Diet-quality scores and the risk of type 2 diabetes in men

Dietary patterns and the risk of obesity, type 2 diabetes mellitus, cardiovascular diseases, asthma, and neurodegenerative diseases

Diet and lifestyle play a significant role in the development chronic diseases; however the full complexity of this relationship is not yet understood. Dietary pattern investigation, which reflects the complexity of dietary intake, has emerged as an alternative and complementary approach for examining the association between diet and chronic diseases. Literature on this association has largely focused on individual nutrients, with conflicting outcomes, but individuals consume a combination of foods from many groups that form dietary patterns. Our objective was to systematically review the current findings on the effects of dietary patterns on chronic diseases. In this review, we describe and discuss the relationships between dietary patterns, such as the Mediterranean, the Dietary Approach to Stop Hypertension, Prudent, Seventh-day Adventists, and Western, with risk of obesity, type-2 diabetes mellitus, cardiovascular diseases, asthma, and neurodegenearive diseases. Evidence is increasing from both observational and clinical studies that plant-based dietary patterns, which are rich in fruits, vegetables, and whole grains, are valuable in preventing various chronic diseases, whereas a diet high in red and processed meat, refined grains and added sugar seems to increase said risk. Dietary pattern analysis might be especially valuable to the development and evaluation of food-based dietary guidelines.

Dietary Patterns and Type 2 Diabetes: A Systematic Literature Review and Meta-Analysis of Prospective Studies

Background: Different methodologic approaches for constructing dietary patterns and differences in their composition limit conclusions on healthful patterns for diabetes prevention.Objective: We summarized evidence from prospective studies that examined associations of dietary patterns with type 2 diabetes by considering different methodologic approaches.Methods: The literature search (MEDLINE and Web of Science) identified prospective studies (cohorts or trials) that associated dietary patterns with diabetes incidence in nondiabetic and apparently healthy participants. We summarized evidence by meta-analyses and distinguished different methodologic approaches.Results: The search resulted in 48 articles comprising 16 cohorts. Adherence to the Mediterranean diet (RR for comparing extreme quantiles: 0.87; 95% CI: 0.82, 0.93), Dietary Approaches to Stop Hypertension (DASH) (RR: 0.81; 95% CI: 0.72, 0.92), and Alternative Healthy Eating Index (AHEI) (RR: 0.79; 95% CI: 0.69, 0.90) was associated with significant risk reductions of incident diabetes. Patterns from exploratory factor and principal component analyses characterized by red and processed meat, refined grains, high-fat dairy, eggs, and fried products ("mainly unhealthy") were positively associated with diabetes (RR: 1.44; 95% CI: 1.27, 1.62), whereas patterns characterized by vegetables, legumes, fruits, poultry, and fish ("mainly healthy") were inversely associated with diabetes (RR: 0.84; 95% CI: 0.77, 0.91). Reduced rank regression (RRR) used diabetes-related biomarkers to identify patterns. These patterns were characterized by high intakes of refined grains, sugar-sweetened soft drinks, and processed meat and were all significantly associated with diabetes risk.Conclusions: Our meta-analysis suggests that diets according to the Mediterranean diet, DASH, and AHEI have a strong potential for preventing diabetes, although they differ in some particular components. Exploratory dietary patterns were grouped based on concordant food groups and were significantly associated with diabetes risk despite single-component foods having limited evidence for an association. Still, they remain population-specific observations. Consistent positive associations with diabetes risk were observed for 3 RRR patterns.

A systematic review of diet quality indices in relation to obesity

Tools, called ‘diet/dietary quality indices’, evaluate the level of adherence to a specified pattern or a set of recommendations in populations. Yet, there are no review studies providing unanimous comprehensive results of dietary indices on obesity. We reviewed observational studies, focusing on the association of diet quality indices with general obesity or abdominal obesity in adults. We systematically conducted a search in all English language publications available on MEDLINE, ISI Web of Science and Embase between January 1990 and January 2016. Among the wide variety of indices and weight-derived variables, studies with dietary-guideline-based indices and mean changes for weight gain or OR for general obesity and abdominal obesity were selected. From a total of 479 articles, thirty-four studies were selected for the current review, ten of which had prospective designs and twenty-six had cross-sectional designs. Associations of weight status with the original Healthy Eating Index (HEI) and other versions of the HEI including alternative HEI, HEI-2005 and HEI-05 were examined in thirteen studies, with ten studies revealing significant associations. The HEI was a better general obesity predictor in men than in women. Diet scores lacked efficacy in assessing overall diet quality and demonstrated no significant findings in developing countries, in comparison with US populations. In addition, indices based on dietary diversity scores were directly associated with weight gain. Despite the insufficient evidence to draw definitive conclusions about the relation between dietary indices and obesity, HEI was found to be inversely associated with obesity and diversity-based indices were positively associated with obesity.

