas as a Portion Size Estimation Aid in Japan

This study aimed to develop a digital photographic food atlas as a portion size estimation aid. Commonly consumed foods were identified from the 5512-day weighed dietary records of 644 Japanese adults. Portion sizes were determined based on the market research and distribution of food consumption in the dietary records. Each food item was classified into one of two photo types: a series of photographs showing gradually increasing portion sizes or guide photographs representing a range of portion sizes and food varieties in one photograph. Photographs of the food were taken at an angle of 42°, along with appropriate reference objects such as chopsticks. In total, 209 food and dish items were included in the food atlas. Series of photographs were taken for 105 items that are not usually served in predetermined amounts (e.g., rice and pasta), whereas guide photographs were taken for 104 items usually served in predetermined amounts (e.g., bananas and cookies). Moreover, photographs were taken for 12 kinds of household measurement items, such as cups and glasses. The food atlas could be a valuable tool for estimating the portion size in dietary surveys. Evaluating the validity of this food atlas for portion size estimation is warranted.

Accuracy of estimates of serving size using digitally displayed food photographs among Japanese adults

We evaluated the accuracy of the estimated serving size using digital photographs in a newly developed food atlas. From 209 food items in the food atlas, we selected 14 items with various appearances for evaluation. At the study site, fifty-four participants aged 18-33 years were served fourteen foods in the amount they usually ate. After they left, each food item was weighed by a researcher. The following day, the participants estimated the quantity of each food they served based on food photographs using a web-based questionnaire. We compared the weights of the foods the participants served (true serving sizes) and those determined based on the photographs (estimated serving sizes). For ten of the fourteen food items, significant differences were observed between the estimated and true serving sizes, ranging from a 29⋅8 % underestimation (curry sauce) to a 34⋅0 % overestimation (margarine). On average, the relative difference was 8⋅8 %. Overall, 51⋅6 % of the participants were within ±25 % of the true serving size, 81⋅9 % were within ±50 % and 93⋅4 % were within ±75 %. Bland-Altman plots showed wide limits of agreement and increased variances with larger serving sizes for most food items. Overall, no association was found between estimation errors and participant characteristics. The food atlas has shown potential for assessment of portion size estimation. Further development, refinement and testing are needed to improve the usefulness of the digital food photographic atlas as a portion size estimation aid.

Metabolically Healthy Obesity (MHO) vs. Metabolically Unhealthy Obesity (MUO) Phenotypes in PCOS: Association with Endocrine-Metabolic Profile, Adherence to the Mediterranean Diet, and Body Composition

Obesity and obesity-related low-grade inflammation are common findings in polycystic ovary syndrome (PCOS), the most common endocrine-metabolic disorder-affecting women in reproductive age. The terms metabolically healthy obese (MHO), and metabolically unhealthy obese (MUO) have been introduced to define individuals with obesity in whom cardio-metabolic risk factors are absent or present, respectively. To date, evidence investigating differences in body composition and adherence to the Mediterranean diet (MD) between MHO and MUO-PCOS women are lacking. Aim of this study was to better characterize the determinants of the metabolic health status in PCOS patients with obesity according to MHO and MUO phenotypes by evaluating endocrine-metabolic profile, inflammatory status, adherence to the MD, and body composition. The study population consisted of 94 treatment-naïve women with PCOS and obesity (BMI = 38.23 ± 6.62 kg/m² and age = 24.12 ± 3.68 years). Compared PCOS MHO with PCOS MUO patients, the latter had higher levels of high-sensitivity C-reactive protein (hs-CRP) (p < 0.001), testosterone (p < 0.001), and insulin (p < 0.001), worse metabolic parameters, and higher Homeostatic Model Assessment of Insulin Resistance (HoMA-IR), Visceral Adiposity Index (VAI), and Fatty liver Index (FLI) (p < 0.001). Furthermore, PCOS MUO patients had lower adherence to the MD (p < 0.001) in spite of the same total energy intake (p = 0.102) as compared to PCOS MHO. The presence of MUO was associated with highest hs-CRP levels (OR = 1.49, p < 0.001), more severe hyperandrogenism and cardio-metabolic indices (p < 0.001). On the contrary, being PCOS MUO was associated with lower adherence to the MD (OR = 0.28, p < 0.001), and smaller PhAs (OR = 0.04, p < 0.001). Using a regression linear analysis model PREDIMED score entered at the first step (p < 0.001), followed by VAI (p < 0.001), and FLI (p = 0.032) in this analysis. At ROC analysis, a PREDIMED score of ≤4 (p < 0.001, AUC 0.926) could serve as a threshold for a significantly increased risk of presence the MUO-PCOS phenotype. To the best of our knowledge, this is the first study that characterized MHO and MUO-PCOS women on the basis of their adherence to the MD, body composition, and cardio-metabolic indices, providing evidence of the usefulness of adjunctive diagnostic parameters to better differentiate the MHO/MHO phenotypes in this cohort of PCOS patients with obesity.

Association of Trimethylamine N-Oxide (TMAO) with the Clinical Severity of Hidradenitis Suppurativa (Acne Inversa)

In this case-control, cross-sectional, observational study, we evaluated circulating trimethylamine n-oxide (TMAO) levels, a gut-derived metabolite associated with inflammation and cardiometabolic risk, in patients with hidradenitis suppurativa (HS), a highly disabling inflammatory skin disease associated with an elevated prevalence of comorbidities, especially cardiovascular and metabolic diseases. In this study, we enrolled 35 naive-treatment patients with HS and 35 controls, matched for sex, age, and body mass index (BMI). HS Sartorius score was 49.0 (33.0–75.0), while according to the Harley system 12 and 23 patients presented grade 1 and grade 2 severity, respectively. HS patients had a lower adherence to the Mediterranean diet (MD) (p = 0.002), lower phase angle (PhA) (p < 0.001), and higher circulating TMAO levels (p < 0.001) than the control group. HS patients with grade 2 rather than grade 1 of Harley grade severity showed a higher BMI (p = 0.007), waist circumference (p = 0.016), total energy intake (p = 0.005), and lower PhA (p < 0.001) and adherence to the MD (p = 0.003). Of interest, patients with Hurley grade 2 of severity exhibited higher circulating TMAO levels (p < 0.001) compared to grade 1. Circulating TMAO levels showed a positive correlation with HS Sartorius score even after adjustment for confounding covariates, including BMI, waist circumference, adherence to the MD, total energy intake, and PhA (r = 0.570, p = 0.001). Using a linear regression model, circulating TMAO levels and PhA were the main predictors of the clinical severity of HS.

Portion size estimation in dietary assessment: a systematic review of existing tools, their strengths and limitations

CONTEXT

Overestimation or underestimation of portion size leads to measurement error during dietary assessment.

OBJECTIVE

To identify portion size estimation elements (PSEEs) and evaluate their relative efficacy in relation to dietary assessment, and assess the quality of studies validating PSEEs.

DATA SELECTION AND EXTRACTION

Electronic databases, internet sites, and cross-references of published records were searched, generating 16 801 initial records, from which 334 records were reviewed and 542 PSEEs were identified, comprising 5% 1-dimensional tools (eg, food guides), 46% 2-dimensional tools (eg, photographic atlases), and 49% 3-dimensional tools (eg, household utensils). Out of 334 studies, 21 validated a PSEE (compared PSEE to actual food amounts) and 13 compared PSEEs with other PSEEs.

CONCLUSION

Quality assessment showed that only a few validation studies were of high quality. According to the findings of validation and comparison studies, food image-based PSEEs were more accurate than food models and household utensils. Key factors to consider when selecting a PSEE include efficiency of the PSEE and its applicability to targeted settings and populations.

