Skip to main content Accesibility Help

Bias in dietary-report instruments and its implications for nutritional epidemiology

  • Victor Kipnis (a1), Douglas Midthune (a1), Laurence Freedman (a2), Sheila Bingham (a3), Nicholas E Day (a4), Elio Riboli (a5), Pietro Ferrari (a5) and Raymond J Carroll (a6)...

To evaluate measurement error structure in dietary assessment instruments and to investigate its implications for nutritional studies, using urinary nitrogen excretion as a reference biomarker for protein intake.


The dietary assessment methods included different food-frequency questionnaires (FFQs) and such conventional dietary-report reference instruments as a series of 24-hour recalls, 4-day weighed food records or 7-day diaries.


Six original pilot validation studies within the European Prospective Investigation of Cancer (EPIC), and two validation studies conducted by the British Medical Research Council (MRC) within the Norfolk cohort that later joined as a collaborative component cohort of EPIC.


A sample of approximately 100 to 200 women and men, aged 35–74 years, from each of eight validation studies.


In assessing protein intake, all conventional dietary-report reference methods violated the critical requirements for a valid reference instrument for evaluating, and adjusting for, dietary measurement error in an FFQ. They displayed systematic bias that depended partly on true intake and partly was person-specific, correlated with person-specific bias in the FFQ. Using the dietary-report methods as reference instruments produced substantial overestimation (up to 230%) of the FFQ correlation with true usual intake and serious underestimation (up to 240%) of the degree of attenuation of FFQ-based log relative risks.


The impact of measurement error in dietary assessment instruments on the design, analysis and interpretation of nutritional studies may be much greater than has been previously estimated, at least regarding protein intake.

