Week 6: Lecture 26: 24-Hour Dietary Recall

Hello and welcome dear learners to the NPDL course on nutritional epidemology your way towards a healthy life. In the module 3 dietary assessment, nutritional status and measurement error. For the chapter 26, we will be studying about 24-hour dietary recall. What do you mean by 24 hours diet recall? For that, we will understand the methodology used in the 24-hour dietary recall. Interviewer administered versus self- administered automated tools. strength of the 24-hour dietary recall method as well as the limitations for the same and applications in survey followed by case discussion. So the 24 hours dietary recall is a retrospective dietary assessment method in which a respondent recalls and describe all foods and beverages consumed over the preciding 24 hours. So it's an entire discussion of 24 hours which is taken along with the interviewer and the participant. So there is a purpose for conducting this and there are few key features which are obtaining for this. So to obtain a detailed episode level information about the intake what the participant is taking with respect to the food type the amount of food and the preparation methods. What are the preparation methods like what is chopping board being used? What sort of meals it is being prepared? The group of means and the distribution is being done. The very important thing over here is it is like a timing and the context that it is being taken is very important. So there is an information about the dietary pattern and nutrition associated studies when repeated. The historical development of this cames with uh 20th century mid where in 1950s it was widely used since then it remained one of the most common method in nutritional epidemology. So we can say that it has a long history where it has seen lot of episodes of development advances in technology where you find nowadays that it is a computer assisted dietary interviews followed by automated self- administrative calls which gives a sort of an pattern to get update actually about the timing. Also there is an added version of mobile based dietary assessment system which gives a more ease to the participant. There is a sort of an association of web- based nutrition surveillance tools which makes the advances in the technology with respect to the dietary assessment method which gives advances. There is a better distinct from the other methods where you find on the other hand for food record diary where there is the more prospective way of dealing with the real time record and have a higher burden of understanding with respect to time and remembrance. The other food frequency questionnaire FFQ which is also popular but a very long-term unusual intake less detail per item and recall over weeks and months which takes more constraints on the menu where you have to understand the food fruits categorize vegetables food and sugar in terms of the daily weekly and monthly record. Whereas actually in the short dairy screeners where the brief target nutrients or particular food groups and it doesn't comes very comprehensive. So with the distinct other methods there is a benefit that 24-hour dietary recall is finding itself as a space in the retrospect dietary asset. Then comes the methodology to be used in the 24 hours dietary call. What is this multi-pass method and how does it really takes into the five phases where the pass one that is a quick list where you can understand the recalls of all the foods and beverages as yesterday and even from the 24 hours timing which is being divided from walking to bedtime from midnight to midday. So how it is being seen that the 24 hours is divided between the list without interruption. All the discussion which is being taken is record in verbatim and made a sort of quote actually which gives us a theme where the neutral prompts and reassurance all items are useful where you have to take the record of the breakfast your lunch your afternoon snacks your evening snacks or even your night dinner. The past two comes with forgotten food probes might be like some some of the specific prompts for comic options actually which comes as an reminder where it may be like you might have taken a water or a tea or a coffee or spreads or fruits or some additions actually which gives you more reasons to understand what are the sauces that are being used or what are the supplements that are being missed or what are the sweets that can be added or the food between the meals which make some sort of an addition. where the common omissions cannot be missed. The third and the very important is the time and the occasion. Whereas we have spoken about that Indians particularly they have two or maximum three meals but each of the time the episode comes for time where the breakfast where whether it is 6 to 8 or 8 to 10 or even a breakfast which is followed by a midm morning snacks that is at 10 10 to 11 and there is 11 where there is a lunch 11 to 1 where you can pick up actually to say that there is a tea time after 12:00 a.m. or 12:00 noon followed by evening at 5:00 p.m. Actually, you may have a tea time with snacks or at 9:00 followed by dinner which gives you a more quickly awareness about each time of an episode. Eating occasion labeled collected which is somewhere or the other when you are taking some sort of occasions to have food or the meals the places in chronological order may be coming some