Research Progress Report #22
Food On Film© An Innovative Method for Recording Food Intake of Adults with Intellectual Disabilities or Communication Difficulties
Background: Nutrition education and counseling are keys to successful independent living for people with intellectual and related developmental disabilities (I/DD). In the past, their nutrition services were delivered in institutional settings, but today, most people with I/DD live in community-based group homes and transitional living arrangements: 80% in residences of fewer than 16 people and 66% in residences of fewer than seven people (Prouty & Lakin, 2002).
While there are varying definitions (e.g. 106th Congress, 2000), a “developmental disability“ is likely to continue indefinitely and substantially limit ability to function in three or more major life activities: self-care, receptive/expressive language, learning, mobility, self-direction, ability to live independently or to be economically self-sufficient. A person with a developmental disability needs extended (possibly life-long) individualized and coordinated services, supports, and/or other assistance. Limitations arising from cognitive or mental impairments observed among persons with developmental disabilities are currently being specified as “intellectual disabilities“ (AAMR).
People with I/DD are at a greater risk for physical or psychological problems in addition to their disability, such as depression, lack of environmental access, pressure sores and urinary tract infections. These are referred to as secondary conditions. Although secondary conditions can limit a person’s participation in community life as much or more than the original disability, they are preventable and treatable.
In our 2001-2002 research, we found that nutrition-related secondary conditions, including bowel and gastrointestinal dysfunction, diabetes, weight problems (over- or under-weight) and osteoporosis are among the most prevalent and limiting secondary health conditions of adults with ID/DD residing in community-based, supported living arrangements. To address such conditions, these individuals need nutrition interventions and supports that have been evaluated for effectiveness with their population and for efficacy in preventing and managing secondary conditions. Evaluating nutrition interventions and supports requires that we measure an individual’s health and food intake.
In nutrition studies, food intake is most often measured by 24-hour recall interviews. It is a method that balances reliability of responses with a fairly low respondent burden, and avoids dietary intake changes in response to recording foods at the time they are eaten (Gibson, 1990). Recently, we tested these methods with adults who have I/DD and who live in the community, and found that the results of the 24-hour recall were unreliable, even with a simplified National Health and Nutrition Examination Survey (NHANES) Multiple-Pass Method (Moshfegh, et al.). In the first round of interviews (Summer, 2002), researchers found that all data derived from standard methods of 24-hour recall were rated unreliable (Humphries, Traci, & Seekins, 2002) according to NHANES criteria: “Ss (i.e. participants) very confused or confused with the 24-hour recall period, or Ss had a very difficult time remembering and not giving a reasonable effort or changed their mind several times” (Centers for Disease Control and Prevention, 2002).
Measuring the food intake of adults with I/DD poses particular problems, including:
1. Some participants’ impaired communication skills and styles affect their ability to relay information to the interviewer.
2. Nutritionists may be inexperienced in working with adults with I/DD and may not have the skills to understand unique communication styles.
3. Individuals with impaired memory may be unable to recall what they ate, when they ate it, and the quantity eaten.
4. Adults with I/DD have a wide range of cognitive abilities and may vary in their ability to estimate the amount of food eaten and to describe how food was prepared.
5. Participants may not read and write well enough to maintain food records.
6. Proxy reporters cannot directly observe and then accurately report on the diet of individuals living in the community independently or with minimal support.
In subjects without I/DD, research has shown that still photographs can be used to identify what an individual has eaten and to accurately estimate the quantity of food (Williamson, Allen, Martin, et al., 2003; Bird & Elwood,1983). We hypothesized that using a similar technique would reduce the need for participants with I/DD to rely on memory of what food was eaten, how much was eaten, and when it was eaten.
Research Goals: Our project, called Food On Film©, attempted to refine the 24-hour diet recall method by showing that still photographs are practical and appropriate for use in community settings, and that the refined method produces reliable and valid data.
Participants: The eleven consenting adult volunteers were served by the Montana Developmental Disabilities Program (DDP), and lived in group homes or in semi-independent living arrangements. The participants had a variety of types of developmental disabilities and concurrent and secondary conditions, including one participant with low vision.