Development of a Photographic Food Atlas as a Portion Size Estimation Kit for Malaysian

A photographic food atlas is a series of photographs showing different quantities of different foods. It serves as a portion size estimation aid (PSEA). In Malaysia, the existing food atlases, which display foods in exchanges and standard portion sizes, may not be representative of the actual sizes of the portions of food consumed by the local population. This paper aims to describe the development of a food atlas, namely the 'MY Food Album', and assess its usability as a PSEA. Thirty four participants (aged 31.6±20.9 y) served themselves, in a laboratory setting, what they considered to be typical, small, medium, and large portions of 23 amorphus food items. All food portions were weighed to obtain the mean and standard deviation of the range of food portion sizes to be displayed in the food atlas. Using standard camera and lighting settings, various local foods were photographed at an angle of 45º. A total of 393 food items were categorized into 14 food groups and presented as serial (n=101), guide (n=213) and range (n=79) photographs. The usability of MY Food Album was evaluated by six nutritionists and dietitians using an adapted questionnaire. The food atlas was perceived to be useful to aid in the quantification of food during dietary assessment. It was suggested that the function, dimension and application of fiducial markers be introduced in the food atlas to facilitate its use in size estimation. While MY Food Album was well-accepted as a PSEA, futher validation is required to evaluate the effectiveness of this newly developed food atlas in portion size estimation.

Portion size and consistency as indicators of complementary food energy intake

We evaluated whether novel portion size and consistency indicators can identify children with low complementary food energy intake in southern Ethiopia. We conducted 24-h dietary recalls with caregivers of 548 children aged 6-13 months; additionally, caregivers estimated their child's usual portion size using uncooked rice and selected which of five photographs of porridges of varying consistencies most closely matched the food their child usually ate. Complementary food energy and density from the 24-h recall were used as reference values. We computed correlation coefficients and areas under receiver operating characteristic curves (AUC) and conducted sensitivity and specificity analyses to classify children with low complementary food energy intake. The median complementary food energy intakes for children 6-8, 9-11 and 12-13 months were 312, 322 and 375 kcal; median estimated portion sizes were 50, 58 and 64 ml, respectively. Estimated portion size correlated with total complementary food energy intake and with average energy and quantity consumed per feeding (r = 0.42, 0.46 and 0.45, respectively, all p < 0.001). Reported food consistency was weakly correlated with total complementary food energy intake (r = 0.18) and density (r = 0.10), and energy density of porridge only (r = 0.24, all p < 0.05). Predicted energy intake combining feeding frequency and portion size predicted inadequate energy intake better than did feeding frequency alone in infants 6-8 months [∆AUC = 0.16, 95% confidence interval (CI) 0.04, 0.28] and 9-11 months (∆AUC = 0.09, 95% CI 0.04, 0.14). Caregiver estimates of portion size can improve identification of infants with low complementary food energy intake when more robust dietary assessment is not feasible.

Evaluation of portion size estimation aids for the Korea National Health and Nutrition Examination Survey

BACKGROUND/OBJECTIVES

This study aimed to improve portion size estimation aids (PSEAs) used in the nutrition survey of the Korea National Health and Nutrition Examination Survey (KNHANES) and validate the accuracy and precision of the newly developed aids.

SUBJECTS/METHODS

We conducted intensive interviews with survey experts in KNHANES and consulted with experts to collect opinions about improvement of PSEAs. Based on the results of the interviews, 5 types of PSEAs (rice bowl, earthen pots, mounds, measuring spoons, and thickness sticks) were newly developed using 3-dimensional (3D) modeling or modification of color or shape. Validation tests were conducted with 96 adults 20 years old or older. For the rice bowl and earthen pots, the participants were asked to select the more similar PSEA in size after being shown the real dishes. For the mounds, measuring spoons, and thickness sticks, the participants were presented with actual plates of food and asked to estimate the given portion sizes using the given PSEAs.

RESULTS

The improved 2-dimensional (2D) picture aid for the rice bowl reflecting the size distortion by angle of view using 3D modeling was perceived more closely to the actual size than the current 2D picture (P < 0.001). The change of the color of 2D pictures and 3D models, the change of shape of the measuring spoons, and the 3-dimensionalization of the 2D mounds had no significant improvement in the subjects' perception.

CONCLUSIONS

The currently used 2D PSEAs need to be fully redesigned using 3D modeling to improve subjects' perception. However, change of color or shape will not be necessary. For amorphous foods, it is suggested that more evaluation be performed before reaching a final conclusion in the use of PSEAs, or alternative ways to improve accuracy of estimation need to be explored.

Development and validation of nutrient estimates based on a food-photographic record in Japan

Background

Previous studies have reported that estimates of portion size, energy, and macronutrients such as carbohydrates, proteins, and fat based on the food-photographic record closely correlate with directly weighed values. However, the correlation based on a large sample of the test meal with the evidence of many nutrients is yet to be determined. We conducted this study to assess the correlation and difference between the food-photographic record and weighed results for 44 nutrients based on a larger number of test meals than those in previous studies.

Methods

We assessed the nutrients of test meals using a food-photographic record and direct weighing and compared the results of the two methods. Twenty participants prepared a total of 1163 test meals. Each participant cooked 28–29 different kinds of dishes. Five participants cooked the same dish with their own recipes. For the most commonly consumed 41 dishes, 20 participants served a meal with their usual portion size. For the remaining 73 dishes, five participants served a meal with their usual portion size. An independent researcher weighed each ingredient and calculated the nutrients of the test meals. The participants took photographs of the test meals using a digital camera. Two independent, trained analysts measured the longitudinal and transverse diameters of the food area on the photographs of the test meals, compared the portion size with the reference photographs, and calculated the nutrients based on a database that contained reference photographs.

Results

Rank correlation coefficients between estimates from the food-photographic record of each test meal and weighed results were high for portion size (r = 0.93), energy (r = 0.93), protein (r = 0.90), fat (r = 0.92), and carbohydrate (r = 0.94), and those for the 44 nutrients ranged from 0.78 to 0.94. We found high reproducibility between the two analysts for all the nutrients (r > 0.90).

Conclusions

We found a high correlation and small difference between the food-photographic record method and weighed results of a large number of nutrients in many test meals.

Validation of a life-logging wearable camera method and the 24-h diet recall method for assessing maternal and child dietary diversity

Accurate and timely data are essential for identifying populations at risk for undernutrition due to poor-quality diets, for implementing appropriate interventions and for evaluating change. Life-logging wearable cameras (LLWC) have been used to prospectively capture food/beverage consumed by adults in high-income countries. This study aimed to evaluate the concurrent criterion validity, for assessing maternal and child dietary diversity scores (DDS), of a LLWC-based image-assisted recall (IAR) and 24-h recall (24HR). Direct observation was the criterion method. Food/beverage consumption of rural Eastern Ugandan mothers and their 12-23-month-old child (n 211) was assessed, for the same day for each method, and the IAR and 24HR DDS were compared with the weighed food record DDS using the Bland-Altman limits of agreement (LOA) method of analysis and Cohen's κ. The relative bias was low for the 24HR (-0·1801 for mothers; -0·1358 for children) and the IAR (0·1227 for mothers; 0·1104 for children), but the LOA were wide (-1·6615 to 1·3012 and -1·6883 to 1·4167 for mothers and children via 24HR, respectively; -2·1322 to 1·8868 and -1·7130 to 1·4921 for mothers and children via IAR, respectively). Cohen's κ, for DDS via 24HR and IAR, was 0·68 and 0·59, respectively, for mothers, and 0·60 and 0·59, respectively, for children. Both the 24HR and IAR provide an accurate estimate of median dietary diversity, for mothers and their young child, but non-differential measurement error would attenuate associations between DDS and outcomes, thereby under-estimating the true associations between DDS - where estimated via 24HR or IAR - and outcomes measured.

