Beruflich Dokumente
Kultur Dokumente
Miriam Balogh,
repeat
Harold A.
24-hour
Kahn2 and Jack
dietary
H. Medalie3
recalls
The dietary
purposes has been well summarized by Mojonnier and Hall (1) who report that direct measurement of food intake is feasible only
for small
the subject
groups;
to
that
change
food
diaries
his normal
may
cause
eating
lschemic Heart Disease Project in 1963 (3). Ceramic food models in three sizes were used for foods, the smallest size was counted as a standard unit, the medium size was equivalent to two units and the large size to three units. Other food models made use of natural products in three sizes (nuts, olives, candy, seeds, chocolate, et
cetera). Similarly were also displayed easier for cups, in glasses, different plates, sizes and spoons to make it
to 24-
used
ect
for
(4)
hr recall histories may be more objective than general histories, they suffer because only 1 day is measured. Against this background the present paper investigates the results obtained in repeating a 24-hr recall interview on
several random dates.
the subjects. A food table based on that the Israeli Ischemic Heart Disease Projwas used in conjunction with multipliers
Objective
We wanted
dietary recall
to learn
as a tool
more
for
about
estimating
the 24-hr
dietary in rewere
intake,
the
lation
with particular
to the
attention
to the size of
error
in measuring number
collected.
the repeat
In addition,
24-hr recall
we wanted
with the
to compare history of
usual
Method
dietary
intake.
One hundred volunteers were selected from the male civil service employees who were taking part in the Israel Ischemic Heart Disease Project (2) and attending the Jerusalem Clinic for their third medical examination early in 1968. For ease in
study
representing the number of standard portions of each food reported. Unusual foods or special recipes were hand calculated by the nutritionist into basic nutrients and these were then punched for addition to the nutrients derived from the report of standard foods. Nutrients were calculated the same way for both the dietary history of usual intake and the monthly 24-hr recall histories now to be described. On a randomly chosen day in each calendar month, the nutritionist asked for appointments with several volunteers in a particular office. In the arrangements for interviews we were assisted by a contact man in each location. Subjects were asked to come at an agreed time to the interview room where the food models were on display. The interview proceeded through a recollection of the activities of the previous day with a stop for details at each eating period. After this questioning, the nutritionist repeated to the subject the menu for the whole day and cross-checked him with questions like: Didnt you eat any fruit yesterday? Didnt you have any eggs at all? If they were in the office, subjects were questioned each month (except August) during the year beginning March 1968. Every effort was made to interview the subjects on the same day conIsrael Ischemic Heart Disease Study, P.O.B. 2631, Jerusalem, Israel. Heart and Lung Institute, Bethesda, Maryland. Department of Family Medicine, Tel Aviv University, Israel. The study began with randomized dates assigned to each participant but because of special office conditions it was not practical to continue with random assignments. The actual dates selected for contact in any one office represented a com-
operations
subjects
were
limited
to those
in
one of the three following offices: Finance, the Customs Office, and Knesset (Israeli Parliament). Men
are principally They were told clerical the
that, if included, we would contact them on a random day once a month to inquire in detail what they had eaten on the preceding day. We specifically discouraged those who felt unwilling or unable to keep up this schedule for a full year. The persons who consented to take part were immediately questioned about their usual food intake. The questionnaire used was the same short questionnaire that was designed for the Israeli 304 The American
Journal of Clinical
plex interaction
of all relevant
facts
regarding
the
three offices (e.g., subjects might be interviewed in one office because the interview room in another office was unavailable that day). To the best of
our able knowledge, interview dates by the subjects themselves. were not predict-
Nutrition
24:
MARCH
Printed
in U.S.A.
RANDOM
REPEAT
DIETARY
RECALLS
305
TABLE
Number number
Number
1
of subjects providing specified of 24-hr dietary histories
o f reports (or more) Number of subjects
2 3 4
90 87 84
5 6
7
84 79
73 71
8 9 10 11 (exactly)
take for specific days for an individual in an attempt to obtain data that are representative of the annual dietary intake for that individual. As knowledge accumulates and questions become more precise, randomization so as to permit generalization to the population sampled will become essential. All calculations of sampling error in this paper should be interpreted as applicable to populations with parameters similar to our volunteer group and are offered solely for rough guidance in planning studies aimed at more specific measurements. In the simplest terms, we think the use of volunteers is justified in getting started.
50 28 12
Results Table
with 24-hr
1 presents
dietary
the
number The
of persons
covering 2
histories
tacted; if this was impossible, no substitute day was chosen. Therefore, no report on the subjects intake for that month was taken. The study covers working days during all seasons of the year, including days of slight indisposition when subjects complained of having a common cold, indigestion, or were not feeling too well. For each subject an attempt was made to include two interviews falling on a Sunday or after holidays so as to comprise food eaten on the Sabbath or on a holiday. A comment on the use of volunteers may be helpful. If we were trying to estimate the diet of Israeli male civil service workers, we would not have chosen volunteers, but would have tried to select at random members of that population. But our objective is different. We want to learn something about how people vary in day-to-day nutrient consumption and about the relation between what they report eating usually and the average of what they report eating on several specific days. Our efforts in this study are not directed toward measuring individuals representative of other persons in the population but to measuring dietary in-
months,
3 months,
et cetera.
10 persons
for
only
out of the study before providtwo 24-hr recall reports are exwere successful in obtaining an in each of the 11 months contacted 12 people. For 71 persons we were
able to obtain 8 or more months though we regret not being able more complete coverage, we are
satisfied in the light be of our
rule that
and
was
a subject
unwilling no further
was
to
efforts 2
contacted
interviewed to interview
that
until
spect
the following
presents
calendar
the
him month.
data
Table
basic
to how
within
largest
variable
are the
reported presented
to be more
day-to-day
consumption,
of
the data
variation
are
TABLE after
Number
2
variation: median values of the coefficient of variation within individuals (S/)
Intraindividual
specified
of
number
Total
of 24-hr
dietary
reports
Vegetable protein Total fat
Number subjects
calories
Starch
Sugar
Animal protein
Oleic acid
Linoleic acid
Cholesterol
2 3 4 5 6 7
8
90 87 84 84 79 73
71
9 10 11
50 28 12
0.13 0.16 0.16 0.17 0.20 0.19 0.18 0.18 0.21 0.22
0.16 0.19 0.20 0.20 0.22 0.21 0.23 0.21 0.22 0.20
0.29
0.28 0.27 0.28 0.27
0.29
0.31
0.30
0.32 0.33
0.29 0.29 0.32 0.34 0.34 0.34 0.34 0.33 0.38 0.43
0.17 0.23 0.24 0.25 0.24 0.24 0.25 0.27 0.24 0.20
0.25 0.26 0.26 0.27 0.27 0.26 0.28 0.30 0.32 0.33
0.24 0.26 0.26 0.29 0.27 0.29 0.31 0.30 0.30 030
0.24 0.26 0.28 0.29 0.29 0.29 0.28 0.33 0.33 0.36
0.35
0.40
0.44 0.45 0.44 0.48 0.45
0.35 0.38
0.42
0.50
0.51 0.50
0.46
306
BALOGH
ET
AL.
the standard deviation among for an individual to the average of the daily reports for that individual). Thus, a value of 0.20 signifies a standard deviation (within an individual) that is one-fifth as large as the mean value for that individual. The data in Table 2 are the median values for the entire group under study and show the first 2 months data for those with two or more reports, the first 3 months data for those with
(the
ratio
of
daily
reports
our we
reliance on 24-hr dietary data derived entirely within a few months period, to investigate seasonal variation to determine if it is in fact negligible. Because of these findings, the remainder of this paper will relate only to those 71 individuals for whom we have 8
three
or more
reports,
et cetera.
