Evaluation of web-based, self-administered, graphical food frequency questionnaire.

Computer-administered food frequency questionnaires (FFQs) can address limitations inherent in paper questionnaires by allowing very complex skip patterns, portion size estimation based on food pictures, and real-time error checking. We evaluated a web-based FFQ, the Graphical Food Frequency System (GraFFS). Participants completed the GraFFS, six telephone-administered 24-hour dietary recalls over the next 12 weeks, followed by a second GraFFS. Participants were 40 men and 34 women, aged 18 to 69 years, living in the Columbus, OH, area. Intakes of energy, macronutrients, and 17 micronutrients/food components were estimated from the GraFFS and the mean of all recalls. Bias (second GraFFS minus recalls) was -9%, -5%, +4%, and -4% for energy and percentages of energy from fat, carbohydrate, and protein, respectively. De-attenuated, energy-adjusted correlations (intermethod reliability) between the recalls and the second GraFFS for fat, carbohydrate, protein, and alcohol were 0.82, 0.79, 0.67, and 0.90, respectively; for micronutrients/food components the median was 0.61 and ranged from 0.40 for zinc to 0.92 for beta carotene. The correlations between the two administrations of the GraFFS (test-retest reliability) for fat, carbohydrate, protein, and alcohol were 0.60, 0.63, 0.73, and 0.87, respectively; among micronutrients/food components the median was 0.67 and ranged from 0.49 for vitamin B-12 to 0.82 for fiber. The measurement characteristics of the GraFFS were at least as good as those reported for most paper FFQs, and its high intermethod reliability suggests that further development of computer-administered FFQs is warranted.

New technology in dietary assessment: a review of digital methods in improving food record accuracy.

Methods for conducting dietary assessment in the United States date back to the early twentieth century. Methods of assessment encompassed dietary records, written and spoken dietary recalls, FFQ using pencil and paper and more recently computer and internet applications. Emerging innovations involve camera and mobile telephone technology to capture food and meal images. This paper describes six projects sponsored by the United States National Institutes of Health that use digital methods to improve food records and two mobile phone applications using crowdsourcing. The techniques under development show promise for improving accuracy of food records.

Web-enabled and improved software tools and data are needed to measure nutrient intakes and physical activity for personalized health research.

Food intake, physical activity (PA), and genetic makeup each affect health and each factor influences the impact of the other 2 factors. Nutrigenomics describes interactions between genes and environment. Knowledge about the interplay between environment and genetics would be improved if experimental designs included measures of nutrient intake and PA. Lack of familiarity about how to analyze environmental variables and ease of access to tools and measurement instruments are 2 deterrents to these combined studies. This article describes the state of the art for measuring food intake and PA to encourage researchers to make their tools better known and more available to workers in other fields. Information presented was discussed during a workshop on this topic sponsored by the USDA, NIH, and FDA in the spring of 2009.

Validation of a novel physical activity assessment device in morbidly obese females.

Assessment of physical activity in morbidly obese subjects is important especially in bariatric surgery. We examined the validity of Intelligent Device for Energy Expenditure and Activity (IDEEA) for measuring physical activity and sedentary behavior in morbidly obese women. Activity types, gait counts, and speed detected by the IDEEA monitor were compared to those reported by an observer. The IDEEA monitor detected activity types and gait counts with relatively high accuracy, although slightly lower in extremely obese women than in normal weight controls. The IDEEA monitor accurately estimated gait speeds in both groups. Since gait speed predicts energy expenditure more accurately than gait counts, it is of greater clinical relevance. Reliability of the IDEEA monitor was excellent. The IDEEA monitor is a valid instrument for measuring physical activity and sedentary behavior in extremely obese women, and therefore has potential applications in bariatric surgery both in preoperative evaluation and long-term follow-up.

Relative validity of the Iowa Fluoride Study targeted nutrient semi-quantitative questionnaire and the block kids' food questionnaire for estimating beverage, calcium, and vitamin D intakes by children.

