MULTIMEDIA DIET RECORDS UNDERESTIMATE ENERGY NEEDS 803
camera. In an effort to ensure accurate and complete food records, the R carbon dioxide 0.462TBW 1.01k 0 1.04k h (1)
subjects were provided a training session prior to the study com-
The rate of CO2 production is represented by R, TBW is determined
mencement. Subjects were supplied with standard household mea-
based on d 1 or 14 (kg). The elimination rates of H218O and D2O are
surements, a ruler, a 35-mm camera and a microcassette tape recorder
designated by ko and kh, respectively. A standard respiratory quotient
to measure and record all foods and beverages consumed and leftover
of 0.85 was used for all subjects to prevent bias due to inaccuracies in
for 4 d. Food habits differ on weekends and weekdays (Beaton 1994).
Considering these day-to-day variations, the subjects were assigned a
Data are presented as means SD To compare anthropometric
Wednesday-Saturday or Sunday-Wednesday recording period. Sub-
variables, TEE, and reporting accuracy with age, women were strat-
jects recorded their intake from morning to bedtime on d 4 –7 or 7–11
iﬁed into 49 –59, 60 – 69, 70 –79 and 80 y age groups. Reporting
of the study period. Copies of recipes for homemade meals and labels
accuracy was expressed as mean reported intake by MMDR in MJ/d
from ready-to-eat preparations were requested, as well as speciﬁca-
divided by mean TEE/day 100. Data were analyzed with the
tions regarding the method of preparation and cooking. Subjects were
Student-Newman-Keuls test, and differences among age groups were
asked not to alter their dietary patterns during the study period so
considered signiﬁcant when P 0.05. The SAS statistical package
that the MMDR would be typical of their usual dietary habits.
was used (SAS Institute, Cary, NC).
Subjects who did not maintain a record for 4 d were excluded from
the study. Food records were analyzed using Food Processor 5.0,
ESHA (Portland, OR). When transposing taped records into written
records, pictures were used for cross-referencing dietary intake reports
to determine if foods in taped records and photographs corresponded,
Selected characteristics of the 53 subjects are presented by
but were not used for quantiﬁcation of energy intake.
stratiﬁed age groups in Table 1. Twenty subjects were ex-
To calculate total energy expenditure (TEE), a two-point DLW
cluded from the analyses. Seventeen subjects’ food records
method was used. Baseline urine and saliva samples were collected
were excluded due to incompleteness or technical difﬁculties
and a dose of DLW was administered based on estimated body water
with the recording equipment. Two subjects’ analytical results
(body weight 50%) to the fasted subjects. The dose of 2.5 g
H18 O/kg [10% atom percentage excess (APE)] and 0.12 g D2O/kg suggested a higher turnover of hydrogen than oxygen. One
(99.9% APE) estimated body water was followed by a 50-mL rinse of subject’s analytical results suggested a TEE of 25.2 MJ/d (6022
fruit juice and a mufﬁn. Subjects were asked to abstain from food and kcal/d). This subject’s TEE was considered physiologically
minimize water intake for 4 h and to collect a saliva sample for unlikely and was excluded from the analyses. There were no
determination of body water at 3 and 4 h postdose. Subjects were body weight changes between d 1 (62.9 12.2 kg) and d 14
given urine sample bottles to collect a second void sample at 24 h. On
(62.8 11.8 kg) or between TBW estimations for d 0 (30.4
d 7, the women visited the study location and gave a second void
9.1 kg) by 2H2 O analysis. The
7.1 kg) and d 14 (29.6
urine sample and brought in the frozen samples previously collected.
decay rates of H2 O (ko) and 2H2O (kh) for d 1 and 14 were
On d 14, fasting subjects returned to the study location and gave
0.12 0.03 and 0.09 0.02 pools/d, respectively. Carbon
another second void urine sample and a saliva sample. A 200 g/L
dioxide production (rCO2) was 11.3 3.2 (mol/d).
solution of D2O (0.12 g/kg estimated body water) in tap water was
taken orally and rinsed with 50 mL fruit juice. A mufﬁn was again The study subjects reported signiﬁcantly lower energy in-
provided to break the fast. At 3 and 4 h postdose, subjects were takes 7.5 1.9 MJ/d (1774 476 kcal/d) than their TEE
instructed to provide saliva samples for a second estimate of body determined by DLW 10.4 3.1 MJ/d (2477 729 kcal/d), (P
water. All collected samples were stored in paraﬁlm-wrapped plastic 0.01). This represents a mean reporting accuracy of 76.0
containers and stored at 20°C.
