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Cunningham, Davis, WiegertGluten Free
April 2016
Dear (Editor):
In recent years, the gluten-free diet has become a fad diet among those who do not have celiac disease or a gluten sensitivity. It is perceived to be beneficial for weight loss and overall health among the general population, as many consumers believe that gluten-free products are naturally healthier than those that contain gluten. However, many scientific research studies have shown the gluten-free diet to be deficient in fiber, vitamin D, magnesium, selenium, riboflavin, niacin, thiamine, calcium, folate, vitamin A, zinc, and iron. Studies have found the gluten-free diet to result in higher energy intake, higher consumption of sucrose, and saturated fat when compared to a diet containing gluten. This evaluation was conducted using three day food records of Aramark registered dietitians and interns currently following a gluten-free diet (either for medical or nonmedical reasons), to determine if they are meeting their daily nutrient requirements based on the USDA dietary guidelines.
This study will help provide information on the current trend of following a gluten-free diet. The results of this study revealed that gluten-free diets tended to be low in potassium, calcium, iron, and fiber, and high in calories and fat. This study was conducted in fulfillment of requirements of the Aramark Distance Learning Dietetic Internship.
This study was conducted under the supervision of an Aramark Dietetic Internship Director, with written permission from each participant. The information provided in this study supports the current literature in that gluten-free diets may be beneficial for those with celiac disease or gluten sensitivity, but may be inadequate for the general population. Thank you for your consideration of this manuscript.
Sincerely,
Susan Davis, BS, Dietetics (Corresponding Author)Dietetic InternAramark Healthcare Distance Learning Dietetic [email protected]
Courtney Cunningham, BS, Dietetics (Corresponding Author)Dietetic InternAramark Healthcare Distance Learning Dietetic [email protected]
Stephanie Wiegert, BS, Dietetics (Corresponding Author)Dietetic InternAramark Healthcare Distance Learning Dietetic [email protected]
Allison Charny, MS, RD, CDE, CDN
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Regional DirectorAramark Healthcare Distance Learning Dietetic [email protected]
Emerging Trends ResearchGluten free diet, nutritional analysis, nutritional deficiency, Celiac Disease, Gluten Intolerance
Word Count: 2994
Determining the Nutritional Adequacy of the Gluten-Free Diet
Susan Davis, BS, Dietetics Dietetic InternAramark Healthcare Distance Learning Dietetic [email protected]
Courtney Cunningham, BS, Dietetics Dietetic InternAramark Healthcare Distance Learning Dietetic [email protected]
Stephanie Wiegert, BS, Dietetics Dietetic InternAramark Healthcare Distance Learning Dietetic [email protected]
Allison Charny, MS, RD, CDE, CDNRegional DirectorAramark Healthcare Distance Learning Dietetic Internship
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Determining the Nutritional Adequacy of the Gluten-Free DietAbstract
Recently, the gluten-free diet has become a fad diet among individuals who do not have a
medical need for the removal of gluten such as celiac disease or a gluten sensitivity. It has been
perceived as beneficial for weight loss and overall health, as many consumers believe that
gluten-free products are healthier than those containing gluten. However, studies found gluten-
free diets can be low in fiber, vitamin D, magnesium, selenium, riboflavin, niacin, thiamine,
calcium, folate, vitamin A, zinc, and iron. Gluten-free diets have also shown to be higher in
overall caloric intake, sucrose, and saturated fat when compared to diets containing gluten. This
evaluation was conducted using three day food records of Aramark registered dietitians and
interns currently following a gluten-free diet (either for medical or nonmedical reasons), to
determine nutritional adequacy based on the U.S. Department of Agriculture (USDA) Dietary
Guidelines. After recording the three day food records into the online nutrient database,
MyFitnessPal, reports were generated for both micro and macronutrients, then data was entered
into an excel document. Each participant’s three day average was calculated for calories,
carbohydrates, fat, percent kcal from total fat, saturated fat, percent kcal from saturated fat,
protein, cholesterol, sodium, sugar, fiber, potassium, vitamin A, vitamin C, calcium, and iron.
These results revealed that, on average, gluten-free diets tend to be low in potassium, vitamin C,
and iron, and high in calories and fat, when compared with the USDA Dietary Guidelines.
