Disability and Health Journal 8 (2015) 146e150 www.disabilityandhealthjnl.com
Brief Report
Digital photography improves estimates of dietary intake in adolescents with intellectual and developmental disabilities Lauren T. Ptomey, Ph.D., R.D., L.D.a,*, Erik A. Willis, M.S.a, Jeannine R. Goetz, Ph.D.b, Jaehoon Lee, Ph.D.c, Debra K. Sullivan, Ph.D.b, and Joseph E. Donnelly, Ed.D.a a
Cardiovascular Research Institute, Division of Internal Medicine, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA b Department of Dietetics and Nutrition, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA c Institute for Measurement, Methodology, Analysis, and Policy, Texas Tech University, 2500 Broadway Street, Lubbock, TX 79409, USA
Abstract Background: Dietary assessment of adolescents with intellectual and developmental disabilities (IDD) is challenging due to the limited cognitive abilities of this population. Objective: The purpose of this study was to determine the feasibility of using of digital images to improve the estimates of energy and macronutrient intake from proxy-assisted 3-day food records in adolescents with IDD. Method: Participants used a mobile device to take photos of all food and beverages consumed over a three-day period and simultaneously completed a standard parent-assisted 3-day food record at two separate time points. A registered dietitian reviewed and recorded the differences between the standard record and the images. The proxy-assisted records and the photo-assisted records were analyzed separately. Results: One hundred and thirty eating occasions were entered (20 participants (age 5 14.9 6 2.2 yrs, 45.0% female)). Photo-assisted records captured significantly higher estimates of energy intake per eating occasion than regular proxy-assisted records (P 5 0.001) as well as significantly greater grams of fat (P 5 0.011), carbohydrates (P 5 0.003), and protein (P 5 0.004). Conclusion: The use of photo-assisted diet records appears to be a feasible method to obtain substantial additional details about dietary intake that consequently may improve the overall estimates of energy and macronutrient intake when using proxy-assisted diet records in adolescents with IDD. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Intellectual disabilities; Adolescents; Dietary assessment; Technology; Photo-assisted food record
Due to the complexity of nutrition and the numerous health risks that accompany poor diet quality and excessive energy intake, it is essential to have methods to assess dietary intake. Dietary assessments increase the effectiveness of both health interventions and policies at the individual as well as the population level. Overall, the high prevalence of obesity is a serious problem, and research shows that obese adolescents are up to four times more likely than their healthy weight peers to become obese adults and to develop chronic diseases, such as hypertension, type 2 diabetes, and metabolic syndrome.1 Since obesity research in
Conflict of interest: The authors report no conflict of interest. * Corresponding author. Cardiovascular Research Institute, Division of Internal Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd, Mail Stop #1007, ATTN: Energy Balance Lab, Kansas City, KS 66160, USA. Tel.: þ1 913 945 8182; fax: þ1 913 945 8280. E-mail address: [email protected] or [email protected] (L.T. Ptomey). 1936-6574/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2014.08.011
adolescents with intellectual and developmental disabilities (IDD) is limited, the need for valid dietary assessment is high: the prevalence of obesity in adolescents with IDD is approximately 2e3 times greater than in adolescents without IDD.2e6 Researchers have not yet validated a method for dietary intake assessment in individuals with IDD due to significant barriers in collecting accurate and reliable data. These barriers include compromised cognitive functioning, poor memory, and a shortened attention span.7,8 One of the most common dietary assessments used in the general population is diet records. Diet records have the potential to provide accurate data for food consumed during the recording period. They allow respondents to record food and beverages as they are consumed, lessening the problem of omission and increasing the described detail of foods. For these reasons, diet records are often regarded as one of the best dietary assessment methods.9 However, diet records, like all dietary assessments, are imperfect
L.T. Ptomey et al. / Disability and Health Journal 8 (2015) 146e150
because they rely on self-report and a person’s ability to correctly describe what was consumed.10 Therefore, this method may not be appropriate in individuals with IDD. As a result, the use of proxy-assisted diet records has been shown to provide more accurate dietary information in adults with IDD.11,12 Proxy-assisted diet records are an assessment method in which a family member or support person assists a participant in completing a diet record. Proxy-assisted records are commonly used in populations with limited reporting capabilities, such as children and individuals with Alzheimer’s.13 While proxy-assisted diet records have been shown to work in adults with IDD, adolescents have different limitations than adults (school lunches, lack of responsibility for preparing their own meals, use of technology), and the feasibility of this method in adolescents has not been assessed. In addition, photo-assisted dietary assessment is another method that has been validated in the general population14e21 and has been determined feasible in adults with IDD.22,23 Photo-assisted dietary assessment is a technique in which digital images are taken of all food and beverages consumed during the record period. The use of photoassisted 24-h food recalls in adults with IDD resulted in a significantly greater energy intake being reported per eating occasion when compared to the standard recalls (P 5 0.002) as well as a greater intake of fat (P 5 0.006), protein (P 5 0.029), and carbohydrates (P 5 0.003).24 The authors concluded that photo-assisted recalls have the potential to be a more accurate dietary assessment technique in individuals with IDD than 24-h recalls alone.24 While previous studies in adults with IDD have determined that both proxy-assisted diet records and photoassisted recalls can provide accurate dietary assessments and that the photo-assisted recalls potentially improve the total energy and macronutrients reported, no information is available regarding the use these dietary assessments in adolescents with IDD or regarding whether digital photography can improve proxy-assisted food records. Therefore, the aim of this study was to determine if the collection of digital images is a feasible method to improve estimates of energy and macronutrient intake of proxy-assisted 3-day food records in adolescents with IDD.
