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Article

Underreporting of Food Intake by Dietary Recall Is Not Universal: A Comparison of Data from Egyptian and American Women¹

Department of Community Health Sciences, UCLA School of Public Health, Los Angeles, CA 90095 and ^* Food Technology Research Institute, Agricultural Research Centre, Ministry of Agriculture, Cairo, Egypt

²To whom correspondence should be addressed.

	ABSTRACT

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Underreporting of dietary intake has been observed consistently in food consumption surveys in affluent societies and in clinical studies in a variety of settings. Almost one third of quantitative 24-h recalls provided by adults in U.S. surveys appear to result in estimates that are biologically implausible. Underreporting has been linked to obesity in both the U.S. and Europe, with heavier individuals underreporting to a greater degree than lean persons. A relative dearth of data exists from developing countries and those in transition to address the question whether such underreporting is universal. We present the first data from a large survey of women in a rapidly urbanizing developing country to address this question. More than 4500 adult women in Egypt provided quantitative 24-h recalls of food intake on the previous day in 1993–1994, and weights and heights were measured. We compared the data, in terms of the ratio of reported energy intake to estimated basal metabolic rate, to data from 3010 women in the 1994–1996 U.S. Continuing Survey of Food Intake by Individuals, on whom quantitative 24-h recalls were also conducted. The Egyptian women reported food intakes consistent with FAO/WHO recommendations for energy intakes for women of comparable activity levels, whereas the data for U.S. women showed underreporting consistent with other U.S. surveys. Only 10% of Egyptian women reported energy intakes below accepted criteria for plausibility, compared with one third of American women. We discuss possible reasons for this difference, including cultural and food supply differences, and methodological differences between the two surveys.

KEY WORDS: • food intake • dietary surveys • 24-h recall • Egypt • women

	INTRODUCTION

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Monitoring of food consumption patterns in populations requires low cost and nonintrusive methods for eliciting data on food intake of individuals. The 24-h recall is the most commonly used method in large cross-sectional surveys; it has numerous advantages, including responsiveness to changing food supplies and food habits. Therefore, refinement of the methodology and understanding the sources of error it produces have high priority. Estimated energy intakes (EI)³ provide the most convenient variable for assessing the completeness of data provided by this method. Adults who are maintaining their body weight consume energy equal to their expenditure over a fairly short period, and validating criteria exist that reflect total energy expenditure (TEE).

Underestimation of dietary EI in relation to requirements, both theoretical and measured, has been a consistent finding in much of the literature on food consumption in free-living populations and has plagued food consumption survey methodology for decades (Briefel et al. 1997 , Klesges et al. 1995 , Mertz et al. 1991 , Swan, 1983 ). Deliberate fabrication, failure to remember food items or whole eating events, lack of knowledge of the composition of mixed dishes and inability to estimate portion size accurately have all been considered as potential contributors to the underreporting problem.

Greater underreporting of food intake by obese individuals has been observed in a number of studies among U.S. adults (Briefel et al. 1997 , Klesges et al.1995 , Sawaya et al. 1996 , Swan 1983 ), U.S. and UK adolescents (Champagne et al. 1996 , Livingstone et al. 1992 ), and Dutch (Braam et al. 1998 , Lavienja et al. 1998 ), German (Kroke et al. 1999 ) and Greek (Gnardellis et al. 1998 ) adults. The identification of a valid biomarker for TEE, namely, doubly labeled water (Schoeller and van Santen 1982 ), has made direct validation studies of dietary data possible in small studies. By now, the technique has been utilized in several hundred human studies, almost all in affluent societies. The results of these studies have made it very clear that TEE rises with overweight and obesity, whereas self-reported dietary EI does not, thus producing more underreporting of EI by obese than by lean individuals (Prentice et al. 1996 ).

Estimates of population energy requirements, based on estimation of physical activity levels and anthropometry-derived basal metabolic rate (BMR) (FAO/WHO/UNU 1985 , Schofield 1985 ), have also been used as criteria against which to judge the completeness of dietary EI estimates (Briefel et al. 1997 , Klesges et al. 1995 ). These estimates have been widely used, appear to be reasonably valid for population-level estimates (Coward 1998 ) and are recommended as the basis for population-level estimates of energy requirements [International Dietary Energy Consultative Group (IDECG) 1996 ]. Table 1 shows the estimated ratios of EI to BMR for adults by activity level (FAO/WHO/UNU 1985 ).

