Methods of Dietary and Nutritional Assessment and Intervention and Other Methods in The Multiple Risk Factor Intervention Trial1'2

Chapter 3.
Methods of dietary and nutritional assessment

and intervention and other methods in the Multiple Risk
Factor Intervention Trial1’2
Therese A Dolecek, Jeremiah Stamler, Arlene W Caggiula, Jeanne L Tillotson, and / Marilyn Buzzard
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ABSTRACT Various dietary assessment instruments were intakes for the MRFII cohort and for studying trends in food
used in the Multiple Risk Factor Intervention Trial (MRFIT), consumption over the follow-up years in both the special
either to assist with the special intervention program or to assess intervention (SI) and usual care (UC) groups. Selection of this
trial outcomes. For the latter purpose, the 24-h recall was the main method was based on published reports that the 24-h dietary
method and was selected with the understanding that the single recall reasonably characterizes nutrient intakes of large groups
recall collected at baseline and at most annual visits-considered (3-5).
by itself-would be useful mainly for assessing groups rather than The 24-h dietary recall was similarly used in other major
individuals. Major components of the data collection and analysis epidemiologic studies and nutrition surveys including the Ten-
system developed for the 24-h recall included central training and State Nutrition Survey (6); the US Department of Agriculture
certification of nutritionists, a central nutrient coding system, and Household Food Consumption Survey of 1965-1966 (7); the
a food grouping system to assist interventionists in using recall Nationwide Food Consumption Survey of 1977-1978 (8); the
data for counseling. Several additional nutritional assessment Framingham study of 864 men aged 45-64 y, from 1967 to
methods were used for men in the special intervention group only 1970 (9, 10); the first National Health and Nutrition Examina-
to assist them in attaining the dietary goals. These goals consisted tion Survey (NHANES I), from I 97 1 to 1974 (1 1 ); NHANES
chiefly of reduced intake of saturated fat and cholesterol and a II, 1976-1980 (12); the Lipid Research Clinics (LRC) preva-
modest increase in intake of polyunsaturated fat; total fat intake lence study (13); and the LRC Coronary Primary Prevention
was also decreased, primarily for control of energy intake. Short- Trial (14). Together, these studies provide information on
term success at attainment of these nutritional goals was evaluated American dietary patterns and their changes over time that can
by means of 3-d food records collected before the intervention and be compared with data collected in MRFIT.
after the initial lO-wk intensive intervention period. The MRFIT For each MRFIT participant, one 24-h recall was collected at
nutrient goals, which became more vigorous at certain points in the baseline. As is well known, a single 24-h recall is limited in its
trial, were translated into food patterns. Adherence to these food ability to provide a valid characterization of the nutrient pattern
patterns was also assessed by scoring of 3-d records and by of individuals, to distinguish one person from another within a
subjective evaluation by nutritionists throughout the trial. Methods more or less homogeneous population, and to classify (rank)
of collecting other trial data are also described in this chapter. individuals by nutrient intake. Problems stemming from rela-
Am J Clin Nutr 1997;65(suppl): 196S-2 lOS. tively high intraindividual variability compared with interindi-
vidual variability have been extensively documented (15-18).
KEY WORDS Nutrition methods, nutrition intervention, This aspect of the 24-h recall, its implications for data pre-
dietary assessment, dietary data collection sented in this monograph, and approaches for dealing with the
cited limitations are discussed further in Chapter 4 (19).
NUTRITION METHODS FOR ALL MEN Nutrition data system and the Nutrition Coding Center
A 24-h dietary recall data collection and analysis system was

This chapter presents the nutrition methods used in the
established by the National Heart, Lung and Blood Institute
Multiple Risk Factor Intervention Trial (MRFIT) that are re-
(NHLBI) to meet the research needs of MRFIT and the LRC
lated to the content of this monograph. Two previous MRFIT
Coronary Primary Prevention Trial (20, 21). These clinical
monographs give details on intervention and quality control
methods of the trial, including nutrition and nutrition-related
methods (1, 2). I From the Division of Epidemiologic Studies, Illinois Department of
Public Health, Springfield; the Department of Preventive Medicine, North-
western University, Chicago; the Graduate School of Public Health, Uni-
Twenty-four-hour dietary recall
versity of Pittsburgh; Jacksonville, FL; and the Medical College of Vir-
ginia, Richmond.
Rationale
2 Address reprint requests to GA Grandits. Division of Biostatistics,
The 24-h dietary recall was chosen as the principal data University of Minnesota, 2221 University Avenue, SE, Minneapolis, MN
collection technique for establishing baseline food and nutrient 55414.
196S Am J C/in Nuir 1997;65(suppl):196S-2 105. Printed in USA. © 1997 American Society for Clinical Nutrition
METHOD ISSUES l97S
trials were funded simultaneously to investigate approaches to TABLE 1

the primary prevention of coronary heart disease. The data Available nutrient data from 24-h dietary recall analyses in the Multiple
collection and analysis system was composed of 1) a master Risk Factor Intervention Trial (MRFIT) with use of the University of
Minnesota Nutrition Coding Center food table (version 11)
table of nutrient composition of foods and recipes, with an
accompanying codebook and instruction manual; 2) a collab-
Energy Saturated fatty acids
orative program based at the Nutrition Coding Center (NCC) Protein Total
(now called the Nutrition Coordinating Center) for the training, Total carbohydrate 4:0’
standardization, and certification of field nutritionists in data Alcohol 6:0’
collection procedures; 3) centralized coding of all dietary recall Water 8:0’
data collected in both studies; and 4) comparable editing and Ash 10:0’
quality control procedures with flexible data processing tech- Cholesterol 12:0’
niques. Detailed descriptions of the system, including its de- Caffeine 14:0’
Dietary fiber’ 16:0’
velopment and evolution, have been reported (20-22). An
Water-soluble fiber’ 18:0’
overview of the NCC data system is included as Appendix A.

Water-insoluble fiber 20:0’
MRFIT nutrition publications and presentations before 1986
Crude fiber 22:0’
reported nutrient intake data based on NCC food table number Sucrose Monounsaturated fatty acids
8. In November 1985, all MRFIT dietary recalls were reana- Starch Total
lyzed with use of food table number I 1 , which includes more Other carbohydrates 14:1’
complete fatty acid composition data, as well as micronutrient Total vitamin A 16:1’
data that were not previously available (see Appendix A for 13-Carotene’ 18:1 (oleic)
further detail on the differences between these two versions of Retinol’ 20:1’
the food table). The available nutrient data are shown in Total a-tocopherol equivalents 22:1’
a-Tocopherol Polyunsaturated fatty acids
Table 1.
3-Tocopherol Total
MRFITfood group system y-Tocopherol 18:2 (linoleic)’

-Tocopherol 18:3 (linolecic)’
The MRFIT food group system was developed as a practical Vitamin D 18:4’
means of analyzing and reporting dietary recall data for inter- Vitamin C 20:4’
vention focused on modification of amount and type of dietary Thiamine 22:5’
lipids. Appendix B lists the 20 major MRFIT food groups and Riboflavin 22:6’
the recommended use of these foods for men in the SI group. Niacin
The food group approach supplied a link between nutrient Folic acid
Vitamin B-6’
specifications for SI men and food selections necessary to meet
Vitamin B-12’
those specifications. Ascertainment of desirable or undesirable
Calcium
shifts in relevant nutrient intake, as expressed by key food
Iron
groups, allowed fine tuning of the MRFIT nutrition interven-
Magnesium’
tion. Appropriate dietary changes could be emphasized, and Phosphorus
food choices inconsistent with the nutrition counseling pro- Sodium
gram could be discouraged. A detailed discussion of the de- Potassium
velopment of the MRFIT food group system and its uses is Copper’
presented elsewhere (23). Zinc’
, Data became available for these nutrients in November 1985, at which

Data collection
time MRFIT dietary recalls were reanalyzed.
Nutritionists certified in standardized procedures adminis-
tered the 24-h dietary
interviews recall
at the third screening
visit and at years 1, 2, 3, 5, and 6 for the SI group and at years follow-up dietary recalls were adjusted to make valid compar-
1, 2, 3, and 6 for the UC group (20-23). Because most annual isons with baseline data. The adjustment involved a redefini-
visits were conducted from Monday through Thursday, most tion of the 24-h period in which food intake was documented.
dietary recalls were collected from Sunday through Wednes- The redefined period included the 24 h preceding the time that
day, with the distribution among these 4 d approximately equal. the participant began his fast. For example, if the participant
Baseline dietary recall data were collected at the third screen- reported beginning his fast at 2000 on Tuesday, the 24-h
ing visit for reasons of efficiency and cost. Superfluous data dietary recall included all foods consumed between 2000 on
collection on nonrandomized screenees was lessened by ad- Monday to 2000 on Tuesday. Specific information on time
ministering the dietary recalls at this time. There was, however, when fasting began was documented on the 24-h recall form as
a disadvantage to this timing: because each participant became part of the interviewing process to make sure that all nutrition-
aware of his risk status at the first and second screening visits, ists were conducting the interview by using the adjusted
it is likely that some men made dietary changes between the procedure.
first screening and the time of being randomly assigned to a The original MRFIT protocol specified that dietary recall
study group, thereby making their reported intakes nonrepre- interviews would be conducted on both study groups at all
sentative of long-term intakes before entry into the trial. annual visits through year 6. Recalls were discontinued, how-
The third screening visit was not a fasting visit but subse- ever, at years 4 and 5 for UC men in response to unanticipated
quent annual visits were; hence, the interviewing procedures of dietary changes and observed blood cholesterol reductions. It
l98S DOLECEK El AL
was thought that exposure to dietary interviews might stimulate affect ability to follow nutrition guidelines as well as recom-
more diet change and further jeopardize attainment of study mendations for hypertension control and smoking cessation.
goals. The year-4 dietary recall was also omitted for SI partic- The nutritionist discussed reported heavy alcohol intake with
ipants so that MRFIT nutritionists would have more time to the principal investigator, physician, behavioral scientist, or
counsel SI men. It was hoped that further blood cholesterol other appropriate staff so that a final joint decision could be
reductions in the SI group could be achieved with greater reached as to exclusion.
nutrition counseling efforts. These and other nutrition data If men indicated at the second screening visit that they were
collection concerns are addressed in the MRFIT quality control unwilling to change their eating patterns, they were excluded.
monograph (22). Other nutrition-related criteria leading to exclusion at the sec-
ond screening visit included untreated symptomatic diabetes or
Other methods for assessment of eating and drinking current treatment with insulin, oral antihyperglycemic agents,
patterns or lipid-lowering drugs. Details of the MRFIT exclusion crite-
ria have been published elsewhere (1, 2).
Nutrition-related baseline questions, including exclusion At the second screening visit, a take-home questionnaire on