The Sun's Vitamin in Adult Patients Affected by Prader-Willi Syndrome

Prader-Willi syndrome (PWS) is a genetic disorder characterized by hyperphagia with progressive, severe obesity, and an increased risk of obesity-related comorbidities in adult life. Although low dietary vitamin D intake and low 25-hydroxy vitamin D (25OHD) levels are commonly reported in PWS in the context of bone metabolism, the association of low 25OHD levels with fat mass has not been extensively evaluated in PWS adults. The aims of this study were to investigate the following in PWS adults: (1) 25OHD levels and the dietary vitamin D intake; (2) associations among 25OHD levels with anthropometric measurements and fat mass; (3) specific cut-off values for body mass index (BMI) and fat mass predictive of the 25OHD levels. In this cross-sectional, single-center study we enrolled 30 participants, 15 PWS adults (age 19-41 years and 40% males) and 15 control subjects matched by age, sex, and BMI from the same geographical area (latitude 40° 49' N; elevation 17 m). Fat mass was assessed using a bioelectrical impedance analysis (BIA) phase-sensitive system. The 25OHD levels were determined by a direct competitive chemiluminescence immunoassay. Dietary vitamin D intake data was collected by three-day food records. The 25OHD levels in the PWS adults were constantly lower across all categories of BMI and fat mass compared with their obese counterpart. The 25OHD levels were negatively associated with BMI (p = 0.04), waist circumference (p = 0.03), fat mass (p = 0.04), and dietary vitamin D intake (p < 0.001). During multiple regression analysis, dietary vitamin D intake was entered at the first step (p < 0.001), thus explaining 84% of 25OHD level variability. The threshold values of BMI and fat mass predicting the lowest decrease in the 25OHD levels were found at BMI ≥ 42 kg/m2 (p = 0.01) and fat mass ≥ 42 Kg (p = 0.003). In conclusion, our data indicate that: (i) 25OHD levels and dietary vitamin D intake were lower in PWS adults than in the control, independent of body fat differences; (ii) 25OHD levels were inversely associated with BMI, waist circumference, and fat mass, but low dietary vitamin D intake was the major determinant of low vitamin D status in these patients; (iii) sample-specific cut-off values of BMI and fat mass might help to predict risks of the lowest 25OHD level decreases in PWS adults. The presence of trained nutritionists in the integrated care teams of PWS adults is strongly suggested in order to provide an accurate nutritional assessment and tailored vitamin D supplementations.

A systematic review of recall errors associated with portion size estimation aids in children

To reduce errors in portion size estimation, a number of aids have been developed and tested. This systematic review synthesizes what is known about error associated with use of different portion size estimation aids (PSEAs) within self-reported dietary recall studies in children (aged ≤18 years). Eight electronic databases were searched using relevant keywords. From 8184 records identified and screened, 327 full texts were retrieved, with 10 records representing 9 studies meeting inclusion criteria. Studies using proxy reporting were excluded. Thirteen PSEAs were identified. To facilitate comparisons between different types of aids they were categorized into 'physical 2-dimensional (2D)', 'digital 2D' and '3-dimensional' PSEAs. Seven were physical 2D (e.g. food atlas), two were digital 2D (i.e. computer-based), and four were 3D (e.g. modelling clay, household items). Comparisons of PSEAs within studies found the smallest estimation errors for digital 2D and largest for 3D aids. Errors in relation to food type were varied, with portions of amorphous foods overestimated in multiple studies. No effects for recall interval time or sex were identified. One study reported a significant improvement in estimation error with increasing age. Across studies, large variations in study design and reporting of estimation error hindered the synthesis of evidence regarding the influence of different types of PSEAs on accuracy. While a definitive conclusion about the most accurate PSEA could not be drawn, a check-list to guide future PSEA development and testing has been proposed in the current review. This will assist comparability with future studies of PSEAs for children facilitate development of more accurate PSEAs in the future.

Progressive 24-Hour Recall: Usability Study of Short Retention Intervals in Web-Based Dietary Assessment Surveys

BACKGROUND

Under-reporting because of the limitations of human memory is one of the key challenges in dietary assessment surveys that use the multiple-pass 24-hour recall. Research indicates that shortening a retention interval (ie, the time between the eating event and recall) reduces the burden on memory and may increase the accuracy of the assessment.

OBJECTIVE

This study aimed to explore the accuracy and acceptability of Web-based dietary assessment surveys based on a progressive recall, where a respondent is asked to record multiple recalls throughout a 24-hour period using the multiple-pass protocol and portion size estimation methods of the 24-hour recall.

METHODS

The experiment was conducted with a dietary assessment system, Intake24, that typically implements the multiple-pass 24-hour recall method where respondents record all meals they had for the previous day on a single occasion. We modified the system to allow respondents to add multiple recalls throughout the day using the multiple-pass protocol and portion size estimation methods of the 24-hour recall (progressive recall). We conducted a dietary assessment survey with 33 participants, where they were asked to record dietary intake using both 24-hour and progressive recall methods for weekdays only. We compared mean retention intervals (ie, the time between eating event and recall) for the 2 methods. To examine accuracy, we compared mean energy estimates and the mean number of reported foods. Of these participants, 23 were interviewed to examine the acceptability of the progressive recall.

RESULTS

Retention intervals were found to be, on average, 15.2 hours (SD 7.8) shorter during progressive recalls than those during 24-hour recalls. We found that the mean number of foods reported for evening meals for progressive recalls (5.2 foods) was significantly higher (P=.001) than that for 24-hour recalls (4.2 foods). The number of foods and the amount of energy reported for other meals remained similar across the 2 methods. In interviews, 65% (15/23) of participants said that the 24-hour recall is more convenient in terms of fitting in with their daily lifestyles, and 65% (15/23) of respondents indicated that they remembered meal content and portion sizes better with the progressive recall.

CONCLUSIONS

The analysis of interviews and data from our study indicate that progressive recalls provide minor improvements to the accuracy of dietary assessment in Intake24. Additional work is needed to improve the acceptability of progressive recalls in this system.

Simple methods to obtain food listing and portion size distribution estimates for use in semi-quantitative dietary assessment methods

Semi-quantitative dietary assessment methods are frequently used in low income countries, and the use of photographic series for portion size estimation is gaining popularity. However, when adequate data on commonly consumed foods and portion sizes are not available to design these tools, alternative data sources are needed. This study aimed to develop and test methods to: (i) identify foods likely to be consumed in a study population in rural Uganda, and; (ii) to derive distributions of portion sizes for common foods and dishes. A process was designed to derive detailed food and recipe lists using guided group interviews with women from the survey population, including a score for the likelihood of foods being consumed. A rapid recall method for portion size distribution estimation (PSDE) using direct weight by a representative sample of the survey population was designed and implemented. Results were compared to data from a 24 hour dietary recall (24HR). Of the 82 food items reported in the 24HR survey, 87% were among those scored with a high or medium likelihood of being consumed and accounted for 95% of kilocalories. Of the most frequently reported foods in the 24HR, portion sizes for many (15/25), but not all foods did not differ significantly (p<0.05) from those in the portion size estimation method. The percent of portion sizes reported in the 24 hour recall falling between the 5th and 95th percentiles as determined by the PSDE method ranged from 18% up to 100%. In conclusion, a simple food listing and scoring method effectively identified foods most likely to occur in a dietary survey. A novel PSDE method produced similar estimates as for the 24HR, while the approach for others should be further considered and validated. These methods are an improvement on those in current use.

