Table of Contents  
Year : 2018  |  Volume : 20  |  Issue : 2  |  Page : 93-103

What’s in your hands? A systematic review of dietary assessment methods and estimation of food sizes in a Primary Care Clinic

1 Department of Family Medicine, University College Hospital, Ibadan, Oyo State, Nigeria
2 Department of Medicine, College of Medicine, University of Ibadan, Oyo State, Nigeria
3 Department of Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Oyo State, Nigeria

Date of Web Publication17-Jul-2019

Correspondence Address:
Adetola M Ogunbode
Department of Family Medicine, University College Hospital, Ibadan, Oyo State
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jomt.jomt_22_18

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Introduction: Many patients with noncommunicable diseases such as obesity are attended to in Family Practice Clinics where quick dietary assessment along with estimation of food sizes as part of lifestyle modification and appropriate intervention could be offered. We performed a systematic review to determine the dietary assessment methods with the best evidence that can be employed in a Family Practice Clinic. Methods: Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines were used to conduct a systematic review of PubMed, Google, and Google Scholar databases from 1992 to 2017. Results: We found 730 original research articles, case–control studies, review articles, proceedings, transactions, and textbooks. Thirty-seven articles were selected out of which two were secondary data, 12 were review articles, 10 were descriptive surveys, and one was a prospective cohort study. There were two randomized controlled trials, two mixed study designs, one working paper, and seven guides. Food portion size estimation using household objects and the hand guide, then the food pyramid guide along with the food-sized plate intervention was documented. Conclusion: In view of the busy nature of Family Practice Clinics in several countries, in performing dietary assessment, food portions can be estimated using household measures and the hand portion guide. The pyramid guide and the portion-sized plate can then be used for intervention.

Keywords: Dietary assessment methods, Family Practice Clinics, food portion, hand portion guide, serving sizes

How to cite this article:
Ogunbode AM, Owolabi MO, Ogunbode OO, Ogunniyi A. What’s in your hands? A systematic review of dietary assessment methods and estimation of food sizes in a Primary Care Clinic. J Med Trop 2018;20:93-103

How to cite this URL:
Ogunbode AM, Owolabi MO, Ogunbode OO, Ogunniyi A. What’s in your hands? A systematic review of dietary assessment methods and estimation of food sizes in a Primary Care Clinic. J Med Trop [serial online] 2018 [cited 2022 Nov 26];20:93-103. Available from:

  Introduction Top

Patients from all walks of life with a myriad of medical conditions, varying from noncommunicable diseases (NCDs), such as obesity, hypertension, and diabetes mellitus, to communicable diseases, such as malaria and typhoid fever, are attended to in first-contact settings such as Family Practice Clinics. As of 2017, World Health Organization (WHO) documented that out of the 56 million deaths globally, 38 million (68%) deaths were due to NCDs,[1] as compared to a decade ago, when NCDs led to about 35 million deaths.[2] Worldwide, this accounted for over half of all the deaths with majority of mortality from NCDs arising from low and middle-income countries.[2] In Africa, NCD deaths per millions was 2.5, whereas total deaths per millions was 10.8.[2]

Behavioral risk factors of most NCDs include unhealthy diet and sedentary lifestyle that contribute to obesity and dyslipidemia.[2] There is a need to emphasize lifestyle modification to reduce the morbidity and mortality from obesity and its health complications. Lifestyle modification can be taught to physicians using pneumonics such as WASHED.[3] W refers to weight control, A means alcohol reduction, S is for smoking cessation, H depicts health education, E means exercise, whereas D stands for diet. The dietary component of this pneumonic includes dietary assessment and advice and is one of the bedrocks of obesity management.

A study was performed in a first-contact setting, a primary care clinic to find out how primary care physicians give dietary advice to patients with obesity who presented to them.[4] The barriers to obesity management included provider, system and patient level barriers, and having poor education in school or during residency about obesity and its management.[4] To address the provider-level barriers, there are several methods that can be used to teach and to introduce simple quick methods of dietary assessment to physicians working in a busy clinic such as the hand portion guide, food photographs,[5] as well as household measures and objects.[6] Counseling and intervention can then be done using pictorials of food pyramids and plate-sized portions.[7]

The aim of this review was to identify dietary assessment methods and counseling methods/interventions that can be used by physicians in a busy Family Practice Clinic.

  Methods Top

Review design

The systematic review design was used with literature records that included original research articles, case–control studies, review articles, proceedings, transactions, and textbooks being assessed. This review was part of a bigger study on predictors of weight reduction within a 25-year span, from 1992 to 2017.