Only
trivial
changes would result if Table 2 were to be restricted to just those subjects for whom eight or more reports are available. Table 2
indicates
a tendency
for larger
values
of the
coefficient of variation to be associated with additional months of data collection. This means that for most nutrients two or three monthly reports fairly close together do not reflect as much variation within the diet as will be observed if additional months of data are collected. Probably this reflects both seasonal variation, which will be missed if the data are collected within the span of only a few months, and also the effect of increasing sample size in reducing the estimation bias for the coefficient of variation. Starch seems to be least affected by a short period of data collection and our estimate of the median coefficient of variation for starch within individuals was subsequently little changed from that derived from only three months data. On the other hand total fat, oleic acid, linoleic acid, and cholesterol seem to reflect
or more months of data collection. We have chosen 8 months because of the sharp drop in number of individuals (only 50) for whom we have 9 or more months data, but we do so with full appreciation that our estimates for total fat, oleic acid, linoleic acid, and
cholesterol may be somewhat biased. Table 3 is based on the 8 to 11 recalls available for the 71 subjects for whom we have 8 or more months data. It shows both the median and 90th percentile value of the coefficient of variation within individuals for each dietary element in our study. Except perhaps for total fat, oleic acid, linoleic acid, and cholesterol, the coefficients of variation are all reasonable estimates of variability for these items in our population. Given this degree of variability the relative standard error of the mean estimated for an individual will, of course, be a function of how many dietary histories are included in the average. The relative standard error of the mean is simply the coefficient of variation divided by the square root of the number of 24-hr reports. For example, assuming that daily reports
period Table
are randomized
throughout
the year
to elimi-
2 suggests that unbiased estimates of most dietary elements are not likely to be derived from data collected for less than about 6 months (in our study data for 6 months covered at least a 7-month calendar period), and for some nutrients almost a whole year
would
TABLE Median
be
required.
Of
course,
this,
as
all
nate or minimize effects of seasonal variation, on the basis of our study population, the number of daily reports needed to estimate an individuals diet with about 0.95 probability of being within 20% of his true value are presented in Table 4. The probability and range of sampling error specified above serve
3 and 90 percentile
Total calories
values
Total carbohydrate
of S
Animal protein Vegetable protein Total fat Oleic acid Linoleic acid Cholesterol
Starch
Sugar
fat
0.19
0.29
at least
0.22 0.31
0.28 0.48
period
0.33
0.48
0.32 0.52
0.25 0.36
0.30
0.46
or more
0.48 0.66
dietary
0.44
0.67 histories.
a 9-month
RANDOM
REPEAT
DIETARY
RECALLS
307
simply required
this
to illustrate
the
number
of replicates
TABLE required
at those
levels.
In
order
to reach
Approximate
for
number
20%
of random
accuracy
24-hr
reports
mean
of accuracy for those individuals reporting more varied diets, it becomes necessary to obtain more daily reports. Thus, Table 4 shows the number of replicates needed to achieve the specified accuracy for a) that half of the population with the least varied diets, and b) 90% of the population, omitting only the 10% with the greatest
level
of individual
Nutrient
Approximate number of random reports required for 95% probability that the sample average is within 20% of the true individual mean
of
of
Total
Total Starch
Sugar Animal
calories
carbohydrate
variation
in day
to day
consumption.
It is
10
23
the table that four reports four seasons of the year proprecision for classifying in-
8
protein 11 11
7
23 27
13 23
dividuals
we have
by nutrient
studied,
intake.
only total for
Of the nutrients
calories, total
carbohydrate,
reasonably cation.