    • Send article to Kindle

      To send this article to your Kindle, first ensure is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the or variations. ‘’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Bias in dietary-report instruments and its implications for nutritional epidemiology
      Available formats
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Bias in dietary-report instruments and its implications for nutritional epidemiology
      Available formats
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Bias in dietary-report instruments and its implications for nutritional epidemiology
      Available formats
Corresponding author
*Corresponding author: Email
Hide All
1Hunter, Dj, Spiegelman, D, Adami, H-O, Beeson, L, Van den Brandt, PA, Folsom, AR, et al. Cohort studies of fat intake and the risk of breast cancer – a pooled analysis. N. Engl. J. Med. 1996; 334: 356–61.
2Fuchs, CS, Giovannucci, EL, Colditz, GA, Hunter, DJ, Stampfer, MJ, Rosner, B, et al. Dietary fiber and the risk of colorectal cancer and adenoma in women. N. Engl. J. Med. 1999; 340: 169–76.
3Michels, KB, Giovannucci, E, Joshipura, KJ, Rosner, BA, Stampfer, MJ, Fuchs, CS, et al. Prospective study of fruit and vegetable consumption and incidence of colon and rectal cancers. J. Natl. Cancer Inst. 2000; 92: 1740–52.
4Beaton, GH, Milner, J, Corey, P, McGuire, V, Cousins, M, Stewart, E, et al. Sources of variance in 24-hour dietary recall data: implications for nutrition study design and interpretation. Am. J. Clin. Nutr. 1979; 32: 2546–9.
5Freudenheim, JL, Marshall, JR. The problem of profound mismeasurement and the power of epidemiological studies of diet and cancer. Nutr. Cancer. 1988; 11: 243–50.
6Freedman, LS, Schatzkin, A, Wax, J. The impact of dietary measurement error on planning sample size required in a cohort study. Am. J. Epidemiol. 1990; 132: 1185–95.
7Kipnis, V, Carroll, RJ, Freedman, LS, Li, L. Implications of a new dietary measurement error model for estimation of relative risk: application to four calibration studies. Am. J. Epidemiol. 1999; 150: 642–51.
8Willett, W. Nutritional Epidemiology. New York: Oxford University Press, 1990.
9Rosner, B, Willett, WC. Interval estimates for correlation coefficients corrected for within-person variation: implications for study design and hypothesis testing. Am. J. Epidemiol. 1988; 127: 377–86.
10Rosner, B, Willett, WC, Spiegelman, D. Correction of logistic regression relative risk estimates and confidence intervals for systematic within-person measurement error. Stat. Med. 1989; 8: 1051–69.
11Bandini, LG, Schoeller, DA, Cyr, HN, Dietz, WH. Validity of reported energy intake in obese and nonobese adolescents. Am. J. Clin. Nutr. 1990; 52: 421–5.
12Livingstone, MBE, Prentice, AM, Strain, JJ, Coward, WA, Black, AE, Barker, ME, et al. Accuracy of weighed dietary records in studies of diet and health. Br. Med. J. 1990; 300: 708–12.
13Heitmann, BL. The influence of fatness, weight change, slimming history and other lifestyle variables on diet reporting in Danish men and women aged 35–65 years. Int. J. Obes. 1993; 17: 329–36.
14Heitmann, BL, Lissner, L. Dietary underreporting by obese individuals – is it specific or non-specific?. Br. Med. J. 1995; 311: 986–9.
15Martin, LJ, Su, W, Jones, PJ, Lockwood, GA, Tritchler, DL, Boyd, NF. 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: 483–90.
16Sawaya, AL, Tucker, K, Tsay, R, Willett, W, Saltzman, E, Dallal, GE, et al. Evaluation of four methods for determining energy intake in young and older women: comparison with doubly labeled water measurements of total energy expenditure. Am. J. Clin. Nutr. 1996; 63: 491–9.
17Black, AE, Bingham, SA, Johansson, G, Coward, WA. Validation of dietary intakes of protein and energy against 24 hour urinary N and DLW energy expenditure in middle-aged women, retired men and post-obese subjects: comparisons with validation against presumed energy requirements. Eur. J. Clin. Nutr. 1997; 51: 405–13.
18Prentice, RL. Measurement error and results from analytic epidemiology: dietary fat and breast cancer. J. Natl. Cancer Inst. 1996; 88: 1738–47.
19Kipnis, V, Midthune, D, Freedman, LS, Bingham, S, Schatzkin, A, Subar, A, et al. Empirical evidence of correlated biases in dietary assessment instruments and its implications. Am. J. Epidmiol. 2001; 153: 394403.
20Carroll, RJ, Ruppert, D, Stefanski, LA. Measurement Error in Nonlinear Models. London: Chapman & Hall, 1995.
21Kaaks, R, Riboli, E, van Staveren, W. Calibration of dietary intake measurements in prospective cohort studies. Am. J. Epidemiol. 1995; 142: 548–56.
