Editorial
See corresponding article on page 80.
Dietary assessment in the digital age: the ongoing quest
for better methods
Marjorie L McCullough
Epidemiology Research Program, American Cancer Society, Atlanta, GA
Measuring dietary intakes in free-living human populations is
difficult, but crucial to understanding the important role that diet
plays in health and disease. Among the many challenges such
studies face are day-to-day variation in intake and participants’
ability to remember foods consumed. Interviewer-based 24-h re-
calls and weighed food records are considered optimal to assess
actual daily intakes, and have been used for national surveillance
and clinical trials. Food-frequency questionnaires (FFQs), which
include food lists to assess frequency of consumption with or
without portion size, are most commonly used in epidemiologic
studies as a cost-efficient approach to assess dietary intakes and
patterns in tens of thousands of participants (1). Indeed, FFQs
have been the mainstay of diet assessment in long-term epidemi-
ologic studies, have been shown to be valid at rank-ordering con-
sumption of a broad range of dietary exposures among individ-
uals, and best capture episodically consumed foods (1, 2). The
use of repeated measures of interviewer-administered 24-h recalls
and self-administered food records have been cost prohibitive for
most large epidemiologic studies.
With the recent widespread consumer adoption of digital tech-
nologies, there is an opportunity to develop self-administered
dietary assessment tools to capture actual daily dietary intakes
at a lower cost. To this end, researchers at the National Can-
cer Institute developed the Automated, Self-Administered 24-h
recall (ASA24) (3), which was modeled after the USDA’s
interviewer-administered multiple-pass diet recall method used
in the NHANES (4). In earlier research using direct observation,
the ASA24 performed well in comparison with interviewer-based
24-h recalls (4).
In this issue of the Journal, Park et al. (5) present results from
the iDATA (Interactive Diet and Activity Tracking in AARP)
study, which compared the performance of the ASA24 to food
records and an FFQ. Over a 1-y period, 1110 participants com-
pleted an average of 5 ASA24 recalls, 2 sets of 4-d food records
(4DFRs), and the National Cancer Institute’s self-administered
online FFQ, the Diet History Questionnaire. These methods were
compared to urinary recovery biomarkers for energy (assessed
via doubly labeled water), protein (via nitrogen), potassium, and
sodium, the latter 3 estimated from an average of two 24-h
urine collections spaced 6 mo apart. A key finding was that
all 3 instruments underestimated average energy, protein, sodium,
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and potassium compared to the recovery biomarkers. How-
ever, after taking energy into account, the percentage of energy
from protein and potassium and sodium density (per 1000 kcal)
from all instruments were comparable to energy-adjusted
biomarker values, with the exception that potassium density
was overestimated with the FFQ (26–40%, compared to –2.1%
to 8% with other methods). The authors also noted that the
FFQ overestimated the mean intake of certain nutrients (e.g.,
vitamin C, carotenoids) compared to the ASA24 and 4DFRs.
The core findings of Park et al. (5) are consistent with other
comparative analyses (6, 7), including a pooled analysis of
5 studies of similar design, 4 of which used interviewer-based
24-h recalls (7). The extension of this work to include the self-
administered ASA24 has important implications for wider adop-
tion of ASA24. iDATA was 1 of 3 studies that were part of the
MEASURE initiative (Multi-Cohort Eating and Activity Study
for Understanding Reporting Error) designed to examine mea-
surement error in self-reported physical activity and dietary as-
sessments. Results from another recently published MEASURE
study, the Women’s Lifestyle Validation Study (WLVS) (6),
found similar patterns of under- and overestimation of recovery
biomarkers as reported here by Park et al. (5). The WLVS exam-
ined how each of the methods (≤ 4 ASA24s, 2 sets of 7-d weighed
food records, and the Harvard FFQ) rank-ordered participants,
and, unlike Park et al., presented correlation coefficients with
biomarkers. Energy-adjusted correlations adjusted for day-to-day
variability in diet and urinary recovery biomarkers were similar
for the ASA24 and FFQ for energy-adjusted protein, sodium, and
potassium, and somewhat higher for the weighed food records
(5). Ideally, future work from the rich iDATA resource will in-
clude analyses using correlation coefficients, as they show the
Address correspondence to MLM (e-mail: marji.mccullough@cancer.org).