Development and Evaluation of a Dietary Approaches to Stop Hypertension Dietary Index with Calorie-Based Standards in Equivalent Units: A Cross-Sectional Study with 24-Hour Dietary Recalls from Adult Participants in the National Health and Nutrition Examination Survey 2007-2010

BACKGROUND

Dietary indexes to assess accordance with the Dietary Approaches to Stop Hypertension (DASH) dietary pattern are useful tools in studies with health-related outcomes. However, scoring algorithms of the dietary index can affect the range of its applications.

OBJECTIVE

The purposes of this study were to develop a DASH dietary index with calorie-based standards in equivalent units and to evaluate the validity and reliability of the index.

METHODS

Calorie-based standards for nine components were determined based on recommended intakes in the DASH eating plan and dietary intakes estimated from two 24-hour dietary recalls of adult participants in the National Health and Nutrition Examination Survey 2007-2008, 2009-2010 (n=9,720). Evaluation tests included descriptive analyses of index scores among US adults stratified by sex and smoking status. Spearman's rank correlations were used to examine the relationships among components and total scores. The developed index was compared with two DASH dietary indexes that use different scoring algorithms to examine the association between total scores and blood pressure status through multivariable regression models.

RESULTS

The newly developed index consisted of seven food group and two nutrient components. The mean and median of total scores among US adults were 42.3 (95% CI 41.6 to 43.0) and 41.6 of 90 points, respectively. The mean total scores among adult women and non-current smokers were higher than their counterparts (P<0.001). The absolute correlation coefficients among the components and between each component and the sum of other components were ≤0.33 and ≤0.35, respectively. After adjusting for age and race/ethnicity, an association between total scores and blood pressure status was found in adult women (P<0.001), but not in adult men. The same pattern was found when the two indexes were used, but the strength of the association varied across the three indexes.

CONCLUSIONS

The developed index appeared to measure accordance with the DASH dietary pattern based on the dietary data from US adults. Further studies are warranted for various applications of the index.

The Mediterranean Diet Score Is More Strongly Associated with Favorable Cardiometabolic Risk Factors over 2 Years Than Other Diet Quality Indexes in Puerto Rican Adults

Background: Multiple diet quality scores have been used to evaluate adherence to specific dietary recommendations or to consumption of healthful foods and nutrients. It remains unknown which score can more strongly predict longitudinal changes in cardiometabolic risk factors.Objective: We aimed to determine associations of 5 diet quality scores [AHA diet score (AHA-DS), Dietary Approaches to Stop Hypertension (DASH), Healthy Eating Index (HEI)-2005, Mediterranean diet score (MeDS), and Alternative Healthy Eating Index (AHEI)] with 2-y changes in cardiometabolic risk factors in adults 45-75 y old.Methods: Data from the Boston Puerto Rican Health Study were analyzed (n = 1194). Diet quality scores were calculated from a baseline-validated food-frequency questionnaire. Multivariable-adjusted, repeated-subjects, mixed-effects models, adjusted for baseline measures, estimated associations between each z score and 14 individual cardiometabolic factors measured at 2 y.Results: MeDS was significantly associated with lower 2-y waist circumference (β coefficient ± SE: -0.52 ± 0.26, P = 0.048); body mass index (BMI; -0.23 ± 0.08, P = 0.005); log-insulin (-0.06 ± 0.02, P = 0.005); log-homeostasis model assessment of insulin resistance (HOMA-IR; -0.05 ± 0.02, P = 0.030), and log-C-reactive protein (-0.13 ± 0.03, P = 0.0002). Similar but weaker associations were observed for the AHEI with BMI, insulin, and HOMA-IR. The AHA-DS was inversely associated with BMI (-0.17 ± 0.08, P = 0.033). Neither the HEI-2005 nor DASH was significantly associated with any variable. Traditional Puerto Rican foods consumed by individuals with high MeDSs included vegetables and meats in homemade soups, orange juice, oatmeal, beans and legumes, fish, whole milk, corn oil, and beer.Conclusions: The MeDS comprises food components and scores associated with a favorable cardiometabolic profile over 2 y in Puerto Rican adults. An overall healthy diet may be particularly beneficial for maintaining a lower BMI. These results can help identify suitable measures of diet quality in epidemiologic studies and craft meaningful nutritional messages and dietary recommendations for the intended population. This study was registered at clinicaltrials.gov as NCT01231958.