Adherence to the Mediterranean Diet, Dietary Patterns and Body Composition in Women with Polycystic Ovary Syndrome (PCOS)

Polycystic ovary syndrome (PCOS) is the most common female endocrine disorder and is characterized by chronic anovulation, hyperandrogenism, and polycystic ovaries. Obesity, low-grade chronic inflammatory status, and insulin-resistance (IR) often coexist in PCOS. The Mediterranean diet (MD) is an anti-inflammatory dietary pattern, which is rich in complex carbohydrates and fiber, and high in monounsaturated fat. There is a close association among obesity, low-grade chronic inflammation, IR, and hormonal derangements in PCOS. The main aim of the present study was to evaluate the adherence to MD, the dietary intake, and the body composition and their association with PCOS clinical severity in a cohort of treatment-naïve women with PCOS when compared with a control group of healthy women matched for age and body mass index (BMI). In this case-controlled, cross-sectional study, we enrolled 112 patients with PCOS and 112 controls. PREvención con DIetaMEDiterránea (PREDIMED) and seven-day food records were used to evaluate the degree of adherence to the MD and dietary pattern, respectively. Body composition was evaluated by bioelectrical impedance analysis (BIA) phase-sensitive system. Testosterone levels and Ferriman-Gallwey score assessed the clinical severity of PCOS. C-reactive protein (CRP) levels were determined with a nephelometric assay with CardioPhase high sensitivity. PCOS women showed higher testosterone levels, Ferriman-Gallwey score, fasting insulin and glucose levels, and Homeostatic Model Assessment (HoMA)-IR when compared with the control group (p < 0.001). In addition, we found that the PCOS women consumed less extra-virgin olive oil, legumes, fish/seafood, and nuts compared with control group. Despite no differences in energy intake between the two groups, the PCOS women consumed a lower quantity of complex carbohydrate, fiber, monounsaturated fatty acids (MUFA), and n-3 polyunsaturated fatty acid (PUFA), and higher quantity of simple carbohydrate, total fat, saturated fatty acid (SFA), PUFA and n-6 PUFA than the control group. The PCOS women have an adverse body composition when compared with controls, with the lowest values of phase angle (PhA) and fat-free mass (p < 0.001). Additionally, after adjusting for BMI and total energy intake, testosterone levels showed significant negative correlations with PREDIMED score (p < 0.001) and consumption of protein (p = 0.005), complex carbohydrate (p < 0.001), fiber (p < 0.001), MUFA (p < 0.001), n-3 PUFA (p = 0.001), and positive associations with CRP levels, simple carbohydrate, SFA, n-6 PUFA (p < 0.001, respectively), and PUFA (p = 0.002). The cut-off for PREDIMED score ≤ 6 (p < 0.001, area under the curve (AUC) 0.848, standard error 0.036, 95% confidence interval (CI) 0.768 to 0.909) could serve as a threshold for significantly increased risk of high value of testosterone levels. In conclusion, a novel direct association between the adherence to MD and the clinical severity of the disease was reported in women with PCOS. This association could support a therapeutic role of foods and nutrients of the Mediterranean dietary pattern in the PCOS pathogenesis likely involving their inflammatory status, IR, and hyperandrogenemia. In addition, we reported a different body composition that is characterized by lower PhA and fat-free mass than controls. These data suggested a role of PhA as a useful marker of the clinical severity of this syndrome and provided strong evidence regarding the strategic relevance of the nutritional assessment in the management of women with PCOS.

Self-Prescribed Dietary Restrictions are Common in Inflammatory Bowel Disease Patients and Are Associated with Low Bone Mineralization

Background and objectives: Despite the serious concerns of patients about the role of food in triggering or ameliorating their intestinal disease, there are few studies dealing with patients’ beliefs and practices regarding diet in inflammatory bowel disease (IBD). The aim of this study was to investigate how the disease affected the dietary habits of patients with IBD, and to assess if patients’ food restrictions were responsible for low bone mineralization. Materials and Methods: For this study, 90 consecutive patients referred for IBD were interviewed regarding their dietary habits. Demographic features and clinical characteristics potentially associated with the dietary habits were collected. A validated and self-administered survey questionnaire dealing with dietary habits and patients’ beliefs and perceptions regarding food was analyzed. Multivariate logistic regression analysis was performed in order to identify risk factors for dietary restrictions among participants and to evaluate the relationship between dietary restrictions and low bone mineral density (BMD). Results: Among the 63 (70%) patients who claimed a self-prescribed dietary restriction, 84% avoided dairy products. Significant risk factors (adjusted odds ratio (OR), 95% confidence interval (CI)) for the dietary restrictions were a younger age (p = 0.02), a higher level of education (p = 0.007), and a higher visceral sensitivity index (p = 0.009). Most (80%) of the patients displayed an inadequate calcium intake, and an abnormal result at dual-energy X-ray absorptiometry (DXA) scan accounting for low BMD was reported in 46 (51%) of them. Dietary restrictions (p = 0.03), and in particular avoiding dairy products (p = 0.001), were significant risk factors for a low BMD, along with female gender (p = 0.001), smoking (p = 0.04), and steroid abuse (p = 0.03). Almost all (86%) patients changed their diet after IBD diagnosis, as 8% believed that foods could have been a trigger for IBD and 37% that a proper diet was more important than drugs in controlling disease. Although 61% of the patients claimed to have received nutritional advice, 78% of the participants showed interest in receiving more. Conclusions: Dietary habits of IBD patients should be investigated by healthcare professionals as part of the routine visit. Clinicians are invited to provide nutritional recommendations to these patients in order to avoid unnecessary self-prescribed dietary restrictions.

Optimizing portion-size estimation aids: a formative evaluation in Malawi

OBJECTIVE

To investigate preferences for and ease-of-use perceptions of different aspects of printed and digitally displayed photographic portion-size estimation aids (PSEA) in a low-resource setting and to document accuracy of portion-size selections using PSEA with different visual characteristics.

DESIGN

A convergent mixed-methods design and stepwise approach were used to assess characteristics of interest in isolation. Participants served themselves food and water, which were weighed before and after consumption to measure leftovers and quantity consumed. Thirty minutes later, data collectors administered a meal recall using a PSEA and then a semi-structured interview.

SETTING

Blantyre and Chikwawa Districts in the southern region of Malawi.

PARTICIPANTS

Ninety-six women, aged 18-45 years.

RESULTS

Preferences and ease-of-use perceptions favoured photographs rather than drawings of shapes, three and five portion-size options rather than three with four virtual portion-size options, a 45° rather than a 90° photograph angle, and simultaneous rather than sequential presentation of portion-size options. Approximately half to three-quarters of participants found the portion-size options represented appropriate amounts of foods or water consumed. Photographs with three portion sizes resulted in more accurate portion-size selections (closest to measured consumption) than other format and number of portion-size option combinations. A 45° angle and simultaneous presentation were more accurate than a 90° angle and sequential presentation of images.

CONCLUSIONS

Results from testing PSEA visual characteristics separately can be used to generate optimal PSEA, which can improve participants' experiences during meal recalls.

Dietary habits affect fatty acid composition of visceral adipose tissue in subjects with colorectal cancer or obesity

PURPOSE

Aim of this study was to identify a possible relationship among dietary fatty acids (FA) intake, FA adipose tissue (AT) profile and cancer condition in lean vs obese subjects affected or not by colorectal cancer (CRC). Actually, inadequate dietary habits together with physical inactivity are primary determinants of obesity and cancer risk. Changes in lipid metabolism play a crucial role in different types of cancer and key enzymes involved in lipid-metabolic pathways, such as stearoyl-coA-desaturase 1 (SCD-1), are differentially expressed in normal and cancer tissues.

METHODS

Food frequency questionnaires (FFQ) were analyzed by Winfood software. FA were assessed by gas-liquid chromatography in visceral AT samples. Estimated desaturase activities were calculated as precursor FA/product FA ratio. Desaturase gene expressions were evaluated by RT-qPCR.

