from the association OF PROFESSIONAL INTEREST

Dietary Patterns: Challenges and Opportunities in

Dietary Patterns Research
An Experimental Biology Workshop, April 1, 2006
Suzen M. Moeller, PhD; Jill Reedy, PhD, MPH, RD; Amy E. Millen, PhD; L. Beth Dixon, PhD, MPH;
P. K. Newby, ScD, MPH, MS; Katherine L. Tucker, PhD; Susan M. Krebs-Smith, PhD, RD;
Patricia M. Guenther, PhD, RD

A
workshop titled “Dietary Pat- ments made on similar topics by two dietary patterns, or combinations of
terns: Challenges and Opportu- or more speakers are summarized in foods and nutrients, in relation to
nities in Dietary Patterns Re- the text under the most appropriate chronic disease. These combinations
search” was held at Experimental subheading. of foods, nutrients, or in some cases,
Biology, April 1, 2006, to address the foods and nutrients, are often in-
current advantages and limitations of tended to represent the total diet or
the various approaches to studying HISTORICAL PERSPECTIVE AND key factors of the diet.
dietary patterns, as well as to con- EVOLUTION OF DIETARY PATTERNS Nutritional epidemiologists cite
sider future research that may be nec- RESEARCH several reasons for examining dietary
essary to determine the best uses of In studies of diet and chronic disease, patterns (1-6). People eat meals with
the different approaches. This article the traditional approach has been to complex combinations of nutrients
summarizes the five presentations at examine associations between indi- that are likely to be interactive or
this workshop, which are outlined in vidual nutrients or food groups with synergistic. Many nutrients are
Figure 1. The presentation topics are risk factors or outcomes related to highly correlated, making it difficult
generally used to structure this chronic conditions. More recently, nu- to examine their separate effects. The
manuscript, although relevant state- tritional epidemiologists have studied effect of a single nutrient may be too
small to detect, but the cumulative
effects of multiple nutrients included
S. M. Moeller is a scientist, Nutrition and Healthy Lifestyles, American in a dietary pattern may be suffi-
Medical Association, Chicago, IL; at the time of the study she was an as- ciently large to detect. Analyses of a
sistant scientist, Department of Ophthalmology and Visual Sciences and large number of nutrients or food
Department of Nutritional Sciences, University of Wisconsin-Madison. J. groups may produce statistically sig-
Reedy is a nutritionist, Risk Factor Monitoring and Methods Branch, Ap- nificant associations simply by
plied Research Program, Division of Cancer Control and Population Sci- chance, and are criticized for using
ences, National Cancer Institute, Bethesda, MD. A. E. Millen is an assis- too many tests. Analyses of single nu-
tant professor, Department of Social and Preventive Medicine, School of trients may be confounded by the ef-
Public Health and Health Professions, University of Buffalo, NY. L. B. fect of dietary patterns. Results from
Dixon is an associate professor and director, Public Health Nutrition, De- clinical trials have shown positive
partment of Nutrition, Food Studies, and Public Health, New York Uni- health outcomes with changes in sev-
versity, NY. P. K. Newby is an assistant professor, Department of Pediat- eral types of dietary behaviors (7,8).
rics, Boston University School of Medicine and Department of Many methods are available for
Epidemiology, Boston University School of Public Health, Boston, MA. characterizing dietary patterns in a
K. L. Tucker is a director, Epidemiology and Dietary Assessment Pro- population. Dietary patterns have
gram, and senior scientist, Jean Mayer USDA Human Nutrition Research been assessed a priori using score-
Center on Aging, Tufts University, Boston, MA. S. M. Krebs-Smith is based approaches, a posteriori using
chief, Risk Factor Monitoring and Methods Branch, Applied Research data-driven techniques such as factor
Program, Division of Cancer Control and Population Sciences, National analysis and cluster analysis, and
Cancer Institute, Bethesda, MD. P. M. Guenther is a nutritionist, Center more recently, using reduced rank re-
for Nutrition Policy and Promotion, US Department of Agriculture, Alex-
gression (1-5). Occasionally, research-
andria, VA.
ers have combined these approaches
Address correspondence to: Suzen M. Moeller, PhD, Nutrition and
(9). These methods often show associ-
Healthy Lifestyles, American Medical Association, 515 North State St,
ations with different disease out-
Chicago, IL 60610. E-mail: suzen.moeller@ama-assn.org
comes that sometimes are stronger
0002-8223/07/10707-0011$32.00/0
than those seen in studies of individ-
doi: 10.1016/j.jada.2007.03.014
ual nutrients (10).