Sex and Race/Ethnicity Differences in Following Dietary and Exercise Recommendations for U.S. Representative Sample of Adults With Type 2 Diabetes

This study examined sex by race/ethnicity differences in medical advice received for diet and exercise with corresponding health behaviors of a U.S. representative sample of adults with type 2 diabetes ( N = 1,269). Data from the National Health and Nutrition Examination Surveys for 2011-2014 for 185 Mexican Americans, 123 Other Hispanics, 392 non-Hispanic Blacks, 140 non-Hispanic Asians, and 429 non-Hispanic Whites were analyzed using logistic regression analyses. Reporting being given dietary and exercise advice was positively associated with reporting following the behavior. There were differences in sex and sex by race/ethnicity for reporting receiving medical advice and performing the advised health behavior. These results suggest the importance of physicians having patient-centered communication skills and cultural competency when discussing diabetes management.

Healthy lifestyle and normal waist circumference are associated with a lower 5-year risk of type 2 diabetes in middle-aged and elderly individuals: Results from the healthy aging longitudinal study in Taiwan (HALST)

Type 2 diabetes mellitus (DM) is known to be closely associated with lifestyle and obesity and has a prevalence that increases with age. This study aimed to assess the short-term composite effect of diet, physical activity, psychosocial health, and waist circumference (WC) on the incidence of DM in the elderly and to provide a lifestyle-based predictive index.We used baseline measurements (2009-2013) of 5349 community-dwelling participants (aged 55 years and older, 52% female) of the Healthy Aging Longitudinal Study in Taiwan (HALST) for fasting plasma glucose, HbA1C, serum cholesterol, triglycerides, blood pressures, WC, and outcomes of home-visit questionnaire. Principal component analysis (PCA) was used to identify participants with a healthy lifestyle (HLF: higher diet, physical activity, and psychosocial scores) and a lower WC, with cutoffs determined by the receiver-operating characteristics. A Cox regression model was applied to 3424 participants without DM at baseline by linking to their National Health Insurance records (median follow-up of 3.1 years).In total, 247 new DM cases (7.2%) were identified. The HLF and lower WC group had a relative risk (RR) of DM of 0.54 (95% CI 0.35-0.82) compared to the non-HLF and higher WC group. When stratified by the presence of impaired glucose tolerance (IGT) or metabolic syndrome (MS), only participants with IGT/MS showed significant risks (RR 0.55; 95% CI 0.33-0.92). However, except for WC, the individual lifestyle factors were nonsignificant in the overall model without PCA.A composite protective effect of HLF and normal WC on DM within 5 years was observed, especially in those with IGT or MS. Psychosocial health constituted an important lifestyle factor in the elderly. The cutoffs identified could be used as a lifestyle-based risk index for DM. Maintaining an HLF to prevent DM is especially important for the elderly.

Adolescent Diet Quality and Cardiovascular Disease Risk Factors and Incident Cardiovascular Disease in Middle-Aged Women

BACKGROUND

Primary prevention of cardiovascular disease (CVD) focuses on treatment of risk factors, including hypercholesterolemia, hypertension, and type 2 diabetes mellitus. We investigated whether a healthy diet in adolescence prevents development of clinical risk factors or incidence of CVD in adulthood.

METHODS AND RESULTS

We examined the time to the first development of ≥1 clinical risk factor (hypercholesterolemia, hypertension, or type 2 diabetes mellitus) or CVD in relation to a high school Alternative Healthy Eating Index (HS-AHEI) within the Nurses' Health Study II. Among those who completed a food frequency questionnaire about their high school diet and adult diet (mean age 42 years), 27 406 women free of clinical risk factors and 42 112 women free of CVD in 1998 were followed to June 2011. Hazard ratios (HRs) and 95% CIs were adjusted for potential confounders in high school and adulthood. We documented 11 542 first diagnoses of clinical risk factors and 423 CVD events. The HS-AHEI was associated with a lower rate of risk factors (HR highest versus lowest quintiles 0.82; 95% CI, 0.77-0.87 [P trend <0.001]), was inversely associated with risk of developing ≥1 clinical risk factor in women with a low, medium, and high AHEI score during adulthood (HR high HS-AHEI/high adult AHEI versus low/low 0.79 [95% CI, 0.74-0.85]), but was not statistically significantly associated with incident CVD.

CONCLUSIONS

A healthy diet during adolescence is associated with lower risk of developing CVD risk factors. As diet tracks throughout life, and adult diet prevents CVD, healthy dietary habits that begin early are important for primordial prevention of CVD.

