Overview of Dietary Assessment in Behavioral Medicine

Nutritional status is one of the most important predictors of health risk. Research consistently demonstrates that diets rich in fruit, vegetables, whole grains, and lean meats from poultry and fish are inversely associated with risk of age-related chronic diseases such as cardiovascular disease, cancer, and diabetes (Kushi et al, 2006; Lampe, 1999; Neuhouser, 2004; Pool-Zobel et al, 1997; Prentice et al, 2004; World Cancer Research Fund/AICR, 2007). Conversely, diets high in refined grains and added sugars, but low in diverse plant foods, increase risk for obesity and obesity-related disorders including cardiovascular disease, cancer, and diabetes (Boynton et al, 2007; Kristal et al, 2000; National Research Council Committee on Diet and Health, 1989; Patterson et al, 2004). Despite the strong and consistent diet-disease associations and recommendations to the public to make healthy food choices and limit or avoid added fats, sodium, and empty calorie-type foods, consumers still, for the most part, select poor diets (Kant and Graubard, 2006). For example, only 11% of American adults obtain the recommended 5-9 servings of fruit and vegetables per day

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(Casagrande et al, 2007). Equally concerning is the high prevalence of daily consumption of sugar-laden empty calorie beverages, such as a soft drink; such high consumption is a common practice among young children, adolescents, and adults (Dubois et al, 2007; French et al, 2003; Rajeshwari et al, 2005; Rampersaud et al, 2003). This discrepancy between available knowledge of nutritional benefits and food intake patterns suggests a strong influence of culture and behavior on dietary practices.

Food choice is a complex behavior. Individuals and groups make dietary selections based on food familiarity, availability, cost, cultural norms, ease of preparation, individual taste, convenience, and many other factors (Drewnowski, 1997; Glanz et al, 1998a, b; Popkin et al, 2005). Therefore, assessment of diet, particularly for the purposes of promoting dietary change or improvement in dietary patterns, must include attention to the behavioral aspects of food intake (van Duyn et al, 2001). Dietary behaviors are extremely personal and efforts to promote healthful dietary changes that are based only on knowledge about foods are not likely to succeed.

Apart from behavioral predictors of food intake, measuring what people eat is particularly complicated for several reasons. To illustrate this point, we can compare the assessment challenges for two exposures: playing golf or tennis and diet. Playing golf or tennis is a single (yes/no) activity - people are either players or not, so individuals usually report with good accuracy whether or not they engage in these activities. Further, since for many people, these activities

occur on a weekly or monthly basis, most people would record with reasonable accuracy that they play golf or tennis once a week. In comparison, over the course of even 1 week, an individual can consume hundreds, even thousands of distinct food items in various combinations, making it cognitively challenging for respondents to accurately report on their intake. Meals can be prepared by others (e.g., in a restaurant, by a spouse, as prepackaged food) so that the respondent may not be cognizant of preparation details such as fat or salt used in cooking or portion size. Further, food choices often vary with seasons and other life activities (e.g., weekends, social engagements, holidays, vacations). In fact, in today's modern food environment with so many choices, particularly, myriad ready-to-eat choices available to consumers, the day-to-day variability in food intake can be so large that it is difficult to identify any underlying consistent pattern. Collectively, these issues make dietary assessment a very complex task for both researchers and clinicians.

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