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author:("subab, Amy F.")
1.  Assessment of the Accuracy of Portion Size Reports Using Computer-Based Food Photographs Aids in the Development of an Automated Self-Administered 24-Hour Recall 
To assess the accuracy of portion-size estimates and participant preferences using various presentations of digital images.
Two observational feeding studies were conducted. In both, each participant selected and consumed foods for breakfast and lunch, buffet style, serving themselves portions of nine foods representing five forms (eg, amorphous, pieces). Serving containers were weighed unobtrusively before and after selection as was plate waste. The next day, participants used a computer software program to select photographs representing portion sizes of foods consumed the previous day. Preference information was also collected. In Study 1 (n=29), participants were presented with four different types of images (aerial photographs, angled photographs, images of mounds, and household measures) and two types of screen presentations (simultaneous images vs an empty plate that filled with images of food portions when clicked). In Study 2 (n=20), images were presented in two ways that varied by size (large vs small) and number (4 vs 8).
Convenience sample of volunteers of varying background in an office setting.
Statistical analyses performed
Repeated-measures analysis of variance of absolute differences between actual and reported portions sizes by presentation methods.
Accuracy results were largely not statistically significant, indicating that no one image type was most accurate. Accuracy results indicated the use of eight vs four images was more accurate. Strong participant preferences supported presenting simultaneous vs sequential images.
These findings support the use of aerial photographs in the automated self-administered 24-hour recall. For some food forms, images of mounds or household measures are as accurate as images of food and, therefore, are a cost-effective alternative to photographs of foods.
PMCID: PMC3773715  PMID: 20102828
2.  Comparing Indices of Diet Quality With Chronic Disease Mortality Risk in Postmenopausal Women in the Women's Health Initiative Observational Study: Evidence to Inform National Dietary Guidance 
American Journal of Epidemiology  2014;180(6):616-625.
Poor diet quality is thought to be a leading risk factor for years of life lost. We examined how scores on 4 commonly used diet quality indices—the Healthy Eating Index 2010 (HEI), the Alternative Healthy Eating Index 2010 (AHEI), the Alternate Mediterranean Diet (aMED), and the Dietary Approaches to Stop Hypertension (DASH)—are related to the risks of death from all causes, cardiovascular disease (CVD), and cancer among postmenopausal women. Our prospective cohort study included 63,805 participants in the Women's Health Initiative Observational Study (from 1993–2010) who completed a food frequency questionnaire at enrollment. Cox proportional hazards models were fit using person-years as the underlying time metric. We estimated multivariate hazard ratios and 95% confidence intervals for death associated with increasing quintiles of diet quality index scores. During 12.9 years of follow-up, 5,692 deaths occurred, including 1,483 from CVD and 2,384 from cancer. Across indices and after adjustment for multiple covariates, having better diet quality (as assessed by HEI, AHEI, aMED, and DASH scores) was associated with statistically significant 18%–26% lower all-cause and CVD mortality risk. Higher HEI, aMED, and DASH (but not AHEI) scores were associated with a statistically significant 20%–23% lower risk of cancer death. These results suggest that postmenopausal women consuming a diet in line with a priori diet quality indices have a lower risk of death from chronic disease.
PMCID: PMC4157698  PMID: 25035143
diet; diet quality indices; mortality risk; postmenopausal women; prospective cohort study
3.  Pooled Results From 5 Validation Studies of Dietary Self-Report Instruments Using Recovery Biomarkers for Energy and Protein Intake 
American Journal of Epidemiology  2014;180(2):172-188.
We pooled data from 5 large validation studies of dietary self-report instruments that used recovery biomarkers as references to clarify the measurement properties of food frequency questionnaires (FFQs) and 24-hour recalls. The studies were conducted in widely differing US adult populations from 1999 to 2009. We report on total energy, protein, and protein density intakes. Results were similar across sexes, but there was heterogeneity across studies. Using a FFQ, the average correlation coefficients for reported versus true intakes for energy, protein, and protein density were 0.21, 0.29, and 0.41, respectively. Using a single 24-hour recall, the coefficients were 0.26, 0.40, and 0.36, respectively, for the same nutrients and rose to 0.31, 0.49, and 0.46 when three 24-hour recalls were averaged. The average rate of under-reporting of energy intake was 28% with a FFQ and 15% with a single 24-hour recall, but the percentages were lower for protein. Personal characteristics related to under-reporting were body mass index, educational level, and age. Calibration equations for true intake that included personal characteristics provided improved prediction. This project establishes that FFQs have stronger correlations with truth for protein density than for absolute protein intake, that the use of multiple 24-hour recalls substantially increases the correlations when compared with a single 24-hour recall, and that body mass index strongly predicts under-reporting of energy and protein intakes.
