Original articleA comparison and validation of child versus parent reporting of children's energy intake using food frequency questionnaires versus food records: Who's an accurate reporter?
Introduction
It is by many agreed that there is no perfect method of assessing dietary intake1 and that dietary intake measurement is complex. Measuring dietary intake in children is particularly challenging as limited valid tools exist to assess dietary intake in pediatric populations.1 Food frequency questionnaires (FFQs) ask respondents to report their usual food intake frequency of a defined list of foods over a nominated period of time and are a potentially valuable tool for assessing dietary intake in children. FFQs have been recommended for use in large cross-sectional and cohort studies1 as they capture usual dietary intake over longer periods of time compared to other methods and can be collected from a large number of people in a relatively short time frame.2 In addition FFQs have a relatively low respondent and analytic burden3, 4 and can be presented using a range of options including self, proxy, interviewer or web administration. However, FFQs have been criticized on the grounds of overestimation of intake,5 limited food lists, portion sizes, and recall bias.5
There are specific additional concerns in using FFQs in children, which are related to child cognitive development and capacity to concentrate, and may influence their ability to both recall foods and estimate portion sizes.6 For these reasons child dietary intake is commonly reported by a proxy, usually parents,6 and most commonly by the mother7 who is regarded as the gatekeeper of food provision within the family environment. In a review of validation studies for the assessment of dietary intake in children, parents were proxies or parental assistance was used in more than 50% of studies.1 The ability of a child to self report food and drink consumed increases with age.6 It has been suggested that to complete an FFQ, children need to be ≥12 years old.8 However, uncertainty exists when a child is between the ages of eight and 12 years as to who (i.e. parent or child) should be asked to report child intake, due to factors including increasing child independence, cognitive abilities and increased consumption of food and drinks outside the home outside of parental control.
The Australian Child and Adolescent Eating Survey (ACAES) is a child-specific FFQ that has been developed and validated in youth aged 9–16 years for fruit and vegetable intake, nutrient and fat intake.9, 10, 11 While the ACAES has been shown to be valid for energy intakes in the younger age groups (8–12 years) for both child and maternal reports,12 it was not clear who was the more accurate reporter, mother or child and accuracy of father report is unknown.
The gold standard method for validation of energy intake is by comparison with total energy expenditure determined using the doubly labeled water (DLW) technique in weight stable individuals. Unfortunately, this technique cannot be used widely due to its high cost and the need for specialized laboratory facilities and staff expertise for analysis.7 As an alternative, weighed food records (WFRs) are commonly used as the reference method in dietary intake validation studies as the errors associated with WFRs and FFQs are considered to be largely independent.13
Therefore this study aimed to determine and compare the accuracy of the reporting of child daily energy intake determined by parent-completed 4-day weighed food records and the ACAES FFQ completed independently by the mother, father and child, in comparison to total energy expenditure (TEE) measured by the DLW method.
Section snippets
Participants
Children aged 8–11 y with two eligible caregivers (defined as residing predominantly with the child) were recruited from the Hunter region, NSW Australia during February 2009 predominantly through university emails and community notice boards. Children were eligible to participate if they were a healthy weight (defined by age and sex-specific Body Mass index (BMI) 18.35–20.74)14; had two caregivers who were willing to attend all required sessions; no known medical conditions affecting body
Results
Eleven child participants were recruited to the study. One child became ill during the study and one child did not adhere to the study protocol; therefore data suitable for analysis were obtained from nine children. These children were all weight stable (±1 kg) during the data collection period. The mean weight variation during the 10-day collection period was 0.15 ± 0.17 kg (range −0.2 to +0.3 kg). The children (n = 9) were mostly female (n = 6) and had a mean ± SD age 9.8 ± 1.3years, BMI
Discussion
This study evaluated the accuracy of child total energy intake reporting by comparing the ACAES FFQs completed independently by the mother, father and child in comparison to total energy expenditure (TEE) measured using DLW. The child-reported FFQ evaluation was the closest to gold standard measure of DLW, indicating that the children were the most accurate reporters (113 ± 35%) using the ACAES FFQ, followed by fathers (121 ± 13%), with mothers (144 ± 26%) the least accurate.
The 4-day WFR
Conclusion
The accuracy of FFQs in estimating child EI compared to the DLW method appears consistent with other published literature. Children were the most accurate reporters when compared to their parents, with fathers more accurate than mothers. The child FFQ report was approximately equal to the 4-day weighed food record in estimating EI in children aged 8–12 years. The ACAES FFQ may be used in studies to estimate TEE in 8–11 year old children but consideration should be given to who reports child
Funding
This study was funded by a new staff grant for T Burrows, University of Newcastle.
Conflict of interest
None.
Acknowledgments
Clare Collins is a NHMRCCDA fellow. TB and, CC were major contributors in: study design, data collection, analysis, and preparation of manuscript. RC, PJ, HT, PD all provided input to study design and preparation of manuscript. All authors have approved the final article. None of the authors had any financial support or relationships that may pose conflict of interest.
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