questions general meal and snack consumption was given to each eligible
During MRFIT screening visits, nutrition-related exclusion volunteer to complete and return at his third screening visit.
criteria were applied for ethical reasons and to disqualify Information was sought as to how often and where participants
volunteers who would probably not be successful in risk factor ate their meals and snacks. The completed questionnaire was
reduction. Initial exclusions were made at the first screening reviewed by the nutritionist at the third screening visit to clarify
visit when a short questionnaire was given to determine num- any questions and to use the information on meal and snack
ber of cigarettes smoked daily and to elicit information con- patterns as a reference during the 24-h dietary recall interview.
cerning three criteria for exclusion: expected move from the
Nutrition-related questions at annual follow-up visits
area, previous hospitalization of 2 wk for “heart attack,” and
prescribed medication for diabetes. In addition to exclusion of In addition to information obtained through the 24-h dietary
men whose risk factors did not place them at sufficiently high recall interview, questions relating to dietary practices and
risk for eligibility, men with a serum cholesterol concentration influences were included on all annual visit forms. The number
350 mg/dL or diastolic blood pressure (DBP) 1 15 mm Hg of questions was reduced at the fourth and fifth annual visits for
were also excluded and referred to a source of medical care. the same reasons that dietary recalls were discontinued, ie, to
At the second screening visit, men with DBP 120 mm Hg avoid influencing dietary practices of UC men and to allow
were excluded and referred, and men with body weight MRFIT nutritionists more time for counseling SI men.
150% of desirable weight for height and sex were excluded. Forms for annual visits in years 1 2, and 3 included
, ques-
Desirable weight was defined as 0.9 of the average weight for tions designed to determine whether personal physicians were
men aged 35-54 y of the same height in the 1960-1962 prescribing special diets for MRFIT participants. The questions
National Health Survey (24). Markedly overweight men were sought reasons for prescription, any printed instructions re-
excluded because they were considered poor candidates for a ceived by the participant, explanation of the diet by health
trial calling for long-term adherence to dietary changes by professionals, participant understanding, self-reported adher-
those randomly assigned to the SI group. ence, and length of time since diet changes had been initiated.
At the second screening visit, questions were also asked Questions were also asked at annual visits in years 1 2, 3, and ,
about frequency of eating meals away from home. The Na- 6 as to factors possibly influencing diet change other than
tional Diet-Heart Study had previously shown that degree of advice from personal physicians. Such factors included the
serum cholesterol reduction was inversely proportional to num- media, advice from MRFIT staff, family influence, community
ber of meals eaten away from home (25). Therefore, MRFIT nutrition education groups, advice from friends, and personal
screenees with serum cholesterol concentrations > 300 mg/dL concern over health.
were excluded if they ate more than five of their largest meals At the first annual visit, an abbreviated food-frequency ques-
away from home each week and stated their inability or un- tionnaire was administered in addition to the 24-h dietary recall
willingness to change this pattern. to assess important food group changes made by both MRFIT
At the second screening visit, men were also asked whether study groups. The form included two sections. Participants
they were following special diets. Men consuming special diets were asked to complete a frequency section on how often
were eligible if, in the judgment of the nutritionists, the pre- certain foods were consumed, using the scale “not at all,”
scnbed diet was compatible with MRFIT food patterns. Incom- “rarely,” “sometimes,” and “often.” Responses were reviewed
patible diets were those with high intakes of fat, saturated fat, with each participant by a MRFIT nutrition counselor, who
or cholesterol. then determined whether any change had been made during the
Excessive alcohol intake, as assessed by the nutritionists preceding year, using the scale “not at all,” “eats more now,”
using the questionnaire at the second screening visit, could be “eats less now,” or “eats none now.”
used by the clinic physician as a reason for exclusion. Volun- All annual visit forms included questions to MRFIT partic-
teers who reported excessive alcohol intake (an average of 5 ipants about their meal patterns. These aimed to determine the
drinks/d) were excluded for two reasons. Even without frank number of meals consumed per day and where those meals
alcoholism, excessive alcohol consumption increases energy were eaten. Restaurant eating practices and carrying of appro-
intake undesirably and decreases intakes of ordinary foods so priate foods in packed lunches were also ascertained as part of
that it is difficult to plan food intake according to desired diet the effort to assess differences in eating practices between the
specifications. Excessive quantities of alcohol also adversely SI and UC groups.
METHOD ISSUES 199S
Frequency data on both caffeinated and decaffeinated coffee energy and blood pressure control, and for general reasons of
usage and caffeine-containing tea and soft drinks were obtained cardiovascular and overall health, those SI men who reported
at annual visits in years 1, 2, and 3. These data were collected intake of 3 alcoholic drinks/d on average were advised to
to supplement information on caffeine intake from the 24-h lower their alcohol intake. Reduction of dietary sodium and
dietary recall. increases in dietary potassium were also encouraged in the
MRFIT participants were asked about their use of alcohol- nutrition counseling of all hypertensive participants.
containing beverages at all annual visits, with increasing detail MRFIT nutritionists also assisted SI participants in resolving
sought during later years. The questions at years 1, 2, and 3 medical problems during the trial that required nutritional
requested information on the number of times such beverages approaches as part of therapy, eg, blood glucose and uric acid
were consumed per week and the number of drinks consumed elevations. Additional objectives were to evaluate the nutrition
on those occasions. Annual visit forms for years 4, 5, and 6 intervention effects on specific subgroups within the random-
obtained the same information with more detail on alcohol ized cohort, to determine any undesirable effects of the inter-
consumption specific to weekdays and weekends. Participants vention program, and to expand knowledge concerning meth-
were asked specifically about consumption of beer, wine, and ods for controlling dietary risk factors in free-living, middle-

liquor at the sixth annual visit. aged American men at increased risk for coronary heart
disease.
NUTRITION INTERVENTION METHODS FOR SI MEN

Nutrition intervention program
Nutrition intervention methods for MRFIT SI men have been The nutrition intervention program was based on the expe-
described in previous reports (1, 2, 20, 22, 23, 26-32). They are riences of the National Diet-Heart Study, the Coronary Preven-
briefly reviewed here. tion Evaluation Program, and the Nutrition Education Project
(25, 33-37). It was originally designed to accomplish the
Nutrition intervention goals and objectives
nutrition goals and objectives in two successive stages based on
The main purpose of nutrition intervention in MRFIT was to a flexible protocol. Comparability of intervention among the 22
achieve a 10% average reduction in serum cholesterol in SI clinical centers was achieved through national and regional
participants whose baseline values were 220 mg/dL. This training workshops and the use of common intervention edu-
was to be accomplished primarily by reducing the proportion of cation methods and materials (31).
total energy from saturated fat, reducing dietary cholesterol The first stage was an intensive intervention program con-
intake, and moderately increasing the proportion of energy sisting of a series of weekly group sessions over 8-10 wk for
from polyunsaturated fat. Because response to dietary fat SI participants and their spouses. Those who were unable to
modification depends, in part, on baseline blood cholesterol attend group sessions could make individual appointments.
concentrations, goals for reduction of serum cholesterol This was followed by an extended intervention, implemented
were established for SI participants according to baseline for the most part on an individual basis, with some group
concentration (Table 2). sessions to address specific problems, eg, weight control and
Because most of the men were overweight, weight loss and difficult dietary change concepts. In the middle of the trial, a
weight control were also nutrition objectives as additional phase 2 intervention program was undertaken, in which a new
means of achieving blood cholesterol reduction, as components set of educational and counseling approaches for nutrition as
of blood pressure control, and as means of aiding SI men who well as for control of smoking and hypertension was used.
quit smoking to avoid or minimize weight gain. To facilitate Although the minimum schedule of contacts for SI partici-
weight control and as part of dietary lipid modification, a pants was one every 4 mo, actual frequency of contact for most
decrease in the proportion of energy from total fat was also one participants was higher than this. An individual follow-up visit
of the MRFIT nutrition objectives for SI men. As an aspect of protocol, based on degree of achieved risk factor reduction,
was implemented after the initial intensive intervention. Nutri-
tion follow-up protocol guidelines for blood cholesterol and
TABLE 2
Goal blood cholesterol reduction for the Multiple Risk Factor weight were established (20, 29).
Intervention Trial special intervention group’
Intervention food patterns
Mean of 1st and 2nd cholesterol
Goal reduction The rationale, diet specifications, food pattern recommenda-
measurements (mg/dL)2
tions, and process by which MRFIT food patterns evolved
%
during the study have been reported (1, 2, 20, 23, 26, 29).
325-349 20
Briefly, MRFIT nutritionists counselled SI participants to make
300-324 18
275-299 16
appropriate dietary changes with flexible eating patterns and
250-274 14 emphasis on adoption of long-term positive changes. Two
225-249 12 carefully designed food patterns provided a basis for nutrition
200-224 10 education materials and interventions used throughout MRFIT.
175- 199 8 The basic MRFIT food pattern was developed in 1973 during
150-174 6 the MRFIT planning period and focused primarily on lowering
Goals are based on the mean of the first- and second-screening blood blood cholesterol and secondarily on overweight, hypertriglyc-
cholesterol measurements. eridemia, and hypertension. Diet specifications were as fol-
2 To convert to SI units (mmollL), multiply by 0.02586.
lows: < 35% of energy from total fat, < 10% from saturated
2005 DOLECEK El AL
fat, 10% from polyunsaturated fat, and < 300 mg choles- Three-day food record
terol. Adjustments to the basic food pattern were made in 1976 Many centers asked SI participants and their spouses to keep
after an evaluation of baseline 24-h dietary recall data revealed
a 3-d food record at the beginning and again toward completion
lower baseline intakes of saturated fat and cholesterol and
of initial intervention. The records served as both an assess-
higher polyunsaturated fat consumption than expected (1).
ment tool and as an educational approach to assist the change
Thus, the initial diet specifications, even when fully achieved,
process.
signified changes in the three dietary lipids that were smaller
than desired. Correspondingly, reduction in blood cholesterol Nutritionist evaluation of adherence to dietary
at the first annual visit did not meet the study goal of 10%. It recommendations
was therefore decided to adjust the basic food pattern. The diet
specification for saturated fat was reduced from 10% to 8% of
Additional nutrition information on adherence to MRFIT
energy and for dietary cholesterol from 300 to 250 mg/d, with food patterns and on factors related to intervention successes or
failures was obtained from all SI participants at 4- and 8-mo
percentages from total fat and polyunsaturated fat unchanged.
intervals between annual visits or was completed by MRFIT
In 1978, a phase 2 intervention program was adopted. It intro-