Methods Participants This study was conducted with twenty adolescents with IDD. Each participant completed a proxy-assisted record and took pictures of the foods eaten during the record period to determine if they provided additional details about the type and amount of foods eaten. All individuals had to be 11e18 years of age with mild (IQ of 50e69) to moderate (IQ of 35e49) IDD, living at home with a parent
147
or legal guardian, of sufficient cognitive ability to understand directions, and able to communicate through spoken language. This study was approved by the University of Kansas’s Human Subjects Committee. Participants and their legal guardian met with a member of the research team who explained the study in detail and who read them a university-approved consent form. Both the participants and the legal guardians were given an opportunity to ask questions about the study. Participants were read an assent using plain language asking if they wanted to participate. If participant gave oral assent, their legal guardian was then asked to sign the consent form. Collection of dietary assessments All participants were given a mobile device with a builtin camera (iPad 2, Apple, Cupertino, CA, USA)25 at the beginning of the study. The device’s rear-facing camera (1280 720 pixels or 0.92 megapixel camera with autofocus) was used for the photo-assisted records. Before the assessment, each participant was instructed on basic mobile device functions, including how to operate the camera application. The study personnel observed the participant independently take satisfactory images. Participants were instructed to complete hard copy, proxy-assisted diet records, with the help of a parent or legal guardian if needed, for three consecutive days (2 weekdays, 1 weekend day). The participants were instructed to also take before and after images, using the mobile device, of all food and beverages consumed at home during that 3-day period, without the help of the parent/ guardian. A fiduciary marker (a 5 cm 5 cm checked square) was included in all images to serve as a reference measure of portion size. To remind participants to comply with the photo/record protocol calendar, prompts were programmed into the mobile device. After the record period was complete, a registered dietitian (RD) reviewed the written proxy-assisted 3-day diet record with the participant without the use of the images. Portion guides were used to help clarify portion size and provide better accuracy. The portion guides used in the interviews were 3-dimensional models consisting of a variety of items intended to provide a reference (i.e., glasses, mugs, bowls, circles, thickness sticks, chip bags, drink bottles, a 12-inch ruler, measuring cups and spoons, a grid, wedges, geometric shapes, and diagrams of chicken pieces).26 Following the review of the proxy-assisted diet record, the RD separately reviewed the date and time stamped images using methods previously published by Ptomey et al24 to obtain additional information about the foods eaten. Each photographed eating occasion or food item was discussed with the participant in order to identify additional details possibly left out of the initial dietary record regarding the food type, portion size, and other characteristics (e.g., drinks, side dishes, ingredients, condiments, etc.). Food items, portion size, and specific details
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about any food items that were different from the written record were recorded in different colored ink in order to distinguish any discrepancies between the photo-assisted record and proxy-assisted record. Additional details, including the reasons for the differences (e.g., forgot food, inaccurate portion size), number of meals captured by images, and total number of meals consumed, were also recorded. Analysis of dietary assessments All diet records were entered into Nutrition Data System for Research (NDSR) software version 201127 by RDs. The original proxy-assisted records without details from the images and the photo-assisted records were entered as two separate records. Dietary analysis from NDSR was used to determine total intake of calories, fat, carbohydrates, and protein at each time point. Not all eating occasions were captured by digital photography due to participants eating lunch and some snacks at school; therefore, only the eating occasions that were captured by photo were analyzed and compared to the proxy-assisted 3-day food record. An eating occasion was defined as any period where at least one food item or caloric beverage was consumed. Statistical analysis The differences in energy (kcals) and macronutrient (grams of fat, carbohydrates, and protein) intake between the proxy-assisted record and the photo-assisted record for each participant were examined. Mixed modeling for repeated measures28e30 was used to examine the differences between two records as it can account for the correlation among meals reported by the same participant. Models were adjusted for each participant’s age, gender, race, and level of IDD severity (mild vs. moderate), thereby improving the accuracy of the energy and macronutrient estimates. Statistical significance was determined at 0.05 alpha level, and all analyses were conducted using Statistical Analysis Systems statistical software package version 9.3 (SAS Institute, Cary, NC, USA).31
Table 1 Demographic data of all participants All participants (n 5 20) Variable
n
Age (yrs.) Gender (%) Male Female Race (%) Asian Black White Mixed Ethnicity (%) Not Hispanic/Latino Hispanic/Latino Level of IDD severity (%) Mild Moderate Secondary diagnosis (%) Autism Down syndrome Other
14.9 6 2.2 11 (55%) 9 (45%) 1 4 14 1
(5%) (20%) (70%) (5%)
20 (100%) 0 (0%) 12 (60%) 8 (40%) 9 (45%) 8 (40%) 3 (15%)
Values are mean (SD) unless otherwise stated.