3
Introduction
The gluten-free diet has been found, through current research, to be a beneficial nutrition
therapy for those with gluten related conditions such as celiac disease, gluten sensitivity, or other
medical diagnoses.1 Celiac disease is an autoimmune disorder that causes adverse effects when
gluten is ingested. Currently, the gluten-free diet is the only known treatment. 2 At this point in
time, the prevalence of celiac disease has risen and is now estimated to affect roughly 1% of the
general population.1 Due to the increase of individuals medically needing to become gluten-free,
those without medical diagnoses are trying this trend. It is now easier than ever to find
prepackaged gluten-free items at any grocery store due to high consumer demand.1,3
In recent years, the gluten-free diet has become a fad diet used for weight loss and
overall health within the general population; although scientific research shows it is not
necessarily healthier for everyone.3 This diet has become more popular because many
consumers believe gluten-free products are healthier than similar food products containing
gluten. Research states the opposite; it has shown that gluten-free products in general are low in
protein and fiber; and higher in sodium, fat, and saturated fat encouraging an inadequate diet.4
According to Kristin Kirkpatrick MS, RD, LD, at Cleveland Clinic, there is no scientific evidence
concluding the removal of gluten from one’s diet is directly related to weight loss, rather, a strict
gluten-free diet may cause an individual to consume healthier, less processed foods; therefore,
resulting in weight loss.5
4
Additional research points to the fact that gluten itself may actually be beneficial to
certain populations without celiac disease or gluten sensitivity. The naturally occurring fructan-
type resistant starches in wheat, oligo-fructose and inulin, are beneficial for creating a healthy
framework of gut bacteria which may further protect the gastrointestinal tract from cancers,
inflammatory diseases, or cardiovascular conditions.3 Gluten may also positively impact the
immune system due to gluten’s high glutamine content.3 Gluten-free diets may be helpful to
those with celiac disease and gluten sensitivity, but can be inadequate for the general
population.
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Current literature on gluten-free diets shows trends in certain micronutrient deficiencies,
surpluses of micronutrients, and recommendations for patient education by researchers as
stated previously. Many scientific research studies have proven the gluten-free diet to be
deficient, specifically in fiber, vitamin D, magnesium, selenium, riboflavin, niacin, thiamine,
calcium, folate, vitamin A, zinc, and iron.2,6,7 If diets are found to be deficient in magnesium, they
will most likely be deficient in potassium as well, since magnesium enhances the absorption of
potassium; naturally foods high in magnesium are most likely high in potassium.8 Studies have
found the gluten-free diet to result in higher energy intake and a higher consumption of sucrose
and saturated fat when compared to a regular diet in healthy individuals.6 In gluten-free children,
research indicated a lower intake of vitamin D, riboflavin, niacin, thiamine, magnesium and
selenium which is in direct relation with the previous research.6 In another study based in Italy,
gluten-free product consumption accounted for 36.3% of the daily total energy intake causing
intakes of simple sugars, fats, and protein to surpass the national recommendations for health.9
Another interesting point research indicates is that patients’ mean BMI seemed to increase
significantly after following a gluten free diet in one study. It was found that 21.8% increased
their BMI two points or more after adhering to a gluten-free diet.10 Researchers have
recommended that patients receive dietary education to reach nutritional adequacy and
understand why fortification of gluten-free foods is important.2 According to researchers,
individuals following a gluten-free diet should not focus solely on avoiding gluten, but individuals
should be cognizant of micronutrient intake and other carbohydrate sources for an overall
healthful and adequate diet.7
6
The purpose of this study is to determine whether individuals following a gluten-free diet,
for both medical or nonmedical reasons, are meeting their daily nutrient requirements based on
the USDA Nutritional Guidelines. All participants of this study are either registered dietitians or
dietetic interns, indicating they have the proper knowledge to follow a nutritionally adequate
gluten-free diet.
According to Subar et al, dietary recalls, which include three day food journals, provide
high-quality dietary intake data with minimal bias, which makes them the preferred tool for
monitoring diets of certain populations, as well as studying diet and disease associations.11
Participants using food records are prompted to record all foods and beverages consumed over a
specific number of days. Food records are of high validity because they do not rely on memory;
although, they may falter when it comes to characterizing an individual’s usual diet due to
within-person variations of day-to-day food intakes.11,12 This study will conduct a dietary analysis,
using MyFitnessPal, to evaluate the individual's’ compliance to nutritional guidelines.
