Question 3
As a practicing registered dietitian, the question is often posed if during one-on-one counseling sessions the RDN should gather the client's 24-hour recall or usual daily recall. After reading this article and discovering the reliability of FFQ's, what do you believe an RDN should use to gather an accurate estimate of the client's usual daily intake?
Posted on behalf of Noel Konken.
Posted on behalf of Noel Konken.
posted by Julie @ 12:01 PM
14 comments
14 Comments:
Many tools possess a benefit in determining the typical diet of a new client. A food frequency quickly pinpoints areas of issue, ie lack of fruits and vegetables, excess of refined foods. However, a two day recall provides a fuller picture of the clients total intake, including factors or how their life style and behavior interacts with their diets. A 24-48 hour recall may not be typical of the client's diet due to instance of changes in behavior or medical conditions requiring recent hospitalization. Therefore, a usual daily intake may be recommended for the most accurate representation of typical diet. Yet, for individuals with complex diet sensitive conditions current lab results as effected by recent dietary changes are pertinent. Through evaluation of the factors mentioned, I believe a 24-48 hour recall is the most effective tool allowing opportunity for client to disclose any recent changes in typical diet.
I generally like to ask clients for a 24-hour recall. I find that when you ask what do you typically eat, the answers tend to be vaguer and generalized. It also depends on what type of information I’m looking for. If a patient is having GI implications or an allergic reaction I would ask for 24-hour recall. If I’m wanting to know about the patient’s fruit and vegetable consumption I would choose a FFQ. In most cases I find that a 24-hour recall is more reliable when looking for specific details in a short period of time.
I do not believe that there is one set standard tool to recommend RDNs to use for one-on-one counseling. The diet assessment tool selection really depends on the context of care. For general healthy eating counseling, a typical daily recall could be effective in establishing an overall picture of dietary patterns. Gaining this basic understanding can guide intervention strategies that are general in nature, such as substitute whole grains for refined or adding one serving of vegetables to dinner. A FFQ could provide a similar overview of dietary patterns, but may be a bit more extensive to administer and assess. A more detailed 24 hour recall can be useful when assessing specific allergies, lab values, or GI symptoms because conditions could be directly tied to certain items in the recall. In my experiences at Crossing Healthcare counseling Type II diabetic patients, a usual daily recall was typically sufficient to develop diet goals. Using this typical day reporting allowed for analysis of if the patient is or is not following a diet conducive to diabetes management. An FFQ would be useful in tracking diet changes over time, since they tend to be objective and partially quantitative. Recalls (24 hour or typical) tend to be more subjective and more difficult to track over time. The goal of counseling is the primary consideration in selecting an assessment tool.
In a perfect world, I like the idea of a 3-day food log or a three 24-hour recalls. As Rachel said, the more time you include in the food recall, the more accurate it is likely to be. I found this very effective when counseling at Health Promotion and Wellness. Three days offered enough time to deduct normal habits but also leave some room for variation from day-to-day habits. That being said, a 3-day food diary is not always conducive to the environment. I think a 24-hour recall is great if the client reflects that the previous day was more-or-less a typical eating day. This could also be combined with a FFQ for more detail and accuracy. I think that when it comes to evaluating client intake, the details of exactly which foods and exactly how much may be less important then the overall eating pattern, but this information is difficult to gather, especially in a one-time assessment.
Typically, I prefer to use a 24-hour recall and follow-up with a question comparing the recall to a typical day's diet. However, in this instance, it may be too overwhelming and/or time-consuming (particularly if the recall is being asked in a WIC appointment). I feel that the reliability of the FFQ is adequate for use for children, especially the particular FFQ used in the study. While some FFQs are more time and labor-intensive, I feel that the Child Food and Beverage Intake Questionnaire is a reliable and valid tool that is appropriate for children due to its lower respondent burden and short completion time. Using a FFQ would be most appropriate for settings such as WIC, where there are several follow-up appointments to track the growth and wellbeing of the child. For settings where a follow-up is less frequent, it may be best to use a typical day recall or a 24-hour recall.
I think Rachel brings up a valid point. For specific disease states, it is more pertinent to focus on the short-term intake, especially if lab values have been impacted. Overall, I believe the type of questionnaire utilized depends on the setting of practice and relevance to the child's health.