© 2007 by the American Dietetic Association Journal of the AMERICAN DIETETIC ASSOCIATION 1233
OF PROFESSIONAL INTEREST

Organizers

Suzen M. Moeller Chair

Jill Reedy Co-chair
Amy E. Millen Co-chair

Presenters Title of presentation

L. Beth Dixon Historical perspective and evolution of dietary patterns research

Patricia M. Guenther Index-based approaches: USDA’sa revised Healthy Eating Index
P. K. Newby Data driven approaches: cluster and factor analysis
Katherine L. Tucker Constructing variables and the application of dietary patterns
Susan M. Krebs-Smith New ways of thinking about dietary patterns
a
USDA⫽United States Department of Agriculture.

Figure 1. Presentations at the 2006 Experimental Biology workshop on “Dietary Patterns: Challenges and Opportunities in Dietary Patterns
Research.”

No one method of dietary pattern
analysis is regarded as better than all
of the others; there is little consensus
on which approach should be applied
for any given purpose. The reproduc-
ibility and validity of dietary patterns
have been called into question and
may depend on the nature of the diet
assessment measure (food frequency
questionnaire [FFQ], 24-hour recalls,
diet records) and the subjective deci-
sions made by researchers during the
analyses or during the development
of an index. Two recent review arti-
cles highlight the diversity of dietary
patterns research and the current
need for greater attention to method-
ological issues (2,3).
SCORE-BASED APPROACHES
Score-based approaches are based on
dietary recommendations as well as
other knowledge about the subject
matter. These approaches generally
fall into four categories: nutrient ad-
equacy or density scores, variety or
diversity scores, food-group pattern-
ing scores, and index-based summary
scores.
Nutrient adequacy scores include
the nutrient adequacy ratio, defined
as average daily intake of a nutrient
divided by the age- and sex-specific
recommended intake of that nutrient,
and mean adequacy ratios, defined as
the sum of the nutrient adequacy ra-
tio divided by the number of nutrients
having a nutrient adequacy ratio. De-
veloped to evaluate the overall di-
etary quality of food assistance pro-
grams (11), these scores also have
been used to test validity of simple
dietary scores that assess food-group
intake as a way to evaluate overall
dietary adequacy, and to counsel or
educate patients (12,13). Nutrient
density scores were created to evalu-
ate the dietary quality of individual
foods in terms of nutrient content in
relation to total energy, but do not
evaluate a total dietary pattern (14).
Dietary variety has been encour-
aged since the inception of the Nutri-
tion and Your Health: Dietary Guide-
lines for Americans in 1980 (15).
Krebs-Smith and colleagues (16) cre-
ated scores to examine variety among
food groups (defined as the mean
number of different food groups con-
sumed daily) and variety within food
groups (defined as the mean number
of different food subgroups or individ-
ual foods within food groups con-
sumed daily) and found that variety
among food groups explained as much
of the variation in mean adequacy ra-
tio scores as did variety within food
groups. However, neither type of va-
riety was associated with the varia-
tion in intakes of energy, fat, sugar,
sodium, or cholesterol. Kant and col-
leagues (17) assessed dietary variety
among food groups and showed a pos-
itive association between intake of
two or fewer food groups in 1 day
(ie, less diverse diets) and increased
mortality. In contrast, increased vari-
ation within all food groups (defined
as the number of different food types
within each of 10 food groups) was
positively associated with energy in-
take; increased variation within cer-
tain food groups (eg, sweets, snacks,
condiments, entrees, and carbohy-
drates) was positively associated with
body fatness (17). In addition, there
are other food-group patterning
scores based on the five major food
groups: fruits, vegetables, grain, dairy,
and meat (18,19).
Index-based summary scores have
been created based on interpretation
of current dietary guidance. Two well-
known index scores are the Diet Qual-
ity Index (DQI and DQI-Revised)
(20,21) and the Healthy Eating Index
(HEI) (22,23). The DQI-Revised and
the HEI are 100-point scores of 10
components each, reflecting recom-
mendations in the 1992 Food Guide
Pyramid (24) and the Dietary Guide-
lines. The HEI is currently under re-
vision (25) to reflect the key diet-re-
lated recommendations found in the
2005 Dietary Guidelines for Ameri-
cans (26) and to improve the psycho-
metric properties of the index.
Additional scores have been cre-
ated based on dietary recommenda-
tions such as the Recommended
Foods Score (27), the Not Recom-
mended Foods Score (28), the Medi-
terranean Diet Score (29,30), and the
Alternate Healthy Eating Index
(AHEI). Harvard researchers created
the AHEI based on findings from the
Nurses’ Health and Health Profes-
sionals Follow-up studies (31). The
90-point AHEI was more strongly as-
sociated with reduced risk of cardio-
vascular disease in men and women
compared with the HEI. This is not
surprising because the HEI was de-
veloped to reflect general dietary rec-
ommendations and the components of
the AHEI were selected based on find-
ings from previous analyses of diet
and cardiovascular disease.
Studies of dietary patterns using

