Measurement Error and Results From Analytic Epidemiology: Dietary Fat and Breast Cancer

BACKGROUND: International correlational analyses have suggested a strong positive association between fat consumption and breast cancer incidence, especially among post-menopausal women. However, case-control studies have been taken to indicate a weaker association, and a recent, pooled cohort analysis reported little evidence of an association. Differences among study results could be due to differences in the populations studied, differences in the control for total energy intake, recall bias in the case-control studies, and dietary measurement error biases. Existing measurement error models assume either that the sample data used to validate dietary self-report instruments are without measurements error or that any such error is independent of both the true dietary exposure and other study subject characteristics. However, growing evidence indicates that total energy and, presumably, both total fat and percent energy from fat are increasingly underreported as percent body fat increases. PURPOSE: A relaxed dietary measurement model is introduced that allows all measurement error parameters to depend on body mass index (weight in kilograms divided by the square of height in meters) and incorporates a random underreporting quantity that applies to each dietary self-report instrument. The model was applied to results from international correlational analyses to determine whether the differing associations between dietary fat and postmenopausal breast cancer can be explained by measurement errors in dietary assessment. METHODS: The relaxed measurement model was developed by use of data on total fat intake and percent energy from fat from 4-day food records (4DFRs) and food-frequency questionnaires (FFQs) from the original Women's Health Trial. This trial was a randomized, controlled, feasibility study of a low-fat dietary intervention carried out from 1985 through 1988 in Cincinnati (OH), Houston (TX), and Seattle (WA) among 303 women (184 intervention and 119 control) who were 45-69 years of age. The relaxed model was used to project results from the international correlational analyses onto 4DFR and FFQ fat-intake categories. RESULTS AND CONCLUSIONS: If measurement errors in dietary assessment are overlooked entirely, the projected relative risks (RRs) for breast cancer based on the international data vary substantially across percentiles of total fat intake. The projected RR for the 90% versus the 10% fat-intake percentile is 3.08 with the 4DFR and 4.00 with the FFQ. If random (i.e., noise) aspects of measurement error are acknowledged, the projected RR for the same comparison is reduced to 1.54 with the 4DFR and 1.42 with the FFQ. If both systematic and noise aspects of measurement error are acknowledged, the projected RR is reduced to about 1.10 with either instrument. Acknowledgment of measurement error also leads to a projected RR of about 1.10 for the 90% versus the 10% percentile of percent energy from fat with either dietary instrument. IMPLICATIONS: Dietary self-report instruments may be inadequate for analytic epidemiologic studies of dietary fat and disease risk because of measurement error biases.