22.9% (range 43–158%). There were no signiﬁcant differ-
Body composition was calculated using total body water (TBW)
ences in reporting accuracy among the age groups (P 0.05).
and weight on d 0 and 14 using isotope dilution of D2O and H218O
Energy expenditure (MJ/d) as determined by DLW was
on d 0 and D2O on d 14. TBW was calculated using the enrichment
signiﬁcantly higher (P 0.01) in each stratiﬁed age range
of saliva samples taken at 3 and 4 h postdose based on the assumption
when compared to reported energy intake by MMDR (Fig. 1).
that fat-free mass (FFM) is 73.2% hydrated. (Pace and Rathburn
Women in the 50 –59 y age range reported 8.2 2.1 MJ/d
1945). Fat mass was calculated as the difference between body weight
and FFM. (1954 491 kcal/d); however, TEE was 11.5 3.1 MJ/d
The isotopic analysis was conducted using standard vacuum tech- (2759 751 kcal/d), representing a reporting accuracy of 74.4
niques as previously described by Jones et al. (1988). Urine and saliva 22.7%. In the 60 – 69 y age group, reported intake was 7.7
samples containing D2O were measured in duplicate or triplicate 1.3 MJ/d (1780 383 kcal/d) while TEE was determined to
using a 903D dual-inlet isotope ratio mass spectrometer (IRMS), (VG
be 10.6 3.0 MJ/d (2543 712 kcal/d), which calculated to
Isogas, Cheshire, England). For H18O enrichment determination,
a reporting accuracy of 75.2 17.4%. In the 70 –79 y age
1.5-mL physiological samples of urine or saliva were added to Vacu-
group, reported intake was 7.2 2.3 MJ/d (1724 554
tainer tubes. Urine samples were analyzed for C18O2 in three or four
kcal/d) contrasting the TEE of 9.6 2.8 MJ/d (2287 677
replicates as required using a SIRA 12 IRMS (VG Isogas). Carbon
kcal/d); reporting accuracy was 80.3 33.3%. There were
dioxide production was calculated using the equation:
Anthropometric measures of the women studied1
Age, y Category 50–59 60–69 70–79 80–89 All
n 18 17 12 6 53
Age, y 53 13 64 3 74 2 86 4 65 11
Wt, kg 68 15 62 9 58 11 57 7 63 12
Ht, cm 164 5 159 6 157 5 157 6 160 6
BMI,2 kg/m2 25.2 5 24.1 3 23.5 4 24.4 2 24.4 4
Body fat, kg/100 kg 33.8 11.3 21.2 9.7 28.5 8.7 27.2 9.9 27.8 11.1
1 Means SD.
2 Body mass index, BMI [wt(kg)/ht(m2)].
KACZKOWSKI ET AL.
eating for 4 d followed by overcompensation in energy intake
for the next several days during the study period may have
occurred. Subsequently, when the 4-d intake recording period
ended, subjects may have returned to their normal eating
patterns or even overcompensated for their temporary reduc-
tion in food intake while recording. Due to the relatively short
intake recording period, it is difﬁcult to establish whether a
reduction in food intake during the reporting period or under-
reporting errors was the cause of the discrepancy between TEE
and reported intake. In fact, both intake reduction and under-
reporting may have been jointly responsible. Some subjects
may have underreported in an attempt to conform to socially
acceptable food habits while others actually did conform,
eliminating certain foods from their diet over the study period.
Other researchers have reported negative relationships be-
tween reporting accuracy and TEE (Prentice et al. 1986,
Ravussin et al. 1982, Schoeller 1988, Welle et al. 1992) which
is possibly indicative of reluctance to report all food intake.