portion size, forgetting a food, etc.) per eating occasion between the original and photo-assisted records. The most common difference between the photo-assisted records and the original records without images was incorrect portion size (37.4%): for example, a participant would report consuming one slice of pizza while a photo would show that three slices of pizza were consumed. This was followed by forgetting a food eaten (32.1%), missing or incorrect details about food (28.2%), and reporting a food that was not actually consumed (2.3%). Energy and macronutrient intake After adjusting for age, gender, race, and level of IDD severity, photo-assisted records showed significantly higher estimates of total energy intake per eating occasion compared to proxy-assisted records (proxy-assisted [M 6 SE] 5 429.4 6 23.0 kcals vs. photoassisted 5 515.7 6 28.7 kcals, P 5 0.001). This resulted in a 20.1% higher total amount of energy reported per eating occasion. Photo-assisted records also showed
Results Ability to capture photos Twenty one participants enrolled in the study; however, one participant chose to withdraw from the study before the diet assessments were collected due to family conflict. Thus, diet records were collected from 20 participants (age 14.9 6 2.2 yrs, 45.0% female). Table 1 shows demographic data for the 20 participants. Participants captured images for 68.3 6 31.7% of all eating occasions consumed. This resulted in the analysis of 130 eating occasions. There was an average of 2.6 6 2.2 dietary differences (i.e., incorrect
Table 2 Reported energy and macronutrient intake using proxy-assisted records compared to photo-assisted records per eating occasion Original record Photo-assisted record n Energy (kcal) Carbohydrate (g) Fat (g) Protein (g) a
M 6 SE
130 429.4 6 23.0 130 57.1 6 3.2 130 16.0 6 1.1 130 17.2 6 1.1
n
M 6 SE
130 130 130 130
515.7 67.5 19.5 21.0
6 6 6 6
P 28.7 4.1 1.5 1.7
0.001a 0.003a 0.011a 0.004a
Denotes significance at 0.05 alpha level using mixed modeling for repeated measures.
L.T. Ptomey et al. / Disability and Health Journal 8 (2015) 146e150
significantly greater intakes of grams of fat (P 5 0.011), carbohydrates (P 5 0.003), and protein (P 5 0.004) (Table 2). Macronutrient composition The macronutrient composition was evaluated to compare the proxy and photo-assisted records to examine whether certain types of foods were captured differently between methods (e.g., high carbohydrate foods under reported, high fat foods over reported, etc.). Fig. 1 illustrates the macronutrient composition as a percent of total energy intake for both record methods, and shows that there was no significant difference for the percent distribution of grams of fat, protein, or carbohydrates (all P O 0.05).
Discussion This study was designed to determine if digital images are a feasible dietary assessment method and if they provide an improvement in energy and macronutrient intake when combined with 3-day diet records in adolescents with IDD. Similar to previous studies using digital photography in adults with IDD, participants were able to use the device to capture images of their meals.22e24 Participants were able to take photos of their food for 68.3 6 31.7% of all eating occasions. The main reason for not capturing a meal on camera that was reported on the food record was consuming a meal or snack while at school where the mobile devices were not allowed. In this study, 32% of all eating occasions occurred at school. Furthermore, participants were able to take photos without the help of a parent, which suggests that the use of photo-assisted records may decrease the burden on parents during dietary assessment periods. The use of digital images in combination with written records provided significantly greater total energy intake compared the original proxy-assisted food records. These differences in caloric intake suggest that standard proxy-
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assisted food records may underestimate dietary intake amounts in this population. If digital images had not been added to the proxy-assisted food record, the total energy intake would have been underreported by 20%. The macronutrient composition (percent calories from fat, protein, and carbohydrates) between record methods was not different at either time point, indicating that the significant increase in energy intake was responsible for the significant increases in macronutrient intake and that certain foods, such as high fat foods like butter, were not more or less likely to be underestimated during reporting. While this study highlights the feasibility and value of using digital photography in combination with proxyassisted food records in adolescents with IDD, several limitations do exist. It can be suggested that the act of taking photos may help the participants have a better memory of what was eaten; however, Humphries et al found that the act of solely taking a photo did not improve dietary recalls in adults with IDD,23 which is consistent with results of the present study. Another limitation is that participants were not randomly selected as they were enrolled in a lifestyle intervention, which may limit the generalizability of these findings. However, the results were adjusted for age, gender, race, and level of IDD severity to help account for this limitation. Finally, while the photo-assisted record method did show significant increases in estimates of dietary intake, this method has not yet been validated via either weight and measure or doubly labeled water techniques in adolescents with IDD, and future validation studies need to be conducted.