interventionists at regularly held case conferences or reviews
duced a food pattern, named the progressive eating pattern, that
specified greater changes in dietary lipids, ie, saturated fat after each annual visit. During the early follow-up years, only
a subjective assessment of adherence was made, with use of an
intake < 5% of energy and dietary cholesterol < 100 mg/d.
Phase 2 intervention efforts also gave considerably greater
overall rating of excellent, good, fair, or poor as in the National
emphasis to weight control than did intervention in earlier
Diet-Heart Study (25). In later years, nutrition follow-up visit
assessments became more standardized. Three-day food
years. The daily recommendations by major food categories for
records were requested of SI participants as part of regularly
each of the MRFIT food patterns are presented in Table 3.
scheduled 4- and 8-mo follow-up visits for a semiobjective
scoring system of adherence developed by MRFIT
Supplementary nutrition data on SI men
nutritionists.
In addition to the nutrition data collected on all MRFIT men
during the trial (as described above), several additional ques- Food record rating to assess adherence to dietary
tionnaires and a 3-d food record were used to obtain supple- recommendations
mentary information on dietary patterns of SI participants.
The assessment system, called the food record rating (FRR),
is a composite of scores assigned to foods on the 3-d food
Preintervention food-frequency questionnaire
record (22, 27, 28, 32). Briefly, foods containing saturated fats
A food-frequency questionnaire was completed by each SI and cholesterol (meat, dairy, baked goods, and fats) contribute
participant and his spouse before the initial intensive interven- positive points (lipid-raising) to the FRR. On the basis of type
tion. Food preferences, preparation techniques, and purchasing and amount of food items containing polyunsaturated fat, 0, 1,
practices were ascertained with use of this questionnaire. In- or 2 is then subtracted from the 3-d average of the score. Next,
formation from the questionnaire along with the baseline 24-h number of egg yolks consumed during the week of the 3-d food
dietary recall served as the initial dietary assessment from record was ascertained and added to produce the total FRR. An
which the nutrition intervention process began. FRR value 20 was typical for the usual diet of MRFIT men
TABLE 3
Daily recommendations of food categories for special intervention participants in the Multiple Risk Factor Intervention Trial (MRFIT)
Food category Original basic MRFIT Basic MRFIT (1976) Progressive eating pattern (1978)
1 . Lean meats, poultry, fish, or 6-8 oz 6 oz 3 oz; not more than one meal per
low-fat cheese day containing meat, poultry,
fish, or low-fat cheese as a
protein source
2. Meatless meals Encouraged Encouraged as often as possible l/d
3. Egg yolks 2/wk 2/wk None
4. Dairy products 2 servings: < 1% fat (nonfat 2 servings: < 1% fat (nonfat 2 servings: nonfat only
preferred)’ preferred)’
5. Margarines and oils2 2-4 tablespoons (“preferable” and 2-4 tablespoons (“preferable” and 2-3 tablespoons (“preferable”)
“acceptable”) “acceptable”)
6. Breads, cereals, and grains 4 servings 4 servings 5 servings
7. Fruit and vegetables 4 servings 4 servings 5 servings
8. “Once in a while” 2/wk Not routinely recommended None
9. Alcohol Moderate Moderate Limited as necessary for weight
reduction
10. Sugar Limited for weight control Limited for weight control Limited for weight control
11. Salt and high-sodium food Limited for blood pressure control Limited for blood pressure control Limited for blood pressure control
‘ For cheeses, yogurt, and ice milk, < 3% fat is also acceptable.
2 Brands categorized in MRFIT food and grocery guide.
METhOD ISSUES 2OlS
at baseline. Scores of 4-9 represented adherence to the basic the fat-controlled food pattern incorporated the principles of
MRFIT food pattern and scores 3 indicated adherence to the energy balance and ways to reduce energy in daily food selec-
progressive eating pattern. tions. The MRFIT weight control approach focused on energy
Subjective evaluations by the MRFIT nutritionists also be- restriction, increase in moderate physical activity, and behavior
came more standardized in the later years of the trial. A dietary changes associated with excessive food intake and sedentary
checklist with three categories-suitability of home and work- living. Participants were weighed regularly and their weight
ing environments, evidence of deviation from MRFIT eating progress charted as routine components of intervention activi-
patterns, and overall nutrition program motivation-allowed ties. During the extended intervention, groups were often
assessment of behavioral and environmental factors related to formed solely for weight loss. Individual sessions with nutri-
dietary change. A more complete and
adher- accurate dietary tionists also encouraged achievement and maintenance of de-
ence assessment was achieved with combined use of the FRR sirable body weights for hypertension management as well as
and the subjective checklist than was possible with use of each for blood lipid reduction. The final phase 2 intervention pro-
alone or with the approach used in the early years of the trial. gram intensified this emphasis. Weight control concepts were
During phase 2 intervention, the 4- and 8-mo follow-up visit given high priority in educational materials and counseling

forms were modified to allow a more detailed breakdown of the strategies implemented during the last year of the trial.
FRR by food group category. Questions regarding implemen- Hypertensive men participating in the weight reduction ef-
tation of progressive eating pattern and strategies to achieve fort were seen at least once every
8 wk for a l6-wk period. If
nutrition change during phase 2 were also included on the DBP at the end of the 16 wk was < 90 mm Hg, participants
form. In addition, information on participants’ salt and high- were not seen again until the next regular follow-up visit. If
sodium food usage was ascertained at 4- and 8-mo follow-up DBP was 90 mm Hg, stepped-care drug therapy was initi-
visits during the phase 2 intervention. ated. For nonoverweight men, drug therapy was initiated as
A single special assessment of SI participant progress was soon as hypertension was confirmed. Step I medication was an
made during the final phase 2 intervention. These data reflect oral diuretic, either chlorthalidone or hydrochlorothiazide, 50
modes of nutrition intervention attempted during the late stage or 100 mg/d; step 2 added an antiadrenergic drug; step 3 added
of the trial. Nutrition knowledge and behavior of participants an arteriolar vasodilator; and step 4 added guanethidine. Each
and their spouses were characterized. A profile of current step was added as needed to achieve and maintain normoten-
dietary practices related to MRFIT nutrition goals was ascer- sive goal blood pressure.
tamed for each SI participant. An assessment was made of Advice about dietary sources of potassium was given to SI
individual, environmental, and cultural factors possibly related hypertensive men receiving diuretic treatment (38, 39). Potas-
to success or failure in attainment of individualized dietary sium chloride (10% liquid solution) was given at the discretion
goals. of MRFIT physicians for SI participants taking chlorthalidone
or hydrochlorothiazide if serum potassium concentrations were
in the range of 3.0-3.4 mmol/L. Potassium chloride supple-
OTHER INTERVENTION METHODS FOR SI MEN, AND mentation was required for men with symptomatic hypokale-
THEIR NUTRITION COMPONENTS mia or serum potassium concentrations < 3.0 mmol/L, or for
those with a prescription for a digitalis preparation in addition
Treatment of hypertension
to an oral diuretic and who had serum potassium concentrations
The protocol for treating hypertensive men in MRFIT was < 3.5 mmol/L.
described previously (38, 39) and is summarized here. SI men In addition to weight reduction advice for SI hypertensive
were treated by MRFIT staff if their DBP was 90 mm Hg at men, efforts were made to reduce dietary sodium (38, 39). Men
the time they were randomly assigned to the SI group and at a were generally instructed to minimize intake of foods high in
follow-up visit 2-4 wk later, or if during the trial DBP at two salt and to use salt sparingly, if at all, in food preparation and
consecutive visits 4 wk apart was 90 mm Hg. Men already at the table. Any recommendations for sodium reduction were
taking antihypertensive medication when they were randomly not intensive and were made so as to be compatible with the
assigned, or placed on such medication by their private physi- MRFIT food pattern for blood cholesterol reduction. Addition
cians at any time during the course of the trial, were also of dietary advice to lower sodium intake was considered care-
followed as hypertensive participants and if necessary treated fully to avoid potential dietary nonadherence. No effort was
for their hypertension by MRFIT staff. made to check on adherence with advice to lower sodium
The main treatment modality for SI men with confirmed high intake, either by review of food records or by urine sodium
blood pressure was a stepped-care antihypertensive drug regi- measurement. SI men taking maximum doses of step 2 medi-
men. However, the initial effort for obese hypertensive SI men cation or taking step 3 medication and with DBP above the
was to control blood pressure by dietary means, in particular by normotensive goal could remain in their step for an additional
weight reduction through energy restriction (38, 39). (Obesity l6-wk period while reduced sodium intake was more vigor-
was defined as body weight 15% above desirable weight for ously pursued as an adjunct to drug therapy. After 16 wk, these
height.) Overweight participants with a DBP of9O-l04 mm Hg men were directed to either a drug step-up or maintenance
were eligible for a weight reduction program in an effort to schedule as indicated by their DBP.
lower blood pressure before drug therapy was initiated. Espe- Because alcohol intake is a risk factor for hypertension,
cially for these participants, weight control was integrated into MRFIT participants were advised by nutritionists to reduce or
the initial intensive intervention group sessions, along with eliminate consumption especially when difficulty in blood
attention to the other primary concerns of dietary lipid modi- pressure control was encountered. The recommendation was
fication and smoking cessation. Guidance on how to implement consistent with overall nutrition program objectives in that
202S DOLECEK El AL
energy contributed by alcohol can interfere with weight control third screening visits. This information was reviewed by clinic
and provide little nutritional value. Decreased alcohol intake personnel at the third screening visit.
was a common behavior sought by MRFIT nutritionists to help Presumably stressful life events were assessed by a checklist
participants control weight as well as manage hypertension and from a larger set developed by Holmes and Rahe (46). These
reduce blood triglyceride concentrations when elevations were included changes or problems related to health, work, family,
present. and other areas of life in the previous year. The Jenkins
During the first half of 1980, the MRFIT Policy Advisory Activity Survey type A-B score was obtained from question-
Board proposed a change in the hypertension treatment proto- naire data collected at the third screening visit (47, 48). Also,
col for reasons reported previously (38-44). It was recom- in 8 of 22 clinical centers, a structured interview was given to
mended, and accepted by the MRFIT Steering Committee, that assess type A-B behavior pattern (49-51).
only chlorthalidone, not hydrochlorothiazide, be the step 1
diuretic for SI hypertensive men. It was also agreed that the Serum and plasma lipid measurements
maximum chlorthalidone
dosage for those taken off hydrochlo-
Laboratory determinations of blood lipid concentrations
rothiazide be 50 mg/d, not 100 mg/d. An additional change was

