"RESEARCH AND PROFESSIONAL BRIEFS Dietary intake assessed by the Nutrition Screening Initiative Level Il Screen is a sensitive but not a specific indicator of nutrition risk in older adults DIANE C. MII HELL, MS, RD; HELEN SMICIKLAS-WRIGHT, PhD; JANET M. FRIEDMANN, PhD, RD; GORDON JENSEN, MD, PhD (NSI) isa national initiative to pro- mote routine, cost-effective nutri tion screening of older Americans (1-3), NSI personnel developed various mea- sres/indicators withthe purpose ofiden: tifying persons at greater-than-average risk for malnutrition, Ideally, these per- sons would be candidates for compre- hensive assessment and follow-up inter- vention that could result in more positive health outcomes (4), A number of screen- ing tests were developed and widely dis- seminated, including the Determine Checklist, the Level I Sereen, and the Level Il Screen (Lil) (1). These tests are composed of multiple items including questions about food intake. During screening, many community: dwelling older adults report low levels, ff food intake that would be considered Indicative of nutrition risk (4-8). How. ever, the food intake items have not been predictive of health-related out comes including functional disabili health-care costs, and hospitalization 43). Ti Nutrition Sereening Initiative D.C. Mitchell is coordinator of the Diet Assessment Center and H. Smiciklas-Wright is a professor of ‘nutrition in the Department of Nutrition, The Pennsylvania State University, University Park. J. M. Friedmann is an assistant professor of medicine and @. Jensen isan assoctate professor of medicine and director of the Cenuer for Human Nutrition, Vanderbilt University, Nashville, Tenn. Address correspondence to: Diane ©. Mitchell, MS, RD, Coordinator, Diet Assessment Center, Department of Nutrition, Pennsylvania State University, University Park, PA 16802. {842 / ane 2002 Volume 102 Number 8 Iraproving the efficacy of NSI sereen- ing tools requires a careful review of all, testitems (7,8), including an assessment of their eriterion validity or how well they measure what they are interided to measure, The validation of food group intake indicatorsin these screening tools is an important step in evaluating their uility as predictors of compromised nu: tritional status and reduced functional performance (4). Some investigators have compared the validity of the single- food intake questions in the Determine Checklist with intakes assessed by food frequency questionnaires (FFQs), show- ing little association (9); however, there have been no studies’ examining the multiple questions in Level 1 Seren or the Lil in a sirular manner. ‘Therefore, the purpose of this study ‘was to compare the food group intakes assossed from questions embedded in the NSI LIT with those from a more com- prehensive FFQ. METHODS. Free-livingolder(>60years) men (n=84) and women (n=105) were recruited from arural Pennsylvania health maintenance organization database (Penn State Geisinger Gold Health Plan, Danville, Pa) (4). All subjects were non-Hispanic whites living at home. Food frequency data were collected by telephone using the Block 95 FFQ (Block Dietary Dara Systems, Berkeley, Calif). This FFQ was used as the refer cence calibration method for food group intakes in this study. Other studies have indicated that the Block questionnaire is a valid instrument for assessing dietary intakes (10), However, itis much more costly and time consuming to collect than the 4 FFQ questions embedded in the Lil ‘The FFQswere sent to Block Dietary Data, Systems for analysis of mutrientsand food ‘groups. The LIl instrument was modified ‘0 that it could be administered by tele- phone. The modifications were based on pilot testing of the questionnaire, which indicated respondents’ difficulty in un- derstanding the original wording of the [NST questions. Questionnaire statements wererewordedinto direct questions. Table I showsthedifferencesbetween the orig nal questions and the modified (tel phone) version. Alldata were collected by computer-assisted telephone interview using Microsoft Access 97 (Microsoft Cor- poration, Redmond, Wash) For each of the instruments the num: ber of servings from each of 4 groups (ie, breads, dairy, fruits, and vegetables) was calculated, Frequencies of those persons who would be considered at nutrition risk fora given food group by eachinstru- ment were determined using the cut-offs established for the LIL, Four variables were created to assess sensitivity, speci fieity, and positive predictive value of the emberlded FFQ questions in the LI instrument: true positives (TP) or the number who were identified as being at Table 1 Comparison of the Level Il Scraen food group items with the modified telephone version items ‘once or ct a all day at ft rk file once oF nat tal ay at brea, cereal, pasa ce, or ther grains 5 of owor moe cal montatogeve sats “The 4 food group items thal ar part of the Eating Habits aniwocometics sberatory dat, cincal leat, vag orutornt.sctonal situs, 3° shington, DC: The Nutibon Telephone version baw many tie’ per day do you eat rut ike ‘ut wee? aw many tes par day do you eat bread, ‘cereal, pasta, ne, oF oe gra? al he Level Sareea, Waleo corte ering Intve, 1991), "Talopone version of he food group items developed at The Pennsyvania Slate University Cit As. eeammant Conor, Universi Park, PA flloning pial taeing