Search strategy

The Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) guidelines was used being a user-friendly guide [Figure 1]. The inclusion criterion was studies on obesity among adults. Obesity was defined as body mass index more than or equal to 30 kg/m2. The primary search item was dietary assessment whereas the secondary search assessment was dietary intervention. Full texts were checked using the exclusion criterion which was not mentioning dietary assessment techniques.
Figure 1: The Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA) flow chart.

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List of databases searched for extraction and synthesis

Internet search engines were employed such as Google and Google Scholar to extract information. Hand searching of key journals in dietary assessment was done to supplement the electronic search.


The language of the studies reviewed was English.

Search outcome

Seven hundred twenty records were from databases whereas 10 others were from extra sources such as textbooks and monographs. Out of the 730 articles identified, 620 were excluded because of the absence of information on various dietary assessment methods. One hundred ten full texts were found eligible and of these 73 were again excluded.

Analysis process

The remaining 37 articles selected were critically appraised in line with the set objective. Each article was read repeatedly ensuring that all the concepts involving dietary assessment were integrated and that any relationships between food intake and the hand portion guide with household measures were explored. Following the dietary assessment, interventions using the pyramid guide and the portion-sized plate were discussed.

  Results Top

Reports were taken, globally, from both developed and developing nations. Various study designs were used and analyzed. Out of the 37 studies that were documented, two used secondary data, 12 were review articles, 10 were descriptive surveys, whereas one was a prospective cohort study. Two were randomized controlled trials, two were mixed study designs, one was a working paper, whereas seven were instruments or guides. These are depicted in [Table 1] and [Table 2]. There are several dietary assessment methods available with the level of evidence.[8] This is shown in [Table 3]. The precise weighed individual inventory can be used for specific measurements of quantity of food consumed, but it is costly and was reviewed in four articles. The interview methods included diet recall and diet history methods that are quick and easy to administer but are prone to variations and recall bias. The diet recall was the method most commonly mentioned as it was discussed in 11 out of the 37 publications whereas the diet history was used in four of the 37 articles. The food frequency method gives specific details about food consumed and was discussed in seven of the articles. Two of the articles that were about food habit questionnaires and food records, which was the second highest dietary assessment method used, were mentioned in 10 documents. Food habit questionnaires and food records are useful for collecting large data. Food composite analysis is useful for research and was reviewed in six articles. Group methods such as food balance sheets and food accounts are good for planning for the country and were discussed in four of the publications.
Table 1: Study designs of the selected studies from high-income countries

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Table 2: Study designs of the selected studies from low and middle-income countries

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Table 3: Dietary assessment methods

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  Discussion Top

Several methods have been used to assess dietary assessment,[9] and the two classifications used are the individual method and the group method.[10] The individual methods of dietary assessment include the precise weighed individual inventory method, the interview methods (which is subdivided into two: diet recall and diet history), and the food frequency methods. Other individual methods of assessing dietary assessment include the questionnaire method such as food habit questionnaires, food records, and the food composite analysis. The group methods of dietary assessment are composed of the food balance sheet and food accounts.

In the precise weighed individual inventory method, a food inventory is taken at the beginning and end of the process. Weight of food consumed is recorded as well as food wasted. Nutritive value of meals is then calculated from classic food tables.[10]

Interview techniques are another type of method used for individual assessment; these include diet recall and diet history. These are also known as rapid assessment procedure (RAP) and involve interview techniques used to assess the patient’s meal in the shortest time.[9] The 24-h-dietary recall can be done face-to-face or via the telephone.[9] The diet recall is also called the 24-h recall method, where the person remembers details of food consumed as well as timing in the previous 24 h.[11],[12]

A report documented three 24-h recalls in which data collectors were taught to obtain information from dietary recalls for 2 days during the week and for one weekend day using the University of Minnesota Nutrition Data System for Research software.[13] Food models that were three-dimensional were shown to the participants to demonstrate food portion sizes, whereas two-dimensional food models were given to them to take home.[13] The first visit was face-to-face, which was also corroborated by another report, whereas subsequent visits were via telephone interviews.[14] The average nutrient variables from fat (total and saturated) and grams of fiber) were calculated from these three 24-h recalls.[13] The dietary recall is a fast technique in which well-known measures are used. A 7-day dietary recall can also be done as was performed in a research study to find out the nutritional status of Nigerian undergraduates.[15]

The meal-based diet history estimates a person’s normal intake in which every food and beverage consumed at each meal is documented over time.[9] Diet history is what is most useful in epidemiological studies, to get details about the common dietary patterns and not their present pattern.[10] There is a record of daily meals, snack timings, and what each meal consists of.[10] The amount of servings and their portion sizes are used to estimate the quality and amount of foodstuffs. It is a simple and affordable method to use.[10] An example of the diet history form is that from the Texas Department of state health services.[16] In Family Practice Clinics, which are busy clinic settings, the most feasible RAP would be the diet history.