MyFitnessPal is based on the Dietary Guidelines for Americans 2010.13 (MyFitnessPal, 2005-
2016,UnderArmour, Baltimore, MD.)
A current trend in dietetics is personalized nutrition. New personal health testing and
monitoring technologies have created new opportunities for dietetics practitioners.14 Using
MyFitnessPal will allow dietitians to analyze an individual’s diet and understand where they are
not meeting nutritional adequacy with no financial obligation. Use of MyFitnessPal or other
nutrient analysis programs could be a primary indication of directing a more personalized
nutrition approach to improving diets with nutritional inadequacies. According to previous
studies as indicated formerly, patients following a gluten-free diet are at risk for nutrient
deficiencies in vitamin A; B vitamins such as folate, niacin, and thiamin; calcium; vitamin D; iron; 7
phosphorus; zinc; magnesium; manganese; and selenium. 2, 6, 7 In addition, those following a
gluten-free diet generally eat fewer carbohydrates overall, and this diet may contribute to weight
gain. Studies showed many gluten-free products were higher in calories, fats and sodium, and
lower in fiber than similar products containing gluten. MyFitnessPal is a web-based tool that
reports on individuals personalized nutrition and is a tool that is available to the general public to
use as well as dietetic professionals. It allows dietetic professionals to observe where there is
nutritional inadequacy leading to solutions to become more adequate.
In the past several years, gluten-free diets have become increasingly popular, but
research has not kept up with this trend. There have been few research articles within the past
five years that substantiate the nutritional adequacy of the gluten free diet. This project will
contribute to the current literature in determining if individuals following a gluten-free diet are
meeting dietary adequacy. In addition, it will determine if they comprehend the requirements of
the diet, and whether or not Registered Dietitians should incorporate continuous guidance with
their patients. With the introduction of thousands of new gluten-free products on the market,
the expectation of this study is for it to correspond with the outcomes of previous studies.
Methodology
Analyses of gluten-free diets of both men and women above the age of 18, who have
adhered to a gluten-free diet for over a month and have received proper gluten-free diet
education from a healthcare professional, were evaluated to determine the gluten-free diet’s
nutritional adequacy. Three day food journals were obtained from Aramark registered dietitians
and dietetic interns who normally consumed a gluten-free diet, in order to remain within
compliance of Aramark standards for data collection. Three day food journals were used versus
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24 hour recall tools because three day food journals depict a more comprehensive snapshot for
an individual’s overall diet.15,16 Qualitative and quantitative data were collected via three day
food journals which was input into the MyFitnessPal application via computer for analysis.
Qualitative data included the types of food eaten, and quantitative data included the amounts of
foods and portion sizes consumed. Subject demographic information included the participant’s
age, gender and education level. Three day food journals were to be excluded if the participant
had not had proper education on this specific diet or had not seen a dietitian before about how
to properly adhere to a gluten-free diet. Since the participant population consisted of only
registered dietitians and dietetic interns, all participants had received proper education and were
included in the study, but if a participant’s diet was found to contain significant amounts of
gluten after data was collected then it was excluded. No participant recalls were excluded from
the study. Four weeks was allotted to contact Aramark dietitians and dietetic interns to
participate in the study. The study gathered thirteen participants. Nutrition 411’s validated food
record tool was used to collect the three day diet recalls from the participants. Nutrition 411 is a
peer-to-peer network that offers validated nutrition resources for other professionals.17 The tool
requested that the participant record the time when they ate, what the participant ate along
with method of preparation, the amount eaten, and location of meal. Recalls were collected
through email. Diet recall data was stored in a Google excel document and analyzed in
MyFitnessPal.
An observational cross-sectional study design was used where data was collected from
the specified Aramark gluten-free population at one specific point in time. Data collection was
allotted for four weeks. An intervention was not implemented; the study was designed to simply
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be an observation of compliance of those adhering to a gluten-free diet, and an analysis to
determine if the gluten-free diets are nutritionally adequate.
Resources needed for this project included computers, email, MyFitnessPal, and general
office supplies, such as paper, pens and calculators. Data was gathered using a validated three
day food journal tool, and then entered into MyFitnessPal for analysis. The expected duration of
the data collection period was 4 weeks when in actuality it took longer, about 5 and a half weeks.
