RESEARCH

Original Research

Energy Intake in Socially Vulnerable Women

Living in Brazil: Assessment of the Accuracy
of Two Methods of Dietary Intake Recording
Using Doubly Labeled Water
Isabela Lays Lopes Lins, MSc; Nassib Bezerra Bueno, PhD; Ana Paula Grotti Clemente, PhD; Karina Pfrimer, PhD;
Ana Lydia Sawaya, PhD; Telma Maria de Menezes Toledo Florêncio, PhD

ARTICLE INFORMATION ABSTRACT

Article history:
Submitted 1 September 2015
Accepted 23 February 2016
Available online 12 April 2016
Keywords:
Doubly labeled water
Energy intake
Food frequency questionnaire
Low income population
24-hour food recall
2212-2672/Copyright ª 2016 by the Academy of
Nutrition and Dietetics.
http://dx.doi.org/10.1016/j.jand.2016.02.023
Background Diet is related to the prevention of chronic diseases, but assessing dietary
intake is a complex task, especially in socially vulnerable populations.
Objectives To assess the accuracy of the 24-hour food recall (24HFR) and the food
frequency questionnaire (FFQ) methods in socially vulnerable women in Brazil and
compare these methods against doubly labeled water (DLW).
Design Cross-sectional study. Energy intake (EI) was measured using 3 24HFRs and 1
FFQ. Total energy expenditure (TEE) was measured using DLW. Cutoff points were
calculated to assess underreporting and overreporting using both the difference and the
ratio between the EI and TEE.
Participants/setting Sixty-seven socially vulnerable, nondieting adult women with
stable body weight and mothers of malnourished children.
Main outcome measures EI, in kilocalories, derived from 24HFR and FFQ.
Statistical analyses Repeated measures analysis of variance was used to compare EI
and TEE and Bland-Altman graphs were plotted to assess the agreement between these
variables. Spearman correlation coefficient between the ratio of EI to TEE and socio-
economic or anthropometric variables was calculated.
Results Mean TEE was 2,186 kcal (95% CI 2,063 to 2,309 kcal). EI obtained through
24HFR (mean¼1,848.6 kcal [95% CI 1,737.5 to 1,959.7 kcal]) was significantly lower than
TEE (P¼0.01), and significantly lower than the EI obtained through FFQ (mean¼2,084.5
[95% CI 1,929.0 to 2,240.0 kcal]; P<0.01). There were no statistically significant differ-
ences between the EI values of FFQ and TEE (P¼0.89). The distribution of under-
reporters, nonunderreporters, and overreporters were more homogenous in the FFQ
method. There was a positive correlation between body fat percentage and under-
reporting in the FFQ method (r¼0.245; P¼0.046).
Conclusions The methods of assessing dietary intake in our study showed poor
agreement with TEE obtained by DLW. These may, therefore, not be the most suitable
methods for assessing EI in this population.
J Acad Nutr Diet. 2016;116:1560-1567.

lead to better data reliability.7 In addition, it is common to

T
HE PREVENTION AND/OR CONTROL OF CHRONIC
diseases such as obesity is closely related to dietary
intake.1 However, the assessment of individual or
group dietary intake is a complex task because it
involves issues related to socioeconomic status and
biology.2 Dietary intake assessment often attempts to
quantify intake in addition to qualitatively assessing intake.
This information is useful for planning health actions and
formulating dietary recommendations for populations.3,4
Nevertheless, dietary surveys have questionable accu-
racy.5,6 Such methods have flaws inherent to dietary
assessment, and no gold standard is available yet. Studies
that use more than one type of concomitant dietary survey
attempt to validate the methods of assessing dietary intake
using biomarkers because these are not affected by the
biases usually present in survey data collection, such as
recall or interviewer bias.8
The doubly labeled water (DLW) technique is a gold stan-
dard biomarker that allows a precise measurement of the
total energy expenditure (TEE).9 When an organism is in
energy balance, energy expenditure is equal to energy intake
(EI); hence, the DLW may be used to validate methods for
assessing usual EI accurately.10 Studies using the DLW tech-
nique show the limitations of assessing dietary intake
through dietary surveys. In general, the survey methods

1560 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS ª 2016 by the Academy of Nutrition and Dietetics.