PMCID: PMC4082341  PMID: 24918187
24-hour recall; attenuation factors; calibration equations; dietary measurement error; food frequency questionnaire; under-reporting
4.  Dietary Glycemic Index, Glycemic Load, and Risk of Cancer: A Prospective Cohort Study 
American Journal of Epidemiology  2008;169(4):462-472.
Previous studies have provided limited evidence for a harmful effect of high glycemic index and dietary glycemic load on cancer. The authors analyzed associations among glycemic index, glycemic load, and risk of cancer in women and men in the National Institutes of Health–AARP Diet and Health Study. Published glycemic index values were assigned to 225 foods/food groups. Glycemic load was calculated by multiplying the glycemic index, carbohydrate content, and intake frequency of individual foods reported on a food frequency questionnaire. From 1995 through 2003, the authors identified 15,215 and 33,203 cancer cases in women and men, respectively. Cox proportional hazards models were used to estimate multivariate relative risks and 95% confidence intervals. For women and men, respectively, the relative risks for total cancer for high versus low glycemic index were 1.03 (Ptrend = 0.217) and 1.04 (Ptrend = 0.012) and, for glycemic load, were 0.90 (Ptrend = 0.024) and 0.93 (Ptrend = 0.01). Associations with total cancer held only among the overweight for glycemic index and among those of healthy weight for glycemic load. These findings suggest that glycemic index and glycemic load are not strong predictors of cancer incidence. The direction and small magnitude of associations might be explained by the manner in which high glycemic index and glycemic load track with overall diet and lifestyle patterns.
PMCID: PMC2726642  PMID: 19095757
diet; glycemic index; neoplasms; prospective studies
5.  Food Intake Recording Software System, version 4 (FIRSSt4): A Self-Completed 24 Hour Dietary Recall for Children 
The Food Intake Recording Software System, version 4(FIRSSt4), is a web-based 24 hour dietary recall (24hdr) self-administered by children based on the Automated Self-Administered 24-hour recall (ASA24) (a self-administered 24hdr for adults). The food choices in FIRSST4 are abbreviated to include only those reported by children in U.S. national surveys; and detailed food probe questions are simplified to exclude those that children could not be expected to answer (for example questions regarding food preparation and added fats). ASA24 and FIRSSt4 incorporate 10,000+ food images with up to eight images per food to assist in portion size estimation. This paper reviews the formative research conducted during the development of FIRSSt4. When completed, FIRSSt4 will be hosted and maintained for investigator use on the National Cancer Institute’s ASA24 website.
PMCID: PMC3427712  PMID: 22616645
diet; assessment; children; web-based; recall
6.  Coffee consumption and the risk of overall and fatal prostate cancer in the NIH-AARP Diet and Health study 
Cancer causes & control : CCC  2013;24(8):1527-1534.
Evidence on the association between coffee consumption and prostate cancer risk is inconsistent; furthermore, few studies have examined the relationship between coffee consumption and fatal prostate cancer. The aim of this study was to investigate whether coffee intake is associated with the risk of overall and fatal prostate cancer.
We conducted a prospective analysis among 288,391 men in the National Institutes of Health (NIH)-AARP Diet and Health Study who were between 50–71 years old at baseline in 1995–96. Coffee consumption was assessed at baseline. Cox proportional hazards models were used to calculate the age- and multivariable-adjusted hazard ratios (HR) and 95% confidence intervals (CI).
Over 11 years of follow-up, 23,335 cases of prostate cancer were ascertained, including 2,927 advanced and 917 fatal cases. Coffee consumption was not significantly associated with prostate cancer risk. The multivariable-adjusted HRs (95% CI), comparing those who drank six or more cups per day to non-drinker were; 0.94 (0.86–1.02), p-trend=0.08 for overall prostate cancer, 1.13 (0.91–1.40), p-trend=0.62 for advanced prostate cancer and 0.79 (0.53–1.17), p-trend=0.20 for fatal prostate cancer. The findings remained nonsignificant when we stratified by prostate specific antigen (PSA) testing history or restricted to non-smokers.
We found no statistically significant association between coffee consumption and the risk of overall, advanced or fatal prostate cancer in this cohort, though a modest reduction in risk could not be excluded.