and
practical
vegetable
protein
seem
appli-
8 9
10 23
widespread
22 30 44
45
Cholesterol
20
Of course, short cuts are possible and in measuring an individuals diet, each individual is a separate population, so to speak. In order to measure saturated fat intake with about 95% probability of limiting sampling error to 20% of the mean value for 90% of the individuals in a population, it should not be necessary to collect 22 24-hr recall interviews on everyone. As Table 4 shows, nine interviews are adequate for that half of the population eating a less varied diet, and it should be possible to discontinue data collection for such individuals long before obtaining 22 reports. Table 5 contrasts
dietary history in the interview about usual dietary intake that preceded the series of 24-hr recalls. Considering group averages, it is noteworthy that not one of the usual diet averages exceeds the average derived from 24-hr recalls. In the case of starch the averages are equal. For all other nutrients the averages based on 24-hr recalls are slightly larger. The correlation coefficients between nutrients estimated from usual diet history and the same nutrients estimated from an average of 24-hr recalls range from 0.56 for starch to 0.83 for oleic acid with that for total calories about midway between these values at 0.69. Clearly with correlation coefficients in this range we are likely to get substantially different results in epidemiologic studies concerned with classifying individuals if we
were to methods
one other.
of these Which,
if either, is correct? The simplest and truest answer is that we dont know, but we do think it is almost an axiom that most people
must better usually remember than they eat. what can they ate remember yesterday what they
TABLE 5 Comparison of data from usual diet with the average of eight or more
24-hr dietary reports
Group means1 Average of eight or 24-hr more dietary histories
interview
Item
Correlation coefficient between usual diet and average of eight or more 24-hr reports
Total calories
2,390 333
2,577 344
0.69
0.61 0.56 0.61
Total carbohydrate, g
Starch, g#{176} Sugar, g Animal protein, g Vegetable protein, g Total fat, g Saturated fat, g Oleic acid, g Linoleic acid, g
190
135 54 41 73 25 26 15
190
145 60 42 84 28 30 18
0.69
0.63 0.78 0.81 0.83 0.70
Cholesterol, Data
of daily
mg
71 subjects. consumption. from cereal, rice,
424
1
C
470 Expressed
exactly More
0.82 in units
carbolegumes.
from
hydrate
potatoes,
and
308
BALOGH
ET
AL.
In order to investigate whether our observed correlations are low simply because the variables have a large component of
independent
variables
(9).
We
were
also
in-
terested might
whatever day of
special known
effects dietary
measurement
error,
we estimate
the
true
value of the correlation between the variables measured with error according to the following formula rearranged slightly from that given in (5)
=
record as opposed to a nonrecord day. Our data are summarized in the form of coefficients of variation for an individual.
These much
(r*)2
(i
VeX\
-
w)
VeY\
w)
where
r VeX VX
= = = =
observed
correlation
coefficient
true total
correlation variance
coefficient
of X (similarly for Y) of X (similarly for Y)
error variance
in relation to his own mean value. tunately, the authors whose reports literature we wish to use for comparison our findings do not present their data form of coefficients of variation. Two (10, 11) present analysis of variance from which we were able to calculate
tables
pooled
within
person
sum
of squares
and,
in com-
The data are as follows: variance among individuals for average calorie intake, 320,500; average variance of the individuals mean, 32,300; and percentage of variance among individuals represented by the average variance of the individuals mean, 10%. We have no replicated data for the usual diet interview in this study and simply assume its error variance is of the same order
bination with additional data reported on mean values, were able to derive coefficients of variation. One study (12) presented the detailed data for individual subjects and we calculated the coefficients of variation. The comparisons are shown in Table 6. Six of the
seven reasonably values we similar have to the for comparison are
Considering
the range
as that
at 10% culation the true estimated
average
and
estimate
it
of the total. Carrying out the calwe obtain 0.77 (instead of 0.69) as correlation between caloric intake from a history of usual intake and
men
in San
of
The need for improved dietary measurement techniques to classify individuals for epidemiologic studies has been frequently stated (1, 6-8, 20). Because replications of a 24-hr dietary recall interview offer some promise as a practical tool for research in this area, we felt it would be valuable to determine how much daily variation exists as a guide to the number of replications needed for estimates with a specified range of sampling error. In particular, we thought it necessary to introduce a random element in the selection of the date of interview to avoid whatever problems might exist because the data are serially correlated, or are otherwise not randomly distributed even though we found one report stating that daily diet data for individuals can be considered as
York State University staff whom were women (11), it is quite surprising to find so much agreement. Of course it may be coincidental and real differences may have been offset by procedural or sampling differences. The one statistic not in agreement with our own is a coefficient of variation of 0.07 for daily caloric intake of the University study (11). The three other measures we have of coefficients of variation for daily caloric intake within individuals are 0.16, 0.19 and
0.20, outlier
so
consistency
from
in our
popula-
other
which
it may cover
than elsewhere, for prior to obtaining in other populations. We were able to literature correlating cated 24-hr recall
RANDOM
REPEAT
DIETARY
RECALLS
309
TABLE Coefficient
intake
within
Hankin
individuals
et al. (10)
(S5/X)
Young et al (ii) Edholm et al. (12)
Nutrient
Median value among those individuals with eight or more daily reports
7-day
28-day for
14-day
records 12 cadets1
for
0.19
0.22
0.20
0.22
0.07 0 . 22
0.16
Total
Pooled S,/X
fat
ated
table divided
by average.