level of time constraints. The cues of memory to give it according to the time and the occasion are somewhere where you have to say that time and occasion pass three is coming over there. Pass four comes with a detailed cycle giving us particularly about an item for example the bread or the cooking method the sausages that being used or visible ingredients. There is sort of a proportion which gives about a description about the preparation which may be added to state that how it is being prepared in what sense and what timing. What sort of additions particularly for a specific meal is there with respect to the proportion which is being estimated to serve the serving descriptions the served models and the photois and the standard portion scripts which gives us a documented description about the convergence into gram which is very important to be taken as a detailed cycle. For examples, if there is a food which is being offered at a home or even at a street or even at a commercial brand places like hotels to collect recipe ingredients and amount versus actually to the standardized recipe in terms of the local FCT of the database which gives us more dish source inquiry which is somewhat the other way. There are sort of constraints which comes to this but yes this detail cycle is also to be important. Then comes the final review where the systematic review of intake where red back days intake to the participants which gives us more a final probes of anything which is missed in terms of the condiments, supplements, water, chewing items or even alcohol and beverages, breads, sausage, sweets. The confirming the quantity in terms of the ambiguous items again and again is something which is very important for the final review to come and to complete the phase one to the phase 5. So this is a multi-pass methods in 24 hours dietary recall to be completed. What is the methodology of ASA24 which give us an automated self-administered where there is no such as an interviewer who is present but yes there is a historical trained interviewer which can gives versus to modern automated solution where there is a shift you can find it over here where previously it was being taken train interviewer required and a higher cost and limited scale where it is very difficult for human resource to come up which turns to be very costly. Now when we have institutions like NCI National Cancer Institute where the studies on a cancer patient is done with the help of automated solutions that is ASA424. So what is this ASA24? It is a freely available web-based tool where digitally mimics of amm in five-step logic comes to guide the patient or the participants to give an information which is being collected for 24 hours to give a probes. The guides the respondents has to follow independently to fulfill the information where the participant independently enters the feature with respect to the food that is being consumed or the proportions and the sizes in terms of the gram, mig or kgs or eating occasions where it is divided into the different meals where there can be three or four meals. the preparation methods which is being prepared or readily available or has a sort of a mix. There can be a system automatically which calculates the estimate nutrients which is based on the quantity and the occasions and the timings that is being provided where the reports are generated with respect to the selfmitted sort of generation and a stores data electronically. You may have an advantages of ASA4 with a traditional set of things but lowering the cost reducing the interview burden or standardized administration becomes something which as an challenge actually to give it versus to the traditional interview method suitable for large studies which gives more reasons that ASA4 becomes very popular now. But along with that there are few challenges. The challenges comes with it requires literacy in terms of the language or the codes or the requirement of internet which becomes a constraint for those participants who are not to be identified in rural places. may be a difficult for elderly participants to understand and to feed where there can be some chances of miss where there is an assessment which is being required or some sort of an handholding to understand the process technology dependency is completely over there. So technology dependency can be a major challenge to come across to this ASFO. Now taking the interviewer administered versus the self-administered as we find that this is a self-administered being coming as an automated tool where versus interviewer administered is coming as a individual physical level of administration. So we'll try to understand the difficulties actually where there are more chances actually to go to an individual versus to an automated which is also plus addition. But what are the features of getting this two and understanding what are the constraints to meet up this requirement over here. If you talk about the interviewer administered method, it has a very high set of a cost which requires a trained interviewer and a scheduleuling over here. Where versus the self- administered that is ASA4 as studies in the pre previous figure you can understand it is of a lower cost free software and automated coding which is being coming as something as an very addition. What is the respondent burden over here in the AMM? It is lower cognitive load where the interviewer guides the