underestimate EI, which is mainly due to individual
underreporting.11,12
Although the number of studies using DLW to validate
methods of assessing dietary intake are increasing, there is
little research in socially vulnerable populations, such as
those living in outskirts of big cities.13 In addition, socially
vulnerable and lower-educated individuals are more likely to
be nonresponders to surveys, possibly due to lack of under-
standing of the questionnaires.14 Moreover, the prevalence of
overweight and chronic diseases in the low-income strata of
the population has undergone significant increases. There-
fore, the present study aimed to evaluate the accuracy of two
different methods of dietary intake records—the 24-hour
food recall (24HFR) and the food frequency questionnaire
(FFQ) methods—in socially vulnerable women living in slums
in the northeast of Brazil and compare them with the TEE
obtained via DLW. The hypotheses were that both survey
methods would present important underreporting of EI.
METHODS
Population Study
Socially vulnerable women who lived in the seventh
administrative region of Maceió-AL, Brazilian Northeast, were
studied. This administrative region has a Human Develop-
ment Index of 0.528, the lowest of the city, and is home to the
Federal University of Alagoas and its Center for Recovery and
Nutritional Education (CREN-AL) for malnourished children.
The Center treats regularly 100 children with moderate to
severe malnutrition in a daycare hospital system. The families
of these children are usually very poor and have a weak social
network. The majority come from the countryside and settle
in the shantytowns located in the outskirts of the city that
lack infrastructure, and do not bring with them another
family member or friend. Often, they have no affiliation to
any social group and do not attend the local clinic or health
center. Women are usually unemployed or have informal jobs
and receive government benefits to increase income. Overall,
these families are in a situation of extreme social
vulnerability.
The studied women were mothers of the malnourished
children who are attended to in CREN-AL. The sample was
drawn from the 100 mothers bound to CREN-AL. Only
women aged 19 to 45 years were recruited. Pregnant women,
those who had physical disabilities that could interfere with
anthropometry, and those who self-reported to be dieting or
presented with weight change in the previous month or
during the 14 days of DLW assessment were not included.
Data collection was conducted between September 2012 and
August 2013. After all inclusion and exclusion criteria were
applied, the final sample included 67 women.
Socioeconomic data, anthropometric parameters (weight,
height, body mass index [BMI], and body fat percentage), total
energy expenditure, and dietary intake through FFQ and 24HFR
were assessed. Approval for the study was obtained by the Ethics
in Research and Education Center, CESMAC (Centro de Estudos
Superiores de Maceió) University (Alagoas, Brazil) under pro-
tocol no. 1588/12. All participants provided written consent.
Socioeconomic and Anthropometric Characteristics
One standardized questionnaire was used to assess
the socioeconomic and demographic characteristics of
October 2016 Volume 116 Number 10
RESEARCH
participants. Education level, assessed by how many years
the women spent studying, and self-reported family income
data were chosen as predictors of dietary intake under-
reporting. Anthropometric evaluation was performed at
CREN-AL, with all women wearing light clothing and
without shoes. Weight was measured using a calibrated
portable digital scale, with a maximum capacity of 200 kg
and 0.1-kg precision (110 CH; Welmy, São Paulo, Brazil).
Height was measured using a stadiometer (30 to 200 cm)
with an accuracy of 0.1 cm, attached to the digital scale. BMI
was calculated and classified according to the method used
by the World Health Organization.15 Body fat percentage
was obtained by the DLW method. Briefly, subjects ingest
water containing deuterium isotopes and oxygen-18, which
are distributed evenly throughout total body water. Then, it
is assumed that the lean body mass represents a fixed ratio
in the total body water and may be calculated. Thereafter, fat
mass is obtained by subtracting lean body mass from total
weight.16
Evaluation of TEE
To calculate TEE, the multipoint DLW method was used, in
accordance with the recommendations of the International
Dietary Energy Consultancy Group.17 First, baseline urine
samples of all participants were collected after 10 hours of
fasting. Then, each participant received, orally, a dose of DLW.
The DLW was composed of 0.12 g heavy water (99.8% excess
atoms)/kilogram of body water and 2 g H218O (10% excess
atoms)/kilogram of body water. A standard dose was created
considering the average weight (67 kg) of the sample. It was
assumed that 73.2% of body mass was water.18 Subsequently,
urine samples (the second urine of the day) of each volunteer
were collected on the first, second, third, seventh, 12th, 13th,
and 14th days after the baseline collection.
Analyses were performed by mass spectrometry isotope
ratios (ANCA 20-20, Europe Scientific) for carbon (ANCA 20-
22, Sercon) for deuterium at the Mass Spectrometry Labo-
ratory of the School of Medicine of Ribeirão Preto, which is
accredited by the International Atomic Energy Agency. The
spaces isotopic dilution were calculated according to Scho-
eller19 using the baseline sample and the samples taken
during the experimental period. The elimination rate of
deuterium and oxygen-18 were calculated according to
Speakman.16 The rate of carbon dioxide production was
calculated according to Coward and colleagues17 and the TEE
was calculated assuming a respiratory quotient of 0.85. All
measurements met the following criteria: the ratio of dilu-
tion space of deuterium/space dilution of oxygen-18 were
between 1.01 and 1.07 and the differences in the sample
triplicates were 5 delta for hydrogen-2, and 0.5 delta for
oxygen-18.19,20
Evaluation of EI
Two methods to assess dietary intake were used: 24HFR and
FFQ. The 24HFR was applied on 3 different days (4th, 8th, and
12th days, considering the DLW period, with the 8th day
being on the weekend). The FFQ used was a slight adaptation
of the one developed by Cardoso and colleagues21 validated
for low-income women, and was used only once, on the last
day of the DLW period. A pilot test was conducted with the
employees of CREN-AL, and regional foods, such as corn
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1561
RESEARCH
couscous, were added to the original FFQ.21 The usual fre-