PMCID: PMC3717413  PMID: 23681472
Coffee; caffeine; prostatic neoplasms; prospective studies
7.  Simulated Adaptations to an Adult Dietary Self-report Tool to Accommodate Children: Impact on Nutrient Estimates 
To simulate the effect of child-friendly adaptations of the National Cancer Institute's Automated Self-administered 24-hour dietary recall (ASA24) on estimates of nutrient intake.
One hundred twenty children, 8-13 years old entered their previous day's intake using the ASA24 and completed an interviewer-administered recall using the Nutrition Data System for Research (NDSR). Based on a hypothesis that proposed adaptations to the ASA24 will not significantly affect mean nutrient estimates, ASA24 data were manipulated post-administration to simulate a child-friendly version in which two categories of data collection were removed: 1) foods not likely to be consumed by children (45%) based on previous analyses of national dietary data and, 2) food detail questions (probes) to which children are unlikely to know the answers (46%), based on our experience.
Mean estimates of select nutrients between the beta version of ASA24 and the simulated child-friendly recall showed no significant differences, indicating that the food and probe elimination did not significantly affect results. However, a comparison of total sugar and Vitamin C assessments between the original ASA24, the child-friendly version and NDSR showed that the daily nutrient totals for both nutrients were significantly higher in the self-administered methods (both ASA24 and child-friendly version) than in NDSR (interviewer-administered) which warrants a review of different methods for obtaining information about foods that are sources of these nutrients.
The simulation of child-friendly adaptations showed that it is feasible to implement thereby reducing child-friendly response burden without significantly affecting the results.
PMCID: PMC3771395  PMID: 24015716
ASA24; children; dietary recall; self-administered; Automated Multiple Pass Method (AMPM); Automated Self-Administered 24 Hour Recall (ASA24); ASA24-Kids; Food and Nutrient Database for Dietary Studies (FNDDS)
8.  Index-based Dietary Patterns and the Risk of Prostate Cancer in the NIH-AARP Diet and Health Study 
American Journal of Epidemiology  2013;177(6):504-513.
Few studies have investigated the relationship between overall diet and the risk of prostate cancer. We examined the association between 3 diet quality indices—the Healthy Eating Index-2005 (HEI-2005), Alternate Healthy Eating Index-2010 (AHEI-2010), and alternate Mediterranean diet score (aMED)—and prostate cancer risk. At baseline, dietary intake was assessed in a cohort of 293,464 US men in the National Institutes of Health (NIH)-AARP Diet and Health Study. Cox proportional hazards regression was used to estimate hazard ratios. Between 1995 and 2006, we ascertained 23,453 incident cases of prostate cancer, including 2,251 advanced cases and 428 fatal cases. Among men who reported a history of prostate-specific antigen testing, high HEI-2005 and AHEI-2010 scores were associated with lower risk of total prostate cancer (for the highest quintile compared with the lowest, hazard ratio (HR) = 0.92, 95% confidence interval (CI): 0.86, 0.98, P for trend = 0.01; and HR = 0.93, 95% CI: 0.88, 0.99, P for trend = 0.05, respectively). No significant association was observed between aMED score and total prostate cancer or between any of the indices and advanced or fatal prostate cancer, regardless of prostate-specific antigen testing status. In individual component analyses, the fish component of aMED and ω-3 fatty acids component of AHEI-2010 were inversely associated with fatal prostate cancer (HR = 0.79, 95% CI: 0.65, 0.96, and HR = 0.94, 95% CI: 0.90, 0.98, respectively).
PMCID: PMC3657529  PMID: 23408548
diet; food habits; prostatic neoplasms
9.  A mixed-effects model approach for estimating the distribution of usual intake of nutrients: The NCI method 
Statistics in medicine  2010;29(27):10.1002/sim.4063.
It is of interest to estimate the distribution of usual nutrient intake for a population from repeat 24-h dietary recall assessments. A mixed effects model and quantile estimation procedure, developed at the National Cancer Institute (NCI), may be used for this purpose. The model incorporates a Box–Cox parameter and covariates to estimate usual daily intake of nutrients; model parameters are estimated via quasi-Newton optimization of a likelihood approximated by the adaptive Gaussian quadrature. The parameter estimates are used in a Monte Carlo approach to generate empirical quantiles; standard errors are estimated by bootstrap. The NCI method is illustrated and compared with current estimation methods, including the individual mean and the semi-parametric method developed at the Iowa State University (ISU), using data from a random sample and computer simulations. Both the NCI and ISU methods for nutrients are superior to the distribution of individual means. For simple (no covariate) models, quantile estimates are similar between the NCI and ISU methods. The bootstrap approach used by the NCI method to estimate standard errors of quantiles appears preferable to Taylor linearization. One major advantage of the NCI method is its ability to provide estimates for subpopulations through the incorporation of covariates into the model. The NCI method may be used for estimating the distribution of usual nutrient intake for populations and subpopulations as part of a unified framework of estimation of usual intake of dietary constituents.