Changes in Overall Diet Quality and Subsequent Type 2 Diabetes Risk: Three U.S. Prospective Cohorts

OBJECTIVE

Recent public health recommendations emphasize adopting a healthful dietary pattern, but evidence is scarce on whether incremental diet quality changes have an impact on long-term diabetes prevention. We aim to evaluate diet quality changes during a 4-year period and subsequent 4-year type 2 diabetes incidence.

RESEARCH DESIGN AND METHODS

Participants of prospective cohorts, the Nurses' Health Study (NHS), NHS II, and the Health Professionals Follow-up Study, who were free of diabetes at baseline (n = 124,607), were observed for ≥20 years. Diet quality, reflected by the Alternate Healthy Eating Index (AHEI) score, was assessed every 4 years to calculate changes.

RESULTS

We documented 9,361 cases of type 2 diabetes during 2,093,416 person-years of follow-up. A >10% decrease in AHEI score over 4 years was associated with a higher subsequent diabetes risk (pooled hazard ratio 1.34 [95% CI 1.23-1.46]) with multiple adjustment, whereas a >10% increase in AHEI score was associated with a lower risk (0.84 [0.78-0.90]). Greater improvement in diet quality was associated with lower diabetes risk across baseline diet quality status (P for trend ≤ 0.001 for low, medium, or high initial diet quality) and baseline BMI (P for trend ≤ 0.01 for BMI <25, 25-29, or 30 kg/m²). Changes in body weight explained 32% (95% CI 24-41) of the association between AHEI changes (per 10% increase) and diabetes risk.

CONCLUSIONS

Improvement in overall diet quality is associated with a lower risk of type 2 diabetes, whereas deterioration in diet quality is associated with a higher risk. The association between diet quality changes and diabetes risk is only partly explained by body weight changes.

The influence of energy standardisation on the alternate Mediterranean diet score and its association with mortality in the Multiethnic Cohort

The alternate Mediterranean diet (aMED) score is an adaptation of the original Mediterranean diet score. Raw (aMED) and energy-standardised (aMED-e) versions have been used. How the diet scores and their association with health outcomes differ between the two versions is unclear. We examined differences in participants' total and component scores and compared the association of aMED and aMED-e with all-cause, CVD and cancer mortality. As part of the Multiethnic Cohort, 193 527 men and women aged 45-75 years from Hawaii and Los Angeles completed a baseline FFQ and were followed up for 13-18 years. The association of aMED and aMED-e with mortality was examined using Cox's regression, with adjustment for total energy intake. The correlation between aMED and aMED-e total scores was lower among people with higher BMI. Participants who were older, leaner, more educated and consumed less energy scored higher on aMED-e components compared with aMED, except for the red and processed meat and alcohol components. Men reporting more physical activity scored lower on most aMED-e components compared with aMED, whereas the opposite was observed for the meat component. Higher scores of both aMED and aMED-e were associated with lower risk of all-cause, CVD and cancer mortality. Although individuals may score differently with aMED and aMED-e, both scores show similar reductions in mortality risk for persons scoring high on the index scale. Either version can be used in studies of diet and mortality. Comparisons can be performed across studies using different versions of the score.

Adherence to Healthy Eating Index-2010 is inversely associated with metabolic syndrome and its features among Iranian adult women

BACKGROUND/OBJECTIVES

Nowadays, metabolic syndrome (MetS) is deemed as a major public health challenge in both developed and developing countries. Therefore, the aim of this study was to determine the association between Healthy Eating Index-2010 (HEI-2010) score and MetS and its features among Iranian female nurses.

SUBJECTS/METHODS

This cross-sectional study was performed among 1036 Iranian women. A validated, self-administered, dish-based, semiquantitative food frequency questionnaire was used to assess the habitual intake of participants. HEI-2010 score was used to assess diet quality of participants. MetS was defined based on the guidelines of the National Cholesterol Education Program Adult Treatment Panel III (ATP III). Multivariate logistic regression adjusted for potential confounders was used to assess the relation between HEI-2010 and MetS.

RESULTS

After adjusting for potential confounders, participants in the highest quartile of HEI-2010 had the lowest risk of MetS compared with those in the first quartile (odds ratio: 0.72; 95% confidence interval: 0.50-0.96). Furthermore, the risk of MetS features including abdominal obesity, high blood pressure, high serum triacylglycerol and low serum high-density lipoprotein-cholesterol significantly decreased across HEI-2010 quartiles (P<0.05).