Conclusions There is no validated method to collect dietary assessments in adolescents with IDD as adolescents with IDD may have some limitations in accurately describing or remembering what they consume. The use of digital images as a dietary assessment technique for adults with IDD has been published; however, this is the first known study to look at the use of digital photography for improving dietary assessments in adolescents with IDD. Although future research needs to validate dietary assessment methods in adolescents with IDD, the use of digital images in combination with diet records appears to be a feasible method to obtain substantial additional details in terms of energy intake of adolescents with IDD. References
Fig. 1. Macronutrient composition of proxy-assisted and photo-assisted records of adolescents with IDD.
1. Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obes Rev. Sep 2008;9(5):474e488. 2. Curtin C, Anderson SE, Must A, Bandini L. The prevalence of obesity in children with autism: a secondary data analysis using nationally representative data from the National Survey of Children’s Health. BMC Pediatr. 2010;10:11.
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3. Maiano C. Prevalence and risk factors of overweight and obesity among children and adolescents with intellectual disabilities. Obes Rev. Mar 2011;12(3):189e197. 4. Rimmer JH, Yamaki K, Lowry BM, Wang E, Vogel LC. Obesity and obesity-related secondary conditions in adolescents with intellectual/developmental disabilities. J Intellect Disabil Res. Sep 2010;54(9): 787e794. 5. Mikulovic J, Marcellini A, Compte R, et al. Prevalence of overweight in adolescents with intellectual deficiency. Differences in socioeducative context, physical activity and dietary habits. Appetite. Apr 2011;56(2):403e407. 6. Slevin E, Truesdale-Kennedy M, McConkey R, Livingstone B, Fleming P. Obesity and overweight in intellectual and non-intellectually disabled children. J Intellect Disabil Res. 2014 Mar;58(3):211e220. 7. Braunschweig CL, Gomez S, Sheean P, Tomey KM, Rimmer J, Heller T. Nutritional status and risk factors for chronic disease in urban-dwelling adults with Down syndrome. Am J Ment Retard. Mar 2004;109(2):186e193. 8. Humphries K, Traci MA, Seekins T. Nutrition and adults with intellectual or developmental disabilities: systematic literature review results. Intellect Dev Disabil. Jun 2009;47(3):163e185. 9. Thompson FE, Byers T. Dietary assessment resource manual. J Nutr. Nov 1994;124(11 suppl l):2245Se2317S. 10. Goris AH, Westerterp-Plantenga MS, Westerterp KR. Undereating and underrecording of habitual food intake in obese men: selective underreporting of fat intake. Am J Clin Nutr. Jan 2000;71(1):130e134. 11. Adolfsson P, Sydner YM, Fjellstrom C, Lewin B, Andersson A. Observed dietary intake in adults with intellectual disability living in the community. Food Nutr Res; 2008:52. 12. Saunders RR, Saunders MD, Donnelly JE, et al. Evaluation of an approach to weight loss in adults with intellectual or developmental disabilities. Intellect Dev Disabil. Apr 2011;49(2):103e112. 13. Emmett P. Workshop 2: the use of surrogate reporters in the assessment of dietary intake. Eur J Clin Nutr. Feb 2009;63(suppl 1): S78eS79. 14. Higgins JA, LaSalle AL, Zhaoxing P, et al. Validation of photographic food records in children: are pictures really worth a thousand words? Eur J Clin Nutr. Aug 2009;63(8):1025e1033. 15. Martin CK, Han H, Coulon SM, Allen HR, Champagne CM, Anton SD. A novel method to remotely measure food intake of freeliving individuals in real time: the remote food photography method. Br J Nutr. Feb 2009;101(3):446e456. 16. Wang DH, Kogashiwa M, Ohta S, Kira S. Validity and reliability of a dietary assessment method: the application of a digital camera with a mobile phone card attachment. J Nutr Sci Vitaminol (Tokyo). Dec 2002;48(6):498e504. 17. Swanson M. Digital photography as a tool to measure school cafeteria consumption. J Sch Health. Aug 2008;78(8):432e437.