PMCID: PMC3865776  PMID: 20862656
statistical distributions; diet surveys; nutrition assessment; mixed-effects model; nutrients; percentiles
11.  Differences between food group reports of low energy reporters and non-low energy reporters on a food frequency questionnaire 
Low-energy reporters (LERs) and non-LERs differ with respect to a number of characteristics, including self-reported intake of foods. Limited data exists investigating food intake differences with LERs identified using doubly labeled water (DLW).
In the Observing Protein and Energy Nutrition Study (September, 1999-March, 2000), differences were examined between food group reports of LERs and non-LERs on a food frequency questionnaire (FFQ) (n=440).
LERs were identified using DLW. LERs' (n=220) and non-LERs' (n=220) reports of 43 food groups on the FFQ were examined in three ways: whether they reported consuming a food group (yes/no), how frequently they reported consuming it (times/day), and the reported portion size (small, medium, or large). Analyses were adjusted for total energy expenditure from DLW.
LERs compared to non-LERs were less likely to report consumption for one food group among women (soft drinks/regular) and no food groups among men. Reported mean daily frequency of consumption was lower in LERs compared to non-LERs for 23 food groups among women and 24 food groups among men (18 food groups were similar in men and women). Additionally, reported mean portion sizes were smaller for LERs compared to non-LERs for 6 food groups among women and 5 food groups among men (3 food groups were similar in men and women). Results varied minimally by sex and body mass index (BMI).
LERs as compared to non-LERs were more likely to differ regarding their reported frequency of consumption of food groups than their reported consumption (yes/no) of the food groups or the food groups' reported portion sizes. Results did not vary greatly by sex or BMI. It still remains to be known whether improvement in questionnaire design or additional tools or methods would lead to a decrease in differential reporting due to LER status on an FFQ.
PMCID: PMC3721508  PMID: 19559136
energy underreporting; dietary assessment; food frequency questionnaire; foods
12.  Comparison of a web-based versus traditional diet recall among children 
Self-administered instruments offer a low-cost diet assessment method for use in adult and pediatric populations. This study tested whether eight to 13 year old children could complete an early version of the Automated Self Administered 24 (ASA24) hour dietary recall and how this compared to an interviewer-administered 24-hour dietary recall (24 HDR). One-hundred and twenty eight to13 year old children were recruited in Houston from June through August 2009, and randomly assigned to complete either the ASA24 or an interviewer-administered 24 HDR, followed by the other recall mode covering the same time interval. Multivariate analysis of variance, testing for differences by age, gender and ethnic/racial group, were applied to percentages of food matches, intrusions, and omissions between reports on the ASA24 and the interviewer-administered 24 HDR. For the ASA24, qualitative findings were reported regarding ease of use. Overall matches between interviewer-administered and ASA24 self-administered 24 HDR was 47.8 percent. Matches were significantly lower among younger (eight to nine year old), compared to older (10 to 13 year old) children. Omissions on ASA24 (18.9 percent overall) were most common among eight year olds and intermediate among nine year olds. Eight and nine year olds had substantial difficulties and often required aid in completing ASA24. Findings from this study suggest that a simpler version of a web-based diet recall program would be easier for children to use.
PMCID: PMC3379547  PMID: 22717216
diet assessment; computer; 24 hour recall; children
13.  Taking Advantage of the Strengths of 2 Different Dietary Assessment Instruments to Improve Intake Estimates for Nutritional Epidemiology 
American Journal of Epidemiology  2012;175(4):340-347.
With the advent of Internet-based 24-hour recall (24HR) instruments, it is now possible to envision their use in cohort studies investigating the relation between nutrition and disease. Understanding that all dietary assessment instruments are subject to measurement errors and correcting for them under the assumption that the 24HR is unbiased for usual intake, here the authors simultaneously address precision, power, and sample size under the following 3 conditions: 1) 1–12 24HRs; 2) a single calibrated food frequency questionnaire (FFQ); and 3) a combination of 24HR and FFQ data. Using data from the Eating at America’s Table Study (1997–1998), the authors found that 4–6 administrations of the 24HR is optimal for most nutrients and food groups and that combined use of multiple 24HR and FFQ data sometimes provides data superior to use of either method alone, especially for foods that are not regularly consumed. For all food groups but the most rarely consumed, use of 2–4 recalls alone, with or without additional FFQ data, was superior to use of FFQ data alone. Thus, if self-administered automated 24HRs are to be used in cohort studies, 4–6 administrations of the 24HR should be considered along with administration of an FFQ.