Calcu
days)
with
results
obtained
from
an interview
24-hr
reports,
-0.00;
3) based
on average
of
of usual
coefficient
dietary
of 0.67
intake
for
(13).
total
A correlation
(the only
protein
five 24-hr reports, -0.06; and 4) based on average of eight 24-hr reports, +0.00. Similar calculations between serum of the correlation cholesterol and coefficient linoleic acid 0.06 and
-
vegetable
protein,
respectively.
intake +0.00
reports, reports,
subjects
two 24-hr
However,
this
report
did not
agree
with
our
to use is in
finding that the 24-hr data averaged higher levels than the usual diet history. A special and potentially very valuable of replicated 24-hr dietary interviews
these values are subject to substantial sampling error but we do not see any evidence of correlations approaching
studies
in which
particularly
required studies for have
high
individual shown
orders
of
large
values overall
with
increasing is
of
dietary
Our
measurement.
conclusion
dividual
are
seeming
dietary
poorly
contradiction
data
and
serum
cholesterol
experimental
very
correlated
of strong
(14-16).
24-hr recall histories are valuable aids in the difficult and complex area of classifying individual dietary intakes and should be used
more lations frequently, and for particularly for those poputhose specific nutrients for
association between diet and cholesterol (17, 18) has been explained by Keys (19) principally on the basis of error in measurement of individual diets. Repeated 24-hr recall interviews on random dates offer a tool for controlling the degree of error in individual
which the range of variability is not extreme. When daily variation is extreme, the method of replicated 24-hr recall interview will reveal this situation and point toward the hard fact
that no method short large of extensive numbers of daily sam-
dietary
intake
to a level
sufficient
to demon-
strate whether or not correlation between specific nutrients and serum cholesterol increases to substantial levels with improved precision in dietary estimates for individuals. Looking at our own data from this viewpoint we find that the 62 subjects, for whom we have both eight or more 24-hr dietary recalls and a 1968 serum cholesterol meas-
pling with
is likely respect
in accurately
individuals
categorizing
Summary
urement, show correlation coefficients tween serum cholesterol and saturated intake as follows: 1) based on usual diet
tory, -0.00; 2)
based on average of
befat histwo
Following an initial interview on usual dietary intake, volunteers were contacted on a random day each month and given a 24-hr dietary recall interview. For 71 subjects data were obtained from eight or more monthly
interviews. The variation
within
individuals
310
BALOGH
ET
AL.
for specific nutrients, and nuseasonal variation are identified. of 24-hr interviews required to
estimates of individual mean values an approximately 20% margin of sampling error is presented for each nutrient. Correlation coefficients are reported
within
dietary method for epidemiologic Development of questionnaire. Am. i. Epidemiol. 87: 285, 1968. 9. CHALMERs, F., M. CLAYTON, L. GATES, R. Tucicna, A. WERTZ, C. YOUNG AND W. FosTER. The dietary record-how many and which days? i. Am. Dietet. Assoc. 28: 711, 1952. 10. HANKIN, J. H., W. E. REYNOLDS AND S. MARA short
studies.