There was no funding required for this project. All participation was on a volunteer basis.
Descriptive statistics was used which included the percentage of intakes found to be
deficient in specific nutrients and the percentage of diets found to contain gluten or trace
amounts of gluten. The study used general document programs such as Microsoft Office,
Microsoft Excel, and Google Drive for data storage and analysis. (Microsoft Excel Computer
Software, 2010, Microsoft Corporation, Redmond, WA.), (Microsoft Word Computer Software,
2010, Microsoft Corporation, Redmond, WA.), (Google Drive Cloud Storage, 2016, Google Inc.,
Mountain View, CA.)
Results
The Clinical Nutrition Managers of all the Aramark Healthcare locations were contacted
about participating in the study. This email was then forwarded to all dietitians and interns. Only
13 participated in the study, while the rest declined to participate or did not respond. The age
range among the participants was 23-63 years. The participants included 12 females and one
male. All participants have at least a bachelor's degree, four of which also have a master’s
degree. Five of the participants are following a gluten-free diet by choice, while seven of them
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are gluten-free due to a medical diagnosis. Participants have been following the gluten-free diet
for a time length of 2 -24 years; eight of which were following it for less than five years. The
supplements taken among some of the participants included iron, multivitamins, vitamin D and
vitamin B12. Only three of the participants did not take any supplements.
After recording the three day food records into MyFitnessPal and generating the reports
from the site, the data was inputted into an excel document. Each participant’s three day
average was calculated for calories, carbohydrates, fat, percent kcal from total fat, saturated fat,
percent kcal from saturated fat, protein, cholesterol, sodium, sugar, fiber, potassium, vitamin A,
vitamin C, calcium, and iron. Values for calories, carbohydrates, % calories from total fat, %
calories from saturated fat, fiber and potassium can be seen in Table 1. These values were then
compared to the United States Dietary Guidelines DRIs as seen in Tables 2 and 3. It was found
that 30% of participants were over their caloric goal, 62% of participants consumed greater or
equal to 30% calories from fat, 46% consumed 10% or greater calories from saturated fat, 15%
consumed over 2300 mg Na, 38% consumed less than 25 gm of fiber, 92% consumed less than
4700 mg of potassium, 23% consumed less than the recommended amount of vitamin A, 8%
consumed less than the recommended amount of vitamin C, 77% consumed less than the
recommended amount of Ca, and 69% consumed less than the recommended amount of iron.
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Table 1.
Participant: AverageKcal
AverageCHO (g)
Average % kcal fromtotal fat
Average %kcalfrom sat. fat
Average Fiber (g)
Average K+ (mg)
1 2167 347 27 10 48 5329
2 1376 163 30 4 27 1680
3 1384 141 34 10 19 1073
4 1494 163 29 9 17 707
5 2462 309 35 12 28 972
6 1218 117 40 14 19 1044
7 1657 260 26 5 33 2218
8 2195 261 29 6 35 2187
9 1796 187 44 9 26 1131
10 1420 158 34 11 16 1980
11 1306 180 26 6 16 1196
12 1697 196 34 11 36 2038
13 2253 355 32 8 36 2188
Table 2.
Kcal CHO % kcal from total fat
% kcal from saturated fat
DRI: Female 19-30
2000 130 20-35 <10%
DRI: Female 31-50
1800 130 20-35 <10%
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DRI: Female 51+
1600 130 20-35 <10%
DRI: Male 31-50
2200 130 20-35 <10%
Table 3.
Fiber (g) K+ (mg) Vitamin A (mg RAE)
Vitamin C (mg)
Calcium (mg)
Iron (mg)
DRI: Female 19-30
28 4700 700 75 1000 18
DRI: Female 31-50
25.2 4700 700 75 1000 18
DRI: Female 51+
22.4 4700 700 75 1200 8
DRI: Male 31-50
30.8 4700 900 90 1000 8
Discussion
Within this research there were many anticipated problems that occurred. There was
much difficulty in finding outpatient participants on a gluten-free diet within the Aramark
hospital systems of Methodist Health System in Dallas, Virginia Hospital Center, and Riddle
Hospital in Philadelphia. Within these health systems there was a complete lack of outpatient
clinics that employ GI dietitians; therefore, a lack of participants for the study. In order to
overcome this limitation, all Aramark dietitians and managers were contacted to inquire whether
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they were following a gluten-free diet and were willing to participate in our research. This
participant search strategy was beneficial due to the fact that these individuals were all either
registered dietitians or dietetic interns; therefore, having proper knowledge about the gluten-
free diet.