PMCID: PMC3271815  PMID: 22273536
combining dietary instruments; data collection; dietary assessment; energy adjustment; epidemiologic methods; measurement error; nutrient density; nutrient intake
14.  Reactivity and its association with body mass index across days on food checklists 
Characterizing relationships between diet, body weight, and health is complicated by reporting errors in dietary intake data that are associated with body weight. The objectives of this study were to assess changes in reporting across days (reactivity) on food checklists and associations between reactivity and body mass index (BMI) using data from two cross-sectional studies: 1) the Recontacting Participants in the Observing Protein and Energy Nutrition study (n = 297), which was conducted in 2003–2004 and included a 7-day checklist and a 4-day food record (FR), and 2) the America’s Menu Daily Food Report Study (n=530), which was conducted in 1996 and included a 30-day checklist. Zero-inflated Poisson regression was used to assess effects of reporting day on frequency of consumption for the checklists and number of items reported for the FR. Interactions between day and BMI were tested using contrast statements. Frequency of reported consumption declined across days among males and females for total items and many of the eight food groups on the 7-day checklist; among females, the effect of reporting day differed by BMI category for the meat, fish, and poultry group. Smaller declines across days were observed for some of the 22 food groups on the 30-day checklist; no interactions with BMI were apparent. No reporting day effects were observed in the FR data. The results suggest inconsistent reactivity across days, possibly reflecting changes in reporting or consumption behavior. However, the effects are generally small and independent of body weight, suggesting that checklists are potentially useful for the study of body weight and diet.
PMCID: PMC3269781  PMID: 22308230
dietary assessment; food checklist; measurement error; reactivity; body mass index; obesity
15.  Dietary fiber intake and mortality in the NIH-AARP Diet and Health Study 
Archives of internal medicine  2011;171(12):1061-1068.
Dietary fiber has been hypothesized to lower risk of coronary heart disease, diabetes, and some cancers. However, little is known of the effect of dietary fiber on total death and cause-specific deaths.
We examined dietary fiber intake in relation to total mortality and death from specific causes in the NIH-AARP Diet and Health Study, a prospective cohort study. Diet was assessed using a food frequency questionnaire at baseline. Cause of death was identified using the National Death Index Plus. Cox proportional hazard models were used to estimate relative risks (RRs) and two-sided 95% confidence intervals (CI).
During an average of 9 years of follow-up, we identified 20,126 deaths in men and 11,330 deaths in women. Dietary fiber intake was associated with significantly lowered risk of total death in both men and women (multivariate RR comparing the highest vs. the lowest quintile =0.78, 95% CI:0.73–0.82, p-trend, <0.001 in men; 0.78. 95% CI:0.73–0.85, p-trend, <0.001 in women). Dietary fiber intake also lowered risk of death from cardiovascular, infectious, and respiratory diseases by 24%–56% in men and 34%–59% in women. Inverse association between dietary fiber intake and cancer death was observed in men, but not in women. Dietary fiber from grains, but not from other sources, was significantly inversely related to total and cause-specific death in both men and women.
Dietary fiber may reduce the risk of death from cardiovascular, infectious and respiratory diseases. Making fiber-rich food choices more often may provide significant health benefits.
PMCID: PMC3513325  PMID: 21321288
16.  Associations between food patterns defined by cluster analysis and colorectal cancer incidence in the NIH-AARP Diet and Health Study 
To examine associations between food patterns, constructed with cluster analysis, and colorectal cancer incidence within the National Institutes of Health (NIH)–AARP Diet and Health Study.
A prospective cohort, aged 50–71 years at baseline in 1995–96, followed until the end of 2000.
Subjects and Method
Food patterns were constructed, separately in men (n=293 576) and women (n=198 730), with 181 food variables (daily intake frequency per 1 000 kilocalories) from a food frequency questionnaire. Four large clusters were identified in men and three in women. Cox proportional hazards regression examined associations between patterns and cancer incidence.
In men, a Vegetable and Fruit Pattern was associated with reduced colorectal cancer incidence (multivariate HR: 0.85 95%CI: 0.76, 0.94), when compared to less salutary food choices. Both the Vegetable and Fruit pattern and a Fat-Reduced Foods pattern were associated with reduced rectal cancer incidence in men. In women, a similar Vegetable and Fruit pattern was associated with colorectal cancer protection (age-adjusted HR: 0.82 95%CI: 0.70, 0.95), but the association was not statistically significant in multivariate analysis.