quency of consumption on the FFQ was daily, weekly, and
monthly. To assist in the quantification of food portions, a
photograph book was used for both the 24HFR and the FFQ.22
One trained nutritionist applied all the questionnaires by
interview and performed the coding and analysis of dietary
assessments. The values of the frequencies of consumption of
the FFQ were converted to daily consumption with the aid of
Microsoft Excel (version 2007, 2007, Microsoft Inc).
The Brazilian NutWin software (version 1.5, 2002, Federal
University of São Paulo) was chosen to convert the portion
sizes in grams. EI was calculated using the National Nutrient
Database for Standard Reference, release 26 (US Department
of Agriculture), Tabela Brasileira de Composição de Alimentos
(Núcleo de Estudos e Pesquisas em Alimentação), and Tabela
de Equivalentes, Medidas Caseiras e Composição Química Dos
Alimentos 2nd edition (Pacheco M), in this order of prefer-
ence. The same databases and software for both methods
were used. To account for the within-subject variation in
multiple 24HFR, the adjustment suggested by the National
Research Council was used.3 This method is adequate for
small samples with equal number of observations for in-
dividuals. Briefly, it estimates the distribution of intakes by
partitioning the observed variance into its between- and
within-person components, and then shifting each point in
the observed distribution closer to the mean by a function of
the ratio of the square roots of the between-person variance
and observed variance. In this way, the method attempts to
remove the effect of within-person variation on the observed
distribution. A systematic approach is available in Appendix E
of a more recent document.23
Identification of Underreporters of Dietary Intake
The identification of underreporters was made according to
Scagliusi and colleagues.24 The indicators used to assess
underreporting were the mathematical ratio between EI and
TEE and the mathematical difference between EI and TEE.
Because both EI and TEE are prone to within-subject varia-
tions, it is necessary to calculate the variation coefficients. For
the TEE and FFQ, the coefficients of within-subject variability
from the study of Scagliusi and colleagues24 analyzed in the
same laboratory, 8.8% and 23%, respectively, were adopted for
the present study. For the 24HFR, the coefficient of variation
for the three replicates was 23.9% and it was obtained by
dividing the standard deviation by the respective mean of the
EI. From the coefficients of within-subject variation of EI from
both methods and of TEE the limits of the 95% CI, within
which the two measurements, EI from one of the methods,
and TEE should agree, were calculated. This calculation is
given by the following equation:
qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi
2 ½ðCVEI 2 =dÞ þ ðCVTEE 2 Þ
Where CVEI¼the within-subject coefficient of variation (CVs)
of EI, d¼the number of days that the method was applied,
and CVTEE¼within-subject coefficient of variation of TEE.
This led to an expected difference of 18% from the FFQ,
which means that subjects with an EI:TEE above 1.18 are
classified as overreporters, and those below 0.82 as under-
reporters. For 24HFR, the expected difference was 33%, so an
1562 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
EI:TEE below 0.67 identified the underreporters and that
above 1.33 identified the overreporters.
Statistical Analysis
Continuous data are presented as meansstandard devia-
tion, and categorical data are presented as absolute and
relative frequencies. The normal distribution of continuous
data was assessed by Lilliefor test and the homogeneity of
variances by Levene test. To compare the difference between
consumption reported by different methods of food intake
and energy expenditure of groups, a repeated measures
analysis of variance was used, with Bonferroni post hoc.
Fisher exact test was used to compare the association be-
tween classes of reporters and BMI classification within each
evaluation method of dietary intake. The proportions of
classes of reporters between both evaluation methods was
compared by the McNemar test. For the comparisons of
continuous variables among different BMI classes, analysis
of variance with Tukey honest significant difference test
post hoc was conducted.
To assess the agreement between the EI obtained by each
method of dietary intake record and the TEE, Bland-Altman
plots were created. This graph plots the mathematical dif-
ferences between each individual value of two methods over
the mean of the same values. In addition, for each method of
dietary intake record, Spearman correlation coefficients were
calculated between the EI:TEE and the following variables:
age, BMI, years of schooling, and monthly per capita income.
In addition, Kappa statistic was computed to assess agree-
ment between classes of reporting between 24HFR and FFQ.
Statistical analysis was performed using Statistical Package
for the Social Sciences (version 17.0, 2008, IBM-SPSS Inc). The
level of significance was set at 5%.
RESULTS
From the 67 women included, one woman reported
extremely high values for EI in the FFQ (7,500 kcal) and was
excluded from the analysis using continuous values for FFQ.
Nevertheless, this woman was included in the analyses of
under- and overreporters. The socioeconomic, anthropo-
metric, and energy expenditure characteristics of the sample
are shown in Table 1. The studied women were from the low-
income strata, received on average $2.6/day, worked at home,
and had six years of schooling. About 70% of the sample was
overweight, and the mean TEE was 2,186504.2 kcal/day.
Table 2 presents the EI data obtained by FFQ and 24HFR
methods, the EI:TEE, and the difference between EI and TEE
obtained for each method. Results show significant differ-
ences between the methods (P¼0.014). Moreover, the mean
energy value obtained through 24HFR method differed from
the TEE (P<0.001). Nevertheless, there were no differences
between the mean energy value obtained through FFQ and
TEE. The regression coefficient between 24HFR values and
TEE were b¼.199 (95% CI e0.071 to 0.468), and between FFQ
and TEE were b¼e.009 (95% CI e0.208 to 0.190).
Figure 1 shows the Bland-Altman plots, with respective
regression lines. No regression coefficients were significant. A
wide dispersion may be observed in both methods. Impor-
tantly, some subjects had differences over the upper and
lower limit of the 95% CI. This effect was more pronounced
for the 24HFR method compared with the FFQ. However, in
October 2016 Volume 116 Number 10
 RESEARCH

