Accuracy of Self‐Reported Dietary Intake in Low‐ and Middle‐Income Countries: A Review of the Literature
Authors: Bell Winnie Fay , Saltzman Edward , Coates Jennifer 
Published: November 2023

Background

In high‐income countries evidence of systematic underreporting in dietary assessments has been documented in numerous large studies using biomarkers, such as doubly labeled water. Underreporting has been shown to vary with individual characteristics including age, sex, body mass index (BMI), education level, literacy, income, psychosocial, body image and diet behavior. However fewer studies have examined the accuracy of dietary intake assessment in low‐ and middle‐income countries (LMICs) or tried to characterize predictors of under‐ or overreport. This research systematically reviews existing studies from LMICs that compare energy intake (EI) assessed by 24‐hour recalls (24HR) or food records (FR) to an objective measure of energy expenditure (EE), namely doubly labeled water (DLW) or basal metabolic rate (BMR) in order to determine the proportion of misreporting.

Methods

Relevant papers were identified in PubMed using pre‐selected Mesh terms and by searching reference lists of key review articles. Studies that compared a 24HR or FR to DLW or estimated BMR with a related cut‐off were included. The definition of underreporting in each publication was utilized. Any country falling in the low‐ or middle‐income category according to the World Bank's 2016 Country and Lending Groups was included.

Results

A total of 100 articles were identified using the specified search strategy; 47 were retrieved for further review based on titles and abstracts. Sixteen articles met the inclusion criteria, all of which were published between 2000 and 2015. Only three of the 16 studies used DLW to determine EE; the remainder (n=13) relied on BMR calculated by equation to determine misreporting based on the Goldberg Method or an adaptation of it. Twelve of the 16 studies used 24HRs; the remaining four studies used FRs. Only one study was carried out in a low‐income country (Ethiopia); all others were conducted in middle‐income countries: Brazil (n=6), South Africa (n=3), Jamaica (n=2), Egypt, Ghana, Iran, Indonesia, Malaysia, and Mexico (one each).

The prevalence of underreporting ranged from a high of 95% in South African adolescent girls to a low of 6% among Jamaican men; almost half of the studies found underreporting in over 50% of the sample. The underreporting of energy as a percentage of EE (i.e. the extent of underreporting) ranged from 52% in Brazil to 18% in Jamaica and was reported in all DLW studies and in only BMR study. Higher body mass index, older age, lower education levels, and being female tended to correlate with higher levels of underreporting. Seven of the 16 studies provided evidence of overreporting.

Discussion and Conclusion

The significant heterogeneity across study designs, sample sizes, populations, and objectives makes generalizable conclusions about the accuracy of dietary assessment in LMICs challenging. Though the findings raise concerns about underreporting of energy intake in LMICs, the extent and drivers of the issue are not well understood. The majority of research has been conducted in middle‐income countries that are socially, economically and culturally quite different from many poorer countries. Future research should validate 24HR methods in low‐income populations.

Support or Funding Information

This research was conducted as part of the International Dietary Data Expansion (INDDEX) Project, which is implemented by Tufts University's Gerald J. and Dorothy R. Friedman School of Nutrition Science and Policy with funding from the Bill & Melinda Gates Foundation.