1234 July 2007 Volume 107 Number 7


Method Strengths
Score-based methods Characterize total diet
a priori
Intuitively appealing
Types include: nutrient
adequacy or density Analytically simple to
scores, variety or compute
diversity scores, food-
group patterning scores, Easily reproducible and
index-based summary comparable
scores (eg, Diet Quality
Index, Healthy Eating Results can be meaningful,
Index, Alternate Healthy interpretable, and
Eating Index, associated with health
Recommended Foods outcomes
Score, Not
Recommended Foods
Score, Mediterranean
Diet Score)
Data-driven methods Characterize total diet
a posteriori
Allow for biologic interactions
Types include: factor among nutrients
analysis, principal
components analysis, Results can be meaningful,
cluster analysis interpretable, associated
with health outcomes, and
show some reproducibility
across populations
Patterns can be a starting
point for modeling different
types of interactions
because they describe
eating behavior
Factor analysis: describes the
variation in food intake in
the population based upon
correlations between
dietary items; a continuous
variable
Cluster analysis: separates
individuals into mutually
exclusive groups based
upon dietary intakes; a
categorical variable
Figure 2. Strengths, limitations, and research considerations for score-based methods and data-driven methods in dietary patterns research.
OF PROFESSIONAL INTEREST
Limitations
Those that dichotomize
components (eg, met vs not
met) do not take into account
the full range of amounts of
foods consumed.
Those that include a range of
points for each component do
consider variability in intake of
foods but not amounts at the
extremes.
Dependent on the selected
underlying dietary guidelines,
which are generally not specific
to one type of disease.
Subjectivity is introduced in the
interpretation of the guidelines
and construction of the scores
(which foods are selected for
inclusion).
The summation of equally
weighted dietary component
scores implies that each
component is equally important
and additively related to health.
Limited data on the reproducibility
and validity of the methods.
Few rigorous statistical tests have
been used to examine the
validity of derived solutions.
Subjectivity is introduced at
various points in the procedure:
● Grouping of dietary items
● Treatment of input variables (eg,
grams, servings, percent of
energy, standardization)
● Analytic choices and options
(eg, statistical algorithms, use
of rotation)
● Selecting a final pattern solution
July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION
Research considerations
Dietary scores are
multidimensional in design, but
if a summary score is used the
end product is one number that
may provide little information
about the contributing factors.
Therefore, most researchers
report and discuss results from
the individual components as
well as the total dietary score.
For hypothesis testing, a profile
score can be examined related
to some health outcome with a
basic regression equation that
includes multiple components.
Most critical is a better
understanding of the statistical
methods and options used to
derive patterns, and the use of
statistical testing to guide
pattern selection.
A better understanding of how to
model pattern variables in
epidemiologic studies; gene-diet
interactions using patterns; and
impact of measurement error on
patterns.
Priorities for future research
include continued clarification of
the most useful categorization
and treatment of input variables;
an improved understanding of
cultural variation in food
patterns and the need to
understand food groupings in
these contexts; and the effects
of change in dietary patterns
over time.
1235
OF PROFESSIONAL INTEREST
score-based approaches have gener-
ally shown more varied and healthful
diets to be associated with higher in-
come, higher education, higher en-
ergy intake, nutrient adequacy, higher
concentrations of serum nutrients,
higher bone mineral density, reduced
all-cause and cardiovascular disease
mortality, and in some cases, reduced
incidence of and mortality from cer-
tain cancers (1-5). Strengths, limita-
tions, and future research consider-
ations of score-based approaches are
listed in Figure 2.
DATA-DRIVEN APPROACHES: FACTOR
AND CLUSTER ANALYSIS
Methods
Data-driven approaches in dietary
pattern analyses use mathematics to
empirically derive eating behavior
patterns using dietary data collected
from FFQs, 24-hour recalls, or diet
records. In factor and cluster analy-
ses, a larger set of dietary variables
are aggregated and reduced to form a
smaller set of variables. These meth-
ods do not require a prior theory of
what patterns are expected, although
a thorough understanding of the lit-
erature on eating patterns, in con-
junction with a theoretical framework
about eating behavior, can be used
with either method. Nonetheless, it is
critical that the researcher “let the
data do the talking.”
The most common factor analysis
method used in nutritional epidemiol-
ogy is principal components analysis,
a form of exploratory factor analysis
(2). Principal components analysis
does not assume an underlying model
of the factors and uses matrix algebra