18. Dahl Lassen A, Poulsen S, Ernst L, Kaae Andersen K, BiltoftJensen A, Tetens I. Evaluation of a digital method to assess evening meal intake in a free-living adult population. Food Nutr Res; 2010:54. 19. Kikunaga S, Tin T, Ishibashi G, Wang DH, Kira S. The application of a handheld personal digital assistant with camera and mobile phone card (Wellnavi) to the general population in a dietary survey. J Nutr Sci Vitaminol (Tokyo). Apr 2007;53(2):109e116. 20. Lazarte C, Encinas ME, Alegre C, Granfeldt Y. Validation of digital photographs, as a tool in 24-h recall, for the improvement of dietary assessment among rural populations in developing countries. Nutr J. Aug 29 2012;11(1):61. 21. Martin CK, Newton RL Jr, Anton SD, et al. Measurement of children’s food intake with digital photography and the effects of second servings upon food intake. Eat Behav. Apr 2007;8(2):148e156. 22. Elinder LS, Brunosson A, Bergstrom H, Hagstromer M, Patterson E. Validation of personal digital photography to assess dietary quality among people with intellectual disabilities. J Intellect Disabil Res. Feb 2012;56(2):221e226. 23. Humphries K, Traci MA, Seekins T. Food on Film: Pilot Test of an Innovative method for recording food intake of adults with intellectual disabilities living in the community. J Appl Res Intellect Disabil. 2008;21(2):168e173. 24. Ptomey LT, Herrmann SD, Lee J, Sullivan DK, Rondon MF, Donnelly JE. Photo-assisted recall increases estimates of Energy and macronutrient intake in adults with intellectual and developmental disabilities. J Acad Nutr Diet. 2013;113(12):1704e1709. 25. Cushing P, Spear D, Novak P, et al. Academy of Nutrition and Dietetics: standards of practice and standards of professional performance for registered dietitians (competent, proficient, and expert) in intellectual and developmental disabilities. J Acad Nutr Diet. Sep 2012;112(9):1454e1464. 1464 e1e35. 26. Wright JD, Borrud LG, McDowell MA, Wang CY, Radimer K, Johnson CL. Nutrition assessment in the National Health and Nutrition Examination survey 1999e2002. J Am Diet Assoc. May 2007;107(5): 822e829. 27. Schakel, Sally FG. Maintaining a Nutrient Database in a Changing Marketplace: Keeping Pace with Changing Food Products-A Research Perspective. Kidlington, Royaume-Uni: Elsevier; 2001:98. 28. Goldstein H. Multilevel Statistical Models. Chichester, UK: John Wiley & Sons, Ltd; 2010. 29. Raudenbush SW, Bryk AS. Hierarchical Linear Models: Applications and Data Analysis Methods., vol. 1. Thousand Oaks, CA: SAGE Publications, Incorporated; 2002. 30. Hox J. Multilevel Analysis: Techniques and Applications. New York, NY: Routledge Academic; 2010. 31. SAS Institute. SAS/STAT 9.3 User’s Guide. Cary, NC: SAS Institute Inc; 2002-2010.
Brief Report
Digital photography improves estimates of dietary intake in adolescents with intellectual and developmental disabilities Lauren T. Ptomey, Ph.D., R.D., L.D.a,*, Erik A. Willis, M.S.a, Jeannine R. Goetz, Ph.D.b, Jaehoon Lee, Ph.D.c, Debra K. Sullivan, Ph.D.b, and Joseph E. Donnelly, Ed.D.a a
Cardiovascular Research Institute, Division of Internal Medicine, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA b Department of Dietetics and Nutrition, The University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS 66160, USA c Institute for Measurement, Methodology, Analysis, and Policy, Texas Tech University, 2500 Broadway Street, Lubbock, TX 79409, USA
Abstract Background: Dietary assessment of adolescents with intellectual and developmental disabilities (IDD) is challenging due to the limited cognitive abilities of this population. Objective: The purpose of this study was to determine the feasibility of using of digital images to improve the estimates of energy and macronutrient intake from proxy-assisted 3-day food records in adolescents with IDD. Method: Participants used a mobile device to take photos of all food and beverages consumed over a three-day period and simultaneously completed a standard parent-assisted 3-day food record at two separate time points. A registered dietitian reviewed and recorded the differences between the standard record and the images. The proxy-assisted records and the photo-assisted records were analyzed separately. Results: One hundred and thirty eating occasions were entered (20 participants (age 5 14.9 6 2.2 yrs, 45.0% female)). Photo-assisted records captured significantly higher estimates of energy intake per eating occasion than regular proxy-assisted records (P 5 0.001) as well as significantly greater grams of fat (P 5 0.011), carbohydrates (P 5 0.003), and protein (P 5 0.004). Conclusion: The use of photo-assisted diet records appears to be a feasible method to obtain substantial additional details about dietary intake that consequently may improve the overall estimates of energy and macronutrient intake when using proxy-assisted diet records in adolescents with IDD. Ó 2015 Elsevier Inc. All rights reserved. Keywords: Intellectual disabilities; Adolescents; Dietary assessment; Technology; Photo-assisted food record