Materials: Each Food On Film© research kit contained a laminated instruction/prompt card and a 35 mm Olympus TRIP AF 50 automatic camera with time/date stamp. The camera was loaded with Kodak GOLD 100/24-exposure film. To provide a standard background for measurement, each kit also contained five large place mats and five small place mats marked with one inch grids. Kits were stored in insulated lunch bags to protect the cameras and film from direct heat and accidental damage. After the interviews, participants kept the lunch bags as study incentives.
Procedure: For each subject, we compared the reliability of data collected during three 24-hour recall interviews. Interview 1 was conducted in the summer of 2002, and Interviews 2 and 3 were conducted in the summer of 2003. Interview 1 used standard NHANES Multiple-Pass Method procedures with minor modifications. Partial or full Food On Film© protocols were implemented for Interviews 2 and 3. Prior to Interview 2, participants photographed the food they consumed for 24 hours. The developed photos were not available to them in Interview 2. In Interview 3, participants had food intake photographs available as memory and communication aids.
Twelve months elapsed between Interview 1 and Interview 2. Interview 3 was conducted immediately after Interview 2. Food On Film© procedures consisted of:
Day 1 – Evening training session: Researcher reviewed the protocol with participants, distributed kits, and identified direct service staff supports. Participants practiced taking photos of food.
Day 2 – Observation period: For a 24-hour period, participants photographed food before and after each eating occasion. Then the researcher collected the kits and had the film processed.
Day 3 – Two 24-hour recall interviews: The researcher conducted Interview 2, using a modified NHANES Multiple-Pass Method (Moshfegh, et al., 1999). Participants did not see the photos.
Next, the researcher conducted Interview 3, with photographs available to participants as memory aids. Each photo had a time/date stamp, so in Interview 3 it was unnecessary to ask when the participant had eaten the foods shown.
Data Analysis: Using a 5-point Likert scale, on which 1 = Poor (unreliable/indiscernible answer) and 5 = Excellent (reliable/clear answer), a qualified independent rater assessed the reliability of interview data for three questions: (1) What food did the participant eat? (2) How much did the participant eat? and (3) When did the participant eat the food items? Question (3) was answered for the Interview 3 data by recording the time/date stamp on the photo. For each interview, ratings of participants’ responses to each question were averaged.
Comparisons of respondents’ answers between Interview 1 and Interview 2 indicated that taking photos in itself did not improve their ability to recall either what was eaten, how much or when. Results of comparing Interviews 2 and 3, (Table 1) showed that use of photographs during interviews improved the reliability of the responses (see descriptions of Figures 1 and 2). Reliability ratings improved from “Poor” to “Good/Excellent”:
Table 1: Mean Ratings of Reliability Description
|Interview 2||Interview 3||(Interview 2) –
(a) Without the use of photos
(b) With the use of photos
In Interview 2, some participants described what they ate, but the interviewer was unable to understand the response. In Interview 3, the interviewer was then able to use the photograph to correctly interpret the participant’s description. Also in the Interview 3 photos, some participants could respond by pointing to their food items.
Conclusions and Next Steps: Food On Film©, a 24-hour recall method, uses photographs as support tools to yield useful information about dietary adequacy and variety across food groups. The resulting data could describe daily servings of food groups, food habits, diet patterns (meal and snack timing), characteristics of eating occasions (e.g., how many, where, with whom), and food preferences.
Food On Film© cannot reliably measure all aspects of food intake, such as “invisible” nutrients (e.g. table salt, types of dietary fats, etc.). However, it could be combined with food disappearance data and pantry analyses, recipe and menu reviews, interviews with primary food preparers and/or dietary logs kept by identified support persons. We have developed a set of nutrition materials specifically for use in group homes that serve adults with intellectual disabilities. We are pilot testing these materials with six group homes and our measurement design uses Food On Film© in baseline, intervention, and follow-up phases. As an additional outcome, intervention and follow-up photographs may provide information about customizing content and supports to extend the use of the materials.