to identify the principal components
in the data based on a correlation or
covariance matrix of the input vari-
ables. The resulting components, or
factors, are linear combinations of the
observed variables that explain the
variance in the data. The factors can
be rotated to improve interpretabil-
ity; orthogonal rotation is commonly
used. Output from the principal com-
ponents analysis includes factor load-
ings (or scoring coefficients) for each
variable, which can be interpreted as
correlation coefficients. Factor scores
are calculated for each individual by
summing the standardized input
variables, weighted by their factor
loadings. Factor scores often are un-
correlated with each other. Factors
1236 July 2007 Volume 107 Number 7
are not mutually exclusive: individu-
als receive factor scores for each de-
rived factor. Factors are continuous
variables that often are categorized
into quantiles.
A challenging decision in factor (or
cluster) analysis is selecting the solu-
tion, ie, how many factors (or dietary
patterns) are actually meaningful in
the data? A number of criteria can be
used, including scree plots, the Kaiser
criterion (eigenvalues ⬎1), the mag-
nitude of factor loadings, examining
multiple solutions, and, most com-
monly, observing the general inter-
pretability of the solution. Additional
criteria include using prior knowl-
edge or theory to guide solution
choices, using goodness-of-fit statis-
tics, or confirming an exploratory fac-
tor analysis using confirmatory factor
analysis.
In contrast to exploratory factor
analysis, confirmatory factor analysis
involves specifying both the number
of factors and the types of variables
that will load on each factor, allowing
the researcher to use prior knowledge
about the subject matter. The re-
searcher then builds the factor model
and “confirms” the factor structure
and loadings for each variable. It may
be used either on its own or to vali-
date an exploratory factor analysis
procedure. Few studies have used
confirmatory factor analysis (32-36),
and solutions from confirmatory fac-
tor analysis have been found to be
highly correlated with solutions from
exploratory factor analysis (r⬎0.90)
(32,35).
Factor analysis derives patterns
based on the relationships between
the input variables (ie, the foods or
food groups). In contrast, cluster
analysis derives patterns based on
differences in intakes among individ-
uals. Several different types of clus-
tering methods are available. Clus-
tering methods used in nutritional
epidemiology separate individuals
into mutually exclusive, nonoverlap-
ping groups. Individuals belong to one
cluster only, and clusters can then be
used as categorical (nominal) vari-
ables in research. Two clustering
methods are most common: (a)
K-means, an optimization technique,
and (b) Ward’s method, a hierarchical
agglomerative clustering technique.
The first method requires the re-
searcher to prespecify the number of
clusters in the analysis; the second
method does not. The methods can be
used together to better understand
the number of clusters present in the
data.
The many challenges in performing
cluster analysis include choosing a
similarity measure and selecting
which clustering procedure is best.
These choices can impact the cluster
solution and should be considered
carefully. Many of the procedures are
sensitive to outliers, and many re-
searchers standardize their data be-
fore entering variables into the anal-
ysis, although standardization can
dilute differences in the patterns (37).
As with factor analysis, the re-
searcher must select the optimal
cluster solution, usually based on
the interpretability of the clusters.
Additional criteria can be used to
guide cluster selection, including a
dendrogram (Ward’s method only), a
scree plot, the variance explained by
the clusters, and various statistical
tests (eg, cubic cluster criterion).
Cluster means also can be compared
with the full sample means or among
random split samples. Although pat-
terning methods are empirical, and
should be driven by the data, prior
theory also may guide the investiga-
tor. For example, a comprehensive lit-
erature review of articles using factor
and cluster analysis has shown that
“Healthy,” “Traditional,” “Sweets,”
and “Alcohol” patterns are fairly re-
producible across populations (2),
thus a researcher might expect to see
variants of these patterns in his or
her own study. Indeed, humans have
a biological predisposition for sweet
foods, further supporting the proba-
bility of extracting a “Sweets” type of
pattern, which often includes such
foods as baked goods, dairy desserts,
and chocolate. Thus, researchers can
use their knowledge of the literature
as well as biology when approaching a
cluster or factor analysis.
Before beginning an analysis, re-
searchers must decide whether or not
to derive patterns separately for pop-
ulation subgroups. Very few articles
have examined this issue with regard
to age, race/ethnicity, culture, and/or
geography. It is prudent in mixed
samples to begin by deriving patterns
separately for subgroups and to sub-
sequently use statistical testing and a
priori knowledge of pattern– disease
interactions to decide whether or not
to combine subgroups.