RESULTS

Lean and obese CRC subjects showed inadequate dietary habits. In particular, lean CRC subjects showed increase in the intake of saturated FA, specifically palmitic (p = 0.0042) and stearic acid (p = 0.0091), and a corresponding reduction of monounsaturated FA consumption, in particular oleic acid (p = 0.002) with respect to lean without CRC. Estimated SCD-1 activity in AT was increased in all the groups vs lean without CRC (pANOVA = 0.029).

CONCLUSIONS

Unhealthy eating habits, characterizing obese and CRC subjects, may influence the visceral AT profile and contribute to the alteration of the metabolic pathways. The quality of the diet, other than the quantity, can have a main role in the establishment of inflammatory microenvironment and in metabolic changes favouring CRC.

Patient empowerment and the Mediterranean diet as a possible tool to tackle prediabetes associated with overweight or obesity: a pilot study

AIM

The objective of this study was to investigate the effect of implementation of short-term patient empowerment as applied to Mediterranean diet (MD) adherence on metabolic and anthropometric parameters in prediabetic overweight or obese subjects.

METHODS

The sample included 42 subjects with prediabetes, aged 18-75 years and with body mass index (BMI) > 25 kg/m², who received dietary advice on MD by nutritionists during session groups every 2 weeks for 4 months. Data on energy caloric intake and macronutrient consumption were collected using a 7-day food diary record. Adherence to MD was investigated through the PREvención con DIeta MEDiterránea (PREDIMED) questionnaire. No advice was given regarding caloric restriction and physical activity. At baseline and at the end of the study, each subject underwent anthropometric, metabolic, and nutritional assessments.

RESULTS

Approximately 40.5% of subjects had achieved restoration of normal glucose tolerance by the end of the study. Fasting plasma glucose, glycated hemoglobin (HbA1C), BMI, waist circumference, blood pressure, visceral adiposity index, triglycerides, and total and LDL cholesterol levels were significantly decreased, while HDL cholesterol had significantly increased by the end of the study. The subjects significantly increased adherence to MD, as assessed by the PREDIMED questionnaire at follow-up. A reduction of prevalence of the metabolic syndrome was also reported. Interestingly, the PREDIMED score correlated with HbA1C values at follow-up, after adjusting for BMI and total caloric intake.

CONCLUSIONS

Implementation of short-term patient empowerment as applied to MD adherence was shown to improve anthropometric and metabolic parameters in prediabetic overweight or obese subjects. This is of considerable importance, given that diet must be the cornerstone of treatment in patients at high risk of developing type 2 diabetes.

Development and Validation of the Vending Evaluation for Nutrient-Density (VEND)ing Audit

Background: This paper describes the development and validation of the Vending Evaluation for Nutrient-Density (VEND)ing audit to comprehensively evaluate vended products based upon healthfulness, price and promotion, and machine accessibility. Methods: A novel vending nutrient-density score was created to determine the healthfulness of vended snack/beverage products. Field tested in United States colleges, VENDing audit (∑nutrient-density + 10 × % healthy products) and Support sub-scores (price + promotion + accessibility) were calculated for snack/beverage machines. Higher scores indicate more healthful vending options and supports for choosing healthfully. Nutrition Environment Measures Survey-Vending (NEMS-V) was used to validate the nutrient-density score for a sub-sample of machines. Sensitivity and specificity were computed by comparing the number of healthy snacks/beverages determined by NEMS-V and the VENDing nutrient-density scores. Results: Researchers conducted the VENDing audit on 228 snack/beverage vending machines at 9 universities within the United States and used both VENDing and NEMS-V on 33 snack and 52 beverage vending machines. Mean VENDing audit scores were 4.5 ± 2.0 (2.6, 3.4) and 2.6 ± 2.0 (0, 12) for snack/beverage machines, respectively. The number of products considered healthy assessed with both the VENDing nutrient-density scores and the NEMS-V were positively correlated for beverages (r = 0.687, p < 0.001) and snacks (r = 0.366, p < 0.05). The sensitivity was excellent for beverages (0.83) and moderate for snacks (0.69); while the specificity was moderate for both beverages (0.66) and snacks (0.50). Conclusions: The VENDing audit uses unique, valid, and reliable nutrient-density scoring to evaluate snacks/beverages along a continuum of healthful criteria and comprehensively evaluates the full vending environment.

Role of Nutrition and Adherence to the Mediterranean Diet in the Multidisciplinary Approach of Hidradenitis Suppurativa: Evaluation of Nutritional Status and Its Association with Severity of Disease

Hidradenitis suppurativa (HS) is a chronic, inflammatory and debilitating skin disorder. The exacerbating factors of HS include nutrition and adiposity. We aimed to investigate the relationships between body composition and the adherence to the Mediterranean diet (MD) with the severity of HS in a sample of naive-treatment patients with HS. In this case⁻controlled, cross-sectional study, we enrolled 41 HS patients and 41 control subjects. Body composition was evaluated by a bioelectrical impedance analysis (BIA) phase-sensitive system. PREvención con DIeta MEDiterránea (PREDIMED) and the 7-day food records were used to evaluate the degree of adherence to the MD and dietary pattern, respectively. The clinical severity was assessed by using the Sartorius HS score. HS patients had a worse body composition, in particular lower phase angle (PhA) (p < 0.001), and a lower adherence to the MD than controls, in spite of no differences in energy intake between the two groups. The receiver operator characteristic (ROC) analysis showing a value of PhA of ≤ 5.7 and a PREDIMED score of ≤ 5.0 identified HS patients with the highest clinical severity of the disease. After adjusting for sex, age, body mass index (BMI), and total energy intake, the HS Sartorius score maintained negative correlations with PhA (p < 0.001), PREDIMED score, and n-3 polyunsaturated fatty acids (p = 0.005). The results of the multivariate analysis showed PhA and PREDIMED score were the major determinants of HS Sartorius score, explaining 82.0% and 30.4% of its variability, respectively (p < 0.001). Novel associations were demonstrated between PhA and the degree of adherence to the MD with the HS severity. PhA and PREDIMED score might represent possible markers of severity of HS in a clinical setting.

Accuracy in the estimation of children's food portion sizes against a food picture book by parents and early educators

Validated methodological aids for food quantification are needed for the accurate estimation of food consumption. Our objective was to assess the validity of an age-specific food picture book, which contains commonly eaten foods among Finnish children, for parents and early educators in estimating food portion sizes. The food picture book was developed to assist in portion size estimation when filling in food records in the Increased health and wellbeing in preschools (DAGIS) study. All ninety-five food pictures in the book, each containing three or four different portion sizes, were evaluated at real-time sessions. Altogether, seventy-three parents and 107 early educators or early education students participated. Each participant evaluated twenty-three or twenty-four portions by comparing presented pre-weighed food portions against the corresponding picture from the food picture book. Food portions were not consumed by participants. The total proportion of correct estimations varied from 36 % (cottage cheese) to 100 % (fish fingers). Among the food groups, nearly or over 90 % of the estimations were correct for bread, pastries and main courses (‘piece products’ such as meatballs and chicken nuggets). Soups, porridges, salads and grated and fresh vegetables were least correctly estimated (<65 % correct estimations). There were small differences in evaluations of berries and fresh fruits, warm vegetables and pastries between the parents and early educators, but other estimations were mostly similar. The children's food picture book was found to be a useful aid for the estimation of food portion sizes. Parents and early educators evaluated the portion sizes with similar accuracy.