overreporting, which contributed to the balanced mean, but

Table 1. Socioeconomic and anthropometric characteristics with greater variance. Kappa statistics for agreement be-
of socially vulnerable women living in Brazil, whose tween categories of reporting in the 24HFR and FFQ showed
reported energy intake, assessed by the 24-hour food lack of agreement (k¼0.07; P¼0.24). From the 24 under-
record and food frequency questionnaire methods, was
reporters of FFQ, 7 (53.8%) were also underreporters in the
compared with the total energy expenditure obtained by
24HFR.
doubly labeled water (n¼67)
Table 3 shows the differences between the EI obtained by
Variable Result both methods and the TEE stratified by BMI classification.
There were no significant differences between classes. In
meanstandard deviation addition, there was no significant association between the
frequency of underreporters or overreporters across BMI
Age (y) 30.945.36
classes (Figure 3). Overreporting in the FFQ method was
Weight (kg) 67.2913.42 almost higher among eutrophic women (10 out of 19) than in
Height (cm) 155.847.71 obese women (4 out of 18) (P¼0.057). However, there was a
positive correlation between body fat percentage and the
Body mass index 27.725.05
ratio between the EI obtained by the FFQ method and the TEE
Body fat (%) 41.9510.86 (r¼0.245; P¼0.046), indicating that the higher the fat per-
Schooling (y) 6.713.45 centage, the greater the underreporting on the FFQ. The
correlation between 24HFR EI:TEE and body fat percentage
Number of family members 4.851.51
was not significant (r¼e0.18; P¼0.12). In addition, no signif-
Family income per capita 78.154.8 icant correlations were found between per capita income and
(US$/mo) the EI:TEE for both the FFQ method (r¼e0.078; P¼0.53) and
Total energy expenditure 2,186.0504.2 the 24HFR method (r¼0.067; P¼0.59). Years of schooling did
not show any significant correlation with the EI:TEE of both
(kcal)
FFQ method (r¼e0.107; P¼0.40) and 24HFR method
n (%) (r¼e0.001; P¼0.93). Finally, age also did not show significant
Receive governmental 55 (82.1) correlation between FFQ:TEE (r¼e0.17; P¼0.12) or
benefits 24HFR:TEE (r¼e0.07; P¼0.53).

Unemployed 43 (64.2) DISCUSSION

absolute values, the 95% CI of the FFQ was substantially
higher than that of the 24HFR, indicating a much wider
dispersion for this method.
The ratio of EI obtained by the FFQ method and the TEE was
equal to 1, indicating that, on average, the reported EI in the
FFQ agreed with the TEE. Nevertheless, considering the limits
of the CI, the number of underreporters in the FFQ method
(n¼24) was significantly higher than the 24HFR method
(n¼13; P¼0.03) (Figure 2). Figure 2 also shows that the dis-
tribution of underreporters and overreporters was almost
equally distributed for the FFQ method, indicating that,
despite that the mean EI:TEE of the FFQ was equal to 1, there
were high and proportional rates of both underreporting and
This study demonstrated that a sample of women from the
low-income strata in northeast Brazil show high levels of
misreporting of dietary intake by both the 24HFR and FFQ
methods. Furthermore, the frequency of underreporting was
higher in the FFQ method, despite published research indi-
cating that this method may be the best choice for deter-
mining the EI in population studies due to its easy
applicability and relative reliability.25,26 In addition, Bellisle
and colleagues11 stated that FFQ methods usually induce
overestimation of EI, whereas 24HFRs tend to induce un-
derestimation. The present results partially support this
statement, considering that the actual value of EI for the
24HFR was significantly lower than the TEE and the number
of overreporters was significantly higher in the FFQ method
compared with the 24HFR. A study that used data from five