Construction of Variables
As described above, decisions must be
made at several points, including the
form of the food-group input variables
(as grams, number of servings, per-
cent of energy; standardized or not);
the number of clusters or factors (al-
though statistics exist to assist, the
decision is largely driven by inter-
pretability); and the choice of analysis
methods (various statistical algo-
rithms, use of rotation).
Dietary data collection methods
may affect the form and utility of food
patterns. Random error from day-to-
day variability will contribute to mis-
classification of usual dietary pat-
terns with, for example, a single 24-
hour recall; thus, multiple days are
needed, as they are for usual nutrient
intake estimation. FFQs may limit
food groupings, and can obscure eth-
nic or other food-choice differences if
specific foods are collapsed into a
larger group. For example, combining
tortillas with bread may reduce the
ability to separate patterns. Individ-
uals consuming low-fat milk or whole-
grain breads are likely to consume
other foods different from individuals
consuming whole milk or white
bread. For this reason, care must be
given to form food groups that are
meaningful for both the study popu-
lation and the research question.
The number of food groups selected
as input variables also is important.
Too few groups may obscure differ-
ences in use, whereas too many foods
may lead to odd combinations with
undue influence (eg, if there are a few
heavy users and many nonusers of
unusual foods, or when foods that are
generally eaten together are broken
down into detailed subgroups). In ad-
dition, some type of energy adjust-
ment is important before patterning,
because individuals with higher en-
ergy intakes may have unduly large
effects on the patterns. This is partic-
ularly problematic when men and
women are combined, or when the
sample includes a large age range.
The decision of whether or not to
standardize input variables is rele-
vant to cluster analysis. Comparisons
have suggested that unstandardized
variables produce more realistic clus-
ters because standardization can give
undue influence to minor food groups
(37). The number of clusters or factors
selected requires careful judgment
and full description of the decision
process. Rotation of differing num-
bers of factors, for example, can pro-
duce different results and must be
carefully considered. Because there
are numerous points at which deci-
sions must be made, clear explana-
tion of these decisions is important for
interpretation of results.
Reproducibility and Validity
Very few reproducibility and validity
studies have been performed for fac-
tor and cluster analysis. Two studies
examined the reproducibility of fac-
tors derived using an FFQ over 1 year
(38,39), and one study examined the
stability of factors over 9 years (32).
Correlations were reasonable but un-
derstandably weaker over the longer
time period. No studies to date have
examined the reproducibility of clus-
ter analysis, although many studies
have examined the internal reproduc-
ibility of the solution using random
split-sample techniques.
Although patterns will never be ex-
actly the same across studies and
populations, because they are data
driven, both factor and cluster analy-
sis show reasonable reproducibility of
several major patterns. Currently, at
least 84 published studies have de-
rived eating patterns using factor
analysis. Of these, 30% of populations
observed a Healthy pattern, and 27%
observed a Traditional pattern.
Sweets and Western patterns were
observed in 19% of populations,
whereas an Alcohol pattern was seen
in 11% (2) (Newby PK, unpublished
data, 2006). Notably, one of the larg-
est studies to use one standardized
methodological approach (exploratory
factor analysis) across four cohorts in
four European countries found two
consistent dietary patterns (40).
Similar percentages were found
when examining the cluster analysis