OBJECTIVE: Food frequency questionnaires are commonly developed and subsequently used to investigate relationships between dietary intake and disease outcomes; such tools should be validated in the population of interest. We investigated the relative validities of the Iowa Fluoride Study targeted nutrient semi-quantitative questionnaire and Block Kids' Food Questionnaire in assessing beverage, calcium, and vitamin D intakes using 3-day diaries for reference. DESIGN: Cross-sectional. SUBJECTS: Children who completed Iowa Fluoride Study nutrient questionnaire at age 9.0+/-0.7 years (n=223) and/or the Block Kids' Food Questionnaire at age 8.3+/-0.3 years (n=129) and 3-day diaries during similar time periods. MAIN OUTCOMES: Intakes of beverages, calcium, and vitamin D. STATISTICAL ANALYSES: Spearman correlation coefficients, weighted kappa statistics, and percentages of exact agreement were used to estimate relative validities. RESULTS: Correlations between milk intakes (r=0.572) reported on diaries and the Iowa Fluoride Study nutrient questionnaires were higher than correlations for 100% juice, juice drinks, soda pop, and water (r=0.252 to 0.379). Correlations between milk intakes (r=0.571) and 100% juice intakes (r=0.550) reported on diaries and Block Kids' Food Questionnaires were higher than correlations for other beverages (r=0.223 to 0.326). Correlations with diaries for calcium (r=0.462) and vitamin D (r=0.487) intakes reported on Iowa Fluoride Study nutrient questionnaires were similar to correlations with diaries for calcium (r=0.515) and vitamin D (r=0.512) reported on Block Kids' Food Questionnaires. Weighted kappa statistics were similar between the Iowa Fluoride Study nutrient questionnaires and the Block Kids' Food Questionnaires for milk, 100% juice, and vitamin D, but were higher on the Iowa Fluoride Study nutrient questionnaires than on the Block Kids' Food Questionnaires for calcium. Percentages of exact agreement were higher for calcium, but lower for vitamin D for intakes reported on the Iowa Fluoride Study nutrient questionnaires compared to the Block Kids' Food Questionnaires relative to diaries. CONCLUSIONS: Both the Iowa Fluoride Study nutrient questionnaire and the Block Kids' Food Questionnaire provide reasonable estimates of milk, calcium, and vitamin D intakes when compared to 3-day diaries.

Considerations for selecting a dietary assessment system.

The software available with some food composition databases allows for the dietary assessment of individuals and groups and may provide graphic comparisons of nutrient intakes to dietary standards. Four factors to consider when choosing a computerized dietary assessment system are availability of desired database features, efficiency of the search engine in finding foods in the database, educational value of the output, and cost of purchasing and updating the software. Printed output should clearly characterize dietary adequacy with graphs or simple tables. Dietary assessment data used for research must also be available in electronic spreadsheet format for statistical analysis. Peer-reviewed papers in journals that provide overviews of the features of various computerized dietary assessment software are helpful for informing the selection process.

Development of the Iowa bone nutrient food frequency questionnaire based on data from the US Department of Agriculture Continuing Survey of the Food Intake by Individuals.

An easily administered food frequency questionnaire (FFQ)/dietary screener was developed for current (adult) and retrospective (adolescent) intakes of nutrients important for bone development and maintenance. This tool quantified serving sizes and nutrients from foods using gender and age specific techniques. Nutrients of interest were calcium, vitamin D, caffeine and alcohol, and 15 categories of foods were selected for inclusion based on frequency of intake and nutrient density. Calcium-contributing foods were selected from published dietary intake assessment tools. Foods contributing vitamin D, caffeine and alcohol were selected based on nutrient density and Midwest consumption practices. Serving sizes were quantified in standard serving units or as small, medium and large servings. Food items selected for the FFQ/dietary screener were matched to foods from the United States Department of Agriculture (USDA) Continuing Survey of Food Intakes by Individuals (CSFII). Calcium, caffeine and alcohol values were assigned using CSFII data files at median values per 100g intake. CSFII midpoint tertile frequency of intake values for males and females 14-18 and 25-45 years old were used to establish serving weights for small, medium and large servings. CSFII data files provide an efficient way for estimating typical intakes, serving sizes and nutrient values for target groups. Age- and gender-derived data provided realistic estimates of nutrient intakes when using FFQ/dietary screener assessment method.