Table 2. Reported energy intake of socially vulnerable women living in Brazil, obtained by the 24-hour food record and food
frequency questionnaire methods, and indicators of underreport of energy intake, calculated using the total energy expenditure
obtained by doubly labeled water

Food Frequency
Variable 24-h Food Record (n[67) Questionnaire (n[66) P valuea

mean (95% CI)!

Energy intake (kcal/d) 1,848.6 (1,737.5 to 1,959.7)b 2,084.5 (1,929.0 to 2,240.0) 0.01
Energy intake/total energy expenditure 0.87 (0.81 to 0.94) 1.0 (0.9 to 1.1) 0.01
Energy intakeetotal energy expenditure (kcal) e337.4 (e487.6 to e187.2) e93.6 (e293.6 to 106.2) <0.01
a
P value for comparison between 24-hour food record and food frequency questionnaire by a repeated measures analysis of variance.
b
Differs significantly from total energy expenditure by a repeated measures analysis of variance with Bonferroni corrections (P<0.001).

October 2016 Volume 116 Number 10 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1563
RESEARCH

Figure 1. Bland-Altman plots of the energy intake obtained by 24-hour food record (A) and food frequency questionnaire (B)
plotted against the total energy expenditure obtained by doubly labeled water, of socially vulnerable women living in Brazil (n¼67).
Dashed lines represent the linear regression lines. CIs were obtained based on the intrasubject coefficient of variance. Mean¼mean
difference between the experimental method of energy intake record and total energy expenditure.

large surveys of dietary research tools (FFQ and 24HFR)
validated with biomarkers found that the average rate of
underreporting of energy consumption was 28% with an FFQ
and 15% with a single 24HFR. In addition, the use of multiple
24HFR substantially increases the correlation when
compared with a single 24HFR. Furthermore, BMI, level of
education, and age strongly predicted the underreporting of
energy and protein intake.27
Data for the EIeTEE for the FFQ method showed that the
mean reported EI for this method was quite accurate on
average because the mean difference indicated an under-
reporting of only 93 kcal/day. However, when analyzing the
percentage distribution of underreporters, overreporters, and
individuals reporting EI within the 95% CI range, it is possible
to note that the FFQ showed little accuracy to assess the
frequency of under- and overreporters. This large variation in
the detection of under- and overreporters on the FFQ could
not be satisfactorily explained by any of the covariates,
although a significant but otherwise weak positive correla-
tion between the percentage of body fat and the EI:TEE of the
FFQ have been observed. Furthermore, the lack of significance
of the coefficient regression in the Bland-Altman plots shows
that there is no association between underreporting and the
mean between reported EI and TEE.

Figure 2. Percentage distribution of underreporters, normal reporters, and overreporters of energy intake, calculated based on the
total energy expenditure obtained by doubly labeled water in 24-hour food record (A) and food frequency questionnaire (B) of
socially vulnerable women living in Brazil (n¼67). Bars represent 95% CIs. *Frequency on the 24-hour food record was significantly
lower than the correspondent frequency in the food frequency questionnaire method, by the McNemar test (P<0.01).

1564 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS October 2016 Volume 116 Number 10
 RESEARCH

Table 3. Differences and ratios between the reported energy intakes of socially vulnerable women living in Brazil assessed by
the 24-hour food record (24HFR) and food frequency questionnaire (FFQ) methods, and the total energy expenditure (TEE) value
obtained by doubly labeled water method, stratified by body mass index (BMI) class

BMI 25-30 BMI >30

Variable BMI <25 (n[18)b (n[30) (n[18) P valuea

mean (95% CI)!

24HFReTEE e232.7 (e593.1 to 127.5) e333.1 (e555.7 to e110.5) e455.0 (e702.7 to e207.2) 0.49
FFQeTEE 50.9 (e444.3 to 546.2) b
e100.76 (e363.8 to 162.3) e226.42 (e626.9 to 174.0) 0.59
24HFR:TEE 0.95 (0.79 to 1.10) 0.86 (0.76 to 0.96) 0.82 (0.72 to 0.92) 0.30
FFQ:TEE 1.13 (0.88 to 1.38)b 0.97 (0.85 to 1.09) 0.92 (0.76 to 1.08) 0.21
a
Based on one-way analysis of variance.
b
For this subgroup, the sample size was 17 due to the exclusion of an outlier.