were made at regular intervals throughout the trial to assess
made in the SI hypertension treatment protocol in November
effects of intervention. Local laboratories analyzed serum cho-
1981 based on results of a randomized study comparing blood
lesterol for initial screening visits; these laboratories were
pressure lowering in participants taking 100 mg chlorthalidone
standardized by the Centers for Disease Control and Prevention
and those reduced to 50 mg (44). It was recommended that for
Lipid Standardization Program. After the first screening visit,
all SI men on chlorthalidone, the dosage be no greater than 50
all lipid measurements were performed at the MRFIT central
mg/d. Based on these two recommendations, a 50-mg dose of
laboratory in San Francisco.
chlorthalidone was recommended for all SI hypertensive men
Serum total cholesterol, plasma total cholesterol, plasma
unless it was contraindicated.
high-density-lipoprotein (HDL) cholesterol, and plasma tri-
glyceride determinations were made and plasma low-density-
Counseling for smoking cessation lipoprotein (LDL) cholesterol and very-low-density-lipoprotein
The MRFIT smoking cessation program for SI cigarette (VLDL) cholesterol were calculated according to methods of
users has been described in detail (45). Here, only nutrition- the Lipid Research Clinics Program (52, 53). Serum determi-
related aspects are considered. The MRFIT intervention proto- nations were obtained at the first screening visit and at all
col provided for an integrated effort among all modalities annual visits for all men, and at the 4- and 8-mo visits for SI
aimed at control of the major risk factors. Thus, for SI cigarette men. Plasma was obtained and analyzed for total cholesterol at
users, initial intensive intervention involved not only counsel- the second screening visit and from year 2 through the final
ing to achieve smoking cessation, but also recommendations annual visit. In addition, plasma lipoprotein fractions were
for eating habits, as well as antihypertensive treatment when assessed at the second screening visit and at years 2, 4, and 6.
indicated. Given that weight gain is a barrier to sustained Participants came to the second screening visit and all annual
smoking cessation, and has adverse influences on blood pres- visits in a fasting state.
sure and blood lipids, special efforts were made to advise VLDL cholesterol was estimated from the plasma triglycer-
smokers about approaches to prevent or minimize associated ide concentration. When the triglyceride value was < 300
weight gain. mg/dL, VLDL cholesterol was calculated by dividing this
Again,
for cigarette smokers, counseling was approached in value by five (54). HDL-cholesterol measurement involved
the of MRFIT
context food pattern recommendations. Partici- precipitation of VLDL and LDL cholesterol from whole
pants were monitored regularly to identify those who were plasma with a heparin-manganese chloride solution and mea-
gaining weight so that additional attention could be provided surement of the HDL cholesterol content of the supernate by
before a serious problem developed. If food substitutes were the total cholesterol method. LDL cholesterol was then calcu-
being used in place of cigarettes, low-energy food items were lated as the difference between total cholesterol and the sum of
suggested along with other activities such as a short walk daily HDL and VLDL cholesterol.
to help relieve cravings. When the plasma triglyceride concentration was 300 mg/
dL, plasma samples were ultracentrifuged in saline under con-
ditions that enabled the sample to be divided into a top fraction
containing VLDL cholesterol and a bottom fraction containing
OTHER METHODS
LDL and HDL cholesterol. LDL- plus HDL-cholesterol con-
Assessment of sociodemographic and psychosocial centrations of the bottom were determined. LDL cholesterol
variables was precipitated with heparin-manganese chloride solution and
HDL cholesterol was then measured in the supernate. LDL
The extensive MRFIT database allows analyses of nutrition
cholesterol was then calculated as the bottom fraction of cho-
data for subgroups of participants and provides the opportunity
lesterol minus HDL cholesterol, whereas VLDL cholesterol
to control for many potentially confounding variables. A brief
was calculated as the total plasma cholesterol concentration
description of these variables along with time of their ascer-
minus the bottom fraction of cholesterol.
tainment is given here. Age and ethnicity of MRFIT partici-
pants were obtained at the first screening visit. Information on
Blood pressure assessment
education, occupation, income, marital status, and number of
life events was obtained from a self-administered structured Three blood pressure variables-systolic blood pressure,
questionnaire completed by each man between the second and DBP, and use of antihypertensive drugs-are used in data
METHOD ISSUES 203S
analyses for this monograph. Blood pressure measurements Washington, DC: US Government Printing Office, 1972. [DHEW
were obtained at all screening and annual visits for both study publication no. (HSM) 72-8 134.]
groups. SI men also had blood pressure measurements at 4- and 7. Consumer and Food Economics Research Division. Agriculture sur-
vey: food intake and nutritive value of diets of men, women, and
8-mo visits and additionally as specified by the hypertension
children in the United States, spring 1965. US Department of Agri-
treatment protocol. Only clinic staff certified by successful
culture Household Food Consumption Survey, 1965-66. Beltsville,
completion of a written test, a double stethoscope test, and an
MD: Agricultural Research Service, 1969. (Publication no. 62-18.)
audiometry test could obtain blood pressure measurements
8. Science and Education Administration, US Department of Agriculture.
(55). Systolic blood pressure was defined as the first point at Food and nutrient intakes of individuals in one day in the United
which the observer can recognize sounds repeated in phase. States, spring 1977. Nationwide Food Consumption Survey, 1977-78.
The fifth phase of the Korotoff sounds was used to define the Preliminary report no. 2. Washington, DC: US Government Printing
DBP as follows: the first point, after the sounds cease to be Office, 1980.
tapping in quality, at which sounds cease to be heard. 9. The Framingham Study-an epidemiological investigation of cardio-
vascular disease. Section 24. The Framingham Diet Study: diet and the
Smoking assessment regulation of serum cholesterol. Kannel WB, Gordon 1, eds.