Design, feasibility, and acceptability of an intervention using personal digital assistant-based self-monitoring in managing type 2 diabetes.

BACKGROUND: The information processing demands associated with behavioral self-management of diabetes are extensive. Pairing personal digital assistant (PDA)-based self-monitoring with a behavioral self-management intervention may improve adherence and patient outcomes. METHODS: ENHANCE is a randomized controlled trial to test an intervention designed to improve regimen adherence in adults with type 2 diabetes. The intervention, based on Social Cognitive Theory (SCT), is paired with PDA-based self-monitoring. In this paper we describe the: (a) manner in which PDA-based self-monitoring is integrated within the SCT-based intervention, (b) feasibility and acceptability of PDA-based dietary self-monitoring, and (c) issues encountered in teaching participants to self-monitor using a PDA. RESULTS: During the first 30 months of this 5-year study, 232 participants were screened and 151 were randomized. To date, 6 cohorts have completed the study. The retention rate is 85% (n=129). Of those randomized to the intervention (n=74) and completing the study (n=61), 88% reported understanding the usefulness of PDA-monitoring, 85% reported ease in entering foods into the device, 70% reported ease in interpreting feedback graphs, and 82% indicated that they would continue to use the PDA for self-monitoring after the study concluded. Assuming 3 meals per day, participants entered an average of 58% of their meals in their PDA, and 43% were entered assuming 4 meals per day. If we eliminate from the analysis those individuals who entered less than 10% of their expected meals (n=12), the average rate of self-monitoring was 69% assuming 3 meals per day, and 52% assuming 4 meals per day. CONCLUSIONS: PDA-based dietary monitoring is perceived by participants to be useful and acceptable. The approach used to instruct participants in use of the PDA and lessons learned are discussed. PDA technology shows promise as a tool for assisting those with type 2 diabetes in their efforts to manage their disease.

Food composition data: the foundation of dietetic practice and research.

Food composition databases and dietary assessment systems are important tools for food and nutrition professionals. The availability and accessibility of data have improved over time along with the technology to convert the information into useful formats for planning diets, writing educational materials, counseling patients, and conducting research. Primary sources of food composition data include government, academic, and other institutional databases; the food industry; and scientific literature. Changes in the marketplace affect food availability and composition and affect the accuracy and adequacy of food composition databases. Improvements in both food composition data and in dietary assessment methods have worked synergistically to improve estimates of dietary intake. The development of databases for food frequency assessment systems requires special considerations for data aggregation for each food or food grouping in the questionnaires. Considerations for selecting a dietary assessment system include appropriateness of the data for the intended audience or purpose, efficiency of the search strategy for retrieving data, content and format of summary information, and cost. Needs for food composition data vary depending on dietetic practice area; however, most food and nutrition professionals will benefit from becoming more informed about food composition data, exploring new ways to educate themselves about databases and database systems, and advocating for what is most needed in dietetic practice.

Ability of the normal human small intestine to absorb fructose: evaluation by breath testing.