process and the participant doesn't have to take more constraints in terms of remembering where there is lot of cognitive load which is reduced here for the self-administered part. The higher cognitive load is being there. It requires a lot of reading, digital literacy, feeding and sort of an alertness with respect to time and also the food actually that you are consuming. The portion estimation in the AMM is physical 3D model measuring cups and spoons which gives us more a sort of an self reporting and the benefits actually for digitalization to add more to the self-reporting is more by the digital part which is being like interactive proportion size images which is like something which is coming from the imagination. Here on the AMM part what is the training that is to be required? Extensive training is needed for the interviewer where there is no load to the participants but a minimum training is required uh to a participant actually which is more being given with the help of the digit data entry errors are possible to occur as it is self versus the data entry errors in here in ASA4 is completely reduced probing quality dynamic and conversational which is a very basic and very important tool over here and in probing quality for ASA4 the standardized and strictly algorithmic which gives more a benefit to go for a higher versions of developing more AI based assistance what is the best use part for this for the amm it is more like a population with low literacy elderly and younger children whom we can say they are more vulnerable and they are more in need for the nutritional assessment methods. It is more benefiting to them where versus on the ASA4 part it is a large scale epidemological studies tech literates adults can only take part and can get the benefit of this. If I have to give you an example particularly for the AMM, it is a USDAM national nutrition surveys which are being taken followed by the research study clinical assessment which are also being conducted in country like India. example for the ASA 24 that is web- based recalls and smart dietary applications which are very popular nowadays to give us more reasons that ASA4 ASA 24 is getting very popular. So if you are taking the understanding in clearance we will get more benefits to take the advantages where versus if you have to come across the uh challenges and uh uh take ahead the discomforts actually to be reduced from the participants definitely there can be a better choice to be taken for this. Then comes the strength of the 24-hour dietary recall method. Why do we need to take the 24-hour diet recall? And it has to be stated that it is very widely used nutrition assessment method with a severe important strength. The very first intake that I want to highlight over here is like a detailed intake information. The information is more captured with a rich details including cooking methods, exact brands and accurate meal time. So these are very important in the nutritional assessment method. The reasons being stated, it talks about quality, it talks about proportion and it talks about time. It also talks about the adulteration part. So nuances of richness of the information is more over here in the step one. The step two is about the low respondent burden. So this is being counted as something as very important when it takes only 20 to 30 minutes to complete and does not require the participants to weigh the food or keep a diary. Hence the participants are less likely to drop out of the study and they may be more inclusive to give the information as if there is a more pro and a beneficial way to look upon as time as a major constraint. Then comes the minimal reactivity. The step three is somewhere on the other side where you find a food diary where there is lot of strength that you have to give on your brain and memory has to come as lot of remembrance. In terms of minimum reactivity on the either side where you can find that when the recall is announced, respondents cannot alter their diet in anticipation of the assessment which is common flaw in food diaries where you can say that beverages or sweeteners usually you don't want to put it because of lot of social constraints lot of things that you really don't want to add. So there is a minimal reactivity. Then comes the step four that is suitable for diverse population. So as you can understand in counting the strength this becomes very important to be a more inclusive way of taking larger group of population. It can be used flexibly and conveniently among the adults, elders and childrens with a patternal assistance. The parental assistance is something which gives more reasons as being seen as a guardian or a parent to make it more suitable to take this assessment even suitable for use among the illiterate patients as it can be interviewed administered. So there is more suitability on the part over here. Then comes the step five that is captures actual intake. what was consumed as an actual intake versus usual intake not necessarily what can be consumed or what was consumed. So why there is a difference which is very important what exactly is consumed because this method can measure what was consumed rather than the usual intake. The usual intake might be something of your imagination of a person particularly for the place and for the age for the sex and for the income status. But what exactly is consumed is something which is giving