In epidemiological studies, another tool that is commonly used is the food frequency questionnaire (FFQ).[17] FFQs are sometimes referred to as a “list-based diet history” and the participant should estimate the frequency of consumption based on frequency categories that indicate the number of times the food is usually consumed per day, week, month, or year. FFQs may be unquantified, semiquantified, or completely quantified based on the addition of serving sizes. The FFQ was administered to each participant in a study to determine the normal pattern of consumption and the food size using standardized food models.[17] In the food frequency method, the frequency of intake of food items consumed is documented. It is useful for identifying dietary patterns and when looking for dietary associations.[10] Another study combined self-administered FFQs and dietary records. In addition, a study in schools in Lagos, Nigeria, used interviewer-administered questionnaires to assess the dietary history/pattern as well as the food frequency.[18],[19]

Food habit questionnaires are used to document details such as beliefs about food, food preferences, meal preparation techniques, and the circumstances around the meal. All these methods constitute examples of RAP to help accumulate better dietary data during dietary assessment. Food records are also called food diaries or dietary records. The individual documents all foods and beverages consumed for a period between 1 to 7 days.[9] A report had food diaries that included all the food and drinks consumed, documented, and collected over 3 days, a weekend inclusive.[20] Participants can also estimate the amount consumed by using common household measures (e.g., spoons, cups, glasses, and plates) or by using portion size estimation aides.[21]

In the food composite analysis for laboratory estimate, food items are checked at meal times and analyzed.[10] Food composition tables are used to change this intake into actual nutrient intake by the individual or from FFQs by multiplying the frequency of use by the nutrient composition for the portion size specified for each item. These food composition tables may be paper based or electronic.[22] Computerized software programs can be used to calculate nutrient intake by multiplying the reported frequency of each food by the amount of nutrient in a serving of that food.

The group methods for dietary assessment include the food balance sheet and food accounts. The food balance sheet is used to extrapolate the overall food stores of a country and is used to plan food programs.[10],[23] The food balance sheet is also able to track trends in the nation’s food supply and changes in the dietary patterns.[24] The meticulous documentation of meals consumed over time by the family, group, or organization is known as a food account.[10]

In estimating the food size during dietary assessment, a portion is the amount of food an individual decides to eat as a meal or snack, whereas a serving is what is shown on the food label.[25] Several household measures can be used to estimate meals instead of kitchen scales that several Nigerian homes do not have access to.[26],[27] A study was done in a community in Nigeria among 413 participants, using 24-h dietary recall and estimated food portion sizes with measuring guides (household measures) and food models.[28] These household measures included teaspoons, table spoons, cups, and milk tins.[26],[27],[28]

Sanusi and Olurin[28] in 2012 determined that among the cereals and grains, one serving was equivalent to 1.3 slices of bread, 1.3 heaped table spoons of joll of rice, 1.75 heaped table spoons of white rice, one small wrap of “Eko” (maize mold), or a 500-mL cup of fermented maize meal/maize pap “ogi.” One-eighth of a wrap of semolina, one-third of a wrap of pounded yam, 1.75 thin slices of boiled yam, two-third of a small wrap of yam flour “amala,” one-third of a small wrap of cassava flour “Lafun” or cassava flour “Fufu” were also described as a serving.[28] Two-thirds of a milk tin of Cassava flakes “Garri,” 2.5 table spoons of freshly prepared cassava “eba,” or 8.3 medium slices of fried plantain were equal to a serving size.[28]

For the legumes, 1.5 heaped table spoons of boiled beans, a small bean cake “akara,” 1.5 times the size of a small wrap of cowpea pudding “moinmoin,” or three-fourth of a tin cup of cowpea pudding “moinmoin” constituted a serving.[28] For soups and stews, a serving was two-fifth serving spoon vegetable and melon “egusi and efo,” two-third serving spoon of vegetable soup without melon “eforiro,” 3.5 of draw soup “ewedu,” three-fourth of draw soup “ogbonna,” and for stews a serving was 1.3 serving spoons of vegetable oil stew and two-third serving spoon of palm oil stew.[28] For fruits, one small orange or 1.25 banana were a serving, whereas for protein, one small egg or one small piece of meat constituted a serving.[28] Other household materials that can be used to estimate the size of food consumed include an audio tape cassette to estimate a slice of bread or an electric bulb equal to half a cup.[29] This is shown in [Figure 2].
Figure 2: Hand guide.