In a counseling session, I believe a 24-hour recall is appropriate, as it should be quick and easy for the client to remember. While not every day is the same, I find this to be effective, along with probing questions to accurately see someone's general diet. Asking questions such as, "what other proteins do you typically consume" or "what other vegetables do you like to consume at dinner" can help accurately see their intake and assess the problem or nutrition concern present.
I agree with Kirsten in that every client and situation is different, and therefore there is not one set way to go about diet recalls. It depends on why you are counseling the client and if there is a reason to look at a 3 day diet versus 24 hours versus a typical day's diet.
Justine made some interesting points about the usefulness of three-day food records. Three days of recorded actual food intake (especially if it includes one weekend day) could have great value in a counseling scenario. This can be very difficult to gather, however. Depending on the person, this three-day record could be attained. A client that is highly motivated to make a specific diet change and will put in significant effort to get assistance with the change, is more likely to provide this type of extensive diet record. However, trying to get this type of record from an unmotivated client (a non-compliant Type II diabetic for example), may be very difficult. I also agree with Justine's point about the importance of gaining insight into overall eating pattern, rather than focusing on specific foods and portions when a one-time assessment is conducted or if the patient is not highly motivated to change. An overall picture of diet habits and diet quality is a valuable place to start, particularly in initial counseling sessions.
Justine, I like how you mentioned combining a 24 hour recall with a FFQ. I often find myself choosing just one method, but combining different methods can help us better understand their diet and can touch on other areas one method may not have!
To a certain extent the combination of a 24-hour recall and usual diet recall provides a more accurate estimate of the client’s usual daily intake. For a 24-hour recall often misses items that are consumed regularly but not daily, yet it can capture an accurate understanding of diet patterns. While a usual diet history can highlight foods that are regularly consumed, yet miss items that are irregularly consumed. Therefore, I feel that a combination of the two recalls provides a more accurate understanding of food patterns than either one recall alone. This combo strategy may not be as accurate as requesting a client to utilize a food log, but it is inexpensive, quick, and less burdensome for the client while still providing an accurate estimate of the client’s usual daily intake.
I think this depends on the type of situation you are in and the type of client/patient you are working with. I like Justine and Rachel like the idea of a 3-day food recall for accuracy. However, for many people it is hard to remember what they had in the morning let alone 3 days ago. Therefore, I think it is smart to use a 24 hour diet recall or ask the client/patient what a typical day is like for them in case the day before was a bad day or an untypical day. I agree with Holly as well that using an FFQ would be appropriate in a WIC setting. Again, for me it depends on the situation and setting I am in.
Moriah, I agree that there is no perfect answer to this questions as each person and situation may call for a different tool. It seems that this is going to come up again and again through our careers. Maybe the best solution is to be familiar with the diet analysis tools out there and which ones are more effective in different situations.
After ready everyone's comment, it appears the 24-hour recall is still a favorite within a counseling setting. I would agree with this in that a 24-hour recall is typically easy to administer within this setting. I appreciate Justine's comment in that within a 24-hour recall, the dietitian should not get caught up in the nitty-gritty of details of food brands, portions, etc. A dietary recall should be used similar to a FFQ in that it about extract that clients typical habits.
A great method for gathering a client's dietary information is presenting them with the option of either giving a 24-hour recall or their usual dietary intake. Every counseling session that I have given the client this option, they they chose to give me an overview of what they typically eat every day. No matter what method you choose, follow-up questions always help to give a clearer and more accurate picture of their diet. If the counselor notices that their client seems unmotivated or uninterested, a 24-hour recall might be the best method to utilize. If you were to ask an unmotivated client for their typical diet, it could be like pulling teeth trying to get them to give you enough information. Asking for a 24-hour recall could minimize the potential for this.
In response to Kirsten and Rachel, a FFQ could definitely provide a similar overview of dietary patterns. However, in addition to being a bit more extensive to administer and assess, I have learned that FFQ's are rarely used in counseling sessions. They are mostly used for research purposes to assess dietary patterns of large populations.
Tessa, as you mentioned, I have also found that asking about someone’s typical diet or usual food intake often results in people mentioning their healthier food choices while underestimating portions. While a 24-hour recall often reveals those “rare” food items (i.e. fast food) happened to occur during this time period.
As Rachel mentioned the more time that is included in a food recall, the more accurate it should be. But, as Justine mentioned, it is important to not get too bogged down in the details. These tools are to help us understand our clients overall usual diets so we can provide them with the best appropriate nutrition care/support for their situation.
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