Abstract
OBJECTIVE: To validate digitally displayed photographic portion-size estimation aids (PSEA) against a weighed meal record and compare findings with an atlas of printed photographic PSEA and actual prepared-food PSEA in a low-income country. DESIGN: Participants served themselves water and five prepared foods, which were weighed separately before the meal and again after the meal to measure any leftovers. Participants returned the following day and completed a meal recall. They estimated the quantities of foods consumed three times using the different PSEA in a randomized order. SETTING: Two urban and two rural communities in southern Malawi. PARTICIPANTS: Women (n 300) aged 18-45 years, equally divided by urban/rural residence and years of education (≤4 years and ≥5 years). RESULTS: Responses for digital and printed PSEA were highly correlated (>91 % agreement for all foods, Cohen's κw = 0·78-0·93). Overall, at the individual level, digital and actual-food PSEA had a similar level of agreement with the weighed meal record. At the group level, the proportion of participants who estimated within 20 % of the weighed grams of food consumed ranged by type of food from 30 to 45 % for digital PSEA and 40-56 % for actual-food PSEA. Digital PSEA consistently underestimated grams and nutrients across foods, whereas actual-food PSEA provided a mix of under- and overestimates that balanced each other to produce accurate mean energy and nutrient intake estimates. Results did not differ by urban and rural location or participant education level. CONCLUSIONS: Digital PSEA require further testing in low-income settings to improve accuracy of estimations.