you an actual picture. So reality versus actualness or something actually what you assume to see versus what it it is there. Then comes a flexible and adaptable which counts as a major strength over here where face to face followed by telephonic computer assisted and online. The diet recall can be recorded face to face by telephonic and computer assisted and online way which gives more flexibility and adaptableness actually to understand what are the benefits according to the respondents availability to the interviewer time constraints and the mode and the methods that are being used. So these are some strength of the 24 hours diet recall which makes it more popular to be used as. Then comes the limitation. Why not to take the limitations when it is recall bias? The dependence on the respondent short-term memory. The minor snacks and beverages are frequently forgotten or sometimes those are being missed as they are not being taken as regular meals or not being given importance as regular meals. The second is the limitation is day-to-day variation. As a day one, you may have a pie of a pizza or a day two, you may have a salad or you may have a hamburger or day three, you may have some sort of an beverages added or some sort of snacks or noodles. Day four, you may say you may have some sort of stacks or you may have addition of a single or a mix of snacks. So you know a 24 hours period it does not reflect a person's habitual long-term diet. Multiple recalls is required. So 24 hours recall is not only one a person can be judged on. So you can say a habitual intake is more important than a single day recall. It it is it is counted to be as a major uh challenge. Then comes the proportion size. Individuals frequently misestimate the proportion sizes. This leads to nutrient estimate errors and this is very common where you can say I consume one cup of milk. Sometimes the cup might be something which is more than 200 ml where it is more an estimate of a size of a glass where your estimates are just based on what you see and not in terms of the measurement that is required. In the challenges there is always an under reportporting. Sometimes it is say that hey only had a fruits and water which says that the tendency to under reportport is very social and for undesirable foods common with people who are obese people who are on dietary conscious individuals and sometimes they have social constraints. the social desiraability bias. Lot of a time people have an expectation stating that I eat lot of vegetables which might not be the real case or sometimes in a reality the reporting fruit instead of junk food. So maybe saying that he is eating or she is eating fruits but in reality might not be in take in in place of fruit it might be beverages. The respondent may intentionally underreport unhealthy foods or over report good foods which is very common in Indians. Then comes need for multiple recalls. Multiple recalls for two or three more non-consequence. Multiple probes calculate usual intake. So to estimate an usual intake, repeated recalls are required and multiple probes cued memory may be giving you more base. Then comes a limitation of composite and shared dishes. If you see the diets actually which are being taken in Asian countries particularly in India varying with recipes and reconstruction and deconstructing challenges, you may find the share plates in many cultures where you cannot estimate that how you are taking the challenge of identifying the proportion the meals nutrients and ingredients across the household. Then is the application in survey how it is being applicable over here? So in the national nutrition survey the AM is the core instrument used in what we eat in America. Okay. the dietary interview component of the national health and nutrition examination survey in the US and you may find that CNS that is in India it's a very comprehensive national nutrition survey and it uses the dietary recall method to assess the diet intake among Indian populations you may find that these are a very remarkable benefits that you can understand about the Indian population also there is In addition with the recent NFHS which is being conducted the national family health survey which uses dietary intake indicators for nutrition surveillance as well as the dietary interior components of NH and ES which is being very popular in US to be taken as something as a dietary interior component. In nutritional epidemology, it benefits to user tracking the population trends and the dietary patterns they have. It also establishes the dietary guidelines and link it to nutrient exposure to chronic disease risk over the period of time. So you can understand the link between the different disease condition especially the non-communicable disease. what are the sort of nutritionbased intervention studies which are very popular and established a baseline diets. It also gives you the follow-up diets which evaluates the changes in the eating habits after the dietary intervention is done or clinical trials has been done especially in non-communicable disease, cancer, AIDS and other group of patients. Clinical nutrition studies are also a very good example of application where you may find a nutrition survey, the dietary counseling or monitoring of the treatment response which is being given along with the food. So it helps the clinician individualize care and monitor dietary changes