Washington, DC: US Government Printing Office, 1970.
Number of cigarettes smoked per day was recorded at all 10. Mann GV, Pearson 0, Gordon T, Dawber TR. Diet and cardiovascular
visits. Serum thiocyanate determinations were made at the disease in the Framingham Study. I. Measurement of dietary intake.
second screening visit and at all annual visits thereafter (56). Am J Clin Nutr l962;ll:200-25.
Thiocyanate concentrations in blood and in other body fluids 1 1. Preliminary Findings of the First Health and Nutrition Examination
are usually elevated in smokers, probably as a result of trace Survey, United States, 1971-74. Dietary intake and biochemical find-
amounts of cyanide in tobacco smoke. The body’s detoxifica- ings. Washington, DC: US Government Printing Office, 1974.
[DHEW publication no. (HRA) 74:1219-1.]
tion process apparently converts cyanide to thiocyanate, which
12. Dietary Intake Source Data. United States, 1976-80. Data from the
has a biological half-life of “2 wk. Although certain foods and
National Health and Nutrition Examination Survey. US DHHS PHS
occupational exposures increase blood thiocyanate concentra-
NCHS series 1 1 no. 231. Hyattsville, MD: US Department of Health
tions, cigarette smoking appears to overwhelm these influences and Human Services, 1983. [DHHS publication no.(PHS)83-l63l.]
with respect to its contribution to blood concentrations, making 13. The Lipid Research Clinics population studies data book. Volume II.
blood thiocyanate concentration a reasonably objective mea- The prevalence study-nutrient intake. Bethesda, MD: National Insti-
sure of smoking behavior. For smoking status, the report by the tutes of Health, 1982. [US DHHS PHS NIH publication no. 82-20 14.]
participant of current practice (smoker, quitter, or nonsmoker) 14. Lipid Research Clinics Program. The Lipid Research Clinics Coronary
was adjusted on the basis of the blood thiocyanate concentra- Primary Prevention Program trial results: I. reduction in the incidence
tion (45). Carbon monoxide in expired air was also measured of coronary heart disease. JAMA 1984;251:351-64.
with use of the Ecolyzer to evaluate current smoking status and 15. Liu K, Stamler J, Dyer A. Statistical methods to assess and minimize
the role of intra-individual variability in obscuring relationships be-
to aid the smoking cessation effort with SI men (45).
tween dietary lipids and serum cholesterol. J Chronic Dis
l978;31:399-4l8.
Body mass measurement 16. Beaton OH, Milner J, Corey P, et al. Sources of variance in 24-hour
Weight (disrobed) was measured in pounds during the phys- dietary recall data: implications for nutrition study design and inter-
ical examination at the second screening visit. Height was also pretation. Am J Clin Nutr l979;32:2546-59.
17. Hegsted DM. The classic approach-the USDA Nationwide Food
measured and body mass index calculated after conversion of
Consumption Survey. Am J Clin Nutr 1982;35:1302-5.
the two measures to metric units (kg/rn2). Weight was mea-
18. Jacobs DR. Anderson iT, Blackburn H. Diet and serum cholester-
sured at all annual visits for all participants. SI men were also
ol-do zero correlations negate the relationship? Am J Epidemiol
weighed at the 4- and 8-mo follow-up visits (not disrobed).
1979;l 10:77-87.
Percentage desirable weight was calculated by dividing the 19. Grandits GA, Bartsch GE, Stamler J. Chapter 4. Method issues in
weight by 0.9 times the average weight-for-height for men dietary data analyses in the Multiple Risk Factor Intervention Trial. In:
35-54 y of age, as reported by the National Health Examina- Stamler J, Caggiula AW, Cutler JA, et al, eds. Dietary and nutritional
lion Survey for 1960-1962 (24). U methods and findings: the Multiple Risk Factor Intervention Trial
(MRFIT). Am J Clin Nutr 1997;65(suppl):2l 15-275.
20. Tillotson J, Gorder DD, Kassim N. Nutrition data collection in the
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2. Multiple Risk Factor Intervention Trial. Quality control of technical 22. Tillotson JL, Gorder DD, DuChene AG, Grambsch PV, Wenz J.
procedures and data acquisition. Control Clin Trials 1986;7(suppl): Quality control in the Multiple Risk Factor Intervention Trial: nutrition
15-1955. modality. Control Clin Trials 1986;7(suppl):66S-90S.
3. Young CM, Hagan GG, Tucker RE, Foster WD. A comparison of 23. Gorder DD, Dolecek TA, Coleman (3G. Dietary intake in the Multiple
dietary study methods. II. Dietary history versus seven-day record Risk Factor Intervention Trial (MRFIT): nutrient and food group
versus 24-hour recall. J Am Diet Assoc 1952;28:218-2l. changes over 6 years. J Am Diet Assoc l986;86:744-5l.
4. Trulson MF, McCann MB. Comparison of dietary survey methods. J 24. Roberts J. National Center for Health Statistics-weight by height and
Am Diet Assoc l959;35:672-6. age of adults. United States, 1960-62. Vital Health Stat [1 1] l966;l4.
5. Keys A. Dietary survey methods. In: Levy RI, Ritldnd BM, Dennis 25. The National Diet-Heart Study Research Group. The National Diet-
BH, Ernst N, eds. Nutrition, lipids and coronary heart disease. New Heart Study final report. Circulation 1968;37/38(suppl I): 1-428.
York: Raven Press, 1979:1-23. 26. Farrand ME, Mojonnier L. Nutrition in the Multiple Risk Factor
6. Ten-state nutrition survey, 1968-1970. V. Dietary and highlights. Intervention Trial (MRFIT). J Am Diet Assoc 1980;76:347-5 I.
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27. Remmell P. Gorder DD, Hall Y, Tillotson JL. Assessing dietary of a computer-scored test for the type A coronary-prone behavior
adherence in the Multiple Risk Factor Intervention Trial (MRFIT): I. pattern. Psychosom Med 197 1 ;33: 193-202.
use of a dietary monitoring tool. J Am Diet Assoc 1980;76:35l-6. 49. Rosemann RH. The interview method of assessment of the coronary
28. Remmell P. Benfari R. Assessing dietary adherence in the Multiple prone behavior pattern. In: Dembrowski TM, Weiss SM, Shields JL, et
Risk Factor Intervention Trial (MRFIT): II. food record rating as an al, eds. Coronary-prone behavior. New York: Springer-Verlag.
indicator of compliance. J Am Diet Assoc 1980;76:357-60. 1978:55-69.
29. Caggiula AW, Christakis G, et al. The Multiple Risk Factor Interven- 50. The MRFIT Group. The MRFIT behavior pattern study-I. study
tion Trial (MRFIT). IV. Intervention on blood lipids. Prey Med design, procedures, and reproducibility of behavior pattern judgments.
1981 ; 10:443-75. J Chronic Dis 1979;32:293-305.
30. Multiple Risk Factor Intervention Trial Research Group. Multiple Risk 51. Shekelle RB, Hulley SB, Neaton JD, Billings JH, Borhani ND, Gerace
Factor Intervention Trial. Risk factor changes and mortality results. TA. MRFIT behavior pattern study. II. Type A behavior and incidence
JAMA 1982;248: 1465-75. of coronary heart disease. Am J Epidemiol 1985;122:559-70.
31. Dolecek TA, Tillotson JL, Gorder DD, Ashman P, Caggiula AW. The 52. Manual of Operations, Lipid Research Clinics Program. Vol 1. Wash-
nutrition intervention program. In: Materials and methods for a car- ington, DC: US Government Printing Office, 1974. [DHEW publica-
diovascular disease risk factor reduction program: a resource for the tion no. (NIH) 75-628.]

Multiple Risk Factor Intervention Trial. Springfield, VA: National 53. Widdowson GM, Kuehneman M, DuChene AG, Hulley SB, Cooper
Technical Information Service, 1985:91-201. OR. Quality control of biochemical data in the Multiple Risk Factor
32. Dolecek TA, Milas NC, Van Horn LV, et al. A long-term nutrition Intervention Trial: central laboratory. Control Clin Trials
intervention experience: lipid responses and dietary adherence patterns l986;7: 175-335.
in the Multiple Risk Factor Intervention Trial. J Am Diet Assoc 54. Friedewald WT, Levy RI, Fredrickson DS. Estimation of the concen-
1986;86:752-8. tration of low-density lipoprotein cholesterol in plasma, without use of
33. Stamler J. Improving lifestyles to control the coronary epidemic. ultracentrifuge. Clin Chem 1972;18:499-502.
Proceedings of the International Conference. Nutrition, dietetics and 55. Dischinger P. DuChene AG. Quality control aspects of blood pressure
sport. Turin, Italy: Eidzioni Minerva Medica, 1978:5-48. measurements in the Multiple Risk Factor Intervention Trial. Control
34. Stamler J. Lectures on preventive cardiology. New York: Grune & Clin Trials l986;7:l37S-57S.
Stratton, 1967. 56. Buus WC, Kuehneman M, Widdowson GM. Automated method for
35. Jones Ri, Turner D, Ginther J, Brandt B, Slowie L, Lauger G. A determining serum thiocyanate to distinguish smokers from non-smok-
randomized study of instructional variations in nutrition counseling cr5. Clin Chem 1974;20: 1344-8.
their efficacy in the treatment of hyperlipidemia. Am J Clin Nutr
I 979;32:884-904.
36. Mojonnier ML, Hall Y, Berkson DM, et al. Experience in changing APPENDIX A
food habits of hyperlipidemic men and women. J Am Diet Assoc
1980;77: 140-8. Dietary data collection and nutrient calculation of 24-h
37. Stamler J, Farinaro E, Mojonnier LM, Hall Y, Moss D, Stamler R. dietary recalls in the Multiple Risk Factor Intervention
Prevention and control of hypertension by nutritional-hygienic means. Trial’
JAMA 1980;243: 18 19-23.
38. Cohen JD, Grimm RH, Smith WM. Multiple Risk Factor Intervention I Marilyn Buzzard
Trial (MRFII). VI. Intervention on blood pressure. Prey Med
198 l;10:501-18. Yvonne A Sievert
39. Grimm RH, Cohen JD, Smith WM, Falvo-Gerald L, Neaton JD.
Hypertension management in the MRFIT. Six-year intervention results
for men in the special intervention and usual care groups. Arch Intern INTRODUCTION
Med l985;145:119l-9.
40. Bartsch G, Broste 5, Grandits G, Grimm RH, Neaton JD, Svendsen The Nutrition Data System used for standardized collection,
KH. Hydrochlorothiazide, chlorthalidone and mortality in the Multiple coding, and nutrient calculation of 24-h dietary recalls in
Risk Factor Intervention Trial. Circulation 1984;70(suppl MRFIT was developed by the NHLBI in the early l970s. The
II):II-438(abstr). system was designed to meet the research needs of both MR-
41. The MRFIT Research Group. Mortality rates after 10.5 years for FIT and the LRC studies, including the Coronary Primary
participants in the Multiple Risk Factor Intervention Trial. Findings Prevention Trial. In 1974, the NCC was established at the
related to a prior hypotheses of the trial. JAMA 1990;263: 1795-801.
University of Minnesota to centralize the dietary data collec-
42. Smith WM. Effects of thiazide diuretics on plasma lipids-MRFIT.
tion and coding procedures and to maintain the nutrient data-
CVD Epidemiology Newsletter. Dallas, TX: Council on Epidemiol-
base for analysis of the dietary recalls for these two multicenter
ogy, American Heart Association, 1978.
cardiovascular studies.
43. Hypertension Detection and Follow-up Program Cooperative Group.
Five-year findings of the Hypertension Detection and Follow-up Pro-
Development of the Nutrition Data System involved exten-
gram: I. reduction in mortality of persons with high blood pressure, sive collaboration of experts in nutrition, statistics, computer
including mild hypertension. JAMA l979;242:2562-7l. science, and education. The system was designed to be highly
44. Grimm RH. Benefit with lower dose of chlorthalidone. Am Heart J specific for dietary intake of fats and cholesterol and to be
1985; 109:858-64. flexibile so that ongoing changes in the marketplace during the
45. Hughes OH, Hymowitz N, Ockene JK, Simon N, Vogt TM. The two long-term studies could be accommodated. Because data
Multiple Risk Factor Intervention Trial (MRFIT). V. Intervention on were to be collected at 34 different centers (22 for MRFIT and
smoking. Prey Med 1981; 10:476-500.
12 for LRC), the need for standardization and quality control
46. Holmes TH, Rahe RH. The social readjustment rating scale. J Psycho-
was essential.
som Res l967;11:213-8.
47. Zyzanski SI, Jenkins CD. Basic dimensions within the coronary-prone
behavior pattern. J Chronic Dis 1970;22:781-95. ‘ From the Medical College of Virginia, Richmond, and the Division of
48. Jenkins CD, Zyzanski SI, Rosenman RH. Progress toward validation Epidemiology, School of Public Health, University of Minnesota.
METHOD ISSUES 205S
The Nutrition Data System consisted of three major compo- Coding manual
nents: centralized training and certification of dietary inter-
The coding manual was the basic reference manual for
viewers, centralized coding of collected food intake data for
routine coding. The manual included a listing of food descrip-
computerized analysis, and calculation of nutrients using the tions and corresponding code numbers in the nutrient database.
NCC nutrient database. Various aspects of the Nutrition Data The coding manual was organized by major food group and
System have been described (1, 2). The purpose of this Ap- subgroup classifications. Rules providing standardized guide-
pendix is to summarize the data collection and coding proce- lines for coding foods and food combinations not included in
dures and to document sources of nutrient data and the nutrient the database were inserted at appropriate places in the food
calculation system used for analysis of MRFIT dietary recalls. listing. For example, the coding rule for a grilled sandwich,
which specifies one teaspoon of designated fat per slice of
bread, was listed in the coding manual under bread. The coding
rule for meat did not specify whether the meat was trimmed or
METHODS
untrimmed and was included in listings under each meat sub-

Interviewer training, certification, and continuing group. The coding manual also included a comprehensive
education cross-referenced index to facilitate locating foods by their
common names.
The process for training and certification of dietary inter-
viewers for standardized collection of 24-h recalls involved
Coding guides
three phases. The first phase was attendance at a 2-d training
session to acquaint the trainee with the Nutrition Data System. Brand name coding guides were used for coding thousands
Hands-on experience in coding was provided to encourage of brand name products. Use of these guides eliminated the
appreciation for level of detail required for adequate documen-
need to include every item in the nutrient database. For exam-
tation of food intake data. Standardized techniques for con-
ple, the nutrient database included ‘60 generic entries for
margarines categorized by total fat and ratio of polyunsaturated
ducting an effective research interview were presented through
to saturated fatty acids (P:S). The margarine guide, with > 250
written exercises, discussion, demonstration, role playing, and
brand name margarmnes, specified which of 60 generic marga-
use of a videotape illustrating both good and poor interviewing
rime codes in the database best represented each brand name
techniques. Practice in use of the data collection forms and
margarine. Some brand name guides also designated the
food models was also provided.
amounts of standard portions. For example, the cracker guide,
The second phase of the training and certification process
which classified crackers according to two amounts of fat, also
consisted of coding a set of six standardized recalls. The third
indicated the weight of each brand name cracker.
phase involved collection and coding of 10 24-h recalls from
study-similar men with use of MRFIT dietary intake forms and
Fat specificity in food preparation
protocol. All data were reviewed by NCC nutritionists. If the
collected and coded data did not meet acceptable levels of Specificity for fats used in recipes and other food prepara-
accuracy and specificity, the procedures were repeated. When tions was achieved by permitting the designation of any type or
prescribed standards were met, the interviewer was certified to brand of fat used in any preparation method. For example, a
piece of fried chicken might have been prepared with any one
collect MRFIT dietary recalls.
of > 100 fats listed in the nutrient database. These fats repre-
A continuing education program for dietary interviewers was
sented > 500 brand name oils, shortenings, and margarines, as
designed to maintain high quality data collection and documen-
well as various generic types of fats such as butter, bacon fat,
tation. Use of “Dietary Inquiry,” a form for requesting addi-
lard, corn oil, or wheat germ oil. Similarly, the system permit-
tional information or for clarifying ambiguous documentation,
ted designation of any type or brand of fat as a major fat
provided immediate,
individualized feedback to interviewers.
ingredient in recipes.
The Communique, a bimonthly newsletter, addressed actual or
Computerized algorithms for coding standard food prepara-
potential documentation problems and provided information
tions were incorporated into calculation software to facilitate
relating to new products, new entries, or changes in NCC
coding and permit maximum flexibility for preparation meth-
procedures or personnel. The bimonthly Worksheet consisted
ods and fat options. For example, coding for breaded and fried
of exercises to enhance good documentation practices.
fish designated the preparation code BDF (for “breaded and
fried”) and the fat code BCOM (to indicate preparation in a
Coding procedures medium-priced commercial establishment). These codes then
prompted the computer to calculate automatically the amounts
Coder training of fish, flour, salt, and fat based on total amount of breaded and
Coding, the process of converting food intake data into code fried fish consumed. The type of fat was the oil most corn-
numbers and amounts for nutrient calculation, was performed monly used for frying fish in medium-priced commercial es-
by trained food coders who had received extensive instruction tablishments. Computerized algorithms were used for all stan-
in use of the coding manual and coding procedures. Approxi- dard preparations of meat, poultry, fish, eggs, and vegetables.
mately 100 h of practice in coding was required before new Table Al lists computerized food preparation algorithms.
coders were permitted to code study data. Food coders worked
under direct supervision of staff nutritionists who were avail- Coding of uncommon foods
able at all times to resolve coder questions and to decide how A comprehensive cross-referenced “uncodables” file con-
to handle ambiguous documentation. sisted of directions for coding > 2000 infrequently consumed
206S DOLECEK El AL
TABLE Al
Computerized food preparation algorithms
For meat, fish, and poultry (to be used only when fat was added in cooking)
Pan: pan fried or grilled-cooked in skillet, unbreaded, moderate amount of fat; computerized rule: 1/2 tsp fat/oz of meat. Meat pan
fried in its own fat (no fat added)-no prep code needed.
BDF: breaded and fried-food coated with crumbs or flour before frying in moderate to deep fat; computerized rule: 1 tsp fatloz of meat
(breading and “wash” are disregarded).
BSI: oven cooked, broiled, or grilled, and basted or braised with fat; computerized rule: 1/2 tsp fatloz of meat.
MAR: for meat, fish, or poultry marinated in oil-containing mixture and basted during broiling; computerized rule: 1/2 tsp fatloz of meat.
If not basted during cooking, disregarded fat if marinated.
For vegetables
SES: seasoned-vegetables, rice, or pasta seasoned with type of fat in cooking (butter, margarine, pork fat, etc); use also for stir fried.
Computerized rule: 1 tsp fat per 1/2-cup portion.

BVF: breaded vegetable, fried-computerized rule: 1 tsp per 1/2-cup portion.
For eggs (to be used only when fat was added in cooking)
EGF: egg, fried-computerized rule: 1 tsp fat per egg. For scrambled egg, omelet, and imitation egg, use APF code.
For recipes with variable principal fat source