ol to orginal qusetlernaire ers“RESEARCH AND PROFESSIONAL BRIEFS _—_ Table 2 Senstiviy, specicity. and postive predictive valve of a modified Level i Screan for nutrition risk in older adults Food Fisk cutott Group’ Positive focrsk* ——Negativeforriskt Sensitivity" Specificity’ ——_—Postve rou (Ties per ey Tue False =| Tue False bradictve Vogeabie a Mele Formate Dai a ele & 2 Fomate 7% a Frat = a 2 & ale 100, 53 Female 3 i 0 Bread os a 102 2 00 2 sie “a i 100 3 Female 61 i 400 2 tol at ck by he ood ),fsaies (9108). identi as at rik by te Leva Soon and bythe food trequency questonna: fis pos “rue negative for ok TN) =iersiied as nt tk i tila as tt rk by fe Lave Seren but at eke ' abily fo Genbily al hase al ven see TPIT FA) 00, the Level i Screen and nt the food equency questionnaire *Spectity ie the ably to dontiy al hove not |e nuton tek (FRA TN)» 100 ‘Poste precicave valu 's the Ikeirood tit a subject wo is iended a6 St puion risk vyis a isk by to0d frequency question; alse negate fr rk 1 fr rik FP)=isentod as at rik TPIT + FP) 100. rs risk by both instruments, false negatives (FN) or the number whe were at risk by the FFQ butwere identified as not at risk by the LI, false positives (FP) or the number identified as at risk by the LIT but who are not at risk by the FFQ, and true negatives (TN) or the number who are identified as not at risk by both instru- ments (11). These are standard proce: dures in evaluating the appropriateness of screening tools (8,11). Sensitivity, specificity, and positive predictive value were calculated as follows: sensitivity (ability o identity all those at risk)=(TP? (TP4FN))x100, specificity (ability to identify all those not at risk)=(TN/ (FP+TN)}%100, and positive predictive value (the likelinood that a subject who is identified as ab risk actually is at nisk)=(TP/(TP +FP))x100. RESULTS AND DISCUSSION In general, the sensitivity, specificity, and positive predictive value of the LIT embedded FFQ questions indicate that there would be considerable misclass- ification of those not at nutrition risk as determined by food intake measuresand to a lesser extent those at nutrition risk (Pable2). Specifically, the Lll food group questions were sensitive in identifying persons whose intakes were low but lacked specificity for most of the food groups. There were some notable differ ences arwang the food groups as well as some substantial gender differences within food groups. For both the bread and vegetable groups, the screening questions demon: strated high sensitivity (98% to 100%) and low specificity (2% to 13%) with positive predictive values varying from about 50% to 70%. Values were simular for males and females. The dairy group screening question had a moderate sen: sitivity (74%), and a relatively low speci- ficity (26%). "There was a low positive predictive value that differed substan- tially between males (5%) and fernales (3896). The fruit group question had the Iowest sensitivity (20%) overallwithcon- siderable differences between males (100%) and females (17%) Althougit it would be undesirable to have mang false negatives, that is, failure toldentify those who are really at risk of low intakes, a high proportion of false positives is not acceptable. It is na more likely to be practical to intervene on large numbers of those not atrisk than it is toassess diet by more costly methods. Whereas intervention is unlikely to be based on only these questions, their va. lidity and utility in the sereening tools ‘warrants examination, (One explanation for the poor specificity may be that the changes in wording that were made to administer the LIE by t ‘phone was sufficient to influence the true speeifcity. However, when this question- naire vas administered in its original ver- sion ina larger subset of this same popula tion, greater than 50% of the older adults ‘were identified as at nutrition risk. (4), Also, differences ini the wording be- tween the more detailed questions about serving size on the FFQ vs asking how often or how many tines per day a par- ticular food group would be consumed may have contributed to the lower speci- ficity. The Level If instrument relies on a respondent's ability to total the number of times per day a food group would be consumed without any guidance about what constitutes serving, This could be ofparticular concern for the bread group because a larger mumber of servings are recommended. For other groups the cut offthat defines riskin the Lifcould result in an invalid determination of risk. One ‘modification o thescreeningitems could be to change the risk cut-offs to reduce the likelihood of false positives. Im audition, there is no reference to what is included in each of the groups. Respondentsmighitnot know, for exarnple, whether to count potatoas.a vegetable or starch as it has been more traditionally categorized. Inany case, these issues could easily lead to over- or underestimation of a particular food group, Nore dlifficult to explain are the dis. crepancies we observed between males and feraales. There is no clear evidence in the literature to indicate that. food groups are reported differently by gen- der. One possible explanation is the greater energyintake by males that could lead to differences between the “times per day” asked in the Lil and the more detailed food-speeific “servings per day “Journal of TH AMERICAN