which is very important for a disease condition like tuberculosis or AIDS. Then comes the major application that is public health program. Lot of public health programs which are conducted in India especially the health community better nutrition that is for national nutrition mission or portion aban where you can say it can evaluate the interventions and monitor the food programs assess the dietary adequacy which gives us more benefit to enhance the public health programs quality. I would like to highlight one important case, a case study which investigates the association between dietary sodium intake and hypertension using a 24 hours recall. This method we recruit the participants and the age group is 25 to 65 and the population is 1,000. It is being taken from an urban and rural community as a mix. So you can understand each of the participant completes a two non-consecutive 24 hours recall. The entire information is collected of the data. The estimation of the sodium intake is being taken. It converts the fruit to gram weight using the FCTs and calculate the sodium in milligs for each food. Average of the two recalls is equal to usual day sodium intake. So you can understand the two 24 hours recalls are taken and the usual sodium intake is being calculated. The category is about 200 mg, 200 to 3,999 mg and more than 400 mg. The participants are grouped based on the usual daily sodium intake where you can find from the green to yellow to red. So it is being pointed how it is being taken as low, medium and high. When it comes to the measuring the outcomes particularly for hypertension part as you know there is a high association of sodium intake and hypertension. So the blood pressure measure use a standard protocol of hypertension defines as above 140 mg per Ag and the diastolic blood pressure is 90 mg ag on anti-hypertensive medication. So how to understand that the data are collected 24-hour recall method where you can say the pass one, pass 2, pass 3, pass 4 and pass five what we have understood is being taken properly. The example is like in Italy you may find the sodium is like 520 mg where in dal rice and vegetable pickles it is 1.2 120 1,245 mg. Tea and biscuits it is 120 mg. Chapati at least for two or a curry that is 850 mg. The total sodium was coming 2,727 mg. In foods reported converted using FCT and the total sodium was coming as 2727 mg. The strength of this was it was capturing the detail information. It was taking all the hidden sources like salt, pickles, sauces, water and everything feasible for larger group. Cost effective in terms of comparing the diet record. Better reflection of actual intake of FFQs and standardized via multiple pass method that is AMM. Analysis was done and it was identified that the prevalence of hypertension across sodium intakes population is higher. So higher sodium intake is associated with higher prevalence of hypertension. The potential confounders were considered with respect to age and physical activity, sex and total energy intake and alcohol consumption and BMI, smoking and soio economic status. So it is very important that these associations are one which is maybe a single or in conjunction with. So what is the key takeaway of this case? Using two 24 hours recall allows estimation of usual sodium intake with reasonable accuracy. The findings support a positive association between high dietary sodium intake and hypertension risk. This gives us a demonstration that the effective use of 24 hours recall in epidemological research is very important. The 24 hours dietary recall method is a very practical, very reliable and very widely used tool for assessing the nutrition intake particularly of a mineral like sodium which is classifying the exposure and it has been examined and associated with different research that it has a health outcome particularly hypertension. If at all you have to make any sort of health intervention particularly food based or dietary based it should be based on the associations outcome which are designed from the base of this study. So with this we come end to this chapter and in the summary I would like to highlight that the 24 hours dietary recall is widely used dietary assessment method that has collected the detailed information of all foods and beverages consumed during the previous day. So it's a summary of a 24 hours using the multiple pass method MPM. It improves the recall accuracy by systematically probing from forgotten food and obtaining the detailed information in terms of the proportion and size preparation methods and mealing time. The method provides rich dietary data with relatively low respondent burden and is suitable for diverse population. Technological innovations such as ASA 24 has been enabled which is automated web-based diet recalls enhancing the scalability and the standardization. Despite its strength, the method is uh susceptible to recall bias proportion size estimation errors and day-to-day dietary variation often requiring multiple recalls to estimate the usual intake. So there are some strengths and challenges. Consequently, the 24 hours remains a cornerstone of nutrition epidemology, nation nutrition service and clinical nutrition research and public health programs across the globe. These are a few references which are very important to be taken in consideration. And with this we come an end to this chapter. Thank you. Thank you very much.