Over the last several years, considerable work has gone into improving the methodology for dietary recall interviewing in national surveys in the U.S., with the development of the "multiple-pass" methodology by the U.S. Department of Agriculture, which has the goal of reducing the underreporting gap (Guenther et al. 1996). This method provides the respondent with a variety of aids and prompts to cognitive recall by leading him/her through the time period in question three times as follows: first, to list the foods s/he remembers eating; a second time to add detail; and a third time to review and fill in any gaps. How much difference the change to multiple-pass recall methodology makes for survey purposes is unknown; EI among U.S. adults appear to have increased somewhat over the last decade, but the contribution of improved methodology vs. real increases is not known. The 1994–1996 Continuing Survey of Food Intakes of Individuals (CSFII), which utilized the multiple-pass method, showed an average energy intake for women of 6744 kJ compared with 6396 kJ in the 1985 CSFII (USDA 1987 ).

Almost all of the data that address the issue of underreporting of food intake come from affluent societies. Coward (1998) recently reviewed the literature on double-labeled water studies of TEE in developing countries and found a total of 12 papers. With the use of varying protocols and possessing varying objectives, this small body of work points primarily to the need to gain a better understanding of the variation in energy requirements and tradeoffs that are made in diverse circumstances, for example, in situations characterized by seasonal and within-population variation in energy demands for physical work. None of the studies reviewed provided the kind of self-reported 24-h recall dietary intake data that would allow interpretation of bias in self-reports of food intake.

	SUBJECTS AND METHODS

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
This paper compares data for women aged 18–60 y from the first round of the National Food Consumption Monitoring Survey for Egypt, conducted over the period from late 1993 to late 1994, with the CSFII in the United States for the years 1994–1996. We express the data in terms of reported EI, calculated for a single 24-h recall, in relation to BMR calculated from age, gender and weight (EI:BMR).

Egyptian data.

The Egyptian data were collected as the first round of a planned long-term monitoring system for food consumption and related variables by the Food Technology Research Institute, Agricultural Research Center, of the Egyptian Ministry of Agriculture in collaboration with the UCLA School of Public Health. The study was approved by the Institutional Review Boards of both institutions; in addition, a standing local project advisory committee provided continuous oversight of all issues related to protection of confidentiality.

Data were collected in each primary sampling unit (rural village or urban administrative unit) in five of Egypt’s 24 governorates, including greater Cairo, between November 1993 and October 1994. A stratified, multistage, random-sampling design was used, with sample size for rural and urban areas of each governorate calculated to be proportional to the population as of the 1990 census. Details of sample design have been reported elsewhere (Khorshed et al. 1998 ). Refusal rates were very low (<10%), following on advance publicity for the survey in each sample area. Interviews were completed on 6540 households, ranging from 1.25% of the households in Greater Cairo to 38.8% of households in the small New Valley Governorate. Data are presented here on the 4596 nonpregnant, nonlactating women ages 18–60 y for whom complete 24-h recall, age and anthropometric data were collected. For the present analysis, we excluded women with missing age or anthropometric data, those <18 y and >60 y of age to provide comparability with the U.S. data set (total 861); we also excluded 1083 women who were pregnant or breast-feeding because the U.S. data set does not include sufficient numbers of pregnant and breast-feeding women for comparison.

Interviews were conducted in the households with the adult individual responsible for food shopping and preparation for the family. Total interview time ranged from 1.5 to 3 h, depending primarily on the size of the family. Data collected included the following: sociodemographic information; questions on food habits and food sources (markets, home production) and food security; a household food-frequency questionnaire covering the previous year; and quantitative 24-h recall of food intake for the previous day for the household, for the respondent and for a child between 2 and 6 y of age if there was one in the family. Height and weight were measured using a portable stadiometer and spring scales that were calibrated daily. A subsample of 1–5% of households was revisited by another interviewer within a few days, and portions of the interview were readministered to provide for quality control and identify needs for retraining of interviewers.

