Review

Nutritional Epidemiology and Dietary Assessment for

Patients With Kidney Disease: A Primer
Valerie K. Sullivan and Casey M. Rebholz

Nutritional epidemiology seeks to understand nutritional determinants of disease in human populations Complete author and article
using experimental and observational study designs. Though randomized controlled trials provide the information provided before
references.
strongest evidence of causality, the expense and difficulty of sustaining adherence to dietary in-
terventions are substantial barriers to investigating dietary determinants of kidney disease. Therefore, Am J Kidney Dis.
nutritional epidemiology commonly employs observational study designs, particularly prospective 81(6):717-727. Published
online January 4, 2023.
cohort studies, to investigate long-term associations between dietary exposures and kidney disease.
Due to the covarying nature and synergistic effects of dietary components, holistic characterizations of doi: 10.1053/
dietary exposures that simultaneously consider patterns of foods and nutrients regularly consumed are j.ajkd.2022.11.014
generally more relevant to disease etiology than single nutrients or foods. Dietary intakes have tradi- © 2023 by the National
tionally been self-reported and are subject to bias. Statistical methods including energy adjustment Kidney Foundation, Inc.
and regression calibration can reduce random and systematic measurement errors associated with
self-reported diet. Novel approaches that assess diet more objectively are gaining popularity but have
not yet fully replaced self-report and require refinement and validation in populations with chronic
kidney disease. More accurate and frequent diet assessment in existing and future studies will yield
evidence to better personalize dietary recommendations for the prevention and treatment of kidney
disease.

N utritional epidemiology seeks to understand nutri-

tional determinants of disease in human populations.
Some of the earliest epidemiological studies in nutrition
investigated the role of diet in the development of car-
diovascular disease. Since then, links between diet and
numerous chronic diseases, including chronic kidney
disease (CKD), have been discovered through epidemio-
logic investigations. With the rising global prevalence of
CKD,1 improved understanding of how diet affects the risk
and progression of CKD is imperative to inform care and
prevention recommendations.
Epidemiological studies have traditionally relied on self-
reported dietary intakes to estimate associations with CKD.
However, innovations that overcome limitations of such
methods are gaining popularity. This primer offers an
overview of nutritional epidemiology, including study
designs, exposure definition, traditional and novel diet
assessment methods, sources of error, and statistical con-
siderations, to guide researchers and clinicians in inter-
preting and conducting investigations of diet in CKD.
Study Designs in Nutritional Epidemiology
Randomized controlled trials (RCTs) are considered the
most rigorous design to establish causality. Randomized
allocation distributes confounding factors similarly be-
tween groups and removes the exposure decision from
participants and investigators, thereby minimizing con-
founding. Nutrition RCTs include controlled feeding
studies, single nutrient or dietary component studies, and
dietary counseling studies (Table 1). One of the largest and
longest nutrition RCTs in kidney disease research, the
Modification of Diet in Renal Disease (MDRD) Study,
investigated the effect of restricting protein intake on
glomerular filtration rate decline.2 Others have investigated
the effect of dietary patterns or nutrients on kidney func-
tion decline, blood pressure, anthropometrics, and
biochemical derangements.3,4
In human nutrition RCTs, the identity of the intervention
is difficult to hide from participants, prohibiting double
masking. Systematic errors may arise if intervention adher-
ence and outcome ascertainment differ by randomization
group due to the participants being cognizant of their group
assignment. In addition, a truly unexposed “control” group is
impossible in many dietary studies because all people
consume food. Failure to detect an intervention effect may
result from insufficient difference between the (lesser
exposed) control group and the (more exposed) intervention
group, rather than a true lack of effect. Assessment of baseline
intake or nutritional status and background diet (the dietary
context in which a food or nutrient is consumed) throughout
the study duration may be useful to interpret effects.
Finally, the expense and difficulty of sustaining adherence
to dietary interventions limit the duration and scale of RCTs
in nutrition research. Defining “adherence” a priori and
incorporating methods to assess it (eg, direct observation,
return of unconsumed items, biomarker assessment, self-
report) are essential to monitor whether the intended
intervention is delivered. Ensuring palatability and accept-
ability of study diets (eg, by previewing menus or tasting
study foods) and communicating clearly and regularly with
participants throughout the study duration can promote
retention and adherence. Incorporating a run-in period may
be useful to evaluate adherence before randomization and to
standardize baseline exposure. Additional considerations for
designing and conducting human nutrition RCTs are
detailed elsewhere.5,6
Due to the long lead times and large sample sizes
required to detect intervention effects on hard end points,