A limitation of this investigation was that by introducing the photo support we essentially added another “pass” to the multiple-pass interview technique. It is possible that simply the addition of one more opportunity for participants to remember their food intake provided higher ratings on Interview 3. However, because the photo support represented approximately the 6th pass, we think the effect is due to the images that prompted additional memories and assisted in communication rather than participants being asked to recall one more time.
Food On Film© is a practical, appropriate tool for evaluating nutrition education interventions with adults who live in the community and who have intellectual and related developmental disabilities. It also may be appropriate for use with adults who have other cognitive impairments such as traumatic brain injury or dementia. Surprisingly, even the participant with low vision could take the photographs when provided with appropriate support.
Food On Film© also has potential for use in multi-cultural populations where participants and interviewers (e.g. dieticians, health educators) have significant communication barriers due to language or unfamiliar food items or customs. In rural areas where regular face-to-face access to health care professionals is difficult, Food On Film© could also be used as an important telemedicine application.
We don’t know if the picture taking activity in Food On Film© itself results in improved diets (as Gibson reported in 1990 on the effect of keeping dietary logs). Further investigation is needed to determine whether photographing foods eaten might motivate individuals to eat less junk food or increase the consumption of fruits and vegetables. In 2002, the U.S. Surgeon General declared improved nutrition for this population to be a national priority.
Food On Film© has great potential for improving communication about food choices and nutrition.
Resources and References
Bird, G., & Elwood, P. (1983). A photographic method of diet evaluation. Human Nutrition: Applied Nutrition. 37A: 474-477.
Bird G., & Elwood, P. (1983). The dietary intakes of subjects estimated from photographs compared with a weighed record. Human Nutrition: Applied Nutrition. 37A: 470-473.
Gibson, R. (1990). Principles of nutritional assessment. Oxford: Oxford University Press.
Humphries, K., Traci, M. & Seekins, T. (November, 12, 2002). Nutrition science and the study of adults with developmental disabilities. Presentation at annual meeting of the American Public Health Association. Philadelphia.
Humphries, K., Traci, M., Seekins, T. & Brusin, J. (2002). Nutrition and disability: Rural disability and rehabilitation research progress report #14. Missoula: The University of Montana Rural Institute.
Lollar, D. (2001). Public health trends in disability: Past, present, and future. In G. Albrecht, K. Seelman, & M. Bury (Eds.), Handbook of disability studies. Thousand Oaks, CA: Sage Publications.
Marge, M. (1988). Health promotion for persons with disabilities: Moving beyond rehabilitation. American Journal of Health Promotion, 2, 29-44.
Moshfegh, A,, Borrud, L, Perloff, B., & LaComb, R. (1999). Improved method for the 24-hour dietary recall for use in national surveys. FASEB Journal, 13(4): A603.
National Center for Health Statistics (2002). National Health and Nutrition Examination Survey (NHANES). Atlanta: Centers for Disease Control and Prevention.
Prouty, R. & Lakin, K. (2002), Residential services for persons with developmental disabilities: Status and trends through 2001. Minneapolis: University of Minnesota, Institute on Community Integration.
Traci, M., Geurts, S., Seekins, T., Burke, R., Humphries, K. & Brennan, L. (2001). Health status of adult Montanans in supported and semi-independent living arrangements: Overall summary of the Secondary Conditions Surveillance Report. Missoula: The University of Montana Rural Institute.
U.S. Congress. (2000). Developmental Disabilities Assistance and Bill of Rights Act: Public Law 106-402, 114 Stat. 1677, Subtitle A – General Provisions, Sec. 102 Definitions. 42 USC. Washington, DC.
U.S. Surgeon General. (2002). Closing the gap: A national blueprint to improve the health of persons with mental retardation. Washington, DC.
Williamson, D., Allen, H., Martin, P., Alfonso, A., Gerald, B. &, Hunt, A. (2003). Comparison of digital photography to weighed and visual estimation of portion sizes. Journal of the American Dietetic Association, 103(9): 1139-1145.
For more information, contact:
Kathleen Humphries, Ph.D.
Montana Disability and Health Program
The University of Montana Rural Institute
52 Corbin Hall, Missoula, MT 59812-7056
Opinions expressed are those of the authors, and not necessarily those of the funding agencies.
This report is available in Braille, large print and text formats on request.