The quantitative 24-h recall of household food consumption was an innovation developed by the field staff after pilot testing early versions of the interview questionnaire. In the Egyptian cultural context, women tend to be wholly responsible for the planning, management and allocation of household food supplies. Women found that in order to recall their own and the child’s intakes, they first had to reconstruct mentally what they had prepared and served to the family. Developmental testing of the instrument led us to the conclusion that doing a quantitative recall of all food served to household members the previous day was a logical prelude to reporting individual intake for most women.

Twenty-four hour recall data were converted to estimated nutrient intakes utilizing a modification of the Food Intake Analysis System (FIAS) (University of Texas and U.S. Department of Agriculture, Version 2.3), which used the USDA Nutrient Composition Database for Standard Reference, Release #10. We modified the system to create nutrient values for unenriched and unfortified versions of all ingredients and foods whose values in the USDA database reflect U.S. enrichment and fortification practices. Additionally, we collected household recipes for all mixed dishes, tested all that required the derivation of water or fat retention or loss factors (>1100 recipes) in a test-kitchen setting, and utilized these in calculating nutrient intakes. A small number (<10) of food items or ingredients were present in the Egyptian food supply that did not have exact equivalents in the USDA database; these were assigned values for items with apparently similar nutrient content based on local food composition information.

U.S. data.

For the U.S. women, we utilized data from the CSFII 1994–1996 (U.S. Dept of Agriculture 1998 ). This data set included 3010 nonpregnant, nonlactating women ages 18–60 y who had a single-day 24-h recall of food intake and data on age, height and weight and 2763 women who had a second recall collected on a nonconsecutive day by telephone, using the same methodology. Height and weight were self-reported in the CSFII. The sample was a multistage, stratified probability sample, designed to be nationally representative of noninstitutionalized persons residing in households in the U.S. for each of 40 analytic domains defined by sex, age and income level. The response rate in the 1994–1996 CSFII was 80%. Data collected included sociodemographic information and a quantitative 24-h recall of food intake for the previous day for the female respondent and, when appropriate according to the sample, for an adult male or a child within the household. The 24-h recall methodology used was the "multiple-pass" method described previously, and measuring aids were used to help the respondent in estimating amounts. Data on food intake were converted to nutrient intake estimates using the SurveyNet system (USDA and University of Texas), which utilized the same nutrient database as FIAS, Version 2.3. Thus the food composition databases for conversion of data to energy intakes were identical in the Egyptian study and in the CSFII 1994–1996. We included all ethnic groups because EI patterns have been demonstrated in the NHANES III data to be similar for non-Hispanic Caucasians, non-Hispanic Blacks, and Mexican-Americans (Briefel et al. 1995 ). In the present analysis, we utilize the 2 d of recall in the CSFII data set separately for comparability with the Egyptian data set.

Calculation of estimated BMR and EI:BMR.

BMR was calculated for each subject using prediction equations developed by Schofield et al. (1985) , adopted by the FAO/WHO/UNU (1985) committee on energy requirements and utilized by Klesges et al. (1995) and Briefel et al. (1997) in their analyses of underreporting of dietary intake in the NHANES II and III surveys in the U.S. EI:BMR ratios were then calculated for each individual.

Statistical analysis.

Statistical methods included chi-square analysis for categorical variables, Student’s t tests for independent samples for continuous variables, Pearson correlations and ANOVA.

	RESULTS

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

 
Ages of the respondents were similar, with medians of 40 and 39 y for the Egyptian and American women, respectively (Table 2 ). The American women were significantly more likely to be urban residents (P < 0.05). The Egyptian sample had a higher proportion of both overweight (BMI = 25–30 kg/m²) and obese (BMI >30 kg/m²) women than the American sample (P < 0.001), although the prevalence of overweight and obesity was high in both samples. Underweight (BMI <18 kg/m²) was relatively rare in both groups (<1% in the Egyptian women and 2.8% in U.S. women). There were marked differences in formal education between the two survey groups (P < 0.001). Sixty-five percent of the Egyptian women had less than a high school education, compared with only 7% of American women; 41% of the Egyptian women reported being illiterate, compared with <1% of American women. Almost half of the American sample reported having some formal education beyond high school, compared with 8% of the Egyptian women.

The EI:BMR ratio for women in both populations was negatively related to BMI (r = -0.156 in the Egyptian sample and r = -0.239 in the American sample, both P < 0.0001). Table 5 shows the percentage of respondents whose reported intakes were <0.92 BMR by category of BMI (obese, overweight, normal and underweight). In both populations, heavier women reported significantly lower EI in relation to estimated BMR than lighter women, but in the Egyptian sample, all groups were within the expected range of EI:BMR for women; in the American sample, all BMI groups had averages that were considerably lower. The relationship between EI:BMR and BMI was stronger in the American data set; obese American women had an average EI:BMR 20.5% lower than those of normal weight women, whereas for Egyptian women, obese subjects had average EI:BMR 13% lower than those of normal weight.

	DISCUSSION

TOP ABSTRACT INTRODUCTION SUBJECTS AND METHODS RESULTS DISCUSSION REFERENCES

We do not think that the Egyptian women have substantially higher energy expenditures than assumed here and therefore underreported intake. More than half the sample were urban dwellers, and our previous detailed work on women’s time allocation in an Egyptian Nile Delta village indicates that even in rural areas, energy expenditure of women is generally light by the standards assumed in the FAO/WHO/UNU 1985 report (Kirksey et al. 1992, Ricci et al. 1996). Although mild-to-moderate malnutrition, manifested as stunting in preschool children and as micronutrient deficiencies in women and children, is common, adult underweight is rare, and obesity in women is as common or even more prevalent in Egypt than in the U.S. (Khan et al. 1996 , Khorshed et al. 1998 ) (Table 2) .

A likelier set of possible explanations is rooted in cultural context. Egyptian women may simply be better reporters of their food intake than are Americans. Egyptian women, particularly the respondents to this survey, who were selected as the individuals responsible for food procurement and preparation for the family, have very clear gender-defined roles with regard to responsibility for the family’s food. They are responsible for what everyone in the family eats, for planning and procurement, for kitchen and household management either directly or by supervising others, and for allocation of food to family members and guests at the table. They tend to be very conscious of quantities and are functionally numerate even when not literate, due to their responsibility for purchase of food by weight and for management of the household food budget. Much more cooking is done from scratch in the Egyptian setting than in the American context, with fewer preprepared mixed dishes available and fewer meals eaten outside the home. Such an interpretation is consistent with observation in a Greek study (Gnardellis et al. 1998 ) that men, who presumably have less intimate understanding of food preparation, underreported their intakes more than women. Our survey did not collect quantitative intake data on men, thus we cannot address gender differences in this population.

Meal patterns are somewhat more consistent and snacking is much less common for most families in Egypt than in the U.S. The Egyptian food supply is abundant and varied, with variety being limited more by economic access and preference than by availability, at least on a year-round basis; nevertheless, the total number of separate items an individual or family consumes over a period of time may be a great deal smaller than in a North American eating environment, thus simplifying the recall task.

It is also possible that some aspect(s) of the study methods contributed to the differences observed. The food composition database was essentially the same for the two studies with regard to energy values of ingredients; however, our careful collection of recipes and test-kitchen testing to fine-tune fat and water retention and loss factors in the Egyptian survey may have provided a food composition database superior to the USDA default values for mixed dishes. There is no way to evaluate the contribution of this methodological detail to the results; however, we may assume that it resulted in more rather than less accuracy in conversion of food-level data to nutrient intake estimates. We do not believe that there are any substantial errors in the energy density of food items in the Egyptian data set both because of the careful quality control of the database and because the estimates for macronutrient composition of women’s diets in the Egyptian data are very reasonable (average 22% of energy from fat in rural areas and 27% in cities) (Khorshed et al. 1998 ).

Anthropometric data were collected differently in the two surveys, with the CSFII data representing self-reported heights and weights and the Egyptian data including measured anthropometry. Assuming that bias in self-reporting would be toward lighter rather than heavier weights (Rowland 1990 ), any bias from this difference should have operated in the opposite direction, i.e., to inflate the EI:BMR estimates for the American women.

Interviews were conducted in respondents’ homes in both surveys, by interviewers with comparable qualifications (high school or university educated women). The Egyptian study used a three-person team (usually two women interviewers in the household); the U.S. survey used a single interviewer/recorder. It is possible that the more heavily staffed design resulted in more complete probing and recording of data; however, given the extensive attention to quality control in the CSFII, we do not think this is likely to have been an important influence. It is quite likely, however, that recipes elicited in the Egyptian survey are more complete and accurate than those in the U.S. survey because the respondent was much more likely to have prepared the reported mixed dish herself.

Still another possibility is that the quantitative 24-h household food use recall, immediately before the subject’s recall of her own food intake, provided an orientation aid to recall similar to the cognitive advantage intended to be conferred by the "multiple-pass" 24-h recall method recently developed by USDA. In effect, the Egyptian women were trained subjects, both by virtue of their day-to-day responsibility for food in the household and by virtue of the immediately prior recall of use of food by the entire household. Although we developed and included this innovation in response to the particular culturally defined roles of Egyptian women, it has likely produced the unexpected effect of increasing the accuracy of their reports of their own food intake. This observation supports the conclusion of Klesges et al. (1996) that training the respondent is essential to obtaining complete recall information, and emphasizes the importance of further development of methodology such as the "multiple-pass" method in the U.S. and the household recall in Egypt, which provide culturally appropriate ways of enabling the survey subject to recall events as completely as possible.

Overweight and obesity were associated with decreasing EI:BMR in both data sets, but more strongly among the U.S. women. Obesity (BMI 30 kg/m²) characterized almost one third of the women in the Egyptian sample and 20% in the 1994–1996 CSFII. The health consequences of obesity are only beginning to be appreciated in Egyptian culture, and social pressure to maintain a lean body shape is nascent but not highly prevalent (Basyouny 1998 ). We noted the lowest prevalence of obesity among the least and most highly educated women in our Egyptian sample (data not shown); among the educated women, this may reflect the beginning of conscious efforts to control excess body weight. However, it is likely that there is not yet a great deal of self-consciousness about food intake among obese individuals, which may have contributed to more accurate dietary reporting among Egyptian women.

As relative weight for height increases, TEE and the physical cost of activity increase (Prentice et al. 1996 ); however, activity levels themselves may actually decrease. Thus it is not impossible that reported EI:BMR would decline slightly with obesity in the absence of underreporting or dieting. The prevalence of dieting among American women is very high (43.6% in a recent report) (Serdula et al. 1999 ) and does account for some (but not all) of the apparent underreporting in the CSFII data set. Women who reported being on a diet to lose weight had an average EI:BMR of 0.93 ± 0.52, whereas those not reporting being on a diet had a mean EI:BMR of 1.20 ± 0.55, a difference of approximately the same magnitude as that between dieters and nondieters in the NHANES III data (Briefel et al. 1997 ). Thus, in the American data set, some of the low EI:BMR values may result not from underreporting per se but actual low intakes related to attempts to lose weight. Although we are aware of no data on the subject, we do not believe that, at this time, dieting among overweight Egyptian women is common enough to influence the distribution of reported energy intakes.

	ACKNOWLEDGMENTS

 
The authors thank Sydne Newberry and two anonymous reviewers for helpful editorial suggestions and Mark Damesyn and Magda Shaheen for data management assistance.

	FOOTNOTES

 
¹ Supported by #58–319R-3–008 and #58–3148-8–032 from the U.S. Department of Agriculture, by the Egyptian Ministry of Agriculture through the National Agricultural Research Program, and #2P01CA42710 from the National Cancer Institute.

³ Abbreviations used: BMI, body mass index; BMR, basal metabolic rate; CSFII, Continuing Survey of Food Intake of Individuals; EI, energy intake; IDECG, International Dietary Energy Consultative Group; NHANES, National Health and Nutrition Examination Survey; TEE, total energy expenditure.

Manuscript received November 22, 1999. Initial review completed January 6, 2000. Revision accepted March 23, 2000.

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