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 Sullivan and Rebholz

Table 1. Study Designs Commonly Used in Nutritional Studies of Kidney Disease

Description
Randomized Trials
Controlled feeding • Study menu is designed to
studies meet desired intake targets
• All foods and beverages
are provided for participants
Single nutrient or dietary • Only the food(s) or
component studies nutrient (supplement)
being studied is directly
manipulated
• Instruction regarding other
dietary choices may or may
not be provided
Dietary counseling • Participants are instructed to
studies modify their diets
• Food is usually not
provided
Observational Designs
Prospective cohort • Observed diet is associated
studies with subsequent health
outcomes
Cross-sectional studies • Observed diet is associated
with concurrent health status
Strengths
• Nutritional composition of
diet can be determined
with high accuracy
• High control is permitted
over dietary and
nondietary confounders
• Useful to test efficacy of
diet to affect clinical
outcomes
• Effect of an intervention is
observed within realistic
context of participants’
usual diets
• Feasibility observed in
real-world setting
• Self-selected diet is
observed as it naturally
occurs
• Long follow-up time
permits observation of
hard end points (eg,
mortality, incident disease)
• Self-selected diet is
observed as it naturally
occurs
Limitations
• Expensive
• Requires skilled staff and
metabolic kitchen to prepare
diets
• High participant burden
• Heterogeneity in intervention
effects may result from
participant differences in how
they incorporate study foods
into their habitual diets (eg,
substitution vs addition)
• Diet composition is unknown
• Skilled practitioners are
required to deliver participant
education
• Diet composition is unknown
• Diet is usually only assessed
at baseline or early in follow-
up and does not capture
changes that may occur over
time
• Direction of associations
cannot be determined;
possible reverse causation

the outcomes of nutrition RCTs are commonly interme-
diate markers of disease risk, with the notable exception of
the Prevenci
on con Dieta Mediterr
anea (PREDIMED) study,
a multicenter randomized trial that demonstrated a pro-
tective effect of a Mediterranean diet on incident cardio-
vascular disease compared with a lower-fat diet.7 Trials in
patients with kidney disease have used declines in
glomerular filtration rate of varying magnitudes or the
onset of proteinuria as surrogate outcomes for the devel-
opment of kidney failure8,9 which may take years to occur.
Although sample size and study duration for RCTs inves-
tigating hard end points (kidney failure, death, cardio-
vascular events) could be minimized by enrolling
participants with advanced CKD, dietary interventions may
not be equally effective at later versus early stages.10
Evidence regarding the long-term effects of dietary
exposures on hard end points have mostly originated from
observational study designs, predominantly prospective
cohort studies, based on the participants’ self-reported
dietary intakes. Several large cohorts established
throughout the past 50 years, including the Chronic Renal
Insufficiency Cohort (CRIC) study of adults with existing
CKD11 and the Chronic Kidney Disease in Children (CKiD)
study of children with existing CKD,12 continue to yield
important discoveries of associations between diet and
CKD progression, as well as other important clinical out-
comes.13,14 Cohorts of individuals without CKD at base-
line, such as the Atherosclerosis Risk in Communities
(ARIC) study, have been used to study the association
between diet and incident CKD.15
In prospective cohort studies, assessment of dietary
exposures before outcomes occur supports causal infer-
ence. By contrast, cross-sectional studies such as the Na-
tional Health and Nutrition Examination Survey
(NHANES) assess exposure and disease simultaneously
and, therefore, yield weaker evidence regarding causal
effects of diet on disease but are useful to describe dietary
intakes and quantify the burden of insufficient or excess
intakes in a population. In observational studies, exposure
is selected by participants rather than assigned, so the in-
fluence of confounding factors on observed associations
must be accounted for in statistical analyses.
Defining Dietary Exposures
Diet is a complex exposure that varies in composition and
quantity within and between days and seasons. The co-
varying nature of dietary components further complicates
the definition and statistical modeling of dietary exposures.
Conceptualizations of dietary exposures range from a