Due to the complexity of nutrition and the numerous health risks that accompany poor diet quality and excessive energy intake, it is essential to have methods to assess dietary intake. Dietary assessments increase the effectiveness of both health interventions and policies at the individual as well as the population level. Overall, the high prevalence of obesity is a serious problem, and research shows that obese adolescents are up to four times more likely than their healthy weight peers to become obese adults and to develop chronic diseases, such as hypertension, type 2 diabetes, and metabolic syndrome.1 Since obesity research in
Conflict of interest: The authors report no conflict of interest. * Corresponding author. Cardiovascular Research Institute, Division of Internal Medicine, University of Kansas Medical Center, 3901 Rainbow Blvd, Mail Stop #1007, ATTN: Energy Balance Lab, Kansas City, KS 66160, USA. Tel.: þ1 913 945 8182; fax: þ1 913 945 8280. E-mail address: [email protected] or [email protected] (L.T. Ptomey). 1936-6574/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.dhjo.2014.08.011
adolescents with intellectual and developmental disabilities (IDD) is limited, the need for valid dietary assessment is high: the prevalence of obesity in adolescents with IDD is approximately 2e3 times greater than in adolescents without IDD.2e6 Researchers have not yet validated a method for dietary intake assessment in individuals with IDD due to significant barriers in collecting accurate and reliable data. These barriers include compromised cognitive functioning, poor memory, and a shortened attention span.7,8 One of the most common dietary assessments used in the general population is diet records. Diet records have the potential to provide accurate data for food consumed during the recording period. They allow respondents to record food and beverages as they are consumed, lessening the problem of omission and increasing the described detail of foods. For these reasons, diet records are often regarded as one of the best dietary assessment methods.9 However, diet records, like all dietary assessments, are imperfect
L.T. Ptomey et al. / Disability and Health Journal 8 (2015) 146e150
because they rely on self-report and a person’s ability to correctly describe what was consumed.10 Therefore, this method may not be appropriate in individuals with IDD. As a result, the use of proxy-assisted diet records has been shown to provide more accurate dietary information in adults with IDD.11,12 Proxy-assisted diet records are an assessment method in which a family member or support person assists a participant in completing a diet record. Proxy-assisted records are commonly used in populations with limited reporting capabilities, such as children and individuals with Alzheimer’s.13 While proxy-assisted diet records have been shown to work in adults with IDD, adolescents have different limitations than adults (school lunches, lack of responsibility for preparing their own meals, use of technology), and the feasibility of this method in adolescents has not been assessed. In addition, photo-assisted dietary assessment is another method that has been validated in the general population14e21 and has been determined feasible in adults with IDD.22,23 Photo-assisted dietary assessment is a technique in which digital images are taken of all food and beverages consumed during the record period. The use of photoassisted 24-h food recalls in adults with IDD resulted in a significantly greater energy intake being reported per eating occasion when compared to the standard recalls (P 5 0.002) as well as a greater intake of fat (P 5 0.006), protein (P 5 0.029), and carbohydrates (P 5 0.003).24 The authors concluded that photo-assisted recalls have the potential to be a more accurate dietary assessment technique in individuals with IDD than 24-h recalls alone.24 While previous studies in adults with IDD have determined that both proxy-assisted diet records and photoassisted recalls can provide accurate dietary assessments and that the photo-assisted recalls potentially improve the total energy and macronutrients reported, no information is available regarding the use these dietary assessments in adolescents with IDD or regarding whether digital photography can improve proxy-assisted food records. Therefore, the aim of this study was to determine if the collection of digital images is a feasible method to improve estimates of energy and macronutrient intake of proxy-assisted 3-day food records in adolescents with IDD.