Secondly, there is currently not a comprehensive gluten-free nutrient analysis database.
There were food items that participants consumed which were very difficult to analyze because
the product’s nutritional facts could not be found within a comprehensive database leading to
the use of MyFitnessPal. Thirdly, the database, MyFitnessPal, does not analyze some pertinent
micronutrients needed to compare the gluten-free diet to other studies. These nutrients include
folate, niacin, thiamin, vitamin D, phosphorus, zinc, magnesium, manganese, and selenium.
Other databases that included these micronutrients did not include gluten-free products in their
food search engine. Within MyFitnessPal, all nutrition facts are input into the database by the
general population users leaving significant room for error; however, MyFitnessPal has one of
the largest food databases which includes over 5,000,000 foods. According to one study, all food
databases contain data that are combined from numerous sources which can be of uneven
quality, reliability, representativeness, and accuracy.14 Some of this variability can be minimized,
but many environmental factors are inherently variable, possibly altering the chemical
composition and analytical values of the food.14 Thirdly, the database only provides %RDA rather
than mcg for vitamin A, C, iron, calcium.
After analysis of the results from MyFitnessPal, it was discovered that the %RDA of iron,
calcium, vitamin C, and vitamin A does not change based on the age or gender of the participant.
For example, older females have an increased RDA for calcium, but the RDA was the same for
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younger females and older females within MyFitnessPal. Another example being that younger
females have a higher RDA for iron,but the iron RDA stayed the same for all ages.
The sample population for this study was small containing only 13 participants. Overall,
many of these participants consumed unbalanced meals due to vacation or travel; they explained
their intakes were not typical resulting in data that may not be typical for the gluten-free diet.
For future implementation of this study, many changes should occur to produce a more
accurate outcome. In regards to finding participants, it would be ideal to find an outpatient
population that follows a gluten-free diet, who has previously collaborated with a dietitian. In
regards to the analysis portion, an all inclusive database would ideally be used which includes a
large number of gluten-free foods as well as the ability to analyze micronutrients like vitamin D,
magnesium, selenium, riboflavin, niacin, thiamine, folate, and zinc. If there was more time
allotted to this study it would have been more accurate to have the participants record a three
day food journal at least four times a year to get a more comprehensive glimpse of their normal
diet.
Conclusion
This research study has shown similar results to those research studies prior. While all
participants had adequate nutrition knowledge, they fell short on many micronutrients, the
major ones being potassium, calcium and iron. Fiber was also inadequately consumed. Some
macronutrients, however, were consumed in excess. Many participants were over their
recommended caloric, fat, saturated fat and sodium intake.
When following a gluten-free diet, individuals must be cautious in making sure all
nutritional values are being met, either by supplementation or by food items being consumed. 23
Many of the participants were supplementing and still not consuming an adequate amount of
each nutrient. When a gluten-free diet is consumed for medical reasons, it is the prefered diet.
However, if a medical diagnosis is not the reason, other diets should be considered for nutritional
adequacy.
Works Cited
1. Sapone A, Bai J, Ciacci C, Dolinsek J, Green P, Hadjivassiliou M, Kaukinen K, Rostami K, Sanders D, Schuman M, Ullrich R, Villalta D, Volta U, Catassi C, Fasano A. Spectrum of gluten-related disorders: consensus on new nomenclature and classification. BMC Medicine. 2012; 10:13.
2. Shepherd SJ, Gibson PR. Nutritional inadequacies of the gluten-free diet in both recently-
diagnosed and long-term patients with coeliac disease. J Hum Nutr Diet. 2013. 26: 349–
358. doi:10.1111/jhn.12018.
3. Gaesser G, Angadi S. Gluten Free Diet: Imprudent Dietary Advice for the General Population. Journal of the Academy of Nutrition and Dietetics.
4. Miranda J, Lasa A, Bustamante MA, Churruca I, Simon E. Nutritional Differences Between a Gluten-free Diet and a Diet Containing Equivalent Products with Gluten. Plant Foods Hum Nutr. 2014. 69:182–18.