22Freedman, LS, Carroll, RJ, Wax, Y. Estimating the relation between dietary intake obtained from a food frequency questionnaire and true average intake. Am. J. Epidemiol. 1991; 134: 310–20.
23Kaaks, RJ. Biochemical markers as additional measurements in studies of the accuracy of dietary questionnaire measurements: conceptional issues. Am. J. Clin. Nutr. 1997; 65(Suppl.): 1232S–9S.
24Bingham, SA, Cummings, JH. Urine nitrogen as an independent validatory measure of dietary intake: a study of nitrogen balance in individuals consuming their normal diet. Am. J. Clin. Nutr. 1985; 42: 1276–89.
25Kaaks, R, Slimani, N, Riboli, E. Pilot phase studies on the accuracy of dietary intake measurements in the EPIC project: overall evaluation of results. European Prospective Investigation into Cancer and Nutrition. Int. J. Epidemiol. 1997; 26(Suppl. 1): s26–36.
26Bingham, SA, Gill, C, Welch, A, Cassidy, A, Runswick, SA, Oakes, S, et al. Validation of dietary assessment methods in the UK arm of EPIC using weighed records and 24-hour urinary nitrogen and potassium and serum vitamin C and carotenoids as biomarkers. Int. J. Epidemiol. 1997; 26(Suppl. 1): S137–51.
27Day, N, Oakes, S, Luben, R, Khaw, KT, Bingham, S, Welch, A, et al. EPIC–Norfolk: study design and characteristics of the cohort. Br. J. Cancer 1999; 80(Suppl. 1): 95103.
28Campbell, WW, Crim, MC, Dallal, GE, Young, VR, Evans, WJ. Increased protein requirements in elderly people: new data and retrospective reassessments. Am. J. Clin. Nutr. 1994; 60: 501–9.
29Zanni, E, Calloway, DH, Zezulka, AY. Protein requirements of elderly men. J. Nutr. 1979; 109: 513–24.
30Oddoye, EA, Margen, S. Nitrogen balance studies in humans: long-term effect of high nitrogen intake on nitrogen accretion. J. Nutr. 1979; 109: 363–77.
31Weller, LA, Calloway, DH, Margen, S. Nitrogen balance of men fed amino acid mixtures based on Rose's requirements, egg white protein, and serum free amino acid patterns. J. Nutr. 1971; 101: 1499–508.
32Bunker, VW, Lawson, MS, Stansfield, MF, Clayton, BE. Nitrogen balance studies in apparently healthy elderly people and those who are housebound. Br. J. Nutr. 1987; 57: 211–21.
33Uauy, R, Scrimshaw, NS, Young, VR. Human protein requirements: nitrogen balance response to graded levels of egg protein in elderly men and women. Am. J. Clin. Nutr. 1978; 31: 779–85.
34Castaneda, C, Charnley, JM, Evans, WJ, Crim, MC. Elderly women accommodate to a low-protein diet with losses of body cell mass, muscle function, and immune response. Am. J. Clin. Nutr. 1995; 62: 30–9.
35Cheng, AHR, Gomez, A, Bergan, JG, Lee, TC, Monckeberg, F, Chichester, CO. Comparative nitrogen balance study between young and aged adults using three levels of protein intake from a combination wheat–soy–milk mixture. Am. J. Clin. Nutr. 1978; 31: 1222.
36Atinmo, T, Mbofung, CMF, Egun, G, Osotimehin, B. Nitrogen balance study in young Nigerian adult males using four levels of protein intake. Br. J. Nutr. 1988; 60: 451–8.
37Rand, WM, Scrimshaw, NS, Young, VR. Retrospective analysis of data from five long-term, metabolic balance studies: implications for understanding dietary nitrogen and energy utilization. Am. J. Clin. Nutr. 1985; 42: 1339–50.
38Tarnopolsky, MA, Atkinson, SA, MacDougall, JD, Chesley, A, Phillips, S, Schwarcz, HP. Evaluation of protein requirements for trained strength athletes. J. Appl. Physiol. 1992; 73: 1986–95.
39Pannemans, DLE, Wagenmakers, AJM, Westerterp, KR, Schaafsma, G, Halliday, D. Effect of protein source and quantity on protein metabolism in elderly women. Am. J. Clin. Nutr. 1998; 68: 1228–35.
40Wayler, A, Queiroz, E, Scrimshaw, NS, Steinke, FH, Rand, WM, Young, VR. Nitrogen balance studies in young men to assess the protein quality of an isolated soy protein in relation to meat proteins. J. Nutr. 1983; 113: 2485–91.
41Young, VR, Wayler, A, Garza, C, Steinke, FH, Murray, E, Rand, WM, et al. A long-term metabolic balance study in young men to assess the nutritional quality of an isolated soy protein and beef proteins. Am. J. Clin. Nutr. 1984; 39: 815.
42Matthews, DE. Proteins and amino acids. In: Shils, ME, Olson, JA, Shike, M, Ross, AC, eds. Modern Nutrition in Health and Disease, 9th ed. Baltimore, MD: Williams & Wilkins, 1999; 1148.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

Public Health Nutrition
  • ISSN: 1368-9800
  • EISSN: 1475-2727
  • URL: /core/journals/public-health-nutrition
Please enter your name
Please enter a valid email address
Who would you like to send this to? *



Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed