Development and Evaluation of a Photographic Atlas As a Tool for Dietary Assessment Studies in Middle East Cultures

Public Health Nutrition: 15(6), 1023–1028 doi:10.1017/S1368980012000171 Development and evaluation of a photographic atlas as a tool for dietary assessment studies in Middle East cultures Maya Tueni1,2,*, Afifee Mounayar1 and Ines Birlouez-Aragon2,3 1Department of Nutrition and Dietetics, Faculty of Science II, Lebanese University, Fanar, Lebanon: 2AgroParisTech, Paris, France: 3Spectralys Innovation Biocitech, Romainville, France Submitted 9 September 2010: Accepted 6 January 2012: First published online 10 February 2012 Abstract Objective: To assess the errors between estimates of amounts based on photographs and actual quantities of food presented to adults or eaten on the previous day. Design: A photographic atlas was constructed by taking digital photographs of three pre-weighed portion sizes of 212 traditional Lebanese dishes. In a first approach, ten portions of real pre-weighed foods were assessed using the photographic atlas. In a second approach, the participants weighed all foods consumed at one meal and recalled the amount of food that was eaten the previous day using the photographic atlas. Differences between actual quantities and estimation were assessed using a signed rank test (P , 0?05). Spearman’s correlation coefficients and bias (Bland–Altman plot) between the methods were calculated. Setting: Lebanese university canteen and Lebanese homes. Subjects: Forty adults (twenty males, twenty females) completed the first protocol and fifty adults (twenty-five males, twenty-five females) completed the second protocol; all were volunteers aged 21 to 62 years. Results: Mean differences between actual and estimated portion sizes by photographs were between 213?1 % and 124?5 % when pre-weighed foods were presented, and between 210?4 % and 13?8 % when foods were consumed the day before. No significant differences were found between actual and estimated portion sizes except for three dishes (loubieh bil zeit, tabbouleh and yachnet bazella). Bland–Altman plots showed good agreement for all dishes with a negligible bias of Keywords 20?2 g between estimated and presented portions, and 26?3 g between estimated Food photographs and eaten portions. Portion sizes estimation Conclusions: In the Lebanese diet, food photographs seem a reliable tool for Dietary assessment quantification of food portion sizes. Lebanon In dietary epidemiological surveys, portion sizes of there is a crucial need to determine the error level induced commonly consumed foods are often roughly estimated by such an approach(8–13). due to high difficulty in remembering and evaluating Some studies have evaluated the errors related to per- them properly(1). ception of foods in photographs while assessing the Two methods have been used to quantify food portion portion of foods presented to the participant(3,6–8,13,14). size: (i) those in which foods are weighed directly; and They speculate that assessment of portion size would not (ii) those in which food quantities are recalled by tools be biased by factors such as participants’ unwillingness to such as household measures, food models, food replicas divulge what they have eaten(1,15). Others have estimated and food photographs. Also standard portions are used the error arising from conceptualization of foods and frequently. memory while recalling amounts eaten by the partici- The most accurate method for measuring food intake pant(4,5,16,17). They consider that the effectiveness of is weighing foods before and after eating(2). This method portion size estimation may be reduced when memory/ is not always the most appropriate however, because recall is required(7,8). it imposes a large burden on participants, is expensive The need to assess the rapid changes in dietary habits and time consuming, and does not allow assessment of in the Mediterranean area over recent years and the lack past intakes(2). of data in Lebanon urged us to perform dietary surveys in Visual aids, such as food photographs, help circumvent this country. To fulfil this objective, a first task consisted in many of these problems and may help improve the developing a photographic atlas to quantify portion sizes accuracy of food portion quantification(3–7). However, of 212 traditional Lebanese dishes, presently not available. *Corresponding author: Email [email protected] r The Authors 2012 Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 10:10:35, subject to the Cambridge Core terms of use. 1024 M Tueni et al. The present study describes the methodology used (twenty-five men and twenty-five women) in which to design and validate this colour photographic atlas. portion sizes of 212 dishes were estimated by household Discrepancies between the food portion size deduced measures (M Tueni and A Mounayar, unpublished results). from the photographs and the corresponding real portion For the majority of the dishes, we added to or subtracted weight were assessed and main bias identified. from the weight of the medium portion a coefficient Specifically, we evaluated (i) the errors related to (2SD) for the small (B) and the large (F) portions, a perception of foods in photographs while assessing the coefficient (SD) for the intermediate virtual portions amounts of foods presented to participants (study 1) and (C and E) and a coefficient (3SD) for the extreme virtual (ii) the errors related to perception, conceptualization of portions (A and G): foods and memory while recalling amounts eaten by X À 3SDðAÞ;XÀ 2SDðBÞ;XÀ SDðCÞ;XðDÞ; participants on the previous day (study 2). X þ SDðEÞ;Xþ 2SDðFÞ;Xþ 3SDðGÞ Methods where X is the weight of the medium portion (D). The SD coefficient represented the standard deviation of Design of the photographic atlas the mean consumption for each food. In order to select portions neither too small nor too large, some food Choice of dishes photographs depicting different portions, computed as The photographic atlas presents 633 colour photographs described above, were shown to the fifty Lebanese adult (format 7?6cm3 4?7 cm) corresponding to 212 traditional volunteers and we asked them their opinion. For example, dishes, usually consumed at home and in Lebanese the mean consumption of mdardara was 200 (SD 45) g, restaurants, and cooked according to two main Lebanese which results in a portion B of 110 g and a portion F (18,19) recipe books . of 290 g. According to the volunteers’ opinions, we decreased B to 100 g and increased F to 300 g. Thus, the Portion sizes (SD) coefficient will be 50 (Fig. 1). The dishes appear according to three portion sizes presented on the same conventional plate. Each portion is Food digital photographs associated with a letter. The general principle is to identify Three different portions of each dish were weighed accu- the consumed portion, either in one of the suggested rately (Tefal 3000 digital electronic scale, 61g precision), photographs (B, D or F) or between two consecutive placed on a white dining plate contrasting with a colour photographs (C or E), including below or beyond the background and photographed from the same angle using extreme photographs (A or G; Fig. 1). a digital camera (Sony-Cyber 72 Power Shot). Portion weights Validation of the photographic atlas The medium portion (D) was chosen in a way to be Two groups of Lebanese volunteers validated the photo- representative of the mean portion size actually consumed graphic atlas. They were recruited by telephone; the by the Lebanese population, as deduced from a pre- phone numbers were selected randomly from the phone liminary food consumption survey carried out between book. The study was approved by the Ethical Committee March and June 2004 on fifty Lebanese adult volunteers of the Lebanese University. Choose the letter corresponding to your consumed portion Between Between Less than Portion Portion Portion More than portions B & D portions D & F portion B B D F portion F A C E G Amounts (g): Portion A Portion B Portion C Portion D Portion E Portion F Portion G 50 100 150 200 250 300 350 Fig. 1 The set of pictures of mdardara (lentils with rice) in three portion sizes and the amounts in grams Downloaded from https://www.cambridge.org/core. 28 Sep 2021 at 10:10:35, subject to the Cambridge Core terms of use. Food photographs for portion estimation 1025 Table 1 Food groups, shapes and Lebanese traditional dishes included in the present study Food category/shape Lebanese traditional dish Meat/number and size of pieces Kafta mechwieh (pieces of ground meat and chopped parsley), chich taouk (pieces of broiled chicken), lahmeh mechwieh (pieces of broiled meat), kebbe bil saniyeh (pieces of ground meat and bulgur) Vegetables/area and depth of mounds on plate Tabbouleh (parsley, tomatoes and bulgur salad), fattouch (fresh vegetable salad with bread), salatet baakle (purslane salad), salatet roka (arugula salad), salatet zaatar (thyme salad), m’saquaa (aubergine salad), baba ghannouj (mashed aubergine with sesame butter), silk (beet salad), hindbeh be zeit (chicory and fried onions) Vegetables/area and depth of foods in sauce or Bemieh (okra in oil), loubieh bil zeit (green beans in oil), yachnet bazella (pea stew), gravy spreading across plate yachnet sabanegh (spinach stew), yachnet loubieh (green bean stew), molokhieh (Jew’s mallow stew) Vegetables/number and size of pieces Batinjane meqli (fried aubergine), warak aanab (stuffed grape leaves), koussa mehchi (stuffed courgettes) Legumes/area and depth of foods in sauce or Adass be hamoud (lentil, beet and potato soup) gravy spreading across plate Legumes/area and depth of mounds

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