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In addition, a convenient method that can be used in the clinic for estimating food sizes is comparing the food consumed to the size of the fist or palm excluding the fingers as well as the thumb size, this could be done in comparison to household objects such as a cup.[21],[30],[31] Protein is measured with the size of the palm excluding the fingers[30] or a full cup or one fist size for a cup of beverage or legumes such as beans.[31] A carbohydrate serving is a fist size, for example, for cereal, but half a fist size or half of a cup if it is rice or pasta.[31] The size of the thumb represents a portion of fat.[30] Vegetable servings are equivalent to half cup or half fist of canned vegetables or full cup or one fist of leafy vegetables, whereas a fruit serving is equal to half a cup of fruit juice or half a fist of canned fruit or one medium fruit, for example, a whole orange[31] or one fist size.[30] A handful of nuts is a portion.[31] This is depicted in [Figure 2].

Intervention following the dietary assessment can be done using the pyramid guide or the portion-sized plate. The pyramid guide is a pictorial that depicts the healthy way food should be combined before eating a meal. It shows different levels of each food group and how much should be consumed.[7] The grains and carbohydrates are at the base, followed by the vegetables and fruits at the middle level, then protein, and finally fats and oils are at the tip of the pyramid.[7] The pyramid guide can be used as a means of intervention initially.

Using the pyramid guide to daily food choices, examples of a serving for carbohydrates are one slice of bread, a biscuit, a small roll, five to six small or three to four large crackers, half cup cooked cereal or rice, and one ounce ready-to-eat cereal.[32] Carbohydrates such as bread are measured comparing each slice to an audio cassette or the size of a woman’s palm stacked 1 inch high.[33] A fist is equal to a cup.[33] Other examples of carbohydrates consumed include bread, boiled yam, boiled plantain flour, “amala,” and boiled cassava flakes, “eba.”

For fruits, a serving is a medium banana, orange, apple, grapefruit, half a melon wedge, three-fourth cup juice, half cup chopped, cooked, or canned fruit, and one-fourth cup dried fruit.[32] Half cup cooked vegetables, half cup chopped raw vegetables, and one cup leafy raw vegetables, such as lettuce or spinach, constitute a serving of vegetables.[32] Cooked lean meat, poultry without skin, or fish a day should total 5 to 7 ounces a day. An egg or half cup cooked beans is equivalent to 1 ounce of meat.[32] A cup of milk, 8 ounces of yogurt, 1 to 1/2 ounces natural cheese, and 2 ounces processed cheese is equal to one serving.[32]

The plate can be portion sized and is another useful method to help people determine the quantity of servings per plate. It is used for dietary intervention.[29] To portion size a plate, the plate could be divided into four: half would be vegetables and fruits whereas a quarter could be starch or carbohydrate or protein especially low-fat protein respectively. This is seen in [Figure 3].
Figure 3: Objects and portion-sized plate.

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These dietary assessment methods are useful in different settings and particularly in a Family Practice Clinic; the RAP can be a quick interview method. The methods, however, have their strengths and limitations that are depicted in [Table 4].
Table 4: Strengths and limitations of the dietary assessment methods[8]

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Future dietary assessments of dietary habits and behavior will include mobile food records using a mobile device of all meals consumed before and after the meal.[34] In a study, pictures of food images were taken using mobile phones and 247 participants were recruited into a randomized controlled trial study that was to be used for validation of a new instrument. Six months later, there was a repeat of these pictures taken. Some authors in this cross-sectional study on image-based dietary assessment tried to find out the ability of dietetics interns and students to perform dietary assessment and concluded that more training could improve identification of food via images.[35] Biomarkers and web-based 24-h recall are methods that could also be useful in dietary assessment.[36],[37]

  Conclusion Top

In view of the busy nature of Family Practice Clinics, in performing dietary assessment, simple, quick to administer, and cost-effective methods should be adopted. Estimation of food sizes should be done using household objects and the hand portion guide. The pyramid guide and the portion-sized plate can then be used for intervention.

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Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]

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