The 24HFR method also detected underreporters. How-
ever, this method showed more accuracy to assess the
different classes of reporters, probably due to the wider
limits of the 95% CI. For the 24HFR method, the CI was
calculated based on the data of the study population,
whereas the FFQ method used an already-determined co-
efficient that did not use data from the study population.
This fact may have contributed to the differences in accuracy
to detect classes of reporters between both methods.
Underreporting of EI observed in the 24HFR method in this
study averaged 377 kcal and 93 kcal FFQ, indicating that
24HFR is less accurate than FFQ. Nevertheless, the low ac-
curacy of the FFQ lowers the precision of this method. In a
study conducted in the United States, also using DLW, it was
shown that none of the studied methods provided accurate
estimates of individual energy needs.28
Another study conducted in Brazil24 evaluated three
methods of dietary intake (ie, FFQ, 24HFR, and food diary)
against DLW, in a sample of university workers with high
schooling levels. The results showed that the average
underreporting for the 24HFR was e544 kcal/day and for the
FFQ of e638 kcal/day. Both values are greater than those
values observed in the present study. In addition, the FFQ was
the method with the highest number of underreporting
(n¼35), whereas the 24HFR showed a lower frequency
(n¼16), similar to the results of the present study.27
The lack of agreement between both methods, as shown by
the Kappa statistic, the significantly higher mean values for
energy intake shown by the FFQ, and the significantly higher
prevalence of overreporting in the FFQ method may indicate
that women answered the questionnaires differently. During
the FFQ interview women are faced with a list of potentially
consumed foods, so it is possible that because of their social
context, women reported the consumption of more foods
than they actually consumed. In low-income contexts, people
usually associate the variety of food consumed with better

Figure 3. Associations between body mass index class and reporting status (underreporters, normal reporters, or overreporters) of
the energy intake of socially vulnerable women living in Brazil (n¼67) obtained by 24-hour food record (A) and food frequency
questionnaire (B). Bars represent 95% CIs. Application of Fisher exact test revealed no significant associations.