5. Kirkpatrick, K. The Surprising Truth about Gluten Free Foods and Weight Loss. Cleveland Clinic. April 14 2014. Website. htp://health.clevelandclinic.org/2014/04/the-surprising-truth-about-gluten-free-food-and-weight-loss/. April 14 2014. Accessed December 5 2015.
24
6. Ohlund K, Ohlund C, Hernell O, Ohlund I. Dietary shortcomings in children on a gluten-
free diet. Journal of Human Nutrition and Dietetics. 2010. 23: 294–300.
7. Wild D, Robins GG, Burley VJ, and Howdle PD. Evidence of High Sugar Intake, and Low
Fibre and Mineral Intake, in the Gluten-free Diet. Alimentary Pharmacology and
Therapeutics. (2010) 32: 573-81.PubMed. 26 Sept. 2014.
8. Higdon J, Drake VJ, Delage B, Volpe SL. Micronutrient Information Center. Magnesium.
2001-2016. Linus Pauling Institute. Oregon State University.
9. Zuccotti G, Fabiano V, Dilillo D, Picca M, Cravidi C, Brambilla P. Intakes of nutrients in
Italian children with celiac disease and the role of commercially available gluten-free
products. J Hum Nutr Diet. 2013. 26: 436–444
10. Kabbani TA, Goldberg A, Kelly CP, Pallav K, Tariq S, Peer A, Hansen M,Leffler D. Body mass index and the risk of obesity in coeliac disease treated with the gluten free diet. Alimentary Pharmacology and Therapeutics. Blackwell Publishing LTD. 2012; 35:723-729.
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11. Subar AF, Kirkpatrick SI, Mittl B, Zimmerman TP, Thompson FE, Bingley C, Willis G, Islam
NG, Baranowski T, McNutt S, Potischman N. The Automated Self-Administered 24-Hour
Dietary Recall (ASA24): A Resource for Researchers, Clinicians, and Educators from the
National Cancer Institute. Journal of the Academy of Nutrition and Dietetics
2012;112(8):1134–1137. doi:10.1016/j.jand.2012.07.016.
12. Yang YJ, Kim MK, Hwang SH, Ahn Y, Shim JE, Kim DH. Relative validities of 3-day food
records and the food frequency questionnaire. Nutrition Research and Practice. 2010.
4(2): 142-148. DOI: 10.4162/nrp.2010.4.2.142.
13. A Message about MyFitnessPal's updated nutrition goals. 2015.
http://myfitnesspal.desk.com/customer/portal/articles/1375583-a-message-about-
myfitnesspal-s-updated-nutrition-goals.
14. Stumbo PJ, Weiss R, Newman JW, Pennington JA, Tucker KL, Wiesenfeld PL, Illner AK,
Klurfeld DM, Kaput J. Web-Enabled and Improved Software Tools and Data Are Needed to
Measure Nutrient Intakes and Physical Activity for Personalized Health Research. The
Journal of Nutrition. 2010 December; 140(12): 2104–2115. Published online 2010 October
27. doi: 10.3945/jn.110.12837.
15. Crawford PB, Obarzaneck E, Morrison J, Sabry ZI. Comparative Advantage of 3 day food
records over 24 hour recall and 5-day food frequency validated by observation of 9 and
10 year old girls. Journal of the American Dietetic Association. 1994 Jun;94(6):626-30.
16. Food Record at a Glance. National Cancer Institute. Dietary Assessment Primer. March 3,
2016. http://dietassessmentprimer.cancer.gov/profiles/record/.
17. Nutrition 411. 24 Hour Diet Recall. 2016. HMP Communications.
http://www.nutrition411.com/content/24-hour-diet-recall
18. 2015-2020 Dietary Guidelines. Health.gov.
http://health.gov/dietaryguidelines/2015/guidelines/appendix-7/
19. Choose Sensibly. Dietary Guidelines. Health.gov.
http://health.gov/dietaryguidelines/dga2000/document/choose.htm
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Appendix
3-Day Food Journal
Please be as specific as possible. Include all beverages, condiments, and portion sizes.
Time Food Item and Method of Preparation
Amount
Eaten Where
27
28
29
Review Date 2/11
G-1523
30