Methods Participants This study was conducted with twenty adolescents with IDD. Each participant completed a proxy-assisted record and took pictures of the foods eaten during the record period to determine if they provided additional details about the type and amount of foods eaten. All individuals had to be 11e18 years of age with mild (IQ of 50e69) to moderate (IQ of 35e49) IDD, living at home with a parent
147
or legal guardian, of sufficient cognitive ability to understand directions, and able to communicate through spoken language. This study was approved by the University of Kansas’s Human Subjects Committee. Participants and their legal guardian met with a member of the research team who explained the study in detail and who read them a university-approved consent form. Both the participants and the legal guardians were given an opportunity to ask questions about the study. Participants were read an assent using plain language asking if they wanted to participate. If participant gave oral assent, their legal guardian was then asked to sign the consent form. Collection of dietary assessments All participants were given a mobile device with a builtin camera (iPad 2, Apple, Cupertino, CA, USA)25 at the beginning of the study. The device’s rear-facing camera (1280 720 pixels or 0.92 megapixel camera with autofocus) was used for the photo-assisted records. Before the assessment, each participant was instructed on basic mobile device functions, including how to operate the camera application. The study personnel observed the participant independently take satisfactory images. Participants were instructed to complete hard copy, proxy-assisted diet records, with the help of a parent or legal guardian if needed, for three consecutive days (2 weekdays, 1 weekend day). The participants were instructed to also take before and after images, using the mobile device, of all food and beverages consumed at home during that 3-day period, without the help of the parent/ guardian. A fiduciary marker (a 5 cm 5 cm checked square) was included in all images to serve as a reference measure of portion size. To remind participants to comply with the photo/record protocol calendar, prompts were programmed into the mobile device. After the record period was complete, a registered dietitian (RD) reviewed the written proxy-assisted 3-day diet record with the participant without the use of the images. Portion guides were used to help clarify portion size and provide better accuracy. The portion guides used in the interviews were 3-dimensional models consisting of a variety of items intended to provide a reference (i.e., glasses, mugs, bowls, circles, thickness sticks, chip bags, drink bottles, a 12-inch ruler, measuring cups and spoons, a grid, wedges, geometric shapes, and diagrams of chicken pieces).26 Following the review of the proxy-assisted diet record, the RD separately reviewed the date and time stamped images using methods previously published by Ptomey et al24 to obtain additional information about the foods eaten. Each photographed eating occasion or food item was discussed with the participant in order to identify additional details possibly left out of the initial dietary record regarding the food type, portion size, and other characteristics (e.g., drinks, side dishes, ingredients, condiments, etc.). Food items, portion size, and specific details
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about any food items that were different from the written record were recorded in different colored ink in order to distinguish any discrepancies between the photo-assisted record and proxy-assisted record. Additional details, including the reasons for the differences (e.g., forgot food, inaccurate portion size), number of meals captured by images, and total number of meals consumed, were also recorded. Analysis of dietary assessments All diet records were entered into Nutrition Data System for Research (NDSR) software version 201127 by RDs. The original proxy-assisted records without details from the images and the photo-assisted records were entered as two separate records. Dietary analysis from NDSR was used to determine total intake of calories, fat, carbohydrates, and protein at each time point. Not all eating occasions were captured by digital photography due to participants eating lunch and some snacks at school; therefore, only the eating occasions that were captured by photo were analyzed and compared to the proxy-assisted 3-day food record. An eating occasion was defined as any period where at least one food item or caloric beverage was consumed. Statistical analysis The differences in energy (kcals) and macronutrient (grams of fat, carbohydrates, and protein) intake between the proxy-assisted record and the photo-assisted record for each participant were examined. Mixed modeling for repeated measures28e30 was used to examine the differences between two records as it can account for the correlation among meals reported by the same participant. Models were adjusted for each participant’s age, gender, race, and level of IDD severity (mild vs. moderate), thereby improving the accuracy of the energy and macronutrient estimates. Statistical significance was determined at 0.05 alpha level, and all analyses were conducted using Statistical Analysis Systems statistical software package version 9.3 (SAS Institute, Cary, NC, USA).31
Table 1 Demographic data of all participants All participants (n 5 20) Variable
n
Age (yrs.) Gender (%) Male Female Race (%) Asian Black White Mixed Ethnicity (%) Not Hispanic/Latino Hispanic/Latino Level of IDD severity (%) Mild Moderate Secondary diagnosis (%) Autism Down syndrome Other
14.9 6 2.2 11 (55%) 9 (45%) 1 4 14 1
(5%) (20%) (70%) (5%)
20 (100%) 0 (0%) 12 (60%) 8 (40%) 9 (45%) 8 (40%) 3 (15%)
Values are mean (SD) unless otherwise stated.