CONCLUSIONS

Higher HEI-2010 scores were inversely associated with lower risk of MetS and its components among Iranian women.

Healthy Dietary Patterns and Oxidative Stress as Measured by Fluorescent Oxidation Products in Nurses' Health Study

Healthy diets may lower oxidative stress and risk of chronic diseases. However, no previous studies examined associations between diet and fluorescent oxidation products (FlOP), a global marker of oxidative stress. We evaluated associations between healthy eating patterns (Alternative Healthy Eating Index (AHEI), Dietary Approach to Stop Hypertension (DASH), and Alternate Mediterranean Diet (aMED)) and FlOP, measured at three excitation/emission wavelengths (FlOP_360, FlOP_320, FlOP_400) from 2021 blood samples collected from 1688 women within the Nurses’ Health Study. AHEI, DASH, and aMED scores were significantly positively associated with FlOP_360 and FlOP_320 concentrations (p-trend ≤ 0.04), but not associated with FlOP_400. Among specific food groups that contribute to these diet scores, significantly positive associations were observed with legumes and vegetables for FlOP_360, vegetables and fruits for FlOP_320, and legumes and alcohol for FlOP_400. Inverse associations were observed with nuts, sweets or desserts, and olive oil for FlOP_360, nuts for FlOP_320 and sweets or desserts for FlOP_400 (all p-trend ≤ 0.05). However, FlOP variation due to diet was small compared to overall FlOP variation. In conclusion, AHEI, DASH, and aMED scores were unexpectedly positively, but weakly, associated with FlOP_360 and FlOP_320. However, these findings should be interpreted cautiously as the determinants of FlOP concentrations are not fully understood.

A High Diet Quality Based on Dietary Recommendations Is Not Associated with Lower Incidence of Type 2 Diabetes in the Malmö Diet and Cancer Cohort

A high diet quality index based on Swedish nutrition recommendations has previously been associated with reduced risk of cardiovascular disease and mortality in the Malmö Diet and Cancer (MDC) cohort. The aim of the present study was to investigate whether this diet quality index was associated with the risk for type 2 diabetes. Of 26,868 participants (44–74 years) in the MDC cohort study, 3838 type 2 diabetes cases were identified from registers during 17 years of follow-up. A diet quality index (from a modified diet history method) was constructed based on adherence to the recommended intakes of saturated fat, polyunsaturated fat, fish, fiber, fruit and vegetables, and sucrose. After adjusting for potential confounders, we observed no significant association between the diet quality index and type 2 diabetes risk. The HR for the highest vs. lowest index category was 1.06 (95% CI: 0.94, 1.20; p-trend = 0.56). Because of the protective associations shown for cardiovascular disease and mortality, the specific dietary components that were chosen to represent adherence to the recommendations may be less applicable to type 2 diabetes risk.

Plant-Based Dietary Patterns and Incidence of Type 2 Diabetes in US Men and Women: Results from Three Prospective Cohort Studies

BACKGROUND

Plant-based diets have been recommended to reduce the risk of type 2 diabetes (T2D). However, not all plant foods are necessarily beneficial. We examined the association of an overall plant-based diet and hypothesized healthful and unhealthful versions of a plant-based diet with T2D incidence in three prospective cohort studies in the US.

METHODS AND FINDINGS

We included 69,949 women from the Nurses' Health Study (1984-2012), 90,239 women from the Nurses' Health Study 2 (1991-2011), and 40,539 men from the Health Professionals Follow-Up Study (1986-2010), free of chronic diseases at baseline. Dietary data were collected every 2-4 y using a semi-quantitative food frequency questionnaire. Using these data, we created an overall plant-based diet index (PDI), where plant foods received positive scores, while animal foods (animal fats, dairy, eggs, fish/seafood, poultry/red meat, miscellaneous animal-based foods) received reverse scores. We also created a healthful plant-based diet index (hPDI), where healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, tea/coffee) received positive scores, while less healthy plant foods (fruit juices, sweetened beverages, refined grains, potatoes, sweets/desserts) and animal foods received reverse scores. Lastly, we created an unhealthful plant-based diet index (uPDI) by assigning positive scores to less healthy plant foods and reverse scores to healthy plant foods and animal foods. We documented 16,162 incident T2D cases during 4,102,369 person-years of follow-up. In pooled multivariable-adjusted analysis, both PDI and hPDI were inversely associated with T2D (PDI: hazard ratio [HR] for extreme deciles 0.51, 95% CI 0.47-0.55, p trend < 0.001; hPDI: HR for extreme deciles 0.55, 95% CI 0.51-0.59, p trend < 0.001). The association of T2D with PDI was considerably attenuated when we additionally adjusted for body mass index (BMI) categories (HR 0.80, 95% CI 0.74-0.87, p trend < 0.001), while that with hPDI remained largely unchanged (HR 0.66, 95% CI 0.61-0.72, p trend < 0.001). uPDI was positively associated with T2D even after BMI adjustment (HR for extreme deciles 1.16, 95% CI 1.08-1.25, p trend < 0.001). Limitations of the study include self-reported diet assessment, with the possibility of measurement error, and the potential for residual or unmeasured confounding given the observational nature of the study design.