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Sullivan and Rebholz
Figure 1. Conceptualizations of dietary exposures. Nutrients are
contained within foods and beverages. Foods and beverages
with similar nutrient profiles may be grouped together. Dietary
patterns encompass the quantity, variety, and combinations of
foods and beverages habitually consumed. Icons were obtained
from Servier Medical Art, licensed under a Creative Commons
Attribution 3.0 unported license.
reductionist focus on nutrients to holistic characterizations
of dietary patterns (Fig 1).
Traditionally, single nutrients have been the focus of
nutritional epidemiology. Given the kidneys’ key role in
metabolizing and excreting several nutrients, they remain
important exposures of interest in kidney disease research.
Guidelines for CKD management have emphasized dietary
protein, phosphorus, potassium, and sodium restrictions.16-21
However, nutrients are rarely consumed in isolation, except
as supplements. Instead, people consume foods, which
contain various nutrient and non-nutrient components that
may affect health, and the bioavailability of these compo-
nents may differ depending on the food source and pro-
cessing. For example, phosphorus from plant sources is less
bioavailable than from animal sources, and almost all
(>90%) phosphorus from additives is absorbed.22 Further-
more, foods are consumed in combinations that may pro-
duce synergistic health effects.23 Therefore, dietary patterns,
which broadly encompass the quantity, variety, and com-
binations of foods and beverages habitually consumed, may
predict long-term health better than single foods or nutri-
ents24 and are the basis of modern dietary guidance.25,26
Dietary patterns may be defined a priori using pre-
defined criteria (Table 2).27-39 For instance, higher
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adherence to a Mediterranean diet,27 Dietary Approaches
to Stop Hypertension (DASH)-style diet,28 and the Dietary
Guidelines for Americans29 have been associated with a
lower risk of incident CKD.40,41 Alternatively, empirical
approaches to defining dietary patterns use statistical
methods, such as factor or cluster analysis, that identify
combinations of foods consumed in a population.42 Other
holistic characterizations of dietary exposures may be
defined based on nutrient and food sources or their effects
on hypothesized mediators of disease risk. As dietary pat-
terns simultaneously represent multiple foods and nutri-
ents, observed associations between dietary patterns and
health cannot be attributed to any single food or nutrient
(eg, protein, sodium, potassium, phosphorus). Thus, ho-
listic dietary patterns complement but do not replace
reductionist single nutrient or food studies. These com-
plementary approaches are both valuable for studying diet-
disease relationships.
Diet Assessment Methods
Several methods are available to assess dietary intakes
(Table 3). We broadly classify these methods as traditional
(self-report) and novel approaches. Each method offers
strengths and limitations to consider when selecting the
optimal assessment for a given population, study design,
and exposure of interest.
Traditional Approaches
Food Frequency Questionnaires
Food frequency questionnaires (FFQs) query habitual
intake over a specified time period using a fixed list of
foods, beverages, and possibly nutritional supple-
ments.24,43 Development or validation of FFQs in the
target population is recommended to ensure the included
foods capture important nutrient sources, which may
differ between social, cultural, and ethnic groups. A short
49-item FFQ developed and validated in patients with CKD
in France acceptably ranked participants’ intakes of nutri-
ents including phosphorus, potassium, and sodium.44 An
analogous 57-item version later developed in the United
States has demonstrated an acceptable assessment of diet
quality but does not assess nutrient intakes.45 Similarly,
FFQs have been developed or adapted for patients on
dialysis.46-49
Food Records
Food records, or food diaries, require respondents to log
dietary intakes in real time over a specified time period,
usually 3 to 7 days. Weighted food records are regarded as
the gold standard quantitative self-reported diet assessment
method and are used to validate other diet assessment
methods. The KDOQI guideline on nutrition in CKD rec-
ommends the use of 3-day food records to assess dietary
intakes in clinical practice.19 Validated online or smart-
phone application–based records can facilitate real-time
data collection, engage users with prompts to record
719
 Sullivan and Rebholz

