April 2004<\/span><\/p>\n Background<\/span><\/strong><\/span>:<\/span> 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). <\/span><\/p>\n While there are varying definitions (e.g. 106th Congress, 2000), a “developmental disability<\/strong>“<\/span> is likely to continue indefinitely and substantially limit ability to function in three or more major life activities: self-care,\u00a0 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<\/strong>“<\/span> (AAMR).<\/span><\/p>\n 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<\/strong><\/span>. 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.<\/span><\/p>\n 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.<\/span><\/p>\n 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<\/em>) 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).<\/span><\/p>\n Measuring the food intake of adults with I\/DD poses particular problems, including:<\/span><\/p>\n 1. Some participants’ impaired communication skills and styles affect their ability to relay information to the interviewer.<\/span><\/p>\n 2. Nutritionists may be inexperienced in working with adults with I\/DD and may not have the skills to understand unique communication styles.<\/span><\/p>\n 3. Individuals with impaired memory may be unable to recall what they ate, when they ate it, and the quantity eaten. <\/span><\/p>\n 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.<\/span><\/p>\n 5. Participants may not read and write well enough to maintain food records.<\/span><\/p>\n 6. Proxy reporters cannot directly observe and then accurately report on the diet of individuals living in the community independently or with minimal support. <\/span><\/p>\n 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<\/span><\/strong> food was eaten, how much<\/span><\/strong> was eaten, and when<\/span> <\/strong>it was eaten.<\/span><\/p>\n Research Goals<\/strong>: <\/span><\/span>Our project, called <\/span> Food On Film\u00a9<\/span><\/em><\/span>, 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. <\/span><\/p>\n Method: <\/strong><\/span><\/p>\n Participants: <\/strong><\/span>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.<\/span><\/p>\n Materials<\/strong><\/span>: Each <\/span> Food On Film\u00a9<\/span> 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.<\/span><\/p>\n Procedure<\/strong><\/span>: 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 <\/span> Food On Film\u00a9 <\/span>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. <\/span><\/p>\n Twelve months elapsed between Interview 1 and Interview 2. Interview 3 was conducted immediately after Interview 2.\u00a0 <\/span> Food On Film\u00a9 <\/span>procedures consisted of:<\/span><\/p>\n Day 1 <\/strong><\/span>– Evening training session<\/span>: Researcher reviewed the protocol with participants, distributed kits, and identified direct service staff supports. Participants practiced taking photos of food.<\/span><\/p>\n Day 2 <\/strong><\/span>– Observation period<\/span>: 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.<\/span><\/p>\n Day 3 <\/strong><\/span>– Two 24-hour recall interviews<\/span>: The researcher conducted Interview 2, using a modified NHANES Multiple-Pass Method (Moshfegh, et al., 1999). Participants did not see the photos.<\/span><\/p><\/blockquote>\n 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.<\/span><\/p>\n Data Analysis<\/strong><\/span>: 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. <\/span><\/p>\n Results:<\/strong><\/span><\/p>\n Comparisons of respondents’ answers between Interview 1<\/span> and Interview 2<\/span> 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<\/span>, (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”:<\/span><\/p>\n <\/a>Table 1: Mean Ratings of Reliability\u00a0\u00a0<\/strong> Description<\/span><\/a><\/span><\/span><\/p>\n
![\"Recall](\"..\/..\/Publications\/_derived\/FoodonFilm.htm_txt_Recall2.gif\")
<\/p>\n![\"Recall](\"..\/..\/images\/Recall1.png\")
<\/p>\n![\"Photo](\"..\/..\/images\/dinner.jpg\")
<\/p>\n![\"Photo](\"..\/..\/images\/afterdinner.jpg\")
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