APF: “add principal fat”-computer adds standardized amount of designated fat to recipes or commercial items designated as APF in
the cookbook.
/ tsp, teaspoon; oz, ounce.
foods or food combinations requiring the use of one or more reviewed in detail by a third coder. This system of duplicate
existing database entries. Use of this file standardized coding coding provided ongoing and immediate feedback to food
while eliminating the need to clutter the database with many coders. If a coder’s performance fell below acceptable stan-
uncommonly consumed recipes and other food items. An ex- dards for accuracy and speed, the coder was removed from
ample of an item in the uncodables file was bobka, a Polish production coding and given individualized refresher training.
bread containing egg; directions specified that bobka was to be If performance continued to be marginal, the coder was termi-
coded as an egg bread. A reference library of domestic and nated or reclassified for other duties.
foreign cookbooks was also maintained to facilitate coding of Computerized edit checking included checks for valid code
uncommon recipes. numbers, units, preparation codes, and fat codes; flagging of
amounts exceeding maximum serving sizes; and flagging of
Default assignments nutrients outside allowable ranges for daily totals. All flagged
Further standardization of coding was achieved by use of data were corrected or verified before final processing of coded
default options that specified the coding when food description data.
details could not be obtained. Default options were provided Consistency in long-term coding was evaluated through an
for both home and commercial preparations as well as for low, external monitoring procedure conducted by the NHLBI Pro-
medium, and high-priced restaurants. For example, default gram Office. Seventy dietary recalls were selected and given
options for frying fat for egg rolls included hydrogenated special identification before annual submission to the NCC
soybean oil for home preparation, a commercial frying short- along with actual study records. Results of five repeated cod-
ening for medium-priced restaurants, and peanut oil for high- ings of these recalls showed no significant differences (P >
priced restaurants. Default assignments were based on fre- 0.05) for any of the calculated nutrients (1).
quency of use in each type of eating situation.
Nutrient calculation
Estimation of amounts Nutrients were calculated from the coded dietary recalls by
Standard food models, geometric shapes, various household the MRFIT Coordinating Center using the nutrient database
measures, and standard serving sizes were used to increase maintained by the NCC (3). The design of the nutrient calcu-
accuracy of estimating portions of food consumed. Computer- lation system, sources of nutrient data, and procedures for
ization of amount conversions further facilitated the coding updating the nutrient database and ensuring its ongoing accu-
process and reduced potential for calculation errors. racy are presented below, followed by descriptions of the
versions of the NCC nutrient database used for calculating
Coding quality control procedures MRFIT dietary recall data and potential for future reanalysis.
Procedures incorporated into the system to ensure accuracy
Design of the nutrient calculation system
and consistency of coding included duplicate coding, comput-
erized edit checking, and external monitoring. Duplicate cod- The nutrient calculation system was designed to provide
ing was performed in a random sample of 20% of all dietary maximum specificity for describing foods while minimizing
recalls. Discrepancies between duplicate codings were re- number of entries in the nutrient database. Nutrient calculations
viewed by a nutritionist, and errors were corrected by the coder for > 150 000 foods and food combinations were possible with
or coders responsible. If more than an allowable number of a nutrient database of < 2000 entries. This was accomplished
errors was made in a batch of 25 recalls, the entire batch was through implementation of coding and calculation features
METHOD ISSUES 207S
described above such as the optional selection of fats in food Detailed historical documentation of all nutrient and nonnutri-
preparations and recipes, use of brand name and other coding ent data, including calculation or other estimation procedures,
guides, and use of computerized algorithms for calculating was maintained for every database entry.
amounts of ingredients in food preparation methods. Imple-
mentation of these features reduced the level of specificity of Procedures for updating the nutrient database
food description in detail to meet dietary assessment objectives Because of the dynamic nature of the marketplace, the avail-
required for research purposes. Limitation of the number of ability of new or improved data, and expanding research inter-
entries in the nutrient database permitted ongoing and efficient ests in new nutrients, the NCC nutrient database was routinely
updating and maintenance of the system. updated. Standardized procedures for systematic updating of
the database were developed to ensure ongoing accuracy and
Sources of nutrient data
internal consistency of the data. These procedures have been
NHLBI nutritionists worked collaboratively with nutrition documented (3). Computerized procedures replaced manual
scientists from the US Department of Agriculture (USDA) to procedures wherever possible to enhance efficiency and reduce
develop the original nutrient database. The primary source of

the potential for error.
nutrient data was the USDA agricultural handbook no. 8 (4). About every 6-12 mo, a new version of the nutrient database
Ongoing updates were based on the revised sections of agri- was released. Table A2 summarizes updates and additions
cultural handbook no. 8 (5) and the updated versions of the included in versions 8 through 1 1 Entries were never deleted.
USDA Nutrient Database for Standard Reference (6). Other from the nutrient database. When a product was discontinued,
USDA sources of nutrient and nonnutrient data (such as den- the entry was “deactivated,” which meant that it could no
sities, recipe yields, and serving size dimensions) included longer be used in coding. However, the item continued to be
various provisional tables (7-1 1), handbooks, and manuals updated with new nutrients or improved data so that recalls
(12-18). collected in the past could be reanalyzed with a more recent
Another major source of nutrient data was information from version of the database.
manufacturers. An extensive manufacturers’ file consisting of
nutrient and ingredient information for thousands of commer- Quality control procedures for nutrient calculation
cial foods was maintained at the NCC. About 3000 of the most
Numerous quality control procedures were incorporated into
common brand name products were updated at least annually.
the system to ensure validity of the nutrient database. All
New products were added in an ad hoc basis as they were
nutrient data were evaluated by the nutrition staff based on
encountered in processing dietary recalls. Information from the
factors such as credibility of the data source, sample size,
manufacturers’ file was used not only to maintain commercial
entries in the database, but also to update brand name coding
guides and to make coding decisions for infrequently con- TABLE A2
sumed commercial products. Nutrient additions and major nutrient and food group updates for
Nutrient and nonnutrient data were also obtained from the versions 8 through 1 1 of the Nutrition Coordinating Center nutrient
scientific literature, international food-composition tables, and database
popular and ethnic recipe books. A computerized recipe file
Database version and updated or added nutrients or food groups
included information on ingredients, amounts, yields, and ref-
erences for “500 recipes. Nutrients for cooked recipes were Version 8 (1982)
calculated from individual cooked ingredients. Nutrient values Saturated, monounsaturated, and polyunsaturated fatty acids update
Sodium and potassium updated’
for recipes were automatically calculated and posted to the
Total a-tocopherol equivalents, and a-, f3-, y-, and &.tocopherols
nutrition database.
added2
To minimize the effect of missing values, which were cal-
Version 9 (1983)
culated as zeros in the nutrient analysis, values were estimated 22 individual fatty acids added
whenever possible. Missing values were permitted only when Breakfast cereals updated, fruit and fruit juices updated, pork products
no data existed to suggest whether or not a nutrient was present updated, caffeine updated
in a food. Estimated values were based on a similar food or a Iron updated
different form of the same food with use of USDA data for Version 10 (1984)
nutrient retentions and moisture adjustments. Other estimated Copper added
values were based on published recipes or food formulas for Version 11 (1985)
Total dietary fiber added; soluble and insoluble fiber, zinc, and
commercial items, product ingredient lists, or other nutrients in
magnesium added; vitamins B-6 and B-12 added; folacin updated
the same food. A more detailed description of procedures used
to estimate values is presented elsewhere ( 19). Missing or I The number of food items in the database was expanded to enhance
estimated values were replaced with empirical data when such specificity for sodium composition.
2 Total a-tocopherol equivalents reflect the partial biological activity of
data became available.
the non-a-tocopherols. Missing values for composite foods were estimated
When nonnutrient data such as portion sizes or recipe yields
based on the tocopherol profile of the ingredient fat. When the values for
were unavailable, NCC nutritionists occasionally obtained in-
individual tocopherols were available, the total a-tocopherol equivalents
formation by purchasing food items to determine weight and
were calculated from the following algorithm; total a-tocopherol equiva-
dimensions for various portions or by preparing recipes to lents = (a-tocopherol) + 0.4 (f3-tocopherol) + 0.1 (‘y-tocopherol) + 0.01
determine yields. Standard laboratory equipment in the Depart- (&.tocopherol) (20). Values reported as vitamin E were converted to total
ment of Food Science and Nutrition at the University of Mm- tocopherol equivalents, and all individual tocopherol activity was esti-
nesota was available for determination of food measurements. mated as a-tocopherol.
208S DOLECEK El AL
sample preparation, analytic method, and use of reference though the individual fatty acid values were not added to the
standards. These procedures are described in detail elsewhere database until several years after the data had been
(3). collected.
All updates to the database were made by an NCC nutri-
tionist, cross-checked by a second nutritionist, and verified
by the first nutritionist before incorporation into the data-
REFERENCES
base. A computer report comparing old with new data was
produced for documentation of each updated entry. For each 1. Tillotson JL, Gorder DD, DuChene AG, Grambsch PV. Wenz J.
new entry, a report of all data elements was provided for Quality control in the Multiple Risk Factor Intervention Trial nutrition
documentation. modality. Control Clin Trials l986;7:66S-90S.
Before the release of a new version of the nutrient 2. Dennis B, Ernst N, Hjortland M, Tillotson J. Grambsch V. The NHLBI
database, the entire food table was reviewed by the nutrition nutrition data system. J Am Diet Assos 1980:77:641-7.
staff for accuracy and internal consistency through use of a 3. Sievert YA, Schakel SF, Buzzard IM. Maintenance of a nutrient
series of computer generated “integrity reports” (3). These database for clinical trials. Control Clin Trials 1989:10:416-25.