Table 2. Examples of a Priori Dietary Patterns and Other Holistic Dietary Exposures
Exposure
Alternate Mediterranean Diet Score (aMed)
Dietary Approaches to Stop Hypertension
(DASH) Diet Score
Healthy Eating Index (HEI)
Alternative Healthy Eating Index (AHEI)
Dietary diversity scores
Plant-based diet indices
Dietary Inflammatory Index (DII)
Dietary acid load
Processing classification systems
Definition References
Scores relative adherence to a Mediterranean-style diet; 27
adapted for use in US populations
Scores relative adherence to the blood pressure–lowering 28
dietary pattern tested in the DASH clinical trials
Scores alignment with the Dietary Guidelines for Americans, 29
with multiple versions corresponding to guideline updates every
5 years
Scores relative adherence to dietary recommendations that are 30,31
predictive of chronic disease risk; updated in 2010 based on
evolving scientific evidence
Assigns greater value to diets with more variety of foods or 32
nutrients
Scores relative adherence to diets richer in plant-derived foods 33
and lower in animal-derived foods, with variations that
additionally consider the nutritional quality of plant-derived foods
Summarizes the inflammatory potential of a diet based on a 34
predefined list of foods, nutrients, and phytochemicals
Summarizes the balance between acid- and base-producing 35-37
foods; estimated by calculating potential renal acid load (PRAL)
or net endogenous acid production (NEAP) based on dietary
protein and mineral intakes
Categorizes foods according to the extent and purpose with 38,39
which they are processed

intake, and save time and costs associated with data entry
into nutrient analysis software.50,51
24-Hour Dietary Recalls
A 24-hour dietary recall queries intake over the past day,
either from midnight to midnight or in the 24-hour
period immediately preceding the recall. Ideally these
recalls are unanticipated by the respondents so that di-
etary intakes preceding the recall are not altered. Multiple
recalls estimate absolute dietary intakes more precisely
than FFQs,52 and the accuracy of reporting can be opti-
mized with a multiple-pass interviewing technique.53
Although they traditionally are administered by trained
interviewers, an automated online version developed by
the National Cancer Institute may be a feasible, less-
resource-intensive option even for large epidemiological
studies.54,55
consumption (to assess net intake) using a handheld
device and with a reference object in the frame to assist
with portion size estimation. Automated software or
human raters subsequently identify foods and portions
consumed to estimate nutrient intakes. Comparable esti-
mates of total energy intake were obtained by adults with
type 2 diabetes using image-based food records versus
weighted food records,59 and a mobile phone–based
automated image analysis application estimated meal
carbohydrate content more accurately than patients with
type 1 diabetes.60
Passive approaches use wearable cameras to capture
daily activities, including eating episodes, without users’
conscious participation. Wearable cameras have been used
to identify the intake of forgotten foods on self-reported
recalls61 and to observe cooking and eating behaviors62
in free-living settings.

Diet Screeners Wearable Technologies

Screeners, or checklists, query the intake of a select few
items or eating behaviors (eg, sodium56 or fruit and
vegetable57 intake). The lack of detail and susceptibility to
systematic error limits their utility as a standalone diet
assessment method for research studies.
Novel Approaches
Image-assisted Dietary Assessment
Image-assisted dietary assessments supplement or replace
traditional self-report methods with photos or videos of
eating episodes in order to improve objectivity and avoid
reliance on memory.58 Active image-assisted approaches
require participants to photograph foods before and after
Wearable technologies offer the ability to passively detect
eating events in real time by monitoring chewing, swal-
lowing, or jaw movements or by monitoring arm gestures
associated with eating. These technologies can be used to
capture the occurrence, timing, rate, and duration of
eating. Bite counters have primarily been used to support
weight loss interventions.63,64 Oral and epidermal sensors
are also in development to detect specific nutrients (eg,
sodium, alcohol) in saliva and sweat.65 The primary
advantage of such technologies is minimization of recall
bias. However, because no single sensor is yet able to
identify specific foods consumed, their portions sizes, or
nutritional composition, they are currently most useful for