Previous studies using self-reported food intakes compared
FIGURE 1 Total energy expenditure (TEE) and energy intake as-
to DLW show a consistent underestimation by participants
sessed by multimedia diet records (MMDR) in women of various age
and a wide variation in the energy intakes reported, depending
groups. Bars indicate means SEM, n are given in Table 1. Uppercase
letters depict signiﬁcant differences (P 0.05) in TEE derived from on the method used (Bingham et al. 1995, Goran and Poehl-
doubly-labeled water analyses among age groups while lowercase man 1992, Johnson et al. 1994, Martin et al. 1996, Schoeller
letters describe differences in MMDR analyses among age groups.
1990). Rothenberg et al. (1998) compared diet histories in
MMDR values were calculated from a 4-d dietary assessment method
elderly Swedish subjects (n 12) to DLW and found that they
using a tape recorder and camera.
underestimated TEE by 12% (8.62 2.06 vs. 9.9 1.43
MJ/d (2060 492 vs. 2366 341 kcal/d). Energy intakes
calculated from 7 d of consecutive weighed food records, 24-h
signiﬁcantly reduced reported intakes and TEE in the 80 y recalls and food frequency questionnaires were compared to
age group compared to the younger age groups, 5.5 0.5 MJ/d DLW in middle-aged women (n 28) by Martin et al. (1996).
(1313 118 kcal/d) and 7.6 1.7 MJ/d (1820 417 kcal/d), TEE was 9.0 2.1 MJ/d for subjects who were participating in
respectively (P 0.05), although these differences were not a long-term dietary intervention study (48.5 5.0 y, 61.8
due to reporting accuracy (74.6 15.2%), but more likely to 6.7 kg). Reporting accuracy was 79.8 17.6% using 7-d
reduced energy requirements. There were no differences in weighed food records. The degree of underreporting was not
anthropometric measures across stratiﬁed age groups in body associated with BMI, anthropometric measures, percentage of
mass index (BMI) (23.5–25.2 kg/m2) or body weight (57.7– energy from fat or carbohydrate or length of time of the dietary
68.0 kg), although body fat percentage was signiﬁcantly lower trial. Reporting accuracy was similar in the present study at
in the 60 – 69 y age group (21.2 9.7%) compared to the 76.0 22.9%; however, neither method using 4-d MMDR or
group mean of (27.8 11.1%), (P 0.05). a conventional 7-d weighed record adequately estimated TEE.
Johnson et al. (1994) examined correlates of reporting accu-
racy in older women (n 56, 66 6 y, 64.1 7.6 kg) and
found underreporting of -2.2 1.8 MJ/d (526 430 kcal)
TEE exceeded reported energy intakes for the subjects in compared to TEE. In this group of normal weight women, TEE
the present study. This indicates that either the subjects were was 9.3 1.0 MJ/d as measured by DLW in a subsample (n
underreporting their food intakes or decreased food consump- 13) of the study population. Percentage body fat was neg-
tion during the 4 d MMDR recording period. Black (1996) atively correlated with underreporting of intake (r 0.42, P
reviewed 574 TEE measurements and reported that in women 0.001). Pannemans and Westerterp (1993) examined a
aged 40 – 64 y (52 8 y, 70 13.3 kg, BMI 26 4.6) mean group of elderly volunteers (n 12) using a 4-d food record
TEE was 9.8 1.7 MJ/d with basal metabolic rate (BMR) and compared these reported intakes with expenditure deter-
representing 5.8 0.7 MJ. This TEE calculation is very mined using DLW. They concluded that food records under-
comparable to the mean energy expenditure of 10.4 3.1 estimate energy expenditure and are inversely correlated with
MJ/d (2477 729 kcal/d) in the present study of older but BMI. Results from the present study did not provide a corre-
slightly lighter women (64.9 11.3 y, 62.4 12.2 kg). lation with BMI nor body fat percentage (data not shown).