Trimethylamine-N-oxide (TMAO) as Novel Potential Biomarker of Early Predictors of Metabolic Syndrome

There is a mechanistic link between the gut-derived metabolite trimethylamine-N-oxide (TMAO) and obesity-related diseases, suggesting that the TMAO pathway may also be linked to the pathogenesis of obesity. The Visceral Adiposity Index (VAI), a gender-specific indicator of adipose dysfunction, and the Fatty Liver Index (FLI), a predictor of non-alcoholic fatty liver disease (NAFLD), are early predictors of metabolic syndrome (MetS). In this cross-sectional observational study, we investigated TMAO levels in adults stratified according to Body Mass Index (BMI) and the association of TMAO with VAI and FLI. One hundred and thirty-seven adult subjects (59 males; 21⁻56 years) were enrolled. TMAO levels were detected using HPLC/MS analysis. Homeostatic Model Assessment of Insulin Resistance (HoMA-IR), VAI and FLI were included as cardio-metabolic indices. TMAO levels increased along with BMI and were positively associated with VAI and FLI, independently, on common potential covariates. The most sensitive and specific cut-offs for circulating levels of TMAO to predict the presence of NAFLD-FLI and MetS were ≥8.02 µM and ≥8.74 µM, respectively. These findings allow us to hypothesize a role of TMAO as an early biomarker of adipose dysfunction and NAFLD-FLI in all borderline conditions in which overt MetS is not present, and suggest that a specific cut-off of TMAO might help in identifying subjects at high risk of NAFLD.

Impact of Nutritional Status on Gastroenteropancreatic Neuroendocrine Tumors (GEP-NET) Aggressiveness

Neuroendocrine tumors (NETs) are rare neoplasms mostly originating from the gastroenteropancreatic tract (GEP-NETs). Data regarding nutritional status in GEP-NET patients are limited. The aim of the study was to investigate the nutritional status and adherence to the Mediterranean Diet (MD) in GEP-NET patients and to correlate them with tumor aggressiveness. A cross-sectional case-control observational study was conducted enrolling 83 patients with well-differentiated G1/G2 GEP-NETs after resection, as well as 83 healthy subjects, age, sex and body mass index-matched. Nutritional status was assessed by evaluating with Bioelectrical Impedance analysis and its phase angle (PhA), adherence to the MD according to PREDIMED score, dietary assessment, anthropometric parameters, and clinico-pathological characteristics. GEP-NET patients consumed less frequently vegetables, fruits, wine, fish/seafood, nuts, and more frequently red/processed meats, butter, cream, margarine, and soda drinks than controls. Patients with more aggressive disease presented a lower adherence to MD according to PREDIMED categories in comparison to G1, localized and free/stable disease status. A smaller PhA value and a lower PREDIMED score were significantly correlated with G2 tumor, metastases, and progressive disease. To the best of our knowledge, this is the first study reporting an association between nutritional status and tumor aggressiveness in a selected group of GEP-NETs. Moreover, higher intakes of food of MD, may represent a potential tool for prevention of tumor aggressiveness. Thus, a skilled nutritionist should be an integral part of the multidisciplinary management of GEP-NET patients.

The Development and Validation of Food Atlas for Portion Size Estimation in the Balkan Region

Assessment of portion sizes is an important factor for the accuracy of food consumption surveys. The objective of this study was to develop and validate a food atlas of commonly consumed foods in the Balkan region in order to improve the accuracy of portion size estimation for food consumption surveys. A list of 135 foods and their portion sizes was based on previously conducted food consumption surveys in this region. Food was cooked, measured and served in three or four portion sizes right before being photographed. A validation study was conducted through the visual perception method. Without receiving training on usage of the food picture book, participants were asked to evaluate two portion sizes of 20 selected foods by comparison with a photo series of each food. Portion sizes were evaluated by 18 nutrition professionals and 17 lay individuals who had no nutritional education. Mean differences and the standard deviations of the mean differences (SD) between the portions estimated by each participant and the served portion were calculated. The percentages of participants who selected the correct, adjacent or distant portion size also were calculated. The number of food items that were quantified within the predefined acceptable range (i.e., mean difference < ∣ 0·7 ∣ and SD < 1) was 16 (80%) among lay individuals and 17 (85%) among nutritional professionals. Among 16 photo series that were assessed as "acceptable," the percentage of all participants, who selected the correct picture, was between 44.3 and 82.9%, with an average of 60.2%. Only three foods were assessed correctly by <50% participants. The percentage of participants who selected the correct or adjacent serving size was above 98% for both lay and professional evaluators. This is the first food atlas containing representative foods and recipes commonly consumed in the Balkan region. However, further adjustments of the methodology should include larger number of food items to be tested, involvement of more participants and provision of training for the users of the food atlas. This food atlas could be used in food consumption surveys in the Balkan region after further testing and validation.

Evaluation of a photographic food atlas as a tool for quantifying food portion size in the United Arab Emirates

Although, United Arab Emirates (UAE) has one of the highest prevalence of overweight, obesity and type 2 diabetes in the world, however, validated dietary assessment aids to estimate food intake of individuals and populations in the UAE are currently lacking. We conducted two observational studies to evaluate the accuracy of a photographic food atlas which was developed as a tool for food portion size estimation in the UAE. The UAE Food Atlas presents eight portion sizes for each food. Study 1 involved portion size estimations of 13 food items consumed during the previous day. Study 2 involved portion size estimations of nine food items immediately after consumption. Differences between the food portion sizes estimated from the photographs and the weighed food portions (estimation error), as well as the percentage differences relative to the weighed food portion for each tested food item were calculated. Four of the evaluated food items were underestimated (by -8.9% to -18.4%), while nine were overestimated (by 9.5% to 90.9%) in Study 1. Moreover, there were significant differences between estimated and eaten food portions for eight food items (P<0.05). In Study 2, one food item was underestimated (-8.1%) while eight were overestimated (range 2.52% to 82.1%). Furthermore, there were significant differences between estimated and eaten food portions (P<0.05) for six food items. The limits of agreement between the estimated and consumed food portion size were wide indicating a large variability in food portion estimation errors. These reported findings highlight the need for further developments of the UAE Food Atlas to improve the accuracy of food portion size intake estimations in dietary assessments. Additionally, recalling food portions from the previous day did not seem to increase food portion estimation errors in this study.

Validation of a self-administered web-based 24-hour dietary recall among pregnant women

Background

The use of valid dietary assessment methods is crucial to analyse adherence to dietary recommendations among pregnant women. This study aims to assess the relative validity of a self-administered Web-based 24-h dietary recall, the R24W, against a pen-paper 3-day food record (FR) among pregnant women.

Methods

Sixty (60) pregnant women recruited at 9.3 ± 0.7 weeks of pregnancy in Quebec City completed, at each trimester, 3 R24W and a 3-day FR. Mean energy and nutrient intakes reported by both tools were compared using paired Student T-Tests. Pearson correlations were used to analyze the association between both methods. Agreement between the two methods was evaluated using cross-classification analyses, weighted kappa coefficients and Bland-Altman analyses.

Results

Pearson correlation coefficients were all significant, except for vitamin B₁₂ (r = 0.03; p = 0.83) and ranged from 0.27 to 0.76 (p < 0.05). Differences between mean intakes assessed by the R24W and the FR did not exceed 10% in 19 variables and were not significant for 16 out of 26 variables. In cross-classification analyses, the R24W ranked, on average, 79.1% of participants in the same or adjacent quartiles as the FR.

Conclusions

Compared to a 3-day FR, the R24W is a valid method to assess intakes of energy and most nutrients but may be less accurate in the evaluation of intakes of fat (as a proportion of energy intake), vitamin D, zinc and folic acid. During pregnancy, the R24W was a more accurate tool at a group-level than at an individual-level and should, therefore, be used in an epidemiological rather than a clinical setting. The R24W may be particularly valuable as a tool used in cohort studies to provide valid information on pregnant women’s dietary intakes and facilitate evaluation of associations between diet and adverse pregnancy outcomes.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1741-1) contains supplementary material, which is available to authorized users.