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Table 3. Comparison of Dietary Assessment Methods

Method Information Collected
Food record Detailed list of identity,
preparation methods, portion
sizes, timing, and context of
foods consumed on 1 or
multiple (usually consecutive)
days
24-hour recall Detailed list of identity,
preparation methods, portion
sizes, timing, and context of
foods consumed in a recent 24-
hour period
FFQ Frequency and sometimes
portion size of foods habitually
consumed over a defined time
period, usually the previous
month or year
Diet screeners Limited information about the
frequency of food consumption
or eating behaviors relevant to a
specific clinical or research
interest
Image-assisted Photographic record of foods
consumed in a single day
Wearable Occurrence, timing, rate, and
technologies duration of eating episodes
Retail sales and Household food purchasing or
purchasing data retail sales data over a defined
time period
Biomarkers Presence and concentration of
compounds in biological
specimens, which are indicative
of nutrients and foods
consumed
Abbreviation: FFQ, food frequency questionnaire.
a
Self-administered online version avoids need for interviewer but requires participant literacy.
Strengths
• Open-ended
• Recorded in real time,
avoiding reliance on memory
• Portion size measured rather
than estimated
• Open ended
• Literacy not requireda
• Low respondent burden
• Inexpensive
• Can capture usual intake of
routinely and episodically
consumed foods
• Computerized scanning of
paper-based FFQs and
online-administered FFQs
automate data entry, with
direct linkage to databases
for nutrient analysis
• Quickly and easily
completed
• Reduces reliance on memory
• Portion size estimation by
software or trained human
rater may improve accuracy
over self-report
• Minimal user burden
• Low risk of bias
• Minimal or no burden to
the consumer
• Unbiased
Limitations
• Intake may be altered by the act of
recording (reactivity)
• High respondent burden
• Literacy required
• Interpreting and entering responses
into nutrient analysis software im-
poses high clinician/researcher
burden and expense
• Reliance on specific memory—
omissions (nonreporting of foods
actually consumed) and intrusions
(reporting of foods not actually
consumed) can introduce bias
• Trained interviewer requireda
• Relies on generic memory;
cognitively challenging to recall and
estimate average intakes over time
• Lacks detail regarding preparation
methods, timing, and context of
intake
• Fixed list does not comprehensively
capture foods consumed
• Not appropriate to estimate
absolute nutrient or energy intakes
• Literacy required, unless interviewer
administered
• Lacks detail; does not
comprehensively assess dietary
intake
• Hidden ingredients and cooking
methods may not be discernible in
photographed foods
• Active approaches rely on user to
remember to photograph all eating
episodes
• Images captured passively by
wearable cameras may be of
insufficient quality to accurately
identify foods
• Does not capture types or portions
of foods consumed
• Does not measure actual food or
nutrient consumption
• Expensive to obtain data
• Details of data collection are not
fully disclosed by private companies
• Expensive to collect and measure
• Biospecimens collection can be
burdensome to participant (eg, 24-h
urine collection)
• Few validated biomarkers of dietary
intake

studying eating behaviors rather than assessing diet
composition.
Retail Sales and Purchasing Data
Market research companies collect point-of-sale data from
food retailers as well as individual- and household-level
purchasing data using barcode scanning.66 Neither retail
sales nor purchasing data directly measure food con-
sumption because they do not account for culinary
preparation, distribution within and beyond the house-
hold, and waste. Still, these data may be useful to evaluate
the nutritional quality of foods purchased, assess trends
over time, and model predicted effects of food refor-
mulation.67 For instance, retail sales were used to identify

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phosphorus-based additives in frequently purchased
grocery items.68
Dietary Intake Biomarkers
Dietary intake biomarkers enable objective measurement
of intake based on concentrations of compounds measured
in a biospecimen, commonly urine or blood. They are
broadly classified as recovery, concentration, and predic-
tive biomarkers.
Recovery biomarker concentrations are considered
gold-standard approaches for dietary assessment and
directly reflect dietary intake.69 Only 4 recovery bio-
markers have been identified: 24-hour urinary nitrogen,
reflecting protein intake; 24-hour urinary potassium and
sodium, reflecting intakes of these minerals; and doubly
labeled water, a measure of energy expenditure that is
interpreted as a marker of energy intake in weight-stable
individuals.70
Concentration biomarkers, such as plasma carotenoids
and vitamin C, correlate with dietary intakes but are
affected by individual-level characteristics (eg, adiposity),
such that measured concentrations do not directly reflect
amounts consumed.69 Predictive biomarkers exhibit a
time-dependent, dose-response relationship with dietary
intakes. They more closely reflect dietary intake than
concentration biomarkers but are not completely recov-
ered in biospecimens, like recovery biomarkers. Only 24-
hour urinary fructose and sucrose have been identified as
predictive biomarkers and are useful measures in research
settings.71
Dietary biomarkers have traditionally been identified
using a hypothesis-driven approach. In recent years,
however, the discovery of novel dietary biomarkers has
accelerated with the advancement of high-throughput
platforms capable of simultaneously identifying many
metabolites and proteins in biospecimens. Characterization
of the food metabolome and proteome—the sum of
compounds resulting from digestion, absorption, and
metabolism of consumed foods72—is currently being
explored to identify objective biomarker “signatures” of
foods and dietary patterns, and to study relationships be-
tween diet and CKD.
Although few foods are uniquely identified by bio-
markers, a profile of biomarkers may serve to characterize
adherence to a particular dietary pattern. Plasma metabolic
signatures of healthy dietary patterns (eg, Alternative
Healthy Eating Index [AHEI]-2010, DASH, Mediterranean)
have been identified in adults with CKD,73 and serum
metabolomic signatures of plant-based diets have been
shown to predict incident CKD.74 Serum metabolomic
markers of dietary acid load have also been identified75 and
predict incident CKD.75
Candidate biomarkers are primarily identified through
cross-sectional correlations with self-reported diet, though
controlled feeding studies are needed before biomarkers
can serve as objective and quantitative dietary intake
markers.76 Challenges include differentiating between
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Sullivan and Rebholz
exogenous (originating from diet) versus endogenous
(originating from host or gut microbiota) compounds,
and evaluating dose-response and temporal response of
compounds to food intake. Because most food-derived
compounds are only present in urine and plasma acutely
after ingestion,77 habitual diet assessment may require
multiple biospecimen collections over time76 or validation
of long-term biomarkers from alternative biospecimens
(eg, hair and nails).
Finally, most nutritional biomarkers have not been
validated in patients with CKD.78 Alternative markers or
methods may be needed when urinary output is altered or to
account for water-soluble solute removal in dialysate.78,79
Summary of Dietary Assessments
Errors associated with self-reported diet, their impacts on
associations with outcomes, and strategies to reduce them
are well researched.80,81 Novel dietary assessment ap-
proaches reduce some of these errors, but they have not
yet replaced traditional methods. Combining self-report
with novel assessments may more comprehensively and
accurately ascertain dietary intakes.
Sources of Error in Diet Assessment
Measurement Error: Random
True dietary intakes vary within people, day to day. The
degree of intraindividual variability differs by food and
nutrient, with higher variability for episodically consumed
foods (eg, organ meats) and nutrients concentrated in few
food sources (eg, vitamin A). A single day’s intake—even
if recorded correctly—does not accurately represent an
individual’s usual dietary intake of most foods or nutrients.
Because usual intake is generally more relevant to CKD,
such daily deviations from the true long-term average are
regarded as random measurement error. Averaging intakes
across multiple dietary assessments can improve precision
of an individual’s estimated usual intake by reducing
random error.82 However, the representativeness of
collected days should be considered. Dietary intakes may
vary across seasons and days of the week,83 and differ on
dialysis versus nondialysis treatment days.84,85 In addition,
dietary intakes on consecutive days are more closely
correlated than nonconsecutive days, resulting in under-
estimation of within-person variation in intakes. Gains in
precision and representativeness must be weighed against
the expense and participant burden of multiple assess-
ments. Distributing shorter automated dietary assessments
(eg, automated self-administered 24-hour recalls54,86)
over time, and including weekdays versus weekends and
dialysis versus nondialysis days, may help maximize
representativeness while reducing participant burden and
expense.
For epidemiological research questions, group-level
(rather than individual) usual intake estimates are typi-
cally of interest. On any given day, observed intakes in a
population will include individuals with exceptionally
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Sullivan and Rebholz
high and low true single-day intakes, but the distribution