BACKGROUND & AIMS: Fructose consumption is increasing, and its malabsorption causes common gastrointestinal symptoms. Because its absorption capacity is poorly understood, there is no standard method of assessing fructose absorption. We performed a dose-response study of fructose absorption in healthy subjects to develop a breath test to distinguish normal from abnormal fructose absorption capacity. METHODS: In a double-blind study, 20 healthy subjects received 10% solutions of 15, 25, and 50 g of fructose and 33% solution of 50-g fructose on 4 separate days at weekly intervals. Breath samples were assessed for hydrogen (H2) and methane (CH4) during a period of 5 hours, and symptoms were recorded. RESULTS: No subject tested positive with 15 g. Two (10%) tested positive with 25 g fructose but were asymptomatic. Sixteen (80%) tested positive with 50 g (10% solution), and 11 (55%) had symptoms. Breath H2 was elevated in 13 (65%), CH4 in 1 (5%), and both in 2 (10%). Twelve (60%) tested positive with 50 g (33% solution), and 9 (45%) experienced symptoms. The area under the curve for H2 and CH4 was higher (P < .01) with 50 g compared with lower doses. There were no gender differences. CONCLUSIONS: Healthy subjects have the capacity to absorb up to 25 g fructose, whereas many exhibit malabsorption and intolerance with 50 g fructose. Hence, we recommend 25 g as the dose for testing subjects with suspected fructose malabsorption. Breath samples measured for H2 and CH4 concentration at 30-minute intervals and for 3 hours will detect most subjects with fructose malabsorption.

Influence of intervention on beverage choices: trends in the dietary intervention study in children (DISC).

OBJECTIVE: To compare treatment, sex, and visit differences in beverage choice and calcium intake in the Dietary Intervention Study in Children, to compare the relationship of other beverages to milk consumption, and document whether or not the dietary intervention affected choice of beverage and milk type over time. DESIGN: Data from the Dietary Intervention Study in Children, a randomized, controlled, multicenter, clinical trial with five sets of three 24-hour recalls. SUBJECTS: Six hundred fifty-three children from six clinics started the study at age 8 to 10 years. Participants had serum low-density lipoprotein cholesterol levels between the 80th and 98th percentiles of age, and were followed for a median of 7.3 years. INTERVENTION: Children were randomized to a total fat- and saturated fat-modified dietary intervention or usual care. MAIN OUTCOME MEASURES: Volume and percent of total energy from soft drinks, fruit-flavored drinks, fruit juice, and milk, calcium intake in milligrams and per 1,000 kcal, and percent reduced-fat and skim milk consumed. STATISTICAL ANALYSES: General Estimating Equations methodology was used to adjust for treatment, sex, and visit differences. RESULTS: The intervention group consumed more reduced-fat or skim milk than the usual care group. The intervention group also reported a greater increase in calcium per 1,000 kcal than those in the usual care group due to nonbeverage sources. Consumption of soft drinks increased over the course of the study, whereas total milk consumption decreased sharply. CONCLUSIONS: With nutrition education, children can make changes in the type of milk consumed, and in the quantity of dietary calcium consumed.

Randomized controlled trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation.

BACKGROUND & AIMS: Constipation is a common disorder, and current treatments are generally unsatisfactory. Biofeedback might help patients with constipation and dyssynergic defecation, but its efficacy is unproven, and whether improvements are due to operant conditioning or personal attention is unknown. METHODS: In a prospective randomized trial, we investigated the efficacy of biofeedback (manometric-assisted anal relaxation, muscle coordination, and simulated defecation training; biofeedback) with either sham feedback therapy (sham) or standard therapy (diet, exercise, laxatives; standard) in 77 subjects (69 women) with chronic constipation and dyssynergic defecation. At baseline and after treatment (3 months), physiologic changes were assessed by anorectal manometry, balloon expulsion, and colonic transit study and symptomatic changes and stool characteristics by visual analog scale and prospective stool diary. Primary outcome measures (intention-to-treat analysis) included presence of dyssynergia, balloon expulsion time, number of complete spontaneous bowel movements, and global bowel satisfaction. RESULTS: Subjects in the biofeedback group were more likely to correct dyssynergia (P < .0001), improve defecation index (P < .0001), and decrease balloon expulsion time (P = .02) than other groups. Colonic transit improved after biofeedback or standard (P = .01) but not after sham. In the biofeedback group, the number of complete spontaneous bowel movements increased (P < .02) and was higher (P < .05) than in other groups, and use of digital maneuvers decreased (P = .03). Global bowel satisfaction was higher (P = .04) in the biofeedback than sham group. CONCLUSIONS: Biofeedback improves constipation and physiologic characteristics of bowel function in patients with dyssynergia. This effect is mediated by modifying physiologic behavior and colorectal function. Biofeedback is the preferred treatment for constipated patients with dyssynergia.