CONCLUSIONS

Our study suggests that plant-based diets, especially when rich in high-quality plant foods, are associated with substantially lower risk of developing T2D. This supports current recommendations to shift to diets rich in healthy plant foods, with lower intake of less healthy plant and animal foods.

Impact of a Worksite Diabetes Prevention Intervention on Diet Quality and Social Cognitive Influences of Health Behavior: A Randomized Controlled Trial

OBJECTIVE

To evaluate the impact of a worksite diabetes prevention intervention on secondary outcomes regarding the change in diet quality and components of the Health Action Process Approach (HAPA) theoretical framework.

DESIGN

Pretest-posttest control group design with 3-month follow-up.

SETTING

University worksite.

PARTICIPANTS

Employees aged 18-65 years with prediabetes (n = 68).

INTERVENTION

A 16-week group-based intervention adapted from the Diabetes Prevention Program.

MAIN OUTCOME MEASURES

Diet quality was assessed using the Alternative Healthy Eating Index 2010; HAPA components were assessed via written questionnaire.

ANALYSIS

Repeated-measures ANOVA compared the between- and within-group change in outcomes across time.

RESULTS

Significant difference occurred between groups for the change in consumption of nuts/legumes and red/processed meats postintervention and for fruits at 3-month follow-up (all P < .05); a significant increase in total Alternative Healthy Eating Index 2010 score occurred postintervention in the experimental group (P = .002). The changes in action planning, action self-efficacy, and coping self-efficacy from HAPA were significantly different between groups after the intervention; the change in outcome expectancies was significantly different between groups at 3-month follow-up (all P < .05).

CONCLUSIONS AND IMPLICATIONS

The worksite intervention facilitated improvement in diet quality and in planning and efficacious beliefs regarding diabetes prevention. Further research is needed to evaluate the long-term impact of the intervention.

Combined Healthy Lifestyle Is Inversely Associated with Psychological Disorders among Adults

BACKGROUND AND AIMS

Joint association of lifestyle-related factors and mental health has been less studied in earlier studies, especially in Middle Eastern countries. This study aimed to examine how combinations of several lifestyle-related factors related to depression and anxiety in a large group of middle-age Iranian population.

METHODS

In a cross-sectional study on 3363 Iranian adults, a healthy lifestyle score was constructed by the use of data from dietary intakes, physical activity, smoking status, psychological distress and obesity. A dish-based 106-item semi-quantitative validated food frequency questionnaire (FFQ), General Practice Physical Activity Questionnaire (GPPAQ), General Health Questionnaire (GHQ) and other pre-tested questionnaires were used to assess the components of healthy lifestyle score. The Hospital Anxiety and Depression Scale (HADS) was applied to screen for anxiety and depression.

RESULTS

After adjustment for potential confounders, we found that individuals with the highest score of healthy lifestyle were 95% less likely to be anxious (OR: 0.05; 95% CI: 0.01-0.27) and 96% less likely to be depressed (OR: 0.04; 95% CI: 0.01-0.15), compared with those with the lowest score. In addition, non-smokers had lower odds of anxiety (OR: 0.64; 95% CI: 0.47-0.88) and depression (OR: 0.62; 95% CI: 0.48-0.81) compared with smokers. Individuals with low levels of psychological distress had expectedly lower odds of anxiety (OR: 0.13; 95% CI: 0.10-0.16) and depression (OR: 0.10; 95% CI: 0.08-0.12) than those with high levels. Individuals with a healthy diet had 29% lower odds of depression (OR: 0.71; 95% CI: 0.59-0.87) than those with a non-healthy diet.

CONCLUSION

We found evidence indicating that healthy lifestyle score was associated with lower odds of anxiety and depression in this group of Iranian adults. Healthy diet, psychological distress, and smoking status were independent predictors of mental disorders.