October 2016 Volume 116 Number 10 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1565
RESEARCH
social conditions. This could explain, at least partially, the
higher EI reported in the FFQ compared with the 24HFR.
Age, BMI, and schooling are usually considered possible
predictors of misreporting. Nevertheless, none of those var-
iables showed significant associations in the present study,
with the exception of a weak positive correlation between
percentage of body fat and the EI:TEE of the FFQ. Karelis and
colleagues29 demonstrated that 57.5% of underreporting
women had high BMI, fat mass, and visceral fat. Another
study of low-income women in the United States also found
that the percentage of body fat and level of education were
the best predictors of misreporting of EI.30 It is believed that
individuals with low education tend to incorrectly answer an
FFQ.31 This situation probably occurred in this study, where
the majority of the sample was functionally illiterate, and
given the little variance in the education levels, no significant
correlation could be found. The lack of association between
BMI and underreporting was also observed in the study by
Martin and colleagues32 conducted with women in Canada.
In contrast, a study33 of adults conducted in Rio de Janeiro
showed that the estimated EI varied according to nutritional
status and the method used, with underreporting of EI via the
24HFR in mostly obese individuals (41%) and slight over-
reporting via the FFQ method. It is noteworthy that the
aforementioned study used predictive equations rather than
DLW to assess TEE. In another study34 that aimed to identify
the underreporting of regular consumption of energy by
24HFR, an underreporting of habitual energy intake was
observed in communities of Ghana, South Africa, Seychelles,
Jamaica, and the United States. This study34 also considered
the scale of the Human Development Index to detect whether
there was any relationship between economic factors and
greater underreporting. The authors concluded that the
underreporting of EI was present at all scales of the Human
Development Index, and this underreporting increased with
higher BMI individuals.34
Overall, the findings of the present study corroborate the
idea that self-report methods of EI are not accurate, and its
use may lead to biased conclusions.35 Although the FFQ
method showed a more accurate report, with an underreport
of only 93 kcal, its precision was extremely low, with only
32% of participants reporting EI within the limits of the
calculated CI. On the other hand, although the prevalence of
underreporting was <20% in the 24HFR method, the mean
underreporting was >300 kcal, or almost 15% of the actual EI,
which may compromise any dietary plan based on it. In
addition, no covariates could satisfactorily explain the
observed variations.
The present study has several limitations. First, a peculiar
sample was studied, consisting of unemployed women with
excess weight and mothers of stunted children. Although
socially vulnerable, the women were not in food insecurity
situations. Hence, the relatively homogenous population may
have reduced the ability to detect associations between
covariates and misreporting. Second, there is a limitation to
the use of the DLW technique to validate dietary surveys.
DLW is held within a period of 14 days, so it may account for
daily and weekly fluctuations of TEE, failing to cover monthly
fluctuations inherent to methods such as the FFQ.36 To reduce
this bias, all questionnaires were applied within the 14 days
of the DLW period. In addition, in the present study, the CV
for 24HFR was somewhat higher than expected, and it may
1566 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
lead to a lower power to detect erroneous reporting. More-
over, although mathematically sound, the determination of
CV may not necessarily present biological plausibility, espe-
cially in the case of FFQs, in which CVs were obtained from a
different study; hence, the findings based on it must be
cautiously considered.
CONCLUSIONS
Both methods of dietary intake record tested in the present
study showed inadequate precision when compared with
DLW, which is the gold standard biomarker of TEE. The range
of the dispersion obtained in FFQ was greater than the
dispersion obtained in 24HFR. Nevertheless, FFQ did produce
an accurate estimate of EI, whereas this was not the case with
the 24HFR, which grossly underestimated EI. Hence, re-
searchers assessing dietary intake in low-income populations
should be cautious when using the 24HFR or FFQ.
References
1. Malik VS, Willett WC, Hu FB. Global obesity: Trends, risk factors and
policy implications. Nat Rev Endocrinol. 2013;9(1):13-27.
2. Asbeck I, Mast M, Bierwag A, et al. Severe underreporting of energy
intake in normal weight subjects: Use of an appropriate standard
and relation to restrained eating. Public Health Nutr. 2002;50(5):683-
690.
3. National Research Council. Nutrient Adequacy. Assessment Using Food
Consumption Surveys. Washington, DC: The National Academies
Press; 1986.
4. Liu JM, Yang XG, Piao JH, et al. Dietary energy requirements of young
adult women in China by the doubly labeled water method. Asia Pac J
Clin Nutr. 2010;19(4):520-525.
5. Pfrimer K, Vilela M, Resende CM, et al. Under-reporting of food
intake and body fatness in independent older people: A doubly
labelled water study. Age Ageing. 2015;44(1):103-108.
6. Bingham SA. Limitations of the various methods for collecting di-
etary intake data. Ann Nutr Metab. 1991;35(3):117-127.
7. Kristal AR, Peters U, Potter JD. Is it time to abandon the food fre-
quency questionnaire? Cancer Epidemiol Biomarkers Prev.
2005;14(12):2826-2888.
8. Kaaks RJ. Biochemical markers as additional measurements in
studies of the accuracy of dietary questionnaire measurements:
Conceptual issues. Am J Clin Nutr. 1997;65(4):1232-1239.
9. Schoeller DA. Recent advances from application of doubly labeled
water to measurement of human energy expenditure. J Nutr.
1999;129(10):1765-1768.
10. Black AE, Prentice AM, Goldberg GR, et al. Measurements of total
energy expenditure provide insights into the validity of dietary
measurements of energy intake. J Am Diet Assoc. 1993;93(5):572-
579.
11. Schoeller DA. Limitations in the assessment of dietary energy intake
by self-report. Metab Clin Exp. 1995;44(2 suppl 2):18-22.
12. Scagliusi FB, Ferriolli E, Pfrimer K, et al. Underreporting of energy
intake in Brazilian women varies according to dietary assessment: A
cross-sectional study using doubly labeled water. J Am Diet Assoc.
2008;108(12):2031-2040.
13. Dugas LR, Harders R, Merrill S, et al. Energy expenditure in adults
living in developing compared with industrialized countries: A
meta-analysis of doubly labeled water studies. Am J Clin Nutr.
2011;93(2):427-444.
14. Torvik FA, Rognmo K, Tambs K. Alcohol use and mental distress as
predictors of non-response in a general population health survey:
The HUNT study. Soc Psychiatry Psychiatr Epidemiol. 2012;47(5):805-
816.
15. World Health Organization. Physical Status: The Use and Interpreta-
tion of Anthropometry. Geneva, Switzerland: World Health Organi-
zation; 1995.
16. Speakman JR. The history and theory of the doubly labeled water
technique. Am J Clin Nutr. 1998;68(4):932-938.
October 2016 Volume 116 Number 10
 RESEARCH