will cluster around a central mean. Thus, a single 24-
hour recall or record per person is considered sufficient
to estimate population mean intakes, but extreme high
and low consumers will flatten the estimated distribution
of intakes and overestimate the proportion of a popula-
tion in the distribution tails. As such, comparisons of
population intakes to some target—for instance, an
estimated minimum requirement—will overestimate the
proportion of deficient individuals. Statistical methods
are available to more precisely estimate the usual intake
distribution in a population with as few as 2 recalls
obtained from a subset of respondents.87-89 Such
methods should be used when assessing the adequacy or
insufficiency of population intakes relative to a recom-
mended target or when comparing usual intakes between
2 or more groups.
In contrast to 24-hour recalls and food records, FFQs
solicit average consumption over a defined time period
and are intended to capture usual intake. However, dietary
intakes may change over extended periods of follow-up,
especially in persons with CKD, who may experience
changes in appetite and receive dietary counseling. If only
baseline diet is assessed, unmeasured subsequent shifts in
intakes could result in misclassification of exposure status
and attenuation of estimated associations with CKD.
Repeating assessments and averaging intakes across repeated
FFQs may reduce random measurement error arising from
intraindividual changes in dietary intakes over time.90
Measurement Error: Systematic
While repeating dietary assessments can improve precision
by reducing random measurement error, it will not
address systematic misreporting of intakes. The degree of
misreporting varies for different population groups, foods,
and dietary assessment tools.80,91 For instance, people may
overreport intakes of “healthy” foods and underreport
“unhealthy” foods to align with social norms (social
desirability and social approval biases),92 and people with
low true intakes tend to overreport their intake, while
those with truly high intakes tend to underreport (the
“flattened slope phenomenon”).81 Regression calibration
can help correct risk estimates for biased measurements of
self-reported dietary exposures when a less biased refer-
ence assessment is available for at least a subset of the study
population.81,93
Limitations of Food Composition Databases
Whether dietary intakes are self-reported or observed,
conversion to nutrients and foods requires linkage to
nutrient databases. Misestimation of nutrient contents may
arise due to geographical, seasonal, or other natural
sources of variation in the nutritional composition of
foods. For instance, selenium can vary substantially due to
differences in soil content.94 Misestimation also arises
from variation in the composition of prepared foods and
manufactured items. Although some databases include
AJKD Vol 81 | Iss 6 | June 2023
nutrient contents for branded foods or restaurant dishes,
actual nutrient contents may differ substantially from re-
ported values.95,96 In addition, nutrient losses during food
preparation or cooking may not be considered. Finally,
database values do not account for biological availability of
consumed nutrients. For instance, phosphorus intakes
from natural and added sources are weighed equally in
database summations, though true absorption varies sub-
stantially.22 Cautious interpretation of nutrient intakes is
warranted because summed database totals may not fully
represent actual consumed or biologically available
nutrients.
Statistical Modeling in Nutritional Epidemiology
Energy Adjustment
A methodological consideration unique to nutritional
epidemiology is whether and how to adjust for energy
intake.90,97-99 People consuming more energy generally
consume greater absolute amounts of nutrients, and en-
ergy intake itself may be associated with CKD. Associations
between absolute dietary intakes and CKD may, therefore,
be confounded by energy intake. Thus, epidemiological
analyses of associations between dietary intake and CKD
typically aim to statistically isolate between-person varia-
tion in intakes due to energy intake from variation
explained by changes in dietary composition. Controlling
for total energy also helps to reduce error in self-reported
dietary intakes because error in self-reported energy intake
measurement is correlated with error in self-reported in-
takes of nutrients and foods.99 The interpretation of
regression coefficients from energy adjusted models differs
depending on whether nutritional exposures are modeled
continuously or categorically100 and whether other dietary
covariates are included (substitution).101
Substitution
When energy balance is maintained, increasing intake of a
macronutrient or energy-containing food or beverage re-
quires decreasing intakes of others, and its biological effect
may differ depending on what it displaces in the diet. For
instance, replacing saturated fat with unsaturated fat is asso-
ciated with lower coronary heart disease risk whereas no
association is observed when it is replaced with refined car-
bohydrates.102 Specific isocaloric food or macronutrient
substitutions can be modeled by including total energy and
all other energy sources excluding the food or macronutrient
to be substituted as covariates.101 Modeled substitutions
should ideally represent realistic exchanges and consider how
foods are actually consumed within a dietary pattern.103
Models that only adjust energy are difficult to interpret
because associations may be attributable to increasing intake
of the dietary exposure or decreasing intakes of unspecified
other energy sources. Substitution analyses better inform
dietary guidance by identifying appropriate dietary re-
placements to reduce CKD risk.101 A clear and specific
research question will ultimately guide model specification.
723