Inclusion of walnut in the diets of adults at risk for type 2 diabetes and their dietary pattern changes: a randomized, controlled, cross-over trial

BACKGROUND

In our recently published study, including walnuts in the diets of adults with prediabetes led to overall improvement in diet quality. This report adds to those study findings by examining the food groups displaced during walnut inclusion in the diets of those adults with prediabetes.

METHODS

Randomized, controlled, modified Latin square parallel design with 2 treatment arms. The 112 participants (31 men, 81 women) were randomly assigned to a diet with or without dietary counseling to regulate calorie intake in a 1:1 ratio. Within each treatment arm, participants were further randomized to 1 of 2 sequence permutations to receive a walnut-included diet with 56 g (366 kcal) of walnuts per day and a walnut-excluded diet. Participants in the calorie-regulated arm received advice from a dietitian to preserve an isocaloric condition while including walnuts. We analyzed the 12 components of the 2010 Healthy Eating Index to examine dietary pattern changes of study participants.

RESULTS

Seafood and plant protein foods intake significantly increased with walnut inclusion, compared with their exclusion (2.14±2.06 vs -0.49±2.33; p=0.003). The ingestion of healthful fatty acids also significantly increased with walnut inclusion, compared with their exclusion (1.43±4.53 vs -1.76±4.80; p=0.02). Dairy ingestion increased with walnut inclusion in the calorie-regulated phase, compared with walnut inclusion without calorie regulation (1.06±4.42 vs -2.15±3.64; p=0.02).

CONCLUSIONS

Our data suggest that walnut inclusion in the diets of adults at risk for diabetes led to an increase in intake of other healthful foods.

TRIAL REGISTRATION NUMBER

NCT02330848.

Adherence to Mediterranean diet and 10-year incidence (2002-2012) of diabetes: correlations with inflammatory and oxidative stress biomarkers in the ATTICA cohort study

BACKGROUND

The purpose of this work was to investigate the links between oxidative stress, inflammation and coagulation and their effect on Mediterranean diet-diabetes relationship.

METHODS

In 2001-2002, a random sample of 1514 men (18-87 years old) and 1528 women (18-89 years old) was selected to participate in the ATTICA study, where Athens is the major metropolis. A validated questionnaire was used to assess lifestyle and dietary factors. Adherence to Mediterranean diet was recorded using MedDietScore. Among others, oxidative stress and inflammatory biomarkers were recorded. During 2011-2012, the 10-year follow-up was performed. Diabetes incidence was defined according to the American Diabetes Association criteria.

RESULTS

A total of 191 incident cases of diabetes were documented, yielding an incidence of 12.9% (13.4% in men and 12.4% in women). Medium and high adherence was found to decrease diabetes risk by 49% (95% CI: 0.30, 0.88) and 62% (95% CI: 0.16, 0.88), respectively, compared with low adherence. A logarithmic trend between Mediterranean diet and diabetes incidence was also revealed (p for trend = 0.042). Individuals with abnormal waist circumference (>94 for men, >80 for women) were benefited the most. Wholegrain cereals, fruits and legumes had the greatest predictive ability. The anti-diabetic effect of Mediterranean diet correlated with measurements of tumour necrosis factor-α, homocysteine and total antioxidant capacity.

CONCLUSIONS

The reported results support the role of Mediterranean diet as a promising dietary tool for the primary prevention of diabetes, by attenuating inflammation and fostering total antioxidant capacity. This dietary pattern may have therapeutic potential for many cardiometabolic disorders associated with inflammation and/or oxidative stress.

An Update on Nutrients and Blood Pressure

Adverse blood pressure (BP) is a major independent risk factor for epidemic cardiovascular diseases affecting almost one-quarter of the adult population worldwide. Dietary intake is a major determinant in the development and progression of high BP. Lifestyle modifications, including recommended dietary guidelines, are advocated by the American Society of Hypertension, the International Society of Hypertension, the Japanese Society of Hypertension, and many other organisations for treating all hypertensive people, prior to initiating drug therapy and as an adjunct to medication in persons already on drug therapy. Lifestyle modification can also reduce high BP and prevent development of hypertension. This review synthesizes results from the International Study of Macro/Micronutrients and Blood Pressure (INTERMAP), a cross-sectional epidemiological study of 4,680 men and women aged 40-59 years from Japan, the People's Republic of China, the United Kingdom, and the United States, published over the past few years on cross cultural BP differences. INTERMAP has previously reported that intakes of vegetable protein, glutamic acid, total and insoluble fibre, total polyunsaturated fatty acid and linoleic acid, total n-3 fatty acid and linolenic acid, phosphorus, calcium, magnesium, and non-heme iron were inversely related to BP. Direct associations of sugars (fructose, glucose, and sucrose) and sugar-sweetened beverages (especially combined with high sodium intake), cholesterol, glycine, alanine, and oleic acid from animal sources with BP were also reported by the INTERMAP Study.