Using digital photography in a clinical setting: a valid, accurate, and applicable method to assess food intake

BACKGROUND/OBJECTIVES

Regular monitoring of food intake is hardly integrated in clinical routine. Therefore, the aim was to examine the validity, accuracy, and applicability of an appropriate and also quick and easy-to-use tool for recording food intake in a clinical setting.

SUBJECTS/METHODS

Two digital photography methods, the postMeal method with a picture after the meal, the pre-postMeal method with a picture before and after the meal, and the visual estimation method (plate diagram; PD) were compared against the reference method (weighed food records; WFR). A total of 420 dishes from lunch (7 weeks) were estimated with both photography methods and the visual method. Validity, applicability, accuracy, and precision of the estimation methods, and additionally food waste, macronutrient composition, and energy content were examined.

RESULTS

Tests of validity revealed stronger correlations for photography methods (postMeal: r = 0.971, p < 0.001; pre-postMeal: r = 0.995, p < 0.001) compared to the visual estimation method (r = 0.810; p < 0.001). The pre-postMeal method showed smaller variability (bias < 1 g) and also smaller overestimation and underestimation. This method accurately and precisely estimated portion sizes in all food items. Furthermore, the total food waste was 22% for lunch over the study period. The highest food waste was observed in salads and the lowest in desserts.

CONCLUSIONS

The pre-postMeal digital photography method is valid, accurate, and applicable in monitoring food intake in clinical setting, which enables a quantitative and qualitative dietary assessment. Thus, nutritional care might be initiated earlier. This method might be also advantageous for quantitative and qualitative evaluation of food waste, with a resultantly reduction in costs.

Validation of a picture book to be used in a pan-European dietary survey

Objective

To validate a picture book for estimation of food portion sizes using two approaches: (i) ‘perception’ of food portions by comparison with a series of food photos; and (ii) ‘conceptualization and memory’, using the same photos to estimate the amount of served food one hour after self-served food portions.

Design

Each partner developed a country-specific picture book based on the so-called EPIC-Soft picture book. Representative and common photo series were chosen achieving approximately 25 % of the original picture book (n23). Three portions from each photo series were randomly selected.

Setting

The study was performed within the Pilot study in the view of a Pan-European dietary survey – Adolescents, adults and elderly (PILOT-PANEU) project.

Subjects

A sample of adolescents and adults was recruited in five countries: Bulgaria (n103), Finland (n34), Germany (n69), Hungary (n62) and Portugal (n77).

Results

Among the portions of the corresponding photo series and depending on the type of food, from 18 % (cheese) to 96 % (ratatouille) of participants chose the correct portions. In the perception study, agreement between the portions shown and reported was substantial (intraclass correlation coefficient (ICC)=0·805) and the mean difference was very low. In the memory study, agreement between the served and reported portions was lower than in the perception study (ICC=0·536). Agreement also seemed to decrease as the appearance of food on the plate differed from food in the picture.

Conclusions

Overall, the picture series selected can be applied in future intake surveys to quantify foods similar to those depicted in the pictures.

Evaluation of food photographs assessing the dietary intake of children up to 10 years old

OBJECTIVE

Young children lack basic skills related to recognizing the types of foods they consume and dietary surveys often rely on parents' response. The present study aimed to evaluate how well parents of children aged from 3 months to 10 years perceive images of portions of foods commonly consumed by young children.

DESIGN

Pre-weighed, actual food portions (n 2314) were shown to the study participants who were asked to indicate the picture that corresponded to the food in view. Mean differences between picture numbers selected and shown were estimated and compared using unpaired t tests or Tukey-Cramer pairwise comparisons.

SETTING

Real-time testing of parents' perception of food images presenting portion sizes consumed by children up to 10 years old.

SUBJECTS

A convenience sample of 138 parents/caregivers of young children (69 % females).

RESULTS

Individuals selected the correct or adjacent image in about 97 % of the assessments. Images presenting amorphous solids (i.e. pies and pastries with a filling), liquid or semi-liquid dishes (i.e. soups, porridges, fruit and vegetable purées) were more prone to bias. There was no indication that personal characteristics (gender, age, educational background, age, number of offspring) were associated with differences in the way parents/caregivers perceived the food pictures.

CONCLUSIONS

Food pictures may not be appropriate to quantify the intake of liquid, semi-liquid or amorphous solid foods in surveys addressing young children and studies evaluating their performance as food portion anchors should ensure the inclusion of several and various amorphous foods in the assessment.

Accuracy of food photographs for quantifying food servings in a lunch meal setting among Danish children and adults

BACKGROUND

Visual aids, such as food photographs, are widely used in estimating food quantities in dietary surveys. The present study aimed to assess how accurately Danish adults and children can estimate food portion sizes using 37 series of photographs illustrating four to six different portion sizes under real-life conditions; determine whether adults were more accurate than children; and estimate the error caused by using portion size photographs to estimate weights of foods consumed in macronutrient calculation.

METHODS

Six hundred and twenty-two adults and 109 children were recruited in three workplace canteens and in two schools, respectively, to estimate their lunchtime portions based on photographs. Participants were instructed to keep the foods separated on their plate when taking lunch. Participants thereafter estimated their own portions by looking at the relevant series of photographs. The actual food portions were then weighed.

RESULTS

The proportion of correct estimations was 42% overall (range 19-77%). The mean difference (%) between estimated and actual weight was 17% (range 1-111%). Small portion size photographs were more often used correctly compared to larger portion photographs. Children had as many correct estimations as adults, although they overestimated portions more. Participants using fractions of (or more than) one photograph to estimate the portion of a food had significantly larger errors. When calculating the macronutrient content of a weekly menu using the estimated portion sizes, protein had the largest error (29%).

CONCLUSIONS

When used in a real-life situation, the portion size photographs validated in the present study showed a certain inaccuracy compared to the actual weights.

Adherence to the Mediterranean Diet and Circulating Levels of Sirtuin 4 in Obese Patients: A Novel Association

PURPOSE

This study was aimed at evaluating sirtuin 4 (Sirt4) levels in obese individuals, in relation to their adherence to the Mediterranean diet (MD), a healthy dietary pattern characterized by high antioxidant capacity, and markers of visceral fat storage.

SUBJECTS/METHODS

Forty-three obese patients (44% males; BMI: 36.7-58.8 kg/m2) were consecutively included. PREvención con DIeta MEDiterránea (PREDIMED) and the 7-day food records were used to assess the adherence to MD and dietary pattern, respectively. Visceral adiposity index (VAI) was calculated. Sirt4 levels were detected by ELISA method.

RESULTS

The majority of the obese participants (62.8%) had an average adherence to MD. Compared with average adherers, low adherers had higher BMI, energy intake, and percentage of energy from lipids, mainly saturated fat and polyunsaturated fatty acids (PUFA), and lower Sirt4 levels. After adjusting for BMI, Sirt4 levels remained negatively correlated with VAI. After adjusting for total energy intake, Sirt4 levels remained negatively associated with PREDIMED and consumption of n-3 PUFA, vitamins C and E. The threshold value of PREDIMED predicting the lowest decrease in Sirt4 levels was found at a score of 6.

CONCLUSIONS

Less reduced Sirt4 levels in obese patients adhering to MD suggest a further aspect of the antioxidant advantage of MD.

Development of a food atlas for Sri Lankan adults

Background

Obtaining reliable food portion size estimations in dietary surveys found to be a difficult task. A food atlas is a set of photograph series depicting different amounts of a particular food, usually bound together in a single volume that can be used to describe portion sizes. By this paper we aim to explain the methods used in developing a photographic food atlas for Sri Lankan adults and to discuss its usage, advantages and limitations.