Dietary and medical therapy of obesity.

Surgery is not a cure for obesity but is an effective tool for limiting food consumption. If severely obese patients do not respond to a treatment plan that includes nutritional, exercise, and behavioral interventions plus antiobesity drugs, bariatric surgery may be appropriate. Proper diet selection after bariatric surgery involves more than the energy value and macronutrient composition. Adequate vitamin and mineral composition of the diet is essential to ensure that surgery improves nutritional status. Malabsorption is present to some extent with most surgeries. Therefore, diet after surgery should be monitored closely for adequacy by a nutritionist.

Diet quality in young children is influenced by beverage consumption.

BACKGROUND: Replacement of milk with sugar-containing beverages could affect calcium intake and overall diet quality. OBJECTIVE: To describe dairy food, 100% juice and added sugar beverage intakes, contributions of dairy foods to diet quality, and effects of beverages on diet quality in young children. METHODS: We surveyed participants in the Iowa Fluoride Study (n = 645) at ages 1, 2, 3, 4 and 5 years and calculated intakes for 1-5 years (i.e. weighted averages). Nutrient, dairy food and beverage intakes were obtained from 3-day diaries; nutrient adequacy ratios were calculated as the nutrient intake to Recommended Dietary Allowance/Adequate Intake ratio; and dairy-dependent percentages were calculated as fractions of total diet nutrient adequacy ratios (truncated at 1) not met by non-dairy foods. RESULTS: Milk intakes were inversely associated with intakes of juice drinks (2, 4, 5 and 1-5 years), soda pop (2, 3, 4, 5 and 1-5 years) and added sugar beverages (2, 3, 4, 5 and 1-5 years). Dairy dependent fractions of 1-5 year nutrient adequacy ratios were 68% for calcium and 61% for vitamin D. Higher 1-5 year calcium adequacy was predicted by higher energy, higher other dairy and lower added sugar beverage intakes while higher vitamin D adequacy was predicted by higher energy and higher other dairy intakes. Overall diet quality was predicted by higher energy, higher other dairy, lower 100% juice and lower added sugar beverage intakes. CONCLUSIONS: Dairy foods remain an important source of calcium and vitamin D, while added sugar beverages and, to a lesser extent, 100% juice decrease diet quality of young children.

Effect of hyperhomocysteinemia induced by methionine administration on flow-mediated dilatation of the brachial artery in healthy subjects.

Homocysteine may contribute to systolic hypertension and cardiac events by decreasing conduit artery compliance and inducing endothelial dysfunction. The effects of the experimental induction of hyperhomocysteinemia on systemic arterial compliance and pulsewave velocity are unclear, with contradictory results from previous studies. The investigators tested whether oral methionine impairs brachial artery compliance in addition to endothelial function.

Associations between Intakes of fluoride from beverages during infancy and dental fluorosis of primary teeth.

OBJECTIVE: We describe associations between primary tooth fluorosis status and intakes of beverages and fluoride from these beverages during infancy. METHODS: Subjects (n = 677) are members of the Iowa Fluoride Study, a cohort of young children followed from birth. Food and nutrient intakes were obtained from 3-day diet records. Diets were analyzed at 6 weeks, 3, 6, 9, 12 and 16 months and cumulatively for 6 weeks through 16 months of age. Primary tooth fluorosis was assessed at 4.5-6.9 years of age and defined as present or absent. Multiple logistic regression analyses were used to develop models to predict fluorosis status. RESULTS: Water-based beverage intakes were higher in subjects with fluorosis than in those without. Specifically, higher intakes of water used to reconstitute formulas at 3, 6 and 9 months; any intake of water as a beverage at 16 months; and higher intakes of combined 100% juice and miscellaneous beverages at 16 months were positively associated with fluorosis (p < 0.05). Fluoride intakes from water sources were also higher in subjects with fluorosis than in those without. Specifically, higher intakes of fluoride from water used to reconstitute formulas at 3, 6, 9 and 12 months and for 6 weeks through 16 months, and higher intakes of fluoride from water as a beverage at 16 months and for 6 weeks through 16 months were positively associated with fluorosis (p < 0.05). CONCLUSION: Infant beverages, particularly infant formulas prepared with fluoridated water, can increase the risk of fluorosis in primary teeth.