Future Directions
Dietary recommendations for chronic disease prevention
and management have evolved from single-nutrient
modifications to a more holistic food-based dietary
pattern approach. A similar trajectory is evident in CKD
guidelines, which call for research investigating the effects
of dietary patterns on clinical outcomes in CKD patients.19
Refinement and validation of novel dietary assessment
methods in CKD populations, including patients on dial-
ysis, will yield more objective measurements of intake,
while automated versions of traditional methods offer the
potential to assess diet more frequently, and in more
detail, than previously possible.
In addition, advancements in “omics” profiling—of the
genome, transcriptome, proteome, metabolome, and gut
microbiome—offer opportunities to investigate mecha-
nisms by which diet affects kidney health. Genetic and
epigenetic variations affect metabolic responses to diet,
and diet can alter gene expression, contributing to inter-
individual transcriptomic, proteomic, and metabolomic
variation that may mediate diet-CKD associations.104,105
Diet can also alter the composition, diversity, and func-
tion of gut microbiota and modulate gut epithelial
permeability,106 thereby altering metabolite generation
(eg, uremic toxins, short-chain fatty acids)107 and trans-
location across the intestinal wall.104 As gut microbiome
disturbances may contribute to CKD disease progression
and complications,108,109 its modulation by diet may
impact prognosis. Omics technologies are increasingly
applied to advance CKD110,111 and diet research.104,112
Application of these advancements in new and existing
studies, combined with more traditional approaches to risk
stratification based on sociodemographic factors, health
status, and disease stage, will yield evidence to form more
personalized dietary recommendations tailored to patients’
characteristics, social background, etiology and stage of
CKD as well as coexisting comorbidities.
Article Information
Authors’ Full Names and Academic Degrees: Valerie K. Sullivan,
PhD, and Casey M. Rebholz, PhD.
Authors’ Affiliations: Department of Epidemiology, Bloomberg
School of Public Health (VKS, CMR), Welch Center for
Prevention, Epidemiology, and Clinical Research, (VKS, CMR), and
Division of Nephrology, Department of Medicine, School of
Medicine (CMR), Johns Hopkins University, Baltimore, Maryland.
Address for Correspondence: Casey M. Rebholz, PhD,
Department of Epidemiology, Johns Hopkins Bloomberg School of
Public Health, 2024 E Monument St, Suite 2-500, Baltimore, MD
21287. Email: crebhol1@jhu.edu
Support: Dr Sullivan was supported by grant T32 HL007024 from
the National Heart, Lung, and Blood Institute. Dr Rebholz was
supported by grants from the National, Heart, Lung, and Blood
Institute (R01 HL153178) and the National Institute of Diabetes
and Digestive and Kidney Diseases (R03 DK128386). The funders
had no role in defining the content of the article.
Financial Disclosure: The authors declare that they have no
relevant financial interests.
724
Sullivan and Rebholz
Peer Review: Received July 25, 2022 in response to an invitation
from the journal. Evaluated by 3 external peer reviewers, with
direct editorial input from an Associate Editor and a Deputy Editor.
Accepted in revised form November 19, 2022.
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