III.
between
the data
obtained
in the interview
of
11.
GEN.
usual intake and the average of eight or more 24-hr recall interviews.. Correlation between serum cholesterol and selected nutrients is presented for dietary
A short dietary method for epidemiologic studies. II. Variability of measured nutrient intakes. Am. i. Clin. Nutr. 20: 935, 1967.
YOUNG, AND
B.
C. M., F.
R. E.
STEELE.
FRANKLIN,
data
based
five,
on usual
and eight
of two,
References
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intake of young 29: 459, 1953. 0. G., J. 0. FLETCHER, AND R. A. MCCANCE. and food intake
Weekly adults.
The
penditure
Brit. I. Nuir.
of individual
men.
1. MoJONNIER, L., AND Y. HALL. The national diet heart study-assessment of dietary adherence. I. Am. Dietet. Assoc. 52: 288, 1968. 2. GROEN, J. J., J. H. MrjuE, H. N. NEUFELD, E. Riss, C. A. BACHRACH, F. W. MOUNT AND H. SMITh. An epidemiologic investigation of
hypertension
a defined
and ischemic
heart
disease
within
of Israel.
3. BALOGH,
segment of the adult male population Israeli. Med. Sci. 4: 177, 1968. M., J. H. MEDALIE, H. Stnm AND
9: 286, 1955. 13. TRULSON, M. Assessment of dietary study methods. I. Comparison of methods for obtaining data for clinical work. i. Am. Dietet. Assoc. 30: 991, 1954. 14. KANNEL, W., T. DAWBER, W. GLENNON AND M. Thoa. Preliminary report: the determinants and clinical significance of serum cholesterol. Mass. i. Med. Technol. 4: 11, 1962. 15. STULB, S. C., J. R. MCDONOUGH, B. 0. GREENBERG AND C. G. Hs. The relationship of
J. J.
GROEN.
The
development
of
a dietary
16.
nutrient intake and exercise to serum cholesterol levels in white males in Evans County, Georgia. Am. I. Clin. Nutr. 16: 238, 1965.
H. A., J. H. MEDALIE, H. N. NEUFELD, E. Riss, M. BALOGH AND J. J. GROEN. Serum cholesterol: its distribution and association with dietary and other variables in a survey of 10,000 men. Israel i. Med. Sci. 5: 1117, 1969. HEOSTED, D. M., R. B. MCGANDY, M. L. MYERS AND F. J. STA.iu. Quantitative effects of dietary fat on serum cholesterol in man. Am. i. Clin. Nutr. 17: 281, 1965. KEYS, A., D R. W. PARLIN. Serum cholesterol response to changes in dietary lipids. Am. i. Clin. Nutr. 19: 175, 1966. KEYS, A. Dietary survey methods in studies on cardiovascular disease epidemiology. Voeding 26: 464, 1965. WIERL, D. 0., AND R. RERD. Development of new or improved dietary methods for epidemiologic investigations. Am. I. Public Health 50: 824, 1960.
KAHN,
questionnaire for an ischemic heart disease survey. Israel I. Med. Sci. 4: 195, 1968. 4. BALOGH, M., J. GROEN, B. Tzua, C. BACHRACH, H. SMITh, P. A. J. KAY AND J. H. MEDALIE. Food Composition Tables. Methodological Manual No. 3, Ischemic Heart Disease Proj-
17.
Statistics.
AND
New 18.
B.,
B.
INDIX
A.
BEEUWKES.
Dietary
Intake
R.
HUENEMANN.
A short
I.
dietary method for epidemiologic studies. Developing standard methods for interpreting
7-day
Assoc.
8.
HANKIN,
20.
food
1967.
STALLONES
records.
AND
I. H.
Am.
Dietet.
MESSINGER.