Adolescents eating diets rich in either lean beef or lean poultry and fish reduced fat and saturated fat intake and those eating beef maintained serum ferritin status.

Reducing red meat intake to lower serum cholesterol may also lower iron and zinc intake. Eighty-six seventh and eighth graders who enrolled in a study comparing serum ferritin, zinc, and cholesterol levels were randomized to a low-fat eating pattern emphasizing either lean beef or lean poultry and fish. Serum data and three 24-hour recalls were collected at baseline and 3 months. The lean beef group ate significantly more beef [26 (4, 37) g/d; P<.01] and both groups reduced total and saturated fat intake. Although serum ferritin level change between baseline and intervention was significantly different between the lean beef and lean poultry and fish groups (median [interquartile range] 0.7 [-6, 8] and -6.8 [-12, 2] microg/dL, respectively), the drop in the lean poultry and fish group was not clinically significant. No differences were observed in iron and zinc intake or in serum zinc and cholesterol levels. Teenagers eating diets low in saturated fat may benefit from adequate amounts of lean red meat.

3-Hydroxypropionic acid and methylcitric acid are not reliable indicators of marginal biotin deficiency in humans.

In two studies comprising 10 and 11 subjects, respectively, marginal biotin deficiency was induced experimentally by an egg-white diet in healthy men and women. The following urinary organic acids were assessed for their usefulness in detecting marginal biotin status: 1) 3-hydroxypropionic acid and methylcitric acid, organic acids that reflect decreased activity of the biotin-dependent enzyme propionyl-CoA carboxylase and 2) methylcrotonylglycine and isovalerylglycine, organic acids that reflect decreased activity of methylcrotonyl-CoA carboxylase. Mean 3-hydroxypropionic acid excretion rates remained normal during biotin depletion in both studies. By the end of the depletion period, 3-hydroxypropionic acid excretion identified only 5 of 21 marginally deficient subjects. Mean methylcitric acid excretion increased (P < 0.0001) in the first study but not in the second. Mean methylcrotonylglycine excretion increased in each study (P < 0.004 and P < 0.05, respectively); methylcrotonylglycine excretion identified 13 of 21 marginally deficient subjects. Mean isovalerylglycine excretion increased only in the first study (P = 0.006) and identified only 6 of 21 deficient subjects. We conclude that none of these organic acids is as sensitive an indicator of marginal biotin deficiency as 3-hydroxyisovaleric acid, which reflects decreased methylcrotonyl-CoA carboxylase.

Raising Medical Students' Awareness of Nutrition and Fitness in Disease Prevention: Nutrition and Fitness Program at the University of Iowa.

At the University of Iowa we devised a learning experience, called the Nutrition and Fitness Program, for third-year medical students. The program was designed to raise awareness of the role of nutrition and exercise in the prevention and treatment of disease. Students spent one afternoon learning about their personal health risk factors, such as body mass index, percent body fat, other anthropometric measures such as waist, hip and mid-arm circumference, blood lipids, bone-mass density, dietary analysis, and fitness assessment. Students spent another afternoon visiting the cardiac rehabilitation center. At the end of each rotation, students gathered for a heart-healthy meal that served as a focus for a discussion with dietitians about important nutrition issues. The literature and our work with medical students support the need and acceptance of a personalized, practical approach to nutrition education. By offering medical students the opportunity to learn about their own nutrition and fitness risk factors, this Nutrition and Fitness Program appears to have played an important role in the students' medical education by narrowing the gap between the "science of nutrition" and the "application of nutrition". Students appreciated learning more about their own health factors and felt that personalizing the information made the learning more valuable and would help in counseling their future patients more effectively.