Cell phone intervention for you (CITY): A randomized, controlled trial of behavioral weight loss intervention for young adults using mobile technology

OBJECTIVE

To determine the effect on weight of two mobile technology-based (mHealth) behavioral weight loss interventions in young adults.

METHODS

Randomized, controlled comparative effectiveness trial in 18- to 35-year-olds with BMI ≥ 25 kg/m(2) (overweight/obese), with participants randomized to 24 months of mHealth intervention delivered by interactive smartphone application on a cell phone (CP); personal coaching enhanced by smartphone self-monitoring (PC); or Control.

RESULTS

The 365 randomized participants had mean baseline BMI of 35 kg/m(2) . Final weight was measured in 86% of participants. CP was not superior to Control at any measurement point. PC participants lost significantly more weight than Controls at 6 months (net effect -1.92 kg [CI -3.17, -0.67], P = 0.003), but not at 12 and 24 months.

CONCLUSIONS

Despite high intervention engagement and study retention, the inclusion of behavioral principles and tools in both interventions, and weight loss in all treatment groups, CP did not lead to weight loss, and PC did not lead to sustained weight loss relative to Control. Although mHealth solutions offer broad dissemination and scalability, the CITY results sound a cautionary note concerning intervention delivery by mobile applications. Effective intervention may require the efficiency of mobile technology, the social support and human interaction of personal coaching, and an adaptive approach to intervention design.

Everything in Moderation--Dietary Diversity and Quality, Central Obesity and Risk of Diabetes

Diet guidelines recommend increasing dietary diversity. Yet, metrics for dietary diversity have neither been well-defined nor evaluated for impact on metabolic health. Also, whether diversity has effects independent of diet quality is unknown. We characterized and evaluated associations of diet diversity and quality with abdominal obesity and type II diabetes (T2D) in the Multi-Ethnic Study of Atherosclerosis. At baseline (2000-02), diet was assessed among 5,160 Whites, Hispanic, Blacks, and Chinese age 45-84 y and free of T2D, using a validated questionnaire. Three different aspects of diet diversity were characterized including count (number of different food items eaten more than once/week, a broad measure of diversity), evenness (Berry index, a measure of the spread of the diversity), and dissimilarity (Jaccard distance, a measure of the diversity of the attributes of the foods consumed). Diet quality was characterized using aHEI, DASH, and a priori pattern. Count and evenness were weakly positively correlated with diet quality (r with AHEI: 0.20, 0.04), while dissimilarity was moderately inversely correlated (r = -0.34). In multivariate models, neither count nor evenness was associated with change in waist circumference (WC) or incident T2D. Greater food dissimilarity was associated with higher gain in WC (p-trend<0.01), with 120% higher gain in participants in the highest quintile of dissimilarity scores. Diet diversity was not associated with incident T2D. Also, none of the diversity metrics were associated with change in WC or incident T2D when restricted to only healthier or less healthy foods. Higher diet quality was associated with lower risk of T2D. Our findings provide little evidence for benefits of diet diversity for either abdominal obesity or diabetes. Greater dissimilarity among foods was actually associated with gain in WC. These results do not support the notion that "eating everything in moderation" leads to greater diet quality or better metabolic health.

Adherence to a Healthy Nordic Food Index Is Associated with a Lower Risk of Type-2 Diabetes--The Danish Diet, Cancer and Health Cohort Study

BACKGROUND

Type-2 diabetes (T2D) prevalence is rapidly increasing worldwide. Lifestyle factors, in particular obesity, diet, and physical activity play a significant role in the etiology of the disease. Of dietary patterns, particularly the Mediterranean diet has been studied, and generally a protective association has been identified. However, other regional diets are less explored.

OBJECTIVE

The aim of the present study was to investigate the association between adherence to a healthy Nordic food index and the risk of T2D. The index consists of six food items: fish, cabbage, rye bread, oatmeal, apples and pears, and root vegetables.

METHODS

Data was obtained from a prospective cohort study of 57,053 Danish men and women aged 50-64 years, at baseline, of whom 7366 developed T2D (median follow-up: 15.3 years). The Cox proportional hazards model was used to assess the association between the healthy Nordic food index and risk of T2D, adjusted for potential confounders.

RESULTS

Greater adherence to the healthy Nordic food index was significantly associated with lower risk of T2D after adjusting for potential confounders. An index