Methods

Foods that are commonly consumed in Sri Lanka were recognized by a local nutritional survey, market survey and interviewing nutrition experts. In obtaining food items, certain dishes were prepared according to a standard recipe book while other items were purchased from recognized restaurants and the local market. White color crockery or/with blue color board was used to present the food items and they were photographed by a professional photographer employing a camera setup recommended for food photography. Three types of photographs have been used to illustrate the food items; serial, range and guide. Mainly the serial photographs were taken using two cameras: one fixed at an angle of 5° to capture aerial views, and the other placed at an angle of 45° to represent the view of a person of average height, sitting at a table, looking at a plate on the table in front of him. The liquid portion series were photographed at an angle of 90° to get life-size images. The range and guide photographs were taken free hand so that all the items could be captured in the best way possible.

Results

A total of 125 foods that are commonly consumed by Sri Lankan adults were selected to be depicted in the atlas; serial photographs of increasing portion sizes (n = 88 foods); range photographs depicting a range of sizes/varieties of a particular food, (n = 11), and guide photographs which represent the brands/types of a certain food item/category available in the market (n = 26).

Conclusion

The food atlas will be a valuable resource for dietary surveys in Sri Lanka as well as in other South Asian countries where similar foods are consumed.

Development of food photographs for use with children aged 18 months to 16 years: Comparison against weighed food diaries - The Young Person's Food Atlas (UK)

Traditional dietary assessment methods, used in the UK, such as weighed food diaries impose a large participant burden, often resulting in difficulty recruiting representative samples and underreporting of energy intakes. One approach to reducing the burden placed on the participant is to use portion size assessment tools to obtain an estimate of the amount of food consumed, removing the need to weigh all foods. An age range specific food atlas was developed for use in assessing children’s dietary intakes. The foods selected and portion sizes depicted were derived from intakes recorded during the UK National Diet and Nutrition Surveys of children aged 1.5 to 16 years. Estimates of food portion sizes using the food atlas were compared against 4-day weighed intakes along with in-school / nursery observations, by the research team. Interviews were conducted with parents the day after completion of the diary, and for children aged 4 to 16 years, also with the child. Mean estimates of portion size consumed were within 7% of the weight of food recorded in the weighed food diary. The limits of agreement were wide indicating high variability of estimates at the individual level but the precision increased with increasing age. For children 11 years and over, agreement with weighed food diaries, was as good as that of their parents in terms of total weight of food consumed and of intake of energy and key nutrients. The age appropriate food photographs offer an alternative to weighed intakes for dietary assessment with children.

Fourth-Grade Children's Reporting Accuracy for Amounts Eaten at School-Provided Meals: Insight from a Reporting-Error-Sensitive Analytic Approach Applied to Validation Study Data

BACKGROUND

Validation studies that have directly assessed reporting accuracy for amounts eaten have provided results in various ways.

OBJECTIVE

To analyze amount categories of a reporting-error-sensitive approach for insight concerning reporting accuracy for amounts eaten.

DESIGN

For a cross-sectional validation study, children were observed eating school-provided breakfast and lunch, and randomized to one of eight 24-hour recall conditions (two retention intervals [short and long] crossed with four prompts [forward, meal name, open, and reverse]).

PARTICIPANTS/SETTING

Data collected during 3 school years (2011-2012 to 2013-2014) on 455 children from 10 schools (four districts) in a southern US state.

MAIN OUTCOME MEASURES

Items were classified as matches (observed and reported), omissions (observed but unreported), or intrusions (unobserved but reported). Within amount categories (matches [corresponding, overreported, and underreported], intrusions [overreported], and omissions [underreported]), item amounts were converted to kilocalories.

STATISTICAL ANALYSES PERFORMED

A multilevel model was fit with food-level explanatory variables (amount category and meal) and child-level explanatory variables (retention interval, prompt, sex, and race/ethnicity). To investigate inaccuracy differences, t tests on three contrasts were performed.

RESULTS

Inaccuracy differed by amount category (P<0.001; in order from largest to smallest: omission, intrusion, underreported match, and overreported match), meal (P=0.01; larger for breakfast), retention interval (P=0.003; larger for long), sex (P=0.004; larger for boys), race/ethnicity (P=0.045; largest for non-Hispanic whites), and amount category×meal interaction (P=0.046). Overreported amounts were larger for intrusions than overreported matches (P<0.0001). Underreported amounts were larger for omissions than underreported matches (P<0.0001). Overall underreported amounts (from omissions and underreported matches) exceeded overall overreported amounts (from intrusions and overreported matches) (P<0.003).

CONCLUSIONS

Amount categories provide a standard way to analyze validation study data on reporting accuracy for amounts eaten, and compare results across studies. Multilevel analytic models reflecting the data structure are recommended for inference. To enhance reporting accuracy for amounts eaten, focus on increasing reports of correct items, thereby yielding more matches with fewer intrusions and omissions.

Development and validation of a food photography manual, as a tool for estimation of food portion size in epidemiological dietary surveys in Tunisia

BACKGROUND

Estimation of food portion sizes has always been a challenge in dietary studies on free-living individuals. The aim of this work was to develop and validate a food photography manual to improve the accuracy of the estimated size of consumed food portions.

METHODS

A manual was compiled from digital photos of foods commonly consumed by the Tunisian population. The food was cooked and weighed before taking digital photographs of three portion sizes. The manual was validated by comparing the method of 24-hour recall (using photos) to the reference method [food weighing (FW)]. In both the methods, the comparison focused on food intake amounts as well as nutritional issues. Validity was assessed by Bland-Altman limits of agreement. In total, 31 male and female volunteers aged 9-89 participated in the study.

RESULTS

We focused on eight food categories and compared their estimated amounts (using the 24-hour recall method) to those actually consumed (using FW). Animal products and sweets were underestimated, whereas pasta, bread, vegetables, fruits, and dairy products were overestimated. However, the difference between the two methods is not statistically significant except for pasta (p<0.05) and dairy products (p<0.05). The coefficient of correlation between the two methods is highly significant, ranging from 0.876 for pasta to 0.989 for dairy products. Nutrient intake calculated for both methods showed insignificant differences except for fat (p<0.001) and dietary fiber (p<0.05). A highly significant correlation was observed between the two methods for all micronutrients. The test agreement highlights the lack of difference between the two methods.

CONCLUSION

The difference between the 24-hour recall method using digital photos and the weighing method is acceptable. Our findings indicate that the food photography manual can be a useful tool for quantifying food portion sizes in epidemiological dietary surveys.

Adaptation of Locally Available Portion Sizes for Food Frequency Questionnaires in Nutritional Epidemiological Studies: How Much Difference does it Make?

Introduction:

There is need for employing strategies to minimize measurement errors while administering semi-quantitative FFQ. The current study was planned to adapt and standardize locally available portion sizes for semi-quantitative FFQ to improve its validity and document the process of standardization of portion sizes.

Methodology:

The study was conducted in 9 villages of the INCLEN-SOMAARTH DDESS (Demographic, Development and Environmental Surveillance Site), Palwal district, Haryana, India. The subjects in these nine villages are part of a cohort study to assess the interaction between societal and household factors with food intake and physical activity of children. Systematic utensil survey was undertaken in 3 randomly chosen households per village i.e. 27 households and the portion sizes were derived from a total of 74 serving utensils. The derived sizes were classified as small (240 ml), medium (320 ml) and large (600 ml). The semi-quantitative FFQ with locally derived portion sizes was then administered to 63 children in 6-12 year age group.

Results:

The volume of food measured by the reference portion sizes generally being employed in the national surveys, would have been underestimated the food consumed by the child by 55-60% as compared to what was being consumed by the children in the study area. The correlation between food intake assessed by 24-hr recall method and FFQ using derived (local) portion sizes was better as compared to that obtained with the semi-quantitative FFQ done with reference portions.

Conclusion:

In conclusion, local portion size adaptation of FFQ for semi-quantification is useful to mitigate measurement errors associated with this technique.