Question 1

What are focus areas of nutritional epidemiology?

Your answer:
c) Both of the options given are correct.
Feedback:
Nutritional epidemiology is epidemiology applied to diet and nutrition related health
concerns. Thus, nutritional epidemiology can defined using the same wording as for the
definition of epidemiology: 1) studies of the distribution of nutrition related diseases and
health-related conditions; 2) investigating of nutritional factors in the aetiology of
diseases and 3) analysis of how nutrition related diseases best can be prevented and
controlled in the population. This means that nutritional epidemiology is concerned with
both how nutrition contributes to disease patterns in the population and how these can be
controlled, i.e. how to promote good health.
Page reference: 595
Question 2

In an epidemiological context, what is the population at risk?

Your answer:
b) The group of people that may experience the outcome we want to study.
Feedback:
In epidemiology, the term risk refers to a probability that a defined outcome or event is
going to occur. Risk of the event of interest differs between different groups of people;
therefore, it is important to specify the population at risk, defined as the group of people
from which the cases are drawn, i.e. that may experience the outcome. This population at
risk is the denominator for calculating disease frequency. If we connect the cases of
disease with the inappropriate population at risk, we may overestimate or underestimate
the health risk. For example, somebody with good intentions might recommend banning
hang gliding between 11 am and 3 pm because a survey showed that most accidents
occurred during these hours. However, a sensible decision should be based on the
denominator as well as numerator. Considering the times of the day hang gliding is most
popular, i.e. the size of population at risk at different, times may show that risk of an
accident is not higher between 11 am and 3 pm. It is very important to find the
appropriate denominator in epidemiological studies.
Page reference: 596
Question 3

In which one of the following circumstances will the prevalence of a disease in the
population increase, all else being constant?
Your answer:
b) If survival time with the disease increases.
 Feedback:
The prevalence of disease is the proportion of the population that has a given disease.
This proportion is determined by how many people get the disease and how long they are
ill, which is linked to how fast they either recover or die. If fewer people get the disease
or they recover faster, the prevalence of the disease will go down. However, if survival
time with the disease increases without any change in recovery rate, the prevalence will
increase. This is a common challenge for may chronic diseases, such as diabetes. Patient
care improves so survival time increases, but the disease is not cured and patients may
develop complications. The total burden of disease may increase.
Page reference: 597
Question 4

Which of the following statements about exposures is true?

Your answer:
a) 'Exposure' refers to contact with some factor that may be harmful or beneficial to
health.
Feedback:
The term exposure is applied to any factor we suspect can influence the occurrence of the
outcome. Thus, potential exposures are a wide array of different factors in our physical,
social or psychological environment. They can either increase or decrease the risk of
disease. In nutritional epidemiology, we are most interested in dietary and nutritional
exposures. These can be defined, split or presented in different ways. An exposure can be
defined as an all or none phenomenon (exposed versus non-exposed) or as graded or
continuous variables. Whether a factor is considered an exposure or an outcome depends
on the study question.
Page reference: 597
Question 5

Epidemiological measures of effect assess the _______ between an exposure and an

outcome.
Your answer:
c) strength of the association
Feedback:
In epidemiological studies, measures of effect assess the strength of association between
an exposure and an outcome. After considering the possible influence of bias, chance and
confounding, combined with findings from other studies and a wider assessment of the
total evidence, measures of effect can inform the judgement of causal mechanisms.
However, the size of the effect on its own does not indicate a causal relationship.
Page reference: 598
Question 6
 It is possible to reduce (though not eliminate) information bias in assessment of dietary
intake by
You did not answer the question.
Correct answer:
b) collecting data about dietary intake at the onset of a study, before people have
experienced symptoms of disease.
Feedback:
Information bias is any type of error in measurement that in a systematic way distorts the
estimate of measures of effect. When our exposure measurement is a self-reported
behaviour, for instance dietary habits, reporting is often affected by factors in the
respondents' lives. An individual may make real dietary changes after a diagnosis of
disease, which distorts the risk factor-disease relationship. Accuracy or completeness of
reporting may differ between groups of people with different levels of disease risk.
Studies that collect information about dietary habits before symptoms of disease have
emerged reduce some of this bias.
Page reference: 601-602
Question 7

In a cohort study, the risk ratio of developing diabetes was 0.86 when comparing
consumers of tea (the exposed) to those who did not drink tea (the unexposed). Which
one statement is correct?
Your answer:
a) The tea drinkers have lower risk of developing diabetes.
Correct answer:
c) Based on the information given we cannot tell if the observed difference in disease risk
is the result of chance.
Feedback:
A risk ratio (RR) below the value of one suggests lower disease risk among the exposed
(the exposure is protective of the disease), a RR above one suggests a higher disease rate
among the exposed (the exposure is harmful). A RR of exactly one indicates no
difference in disease risk between the two groups. However, all estimates of association
will be somewhat uncertain. It is important to assess this uncertainty. One of the preferred
measures of uncertainty is the confidence interval. The confidence interval give an upper
and lower confidence limit for our estimate with a given probability. For example, if the
95 % confidence interval for a RR of 0.86 has a range of 0.70 to 1.06, then a lower risk of
disease (RR of 0.70), no difference in disease risk (RR of 1) and higher disease risk (RR
of 1.06) are all likely RR-values in the underlying population with 95 % probability.
Page reference: 598-599
Question 8
 When epidemiologists judge the evidence to establish possible causes of a health
outcome, they consider
Your answer:
d) All of the options given.
Feedback:
Epidemiologists continuously debate the strategies used to establish that an exposure
causes a specific disease. Philosophers would say that causes can never really be proven.
However, through a broad evaluation of the evidence, using specified criteria and
definitions, the scientific community can build a consensus that a factor most likely is
causal. The options given here are three of several considerations used to establish such
consensus.
Page reference: 604
Question 9

Randomised, controlled trials provide strong evidence that an observed effect is due to
the intervention (the assigned exposure). One reason is because
Your answer:
a) when the participants are randomised, many characteristics and possible confounding
factors are likely to be evenly distributed in the groups.
Feedback:
Chapter 30 highlights that bias, chance and confounding are three influences that may
create flawed study results. An epidemiologist will seek to eliminate these influences as
much as possible when designing a study, as well as taking these influences into account
when interpreting the results. A key feature of the randomised, controlled trial study
design is the random allocation into study groups. The purpose of the random allocation
is to produce comparable groups. If done correctly and the study sample is large enough,
both known and unknown confounding factors that may alter disease risk are likely to be
equally distributed between the groups. In other study designs, we depend on
measurement of known or suspected confounding factors in order to adjust for possible
distortions of the effect of interest.
Page reference: 603
Question 10

Confounding is a particular challenge in nutritional epidemiology because

Your answer:
d) different dietary components are correlated with each other, making it difficult to
separate their effects.
Feedback:
It is difficult to find accurate and inexpensive methods to assess dietary intake in large
studies. In addition, people may change their diet over time. Such problems tend to
reduce the reproducibility and validity of dietary assessment in epidemiological studies.
Confounding arises when a factor, for instance a dietary component, is a true cause of
disease and at the same time is correlated with the exposure variable we are investigating.
Intakes of many dietary factors are correlated with each other. Energy intake is for
instance highly correlated with the intake of protein, fat and carbohydrate in most
population groups. When different exposure variables are closely correlated, assessment
of potential casual relationships is difficult because several effects may be mixed
together. There are available methods to adjust for confounding, although such
adjustments can be challenging and imperfect.
Page reference: 609-610