reports compared database values with calculated algorithms 4. Wau BK, Merrill AL. Composition of foods: raw, processed, prepared.
Revised agriculture handbook no. 8. Washington. DC: US Govern-
or known or expected values. For example, the sum of
ment Printing Office. 1963.
macronutrients plus ash and water was compared with 100 g
5. Composition of foods: raw. processed. prepared. Revised agriculture
for each entry. The reports also facilitated comparison of
handbook nos. 8-1 to 8-10. Washington. DC: US Government Print-
nutrient values within a food group to identify inconsis-
ing Office, 1976 and 1987.
tencies. Any outlying values were either verified or 6. US Department of Agriculture. Nutrient data base for standard refer-
corrected. ence (computerized nutrient data set). Release 6. Springfield, VA:
National Technical Information Service, US Department of Com-
Versions of the database usedfor calculating MRFJT dietary’
merce, 1987.
data 7. US Department of Agriculture. Provisional table on the fatty acid and
After completion of dietary data collection and processing, cholesterol content of selected foods. Washington, DC: US Govern-
the MRFIT recalls were analyzed for nutrients in 1982 with ment Printing Office, 1984.
version 8 of the NCC nutrient database. All MRFIT nutrition 8. US Department of Agriculture. Provisional table on the nutrient con-
tent of bakery foods and related items. Washington. DC: US Govern-
publications before 1986 are based on nutrient calculations
ment Printing Office, 1981.
with version 8. In November 1985, nutrients were recalculated
9. US Department of Agriculture. Provisional table on the nutrient con-
with version 1 1 of the database to take advantage of improved
tent of canned and frozen vegetables. Washington, DC: US Govern-
nutrient data as well as added nutrients. A list of the nutrients ment Printing Office, 1979.
included in versions 8 and 1 1 of the NCC nutrient database is 10. US Department of Agriculture. Provisional table on the nutrient con-
presented in Table I. tent of canned, dried, and frozen fruit. Washington. DC: US Govern-
The 30 nutrients added to the database between versions 8 ment Printing Office, 1981.
and 1 1 included 22 individual fatty acids, total fiber, soluble 1 1 . US Department of Agriculture. Supplement to provisional table, fola-
and insoluble fiber, retinol and f3-carotene equivalents, vita- cm content of foods. Washington. DC: US Government Printing Of-
mins B-6 and B- I 2, copper, zinc, and magnesium. Major fice, 1979.
nutrient updates between versions 8 and 1 1 included a com- 12. US Department of Agriculture. Food yields summarized by different
prehensive review and update of all caffeine, iron, and folic stages ofpreparation. Agriculture handbook no. 102. Washington, DC:
Agricultural Research Service, 1975.
acid values. Food group updates between versions 8 and 11
I 3. US Department of Agriculture. Iron content of food. Home economics
included cereals, fruit, and pork (5).
research report no. 45. Washington, DC: US Government Printing
As indicated previously, design of the NCC nutrient database
Office, 1983.
and calculation system ensures that data collected in the past
14. US Department of Agriculture. Nutritive value of American foods in
can be reanalyzed with an updated version of the nutrient common units. Agriculture handbook no. 456. Washington, DC: US
database. Thus, reanalysis of MRFIT dietary recalls will con- Government Printing Office. 1975.
tinue to be an option for the future. Decision to reanalyze these 15. US Department of Agriculture. Pantothenic acid. vitamin B6 and
data will depend on relevance of changes and additions to the vitamin B12 in foods. Home economics research report no. 36. Wash-
database in light of future research interests. ington, DC: US Government Printing Office, 1969.
When interpreting nutrient data, it is essential to keep in 16. US Department of Agriculture. Procedures for calculating nutritive
mind that the accuracy of nutrient calculations is limited by values of home-prepared foods. Washington, DC: Agricultural
the specificity with which the data were collected. For Research Service, 1966. (Publication no. 62-13.)
17. US Department of Agriculture. The fortification of foods: a review.
example, detailed specificity for type and amount of fat
Agriculture handbook no. 598. Washington, DC: US Government
intake was a major concern in the MRFIT data collection
Printing Office, 1982.
protocol. Sodium, however, was not a major emphasis, and
18. US Department of Agriculture. The sodium content of your food.
no effort was made to differentiate between amounts of
Washington, DC: US Government Printing Office, 1980. (Home and
sodium in brand name products or in food preparation garden bulletin no. 233.)
methods. Thus, despite the capability of the current NCC 19. Schakel SF, Sievert YA, Buzzard IM. Sources of data for developing
system to provide detailed specificity for sodium, the MR- and maintaining a nutrient database. J Am Diet Assoc
FIT sodium calculations must be interpreted with caution. l988;88: 1268-71.
On the other hand, a high degree of confidence may be 20. McLaughlin PJ, Weirauch JL. Vitamin E content of foods. J Am Diet
placed in the validity of the calculations for fatty acids, even Assoc l979;75:647-65.
METHOD ISSUES 209S
APPENDIX B 6. Eggs (Once in a while)

Whole-egg products, egg yolk, and egg recipes, not
Food groups in the Multiple Risk Factor Intervention fat-controlled
Trial and their recommended use category 7. Breads and cereals (OK as is)
Low-fat breads, rolls, and crackers
1 . Meat: low- and medium-fat (OK as is)
Low-fat beef and veal, 3.8-10. 1% fat Cereals, grains, and flours, unsweetened
Low-fat pork, 3.8-10.1% fat
Prepared cereals
Low-fat lamb and miscellaneous meats, 3.8-10.5% fat
Cereals, presweetened
Low-fat poultry, 3.8-10.1% fat Pastas
Low-fat mixed dishes: beef and veal Starchy vegetables, plain
Low-fat mixed dishes: pork 8. Fruit (OK as is)
Low-fat mixed dishes: poultry Citrus fruit and juices without sugar
Medium-fat beef and veal, 10.2-17.5% fat Other fruit, fresh
Medium-fat pork, 10.2-17.5% fat Other fruit, processed without sugar

Medium-fat poultry, 10.2-17.5% fat Dried fruit, uncooked
Medium-fat mixed dishes: beef and veal Dried fruit, cooked without sugar
Medium-fat mixed dishes: poultry Fruit and juices, processed with sugar
Fish, 0.1-8.9% fat Fruit-flavored beverages, predominantly sugar fortified
Fish, 9% fat 9. Vegetables (OK as is)
Shellfish Cooked vegetables
Fish recipes, fat-controlled Raw vegetables
Shellfish recipes, fat-controlled 10. Legumes (OK as is)
2. Meat: high-fat (Avoid) Nonfat cooked and uncooked legumes
High-fat beef, 17.6% fat 1 1 Baked goods and desserts:
. low-fat (OK as is)
High-fat pork, 17.6% fat Low-fat desserts: relatively high in nutrients
High-fat lamb and miscellaneous meats, 17.6% fat 12. Miscellaneous foods: low-fat (OK as is)
High-fat poultry, 17.6% fat Beverage powders and miscellaneous low-fat foods
High-fat mixed dishes: beef Condiments, pickles, and miscellaneous
High-fat mixed dishes: pork Low-fat, low-energy-containing products
High-fat mixed dishes: lamb and miscellaneous meats 13. Miscellaneous foods: low-fat (OK as is)
Organ meats Low-fat cooked legumes
Fish recipes, not fat-controlled Imitation dairy, polyunsaturated vegetable fat: milk and
Shellfish recipes, not fat-controlled cream
3. Dairy: low-fat (OK as is) Imitation dairy, polyunsaturated vegetable fat: cheese
Nonfat milk products, < 1% fat: milk Imitation dairy, polyunsaturated vegetable fat: frozen
Nonfat milk products, < 1% fat: cheese and cheese desserts
dishes Egg whites, imitation eggs, and egg recipes, fat-
Nonfat milk products, < I % fat: frozen desserts controlled
Low-fat milk products, 1-2% fat: milk Nuts, peanut butter, and seeds
Low-fat milk products, 1-2.9% fat: cheese and cheese Low-fat and fat-controlled soups and sauces
dishes Muffins, biscuits, “rich-rolls,” and breading mixes, fat-
Low-fat milk products, 1-2.9% fat: frozen desserts and controlled
yogurt Cookies, fat-controlled
4. Dairy: medium-fat (Once in a while) Cakes and toppings, fat-controlled
Whole-milk products, 5% fat (3-10%): milk Pies, cobblers, shells, and fillings, fat-controlled
Whole-milk products, 5% fat (3-10%): cheese and cheese Miscellaneous fat-containing desserts and snacks, fat-
dishes controlled
Whole-milk products, 5% fat (3-10%): frozen desserts Starchy vegetable and pasta recipes, fat-controlled
and yogurt Cooked vegetable recipes, fat-controlled
Moderately high-fat milk products, 13% fat (10-20% Salads, pasta, vegetable, and fruit, fat-containing, fat-
fat): cheese and cheese dishes controlled
5. Dairy: high-fat and unacceptable medium-fat (Avoid) Textured vegetable protein foods, acceptable fat
Imitation dairy and saturated vegetable fat: milk and 14. Fats and oils: polyunsaturated (OK as is)
cream “Preferred” (highly polyunsaturated)
Imitation dairy and saturated vegetable fat: frozen des- Margarines, oils with ratio of polyunsaturated to satu-
serts and yogurt rated fatty acids (P:S) > 2.5
Moderately high-fat milk products, 13% fat (10-20% “Acceptable” margarmnes, oils, and shortenings, P:S
fat): cream 2.0-2.5
Moderately high-fat milk products, 13% fat (10-20% Salad dressings
fat): frozen desserts 15. Fats and oils: monounsaturated (Once in a while)
High-fat milk products, 28% fat (20-35% fat): cream “Marginally acceptable” margarines, oils, and shorten-
High-fat milk products, 28% fat (20-35% fat): cheese ings, P:S 1.0-1.9
and cheese dishes Avocado, olives, cheese, and salad dressings
210S DOLECEK El AL
16. Fats and oils: saturated (Avoid) Cookies, not fat-controlled

Predominantly saturated vegetable oils, margarines, and Cakes and toppings, not fat-controlled
shortenings, 1.0
P:S < Pies, cobblers, shells, and fillings, not fat-controlled
Animal fats and animal-vegetable blends (predominant- Miscellaneous fat-containing desserts, not fat-controlled
ly animal) Other fat-containing sugars, sweets, and recipe ingredi-
Coconut ents, not fat-controlled
17. Crackers, snacks, and miscellaneous foods: unaccept- 19. Sugars and sweets: low-fat (Once in a while)
able fat (Avoid) Sugars, syrups, and preserves
Textured vegetable protein foods, saturated vegetable fat Low-fat desserts: relatively low in nutrients
Fat-containing crackers and chips Low-fat candies
Fat-containing soups and sauces, not fat-controlled Soft drinks with sugar, with caffeine
Salads, vegetables, and fruit, fat-containing, not fat- Soft drinks with sugar, without caffeine
controlled Caffeine-containing beverages
Cooked vegetable recipes, not fat-controlled Soft drinks, without sugar, with caffeine

Starchy vegetable and pasta recipes, not fat-controlled Soft drinks, without sugar, without caffeine
18. Baked goods and desserts: high-fat (Avoid) Coffee substitutes
Muffins, biscuits, “rich-rolls,” breading mixes, and 20. Alcohol-containing beverages (Once in a while)
granola-type cereals, not fat-controlled Alcoholic beverages

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Chapter 3.

Methods of dietary and nutritional assessment

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A 24-h dietary recall data collection and analysis system was

trials were funded simultaneously to investigate approaches to TABLE 1

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MRFITfood group system y-Tocopherol 18:2 (linoleic)’

, Data became available for these nutrients in November 1985, at which

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NUTRITION INTERVENTION METHODS FOR SI MEN

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For recipes with variable principal fat source

/ tsp, teaspoon; oz, ounce.

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APPENDIX B 6. Eggs (Once in a while)

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16. Fats and oils: saturated (Avoid) Cookies, not fat-controlled

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