17. Coward WA, Roberts SB, Cole TJ. Theoretical and practical consid-
erations in the doubly labelled water (2H2 18O) method for the
measurement of carbon dioxide production rate in humans. Eur J Clin
Nutr. 1988;42(3):207-212.
18. Schoeller DA. Hidrometry. In: Heymsfield SB, Lohman TG, Wang Z,
Going S, eds. Human Body Composition. Champaign, IL: Human Kin-
ects; 2005:25-43.
19. Schoeller DA. Validation of habitual energy intake. Public Health Nutr.
2002;5(6):883-888.
20. Speakman JR, Nair KS, Goran MI. Revised equations for calculating
CO2 production from doubly labeled water in humans. Am J Physiol.
1993;264(6):912-917.
21. Cardoso MA, Luciana YT, Elaine CL. Assessing the validity of a
food frequency questionnaire among low-income women in Sao
Paulo, southeastern Brazil. Cad Saude Publica. 2010;26(11):2059-
2067.
22. Monteiro JP. Consumo Alimentar: Visualizando porções. Série Nutrição
e Metabolismo. Rio de Janeiro, Brazil: Guanabara Koogan; 2007.
23. Institute of Medicine, Food and Nutrition Board. Dietary Reference
Intakes: Applications in Dietary Planning/Subcommittee on Interpreta-
tion and Uses of Dietary Reference Intakes and the Standing Committee
on the Scientific Evaluation of Dietary Reference Intakes. Washington,
DC: The National Academies Press; 2001.
24. Scagliusi FB, Ferriolli E, Pfrimer K, et al. Under-reporting of energy
intake is more prevalent in a healthy dietary pattern cluster. Br J
Nutr. 2008;100(5):1060-1068.
25. Ahn Y, Kwon E, Shim JE, et al. Validation and reproducibility of food
frequency questionnaire for Korean genome epidemiologic study.
Eur J Clin Nutr. 2007;61(12):1435-1441.
26. Willett WC, Hu FB. Not the time to abandon the food frequency
questionnaire. Cancer Epidemiol Biomarkers Prev. 2006;15(10):1757.
27. Freedman LS, Commins JM, Moler JE, et al. Pooled results from 5
validation studies of dietary self-report instruments using recovery
biomarkers for energy and protein intake. Am J Epidemiol.
2015;181(7):473-487.
28. Sawaya AL, Tucker K, Tsay R, et al. Evaluation of four methods for
determining energy intake in young and older women: Comparison
with doubly labeled water measurements of total energy expendi-
ture. Am J Clin Nutr. 1996;63(4):491-499.
29. Karelis AD, Lavoie ME, Fontaine J, et al. Anthropometric, metabolic,
dietary and psychosocial profiles of underreporters of energy intake:
A doubly labeled water study among overweight/obese post-
menopausal women—A Montreal Ottawa New Emerging Team
study. Eur J Clin Nutr. 2010;64(1):68-74.
30. Johnson RK, Soultanakis RP, Matthews DE. Literacy and body
fatness are associated with underreporting of energy intake in US
low-income women using the multiple-pass 24-hour recall:
A doubly labeled water study. J Am Diet Assoc. 1998;98(10):
1136-1140.
31. Brown D. Do food frequency questionnaires have too many limita-
tions? J Am Diet Assoc. 2006;106(10):1541-1542.
32. Martin LJ, Su W, Jones PJ, et al. Comparison of energy intakes
determined by food records and doubly labeled water in women
participating in a dietary-intervention trial. Am J Clin Nutr.
1996;63(4):483-490.
33. Lopes TS, Sichieri R, Moura AS, et al. Validação da estimativa de
ingestão energética por questionário de frequência de consumo de
alimentos e recordatório de 24 horas contra água duplamente
marcada - pesquisa Valida-Rio [Validation of the estimated energy
intake obtained through food frequency questionnaire and 24-hour
food record compared to doubly labeled water - The Valida-Rio
research]. Nutrire. 2009;34(suppl 1):98.
34. Orcholski L, Luke A, Plange-Rhule J, et al. Underreporting of dietary
energy intake in five populations of the African diaspora. Br J Nutr.
2015;113(3):1-9.
35. Dhurandhar NV, Schoeller D, Brown AW, et al. Energy balance
measurement: When something is not better than nothing. Int J Obes
(Lond). 2015;39(7):1109-1113.
36. Livingstone MB, Black AE. Markers of the validity of reported energy
intake. J Nutr. 2003;133(3):895-920.

AUTHOR INFORMATION
I. L. L. Lins is a student, and N. B. Bueno, A. P. Grotti Clemente, and T. M. de Menezes Toledo Florêncio are associate professors, Faculdade de
Nutrição, Universidade Federal de Alagoas, Cidade Universitária-Maceió, Maceió, Alagoas, Brazil. K. Pfrimer is a postdoctoral student, Departa-
mento de Clínica Médica, Universidade de São Paulo, Faculdade de Medicina de Ribeirão Preto, Ribeirão Preto, SP, Brazil. A. L. Sawaya is an
associate professor, Departamento de Fisiologia, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
Address correspondence to: Nassib Bezerra Bueno, PhD, Faculdade de Nutrição, Universidade Federal de Alagoas, Campus AC Simões - Av
Lourival Melo Mota, s/n, Cidade Universitaria - Maceió - AL 57072-900, Maceió, Alagoas, Brasil. E-mail: nassibbb@hotmail.com
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
This study was funded by the Brazilian National Council for Scientific and Technologic Development, process no. 552194/2011-5.

October 2016 Volume 116 Number 10 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1567