portion size, forgetting a food, etc.) per eating occasion between the original and photo-assisted records. The most common difference between the photo-assisted records and the original records without images was incorrect portion size (37.4%): for example, a participant would report consuming one slice of pizza while a photo would show that three slices of pizza were consumed. This was followed by forgetting a food eaten (32.1%), missing or incorrect details about food (28.2%), and reporting a food that was not actually consumed (2.3%). Energy and macronutrient intake After adjusting for age, gender, race, and level of IDD severity, photo-assisted records showed significantly higher estimates of total energy intake per eating occasion compared to proxy-assisted records (proxy-assisted [M 6 SE] 5 429.4 6 23.0 kcals vs. photoassisted 5 515.7 6 28.7 kcals, P 5 0.001). This resulted in a 20.1% higher total amount of energy reported per eating occasion. Photo-assisted records also showed
Results Ability to capture photos Twenty one participants enrolled in the study; however, one participant chose to withdraw from the study before the diet assessments were collected due to family conflict. Thus, diet records were collected from 20 participants (age 14.9 6 2.2 yrs, 45.0% female). Table 1 shows demographic data for the 20 participants. Participants captured images for 68.3 6 31.7% of all eating occasions consumed. This resulted in the analysis of 130 eating occasions. There was an average of 2.6 6 2.2 dietary differences (i.e., incorrect
Table 2 Reported energy and macronutrient intake using proxy-assisted records compared to photo-assisted records per eating occasion Original record Photo-assisted record n Energy (kcal) Carbohydrate (g) Fat (g) Protein (g) a
M 6 SE
130 429.4 6 23.0 130 57.1 6 3.2 130 16.0 6 1.1 130 17.2 6 1.1
n
M 6 SE
130 130 130 130
515.7 67.5 19.5 21.0
6 6 6 6
P 28.7 4.1 1.5 1.7
0.001a 0.003a 0.011a 0.004a
Denotes significance at 0.05 alpha level using mixed modeling for repeated measures.
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significantly greater intakes of grams of fat (P 5 0.011), carbohydrates (P 5 0.003), and protein (P 5 0.004) (Table 2). Macronutrient composition The macronutrient composition was evaluated to compare the proxy and photo-assisted records to examine whether certain types of foods were captured differently between methods (e.g., high carbohydrate foods under reported, high fat foods over reported, etc.). Fig. 1 illustrates the macronutrient composition as a percent of total energy intake for both record methods, and shows that there was no significant difference for the percent distribution of grams of fat, protein, or carbohydrates (all P O 0.05).
Discussion This study was designed to determine if digital images are a feasible dietary assessment method and if they provide an improvement in energy and macronutrient intake when combined with 3-day diet records in adolescents with IDD. Similar to previous studies using digital photography in adults with IDD, participants were able to use the device to capture images of their meals.22e24 Participants were able to take photos of their food for 68.3 6 31.7% of all eating occasions. The main reason for not capturing a meal on camera that was reported on the food record was consuming a meal or snack while at school where the mobile devices were not allowed. In this study, 32% of all eating occasions occurred at school. Furthermore, participants were able to take photos without the help of a parent, which suggests that the use of photo-assisted records may decrease the burden on parents during dietary assessment periods. The use of digital images in combination with written records provided significantly greater total energy intake compared the original proxy-assisted food records. These differences in caloric intake suggest that standard proxy-
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assisted food records may underestimate dietary intake amounts in this population. If digital images had not been added to the proxy-assisted food record, the total energy intake would have been underreported by 20%. The macronutrient composition (percent calories from fat, protein, and carbohydrates) between record methods was not different at either time point, indicating that the significant increase in energy intake was responsible for the significant increases in macronutrient intake and that certain foods, such as high fat foods like butter, were not more or less likely to be underestimated during reporting. While this study highlights the feasibility and value of using digital photography in combination with proxyassisted food records in adolescents with IDD, several limitations do exist. It can be suggested that the act of taking photos may help the participants have a better memory of what was eaten; however, Humphries et al found that the act of solely taking a photo did not improve dietary recalls in adults with IDD,23 which is consistent with results of the present study. Another limitation is that participants were not randomly selected as they were enrolled in a lifestyle intervention, which may limit the generalizability of these findings. However, the results were adjusted for age, gender, race, and level of IDD severity to help account for this limitation. Finally, while the photo-assisted record method did show significant increases in estimates of dietary intake, this method has not yet been validated via either weight and measure or doubly labeled water techniques in adolescents with IDD, and future validation studies need to be conducted.
Conclusions There is no validated method to collect dietary assessments in adolescents with IDD as adolescents with IDD may have some limitations in accurately describing or remembering what they consume. The use of digital images as a dietary assessment technique for adults with IDD has been published; however, this is the first known study to look at the use of digital photography for improving dietary assessments in adolescents with IDD. Although future research needs to validate dietary assessment methods in adolescents with IDD, the use of digital images in combination with diet records appears to be a feasible method to obtain substantial additional details in terms of energy intake of adolescents with IDD. References
Fig. 1. Macronutrient composition of proxy-assisted and photo-assisted records of adolescents with IDD.
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