Measures of energy intake assessment using factual methods The mean TEE in the present study closely approximated
have innate problems due to their subjective nature. Factual TEE found by Starling et al. (1998) who measured TEE using
methods depend on the assumption that the dietary data DLW (n 51, 67 6 y) and found TEE in women was 9.6
compiled are a valid and accurate assessment of intake and 2.7 MJ/d (2306 647 kcal/d). In a subgroup of 70 women
that subjects are in energy balance while the dietary informa- and men, the strongest predictors of TEE were resting meta-
tion is obtained (Jones et al. 1997). Even a novel method of bolic rate (RMR) and VO2 peak which explained 62% of the
dietary intake recording used in this study resulted in subjects variance in TEE. RMR accounted for 63% of TEE 6.1 1.0
reporting only 76.0 22.9% of their energy intake. There are MJ/d (1463 244 kcal/d). Energy expenditure due to physical
several possible reasons for this underestimation. Since mean activity was predicted most closely by (P 0.05) VO2 peak (r
energy intake should equal mean intake in weight-stable sub- 0.43), FFM (r 0.39) and body weight (r 0.34). These
jects, the reported energy intake infers underestimation of studies with similar mean energy expenditures offer validity to
intake or undereating in this population. There was no mean the mean TEE in the present study. The comparable rates of
weight change over the 13 d DLW period; however, under- underreporting found in these studies also lend credence to the
MULTIMEDIA DIET RECORDS UNDERESTIMATE ENERGY NEEDS 805
assumption that many subjects are either unwilling or unable Bingham, S. A. (1991) Limitations of the various methods for collecting dietary
intake data. Ann. Nutr. Metab. 35: 117–127.
to disclose all food intake. Bingham, S. A., Cassidy, A., Cole, T. J., Welch, A., Runswick, S. A., Black, A. E.,
MMDR were chosen because of the perceived reduction in Thurham, D., Bates, C., Khaw, K. T., Key, T. J. & Day, N. E. (1995) Vali-
subject burden when recording meals with a tape recorder as dation of weighed records and other methods of dietary assessment using the
24 h urine nitrogen technique and other biological markers. Br. J. Nutr. 73:
opposed to written records. The cross-referencing of tape-
recorded diaries with photographs taken at the time of con- Black, A. E. (1996) Physical activity levels from a meta-analysis of doubly-
sumption was considered a method which could conceivably labeled water studies for validating energy intake as measured by dietary
reduce the frequency rate of omissions. However, the meth- assessment. Nutr. Rev. 54: 170 –174.
Dwyer, J. T. (1994) Dietary and nutritional assessment of the individual. In
odology still relies on subject competence and willingness to Modern Nutrition in Health and Disease. 8th Edition. Edited by M.E. Shils, J.A.
record daily food intake. Bingham (1991) has suggested that Olson, M. Shike. Lea & Febiger, Philadelphia, Penn. pp. 842– 860.
20% of subjects are either persistent underreporters or habitual Goran, M. I. & Poehlman, E. T. (1992) Total energy expenditure and energy
dieters. She contends that whenever subjects are asked to keep requirements in healthy elderly persons. Metabolism 41: 744 –753.
Johnson, R. K., Goran, M. I. & Poehlman, E. T. (1994) Correlates of over- and
a record of intake it is plausible that they will change their under-reporting of energy intake in healthy older men and women. Am. J. Clin.
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because they become cognizant of how much they really are Jones, P.J ., Martin, L. J., Su, W., Boyd & N. F. (1997) Canadian recommended
nutrient intakes underestimate true energy requirements in middle-aged
consuming. The bias is typically toward underestimating in-
women. Can. J. Public Health 88: 314 –319.
take due to many reasons including memory loss, a desire to Jones, P. J., Winthrop, A. L., Schoeller, D. A., Filler, R. M., Swyer, P. R., Smith, J.
conform to socially accepted food habits and simpliﬁcation of & Heim, T. (1988) Evaluation of doubly labeled water for measuring energy
reporting. Simpliﬁcation of reporting may have been a factor expenditure during changing nutrition. Am. J. Clin. Nutr. 47: 799 – 804.
Martin, L. J., Su, W., Jones, P. J., Lockwood, G. A., Tritchler, D. L. & Boyd, N. F.
in this study because some subjects were not conﬁdent with
(1996) Comparison of energy intakes determined by food records and
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occurred if there was an inclination to put off tape recording Am. J. Clin. Nutr. 63: 483– 490.
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