Abbreviations used: ASA24, Automated, Self-Administered 24-h recall;
FFQ, food-frequency questionnaire; 4DFR, 4-d food record; iDATA, Interac-
tive Diet and Activity Tracking in AARP; WLVS, Women’s Lifestyle Valida-
tion Study.
Received December 5, 2017. Accepted for publication December 6, 2017.
First published online January 26, 2018; doi: https://doi.org/10.1093/
ajcn/nqx066.
1
 2 EDITORIAL
ability of an instrument to capture variation in intakes across in-
dividuals and to discriminate between them (1).
Park et al. (5) conclude that FFQs are biased toward a health-
ier diet and that “future nutrition studies should consider col-
lecting multiple ASA24 records or recalls over time as the
primary method in conjunction with an FFQ in clinical and epi-
demiologic research.” Three points are worth making in relation
to this conclusion. First, only a limited number of objective recov-
ery biomarkers are currently available, and were used to estimate
mean absolute nutrient intakes in this paper. Whether similar find-
ings would be observed for other nutrients that have been more
directly associated with chronic disease outcomes such as cancer
is unclear. Second, the authors presented only absolute mean in-
takes, and as noted above, correlations would be valuable. In the
WLVS, correlations of each self-reported instrument with blood
concentration biomarkers (which are affected by metabolism,
but correlated with dietary intake) for several nutrients were ex-
amined. The FFQ nutrient estimates were more strongly cor-
related than the ASA24s with biomarkers for some nutrients
(e.g., α-carotene and long-chain n–3 fatty acids), whereas oth-
ers, such as folate, were similar for these methods. Regard-
ing an overestimation by the FFQ of certain nutrients, this is
unlikely to be a problem in practice when researchers evaluate
associations with disease (e.g., calculating relative risks for quin-
tile 5 to quintile 1, or per serving), as is typical in epidemio-
logic studies. However, this may be an issue if absolute esti-
mates are more critical (e.g., as in adherence to a feeding trial,
national surveillance, or determining requirements for RDIs), in
which case calibration of the FFQ with a gold standard would be
important.
Park et al. (5) promote the use of multiple ASA24s along
with FFQs in clinical and epidemiologic studies. It has been pre-
viously estimated that for many nutrients and food groups, a
combined use of four to six 24-h recalls and an FFQ can pro-
vide data superior to either method alone—especially for foods
that are not consumed regularly (8). Future methodologic re-
search should examine ways in which studies that utilize both the
ASA24 and FFQ or other multiple methods can provide the most
complete, accurate, and representative picture of an individual’s
dietary intake. Including a daily method such as the ASA24 for
dietary assessment in large proportions of participants in epi-
demiological studies can have additional benefits apart from cal-
ibrating FFQ intake estimates and correcting risk estimates for
measurement error. For example, daily methods can provide de-
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tailed information on meal location, timing, composition and fre-
quency. Researchers considering including multiple dietary as-
sessment methods in their protocols should be cognizant of any
negative impact on participant burden and adherence to study pro-
tocols; their inclusion will depend on population characteristics,
study design, goals, and hypotheses.
The study by Park et al. (5) is a valuable contribution to the
field at a time when consumers are becoming more comfortable
and adept at completing interactive surveys online. The authors’
test of the ASA24 using 4 recovery biomarkers provides support-
ive evidence for use of this instrument in characterizing absolute
mean intakes. The iDATA investigators are to be commended for
their important contribution to the field of diet assessment and for
making the ASA24 available at no cost to researchers.
The author reported no conflicts of interest.
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