literature (Healthy, 36%; Alcohol,
26%; Sweets, 24%; Traditional, 20%;
and Western, 4%) (2) (Newby PK, un-
published data, 2006). Three studies
have compared solutions using both
factor and cluster methods and found
that individuals in the Healthy clus-
ter had higher scores on the Healthy
factor (41-43). Despite these apparent
similarities, it is important to con-
sider the research question when de-
termining whether to use factor or
cluster analysis.
July 2007 ● Journal of the AMERICAN DIETETIC ASSOCIATION
OF PROFESSIONAL INTEREST
Validation studies include three
studies comparing solutions derived
using an FFQ with those using diet
records (35,38,39) and one study com-
paring solutions between a 24-hour
recall and 48-hour recall; reasonable
correlations were observed (2). Only
one study examined the validity of
patterns measured using cluster
analysis (44).
Most important in establishing the
validity of a method is whether or not
it is able to reliably predict disease.
Patterns have been related to anthro-
pometric indicators and obesity, type
II diabetes, metabolic syndrome, mor-
tality, cardiovascular diseases, and
many cancers, although findings have
not been consistent (2,3). Other
strengths, limitations, and future re-
search considerations for data-driven
methods are outlined in Figure 2.
NEW WAYS OF THINKING ABOUT
DIETARY PATTERNS
Dietary patterns are examined for
two reasons: (a) to characterize di-
etary behavior, and (b) to explain the
relationship of diet to health and
other factors. The first reason sug-
gests a descriptive purpose, and the
second suggests a hypothesis test.
Specific questions of interest include:
● What dietary patterns are shown
by the population?
● How close is the individual (or pop-
ulation) to meeting recommenda-
tions on key aspects of diet?
● Who is and is not following recom-
mendations?
● Do identified patterns relate to
health?
● Which dietary patterns are most
predictive of health outcomes?
● What combinations of food intake
explain the most variation in a spe-
cific health outcome?
● How does adherence to dietary rec-
ommendations relate to health
outcomes?
Each of these, although stemming
from one of the two general reasons
above, is a unique question requiring
particular methods to be answered.
Linking Questions to Methods
The issue of what dietary patterns
are shown by the population is per-
haps the one most frequently consid-
1237
OF PROFESSIONAL INTEREST
ered, and both cluster and factor
analysis have been used to address it.
The relative merits of these two meth-
ods have been described above. How-
ever, when deciding between the two,
one should understand that they ap-
proach a problem from different an-
gles and thus answer different ques-
tions. Cluster analysis examines
whether or not there are groups in the
population that are distinctly differ-
ent from one another, and if so, what
typifies their diets? Factor analysis
explores (or confirms) whether there
are underlying patterns that explain
variation in how people eat.
Regardless of which method is
used, once patterns are identified,
their relationship to health or other
outcomes can be explored. This often
is the ultimate purpose of identifying
the dietary patterns. However, one
limitation of both of these methods is
that they are not designed to derive
dietary patterns that are predictive of
disease. For this reason, reduced rank
regression has been proposed as an
alternative (45).
Whereas factor analysis deter-
mines linear functions of predictors
by maximizing the explained varia-
tion of all predictor variables (that is,
the food groups), reduced rank regres-
sion identifies linear functions of pre-
dictors that explain as much response
variation (that is, variation in a set of
intermediary health markers) as pos-
sible. The resulting factors can then
be examined in relationship to health
outcome.
Other questions, such as how close
is the individual (or population) to