DIETETIC ASSOCIATION / 843in the FFQ, for example. The public awareness of the relationship between calcium and osteoporosis, especially amongolderwomen, couldhave resulted in the higher values for the validity mea- sures in the dairy group. However, this does not explain the gender differences across food groups, ‘The NSI isan important public health strategy for identifying older adults with compromised nutrition and health out- comes. Although a number of investiga torshavedescribed associationsbetween the screening tools and functional abili- ties, health-care costs, and hospitaliza- fon (4-6,12,13), further validations will, Improve the utllity of these screens in predicting outcomes of interest (4,7,14). APPLICATIONS ‘The Lil is clearly a feasible, low-cost tool to sereen for nutrition risk in older ——————————. RESEARCH AND PROFESSIONAL BRIEFS adults and the intent of this study is not to discourage its use. However, the em- bedded food group questions in the Lil should be interpreted judiciously in the overall screening process. These spe cific questions by ttemselves were not intended to provide a valid determina. tion of nutrition risk in older adults Further altention should be given to designing foodiintake questions that un- dergo more rigorous testing of criterion validity References Incorporating Nutiion Sereaning and intr. ¥entons into Medica! Practice Washington, OC The Nuon Screening nave, 1998, 2. White JV. ed, The Pola of Nuon fo Chronic Disease Care, Executive Summary. Washington. es Nut intatve, 1997 (dar Americans’ Nutr Practices 2nd Future tional Healin: Cu Posse tah J, Heydt D, Fey ©. Nation risk screening characterstics of rural fide persone: eationtafunetonal imitations and heat care cnerges, Amd Clin Nutr. 1907 e6:819, 228, jensen Gt, Friedmann JM, Coleman CO. Smckias Wright 1. Sereering Yor hoeptazation and nutetonal sks among ot ‘olde! persone. sm J Cin Nut 66. Sehyoun NR, Jacques PF, Dalal GE, Russel Dietary calcium intake and supplement use among older African American, white, and Native American women in a rural southeastern community RONNY A. BELL, PhD, MS; SARA A. QUANDT, PhD; JOHN G. SPANGLER, MD, MPH; L. DOUGLAS CASR, PaD promised bone strength that predis- poses a person to increased risk of fractures, particularly of the hips and limbs. Osteoporosis affects about 10 il- lion people in the United States, with an additional 18 million having low bone 0 steoporosisis characterized by com R.A, Bell (corresponding author) is associate professor, mass, or osteopenia—a condition that increases the risk of osteoporosis (1), Ineidence of osteopenia and osteopard- sis is mmuch greater among white women compared with African American wornen (2-3); little data for Native American wonten is available, A. Quandt is (professor, and L. D. Case is associate professor in tive Department of Public Health Sciences and J. G. Spangler is associate professor with the Department of Family and Community Medicine, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157; Email: roelt@ufubme.edu £844 / Jone 2002 Voluine 102 Number 6 FM. Nutrition 8 be a beter awarenoss/edueatonal toot man 2 Screening ane Am Diet Assoc 1987/97 760 a 7. Flush 0. Evaluating the Nutition Screening ng Iniatve checklist may Initiative. Am J Public Heath, 1983 83:944-956 2B. Beubon 08, Greendale GA, Hareon GG. Nu ison screening in oler persons. J Am Gera "808: 49:495.425 2. hein Ta, Holerd J, Frmery LA, Wales KA Seresning eideny in he gammy the eaten sip Detween dietary adequacy and-nutibonat tok Jam Diet assoc. 198494 (4251427 Tompson FE. Harman AM, Larkin Comparison citwo dietary aueston too against multpie cetay records Calected duringa -yoar period. Am Diet Assoc. M1. Gord CEpidemiogy, 2nd eat hia, Pa: WE Saucers Company, 2000 42. Posner BN dete Ati, Smith KW, Ker OR ‘Nuuion anc nets rick steer: the Nutt Bon Scrosning inate. Am J Publ Heath ieaa,82.972-978 13. Boult C Krinke UB, Urdangarn CF, SkainV. The valiityof autora status a8 & mark 1 ‘ture disabity and depressivesympioms among highisieolger adults J Am Geriatr Soc 109,47 996-009, 14, Bales GW. What doas it mean tobe “at utr= tionalisk'? Seeking clarity on Doha othe eer. ‘aml Cin utr 2008 74 SESS, This research was funded by US Department of Agriculture grant No, 58 1950-019, Loss of bone density and fractures may be prevented or delayed by caleium and vitarnin D intake at or above recom ‘mended levels (4-6). Dietary intake of these nutrients is often reported as low inUS populations. Very few dataexist on theintake of these nutrients amongolder women in rural communities—particu- larly chase of ethnic minority groups, who may be at risk for nutritional deficits (7). The purpose of this paper is to de- scribe the dietary and supplemental in- take of caleium and supplemental intake of vitamin D among older women of 3 ethnic groups ina rural southeastem US community. METHODS. Study Population The Robeson Osteoporosis Screening Study was conducted in Robeson County insoutheastern North Carolina, Thisarea was selected because it is largely rural, has substantial ethnic diversity (approxi mately % African American or Native American), has a high rate of poverty (22.8% compared with 12.6% in Nort Carolina overall), and because of strong associations the research team has with the community (8.9). Women aged 60 ‘years and older were recruited at various