communities may not be truly representative for
those communities, and the disease data may not be
truly comparable. The biggest stumbling block is the
virtual impossibility of linking differences in disease
incidence to dietary differences since many other
factors – genetic, behavioral, and environmental –
will almost certainly be different and may well be
far more important in determining disease risk than
dietary differences.
Case-control Studies
0013 The identification of patients with evidence of a dis-
ease and the comparison of possible risk factors in
these with the same factors in disease-free subjects is a
basic research strategy. Difficulties arise, however,
because the ‘cases’ are often patients with advanced
disease, who may not be representative of all such
patients. Furthermore, the observer cannot always be
‘blind’ with regard to whether a subject is a ‘case’ or a
‘control,’ and so that bias can easily be introduced
into the data on risk factors. Further difficulties arise
in the selection of suitable control subjects without
the disease, and though some of these difficulties can
be overcome by matching for factors such as sex, age,
and area of residence, uncertainties remain about
comparability between the cases and the controls
with respect to factors other than those believed to
be relevant to the disease.
0014 In nutritional research the case-control strategy has
only a very limited place because it necessitates in-
quiries about dietary intakes before the onset of the
disease, and it is very difficult for a patient to separate
out this information from dietary changes which have
been made since symptoms of the disease com-
menced. Furthermore, the case-control approach has
very little place in diseases with a high case fatality,
such as cancer and heart disease, because only a
selected subsample of all cases survive to be included
in any case-control study and these will certainly not
be representative of all patients with the disease. (See
Cancer: Epidemiology.)
Cross-sectional Survey
0015 One of the most common activities in epidemiology
and in social science is the conducting of surveys.
These can give estimates of the prevalence of a dis-
ease, the distribution of dietary intakes, and the levels
of risk factors, and associations between these can be
examined. For such purposes, it is essential that the
population sample selected for the study is truly rep-
resentative of the community being studied, and that
a high response rate is achieved because otherwise
representativeness will be compromised. Attention
has also to be given to the reproducibility of measure-
ments made. INTERSALT, an international collab-
orative study coordinated by WHO, was a good
example of a cross-sectional study. In this, about 40
research centers obtained data on blood pressure and
on salt excretion from 24-hr urine collections (a sur-
rogate for salt intake) in about 200 subjects per
center.
0016Cross-sectional studies have the great advantage
that all the data collected are contemporaneous, that
is, there is no dependence upon the memories of
subjects, nor is there any waiting for disease to
develop. On the other hand, surveys have the great
disadvantage that causal factors which predated the
onset of the disease cannot always be distinguished
from a factor which has been affected by the disease
itself. Thus, in a cross-sectional survey, differences in
dietary intakes between subjects with CHD and other
subjects, could equally well be the result of changes in
diet made by patients after their heart attack, or the
onset of angina, as the cause of the disease process.
0017One valuable role for cross-sectional surveys is the
identification of determinants of risk factors for dis-
ease. Thus the associations between dietary and other
lifestyle factors and, for example, serum cholesterol,
blood pressure, or serum fibrinogen can be examined.
Prospective Studies
0018The prospective, cohort, or longitudinal study is the
classic tool of the epidemiologist. In this, a representa-
tive population sample of subjects (a cohort) is exam-
ined and then followed forward in time. The
association between the levels of the various factors
measured at baseline, and the development of the
disease, is examined. In other words, the predictive
power for subsequent disease of dietary, lifestyle, bio-
chemical, hematological, and other factors is exam-
ined. The great advantage of this strategy is that the
suspected causal factors are measured before the dis-
ease becomes evident, and causal factors can therefore
be distinguished from factors which represent effects
of the disease.
0019The identification of factors showing greater than
chance associations with subsequent disease is how-
ever not the final answer. The degree to which the
predictive power of a factor for the disease is inde-
pendent of other factors must be examined. Thus, on
first analysis the dietary intakes of many dietary
factors is likely to be found to be predictive of a
range of diseases. It must be examined whether or
not such relationships are simply a consequence of
an age effect (older subjects having an increased risk
of most diseases and, probably, a reduced intake of
most nutrients) or due to confounding by smoking
2146 EPIDEMIOLOGY