meeting recommendations for impor-
tant aspects of diet, and who is and is
not following recommendations, often
are addressed by diet quality indices
that are made up of various compo-
nents. If the various components of an
index are unrelated to one another,
then they do not collectively repre-
sent a single underlying construct. In
other words, diet is multidimen-
sional, and the various aspects of diet
captured by the different components
may have separate, important effects
on health outcomes. This multidi-
mensionality suggests the need for
caution in interpreting a single sum-
mary score for any purpose.
For descriptive purposes, a sum-
mary score is instructive only when
scores are very high or very low. In
those cases, it accurately separates
1238 July 2007 Volume 107 Number 7
those with a very good diet (high
score) from those with a poor diet (low
score), and each component is met or
not met to the same degree. Midrange
summary scores only indicate that
the overall diet is neither optimum
nor poor, but give no hint regarding
the individual components—whether
they are all in the midrange, or
whether some are completely met
whereas others are not. A solution to
this would be a profile score in which
the average score for each component
is examined in relationship to its
maximum points, to identify which
aspects of the diet are closest to their
targets and which need improvement.
Most important in
establishing the
validity of a method
is whether or not it
is able to reliably
predict disease.
For hypothesis testing, there are
similar concerns. A summary score
may be helpful when comparing the
lowest quintile to the highest, as is
common in epidemiologic research,
because in those cases, all of the com-
ponents are varying together. Yet
again, subtleties in the midrange are
lost—an important consideration be-
cause most people do not have either
a very good or a very poor diet. An-
other approach would be to examine a
multidimensional profile score in re-
lationship to some health outcome
with a basic regression equation for
multiple independent variables (Xs).
The dependent variable could be
some health outcome, such as blood
pressure, each X could be a compo-
nent of the profile score (or food
group), and the beta would be the
weight determined for each compo-
nent. From this, one could determine
the effect and relative importance of
each component, and the combined ef-
fect of them all, on explaining varia-
tion in the health outcome. However,
without interaction terms, such a
model assumes that these factors act
independently rather than synergisti-
cally and would not provide insight
into how they act together to influ-
ence health.
Final Thoughts
There is an adage that states, “When
all you have is a hammer, everything
starts to look like a nail.” So too, in
dietary patterns research, we may in-
advertently limit ourselves to those
questions for which we think we have
the tools to find an answer.
In expanding our thinking about di-
etary patterns, the first priority is to
determine which questions to answer,
and the second is to ascertain
whether any of the commonly used
methods will answer those questions.
If not, we may need to turn to other
disciplines. For example, theories ex-
ist to explain chaos and complexity.
Mathematics and computer science
have provided ways of ascertaining
patterns for applications in both the
biological and the physical sciences.
Operations research has been used to
solve problems in decision making
and optimization. Human genome re-
search offers an opportunity to study
complex patterns using data mining
methods such as neural networks.
These are promising areas for further
inquiry. The field of dietary pattern
research will be unnecessarily re-
stricted if we only continue to use the
same methods with different data
sets and explore only those questions
we now know how to explore.
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