These results, together with findings from previous studies support the hypothesis that micronutrient dense, low-fat, high-fiber food patterns protect against colorectal cancer.
PMCID: PMC3500882  PMID: 18685556
food patterns; cluster analysis; colorectal cancer; prospective cohort
17.  Added sugar, sugar-sweetened foods and beverages and risk of pancreatic cancer in the NIH-AARP Diet and Health Study 
Although hyperglycemia, hyperinsulinemia and insulin resistance have been hypothesized to be involved in the development of pancreatic cancer, results from epidemiologic studies on added sugar intake are inconclusive.
Our objective was to investigate whether the consumption of total added sugar, sugar-sweetened foods and beverages is associated with pancreatic cancer risk.
We prospectively examined 487922 men and women aged 50–71 years and free of cancer and diabetes in 1995–96. Total added dietary sugar intake in teaspoons per day (based on USDA’s Pyramid Servings Database) was assessed with a food frequency questionnaire. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated with adjustment for total energy and potential confounding factors.
During an average 7.2 years of follow-up, 1258 incident pancreatic cancer cases were ascertained. The median intakes for the lowest and highest quintiles of total added sugar intake were 12.6 g/day and 96.2 g/day. No overall increased risk of pancreatic cancer was observed in men or women with high intake of total added sugar or sugar-sweetened foods and beverages. For men and women combined, the multivariate RRs of the highest versus lowest intake categories were 0.85 (95% CI: 0.68, 1.06; P trend= 0.07) for total added sugar, 1.01 (95% CI: 0.82,1.23; P trend= 0.58) for sweets, 0.98 (95% CI: 0.82,1.18; P trend= 0.49) for dairy desserts, 1.12 (95% CI: 0.91,1.39; P trend= 0.35) for sugar added to coffee and tea, and 1.01 (95% CI: 0.77,1.31; P trend= 0.76) for sugar-sweetened soft drinks.
Our results do not support the hypothesis that consumption of added sugar, or sugar-sweetened foods and beverages is associated with overall risk of pancreatic cancer.
PMCID: PMC3500146  PMID: 18689380
18.  Sugars in diet and risk of cancer in the NIH-AARP Diet and Health Study 
Prospective epidemiologic data on the effects of different types of dietary sugars on cancer incidence have been limited. In this report, we investigated the association of total sugars, sucrose, fructose, added sugars, added sucrose and added fructose in the diet with risk of 24 malignancies. Participants (n = 435,674) aged 50–71 years from the NIH-AARP Diet and Health Study were followed for 7.2 years. The intake of individual sugars was assessed using a 124-item food frequency questionnaire (FFQ). Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% confidence intervals (CI) in multivariable models adjusted for confounding factors pertinent to individual cancers. We identified 29,099 cancer cases in men and 13,355 cases in women. In gender-combined analyses, added sugars were positively associated with risk of esophageal adenocarcinoma (HRQ5 vs. Q1: 1.62, 95% CI: 1.07–2.45; Ptrend = 0.01); added fructose was associated with risk of small intestine cancer (HRQ5 vs. Q1: 2.20, 95% CI: 1.16–4.16; Ptrend = 0.009); and all investigated sugars were associated with increased risk of pleural cancer. In women, all investigated sugars were inversely associated with ovarian cancer. We found no association between dietary sugars and risk of colorectal or any other major cancer. Measurement error in FFQ-reported dietary sugars may have limited our ability to obtain more conclusive findings. Statistically significant associations observed for the rare cancers are of interest and warrant further investigation.
PMCID: PMC3494407  PMID: 21328345
Sugars; added sugars; diet; cancer; AARP Study
19.  The accuracy of the Goldberg method for classifying misreporters of energy intake on a food frequency questionnaire and 24-hour recalls: Comparison with doubly labeled water 
Adults often misreport dietary intake; the magnitude varies by the methods used to assess diet and classify participants. The objective was to quantify the accuracy of the Goldberg method for categorizing misreporters on a food frequency questionnaire (FFQ) and two 24-hour recalls (24HR).
We compared the Goldberg method, which uses an equation to predict total energy expenditure (TEE), to a criterion method that uses doubly labeled water (DLW), in a study of 451 men and women. Underreporting was classified using recommended cutpoints and calculated values. Sensitivity and specificity, positive and negative predictive value (PPV and NPV), and the area under the receiver operating characteristic curve (AUC) were calculated. Predictive models of underreporting were contrasted for the Goldberg and DLW methods.
AUC were 0.974 and 0.972 on the FFQ, and 0.961 and 0.938 on the 24HR for men and women, respectively. The sensitivity of the Goldberg method was higher for the FFQ (92%) than the 24HR (50%); specificity was higher for the 24HR (99%) than the FFQ (88%); PPV was high for the 24HR (92%) and FFQ (88%). Simulation studies indicate attenuation in odds ratio estimates and reduction of power in predictive models.
Although use of the Goldberg method may lead to bias and reduction in power in predictive models of underreporting, the method has high predictive value for both the FFQ and the 24HR. Thus, in the absence of objective measures of TEE or physical activity, the Goldberg method is a reasonable approach to characterizing underreporting.
PMCID: PMC3319469  PMID: 22127332
Diet; Diet Surveys; Energy Intake; Statistical Bias; Questionnaires/standards; Research Design
20.  Validating an FFQ for intake of episodically consumed foods: application to the National Institutes of Health–AARP Diet and Health Study 
Public Health Nutrition  2011;14(7):1212-1221.
To develop a method to validate an FFQ for reported intake of episodically consumed foods when the reference instrument measures short-term intake, and to apply the method in a large prospective cohort.
The FFQ was evaluated in a sub-study of cohort participants who, in addition to the questionnaire, were asked to complete two non-consecutive 24 h dietary recalls (24HR). FFQ-reported intakes of twenty-nine food groups were analysed using a two-part measurement error model that allows for nonconsumption on a given day, using 24HR as a reference instrument under the assumption that 24HR is unbiased for true intake at the individual level.
The National Institutes of Health–AARP Diet and Health Study, a cohort of 567 169 participants living in the USA and aged 50–71 years at baseline in 1995.
A sub-study of the cohort consisting of 2055 participants.
Estimated correlations of true and FFQ-reported energy-adjusted intakes were 0·5 or greater for most of the twenty-nine food groups evaluated, and estimated attenuation factors (a measure of bias in estimated diet–disease associations) were 0·4 or greater for most food groups.
The proposed methodology extends the class of foods and nutrients for which an FFQ can be evaluated in studies with short-term reference instruments. Although violations of the assumption that the 24HR is unbiased could be inflating some of the observed correlations and attenuation factors, results suggest that the FFQ is suitable for testing many, but not all, diet–disease hypotheses in a cohort of this size.
PMCID: PMC3190597  PMID: 21486523
Diet; Food; Epidemiological methods; Questionnaires; Validation studies
21.  Dietary quercetin, quercetin-gene interaction, metabolic gene expression in lung tissue and lung cancer risk 
Carcinogenesis  2009;31(4):634-642.
Epidemiological and mechanistic evidence on the association of quercetin-rich food intake with lung cancer risk and carcinogenesis are inconclusive. We investigated the role of dietary quercetin and the interaction between quercetin and P450 and glutathione S-transferase (GST) polymorphisms on lung cancer risk in 1822 incident lung cancer cases and 1991 frequency-matched controls from the Environment And Genetics in Lung cancer Etiology study. In non-tumor lung tissue from 38 adenocarcinoma patients, we assessed the correlation between quercetin intake and messenger RNA expression of the same P450 and GST metabolic genes. Multivariate odds ratios (ORs) and 95% confidence intervals (CIs) for sex-specific quintiles of intake were calculated using unconditional logistic regression adjusting for putative risk factors. Frequent intake of quercetin-rich foods was inversely associated with lung cancer risk (OR = 0.49; 95% CI: 0.37–0.67; P-trend < 0.001) and did not differ by P450 or GST genotypes, gender or histological subtypes. The association was stronger in subjects who smoked >20 cigarettes per day (OR = 0.35; 95% CI: 0.19–0.66; P-trend = 0.003). Based on a two-sample t-test, we compared gene expression and high versus low consumption of quercetin-rich foods and observed an overall upregulation of GSTM1, GSTM2, GSTT2, and GSTP1 as well as a downregulation of specific P450 genes (P-values < 0.05, adjusted for age and smoking status). In conclusion, we observed an inverse association of quercetin-rich food with lung cancer risk and identified a possible mechanism of quercetin-related changes in the expression of genes involved in the metabolism of tobacco carcinogens in humans. Our findings suggest an interplay between quercetin intake, tobacco smoking, and lung cancer risk. Further research on this relationship is warranted.
PMCID: PMC2847089  PMID: 20044584
22.  Comparing 3 Dietary Pattern Methods—Cluster Analysis, Factor Analysis, and Index Analysis—With Colorectal Cancer Risk 
American Journal of Epidemiology  2009;171(4):479-487.
The authors compared dietary pattern methods—cluster analysis, factor analysis, and index analysis—with colorectal cancer risk in the National Institutes of Health (NIH)–AARP Diet and Health Study (n = 492,306). Data from a 124-item food frequency questionnaire (1995–1996) were used to identify 4 clusters for men (3 clusters for women), 3 factors, and 4 indexes. Comparisons were made with adjusted relative risks and 95% confidence intervals, distributions of individuals in clusters by quintile of factor and index scores, and health behavior characteristics. During 5 years of follow-up through 2000, 3,110 colorectal cancer cases were ascertained. In men, the vegetables and fruits cluster, the fruits and vegetables factor, the fat-reduced/diet foods factor, and all indexes were associated with reduced risk; the meat and potatoes factor was associated with increased risk. In women, reduced risk was found with the Healthy Eating Index-2005 and increased risk with the meat and potatoes factor. For men, beneficial health characteristics were seen with all fruit/vegetable patterns, diet foods patterns, and indexes, while poorer health characteristics were found with meat patterns. For women, findings were similar except that poorer health characteristics were seen with diet foods patterns. Similarities were found across methods, suggesting basic qualities of healthy diets. Nonetheless, findings vary because each method answers a different question.
PMCID: PMC2842201  PMID: 20026579
colorectal neoplasms; food habits; risk
23.  Alcohol Consumption and Lung Cancer Risk in the Environment and Genetics in Lung Cancer Etiology (EAGLE) Study 
American Journal of Epidemiology  2009;171(1):36-44.
The authors investigated the relation between alcohol consumption and lung cancer risk in the Environment and Genetics in Lung Cancer Etiology (EAGLE) Study, a population-based case-control study. Between 2002 and 2005, 2,100 patients with primary lung cancer were recruited from 13 hospitals within the Lombardy region of Italy and were frequency-matched on sex, area of residence, and age to 2,120 randomly selected controls. Alcohol consumption during adulthood was assessed in 1,855 cases and 2,065 controls. Data on lifetime tobacco smoking, diet, education, and anthropometric measures were collected. Adjusted odds ratios and 95% confidence intervals for categories of mean daily ethanol intake were calculated using unconditional logistic regression. Overall, both nondrinkers (odds ratio = 1.42, 95% confidence interval: 1.03, 2.01) and very heavy drinkers (≥60 g/day; odds ratio = 1.44, 95% confidence interval: 1.01, 2.07) were at significantly greater risk than very light drinkers (0.1–4.9 g/day). The alcohol effect was modified by smoking behavior, with no excess risk being observed in never smokers. In summary, heavy alcohol consumption was a risk factor for lung cancer among smokers in this study. Although residual confounding by tobacco smoking cannot be ruled out, this finding may reflect interplay between alcohol and smoking, emphasizing the need for preventive measures.
PMCID: PMC2800301  PMID: 19933698
alcohol drinking; case-control studies; ethanol; lung neoplasms; risk factors; smoking
24.  Tests of the accuracy and speed of categorizing foods into child vs. professional categories using two methods of browsing with children 
This research tested whether children could categorize foods more accurately and speedily when presented with child-generated than professionally-generated food categories; and whether a graphically appealing browse procedure similar to the Apple, Inc, “cover flow” graphical user interface accomplished this better than the more common tree view structure. In fall 2008, one hundred and four multi-ethnic children ages eight to 13 were recruited at the Baylor College of Medicine, Houston, and randomly assigned to two browse procedures: cover flow (with collages of foods in a category) or tree view (food categories in a list). Within each browse condition children categorized the same randomly ordered 26 diverse foods to both child and professionally organized categories (with method randomly sequenced per child). Acceptance of categorization was determined by dietitians. Speed of categorization was recorded by the computer. Differences between methods were determined by repeated measures analysis of variance. Younger children (eight to nine years old) tended to have lower acceptance and longer speeds of categorization. The quickest categorization was obtained with child categories in a tree structure. Computerized dietary reporting by children can use child generated food categories and tree structures to organize foods for browsing in a hierarchically organized structure to enhance speed of categorization, but not accuracy. A computerized recall may not be appropriate for children nine years or younger.
PMCID: PMC2813510  PMID: 20102832
twenty four hour diet recall; children; food categories; food search strategy
25.  Need for Technological Innovation in Dietary Assessment 
PMCID: PMC2823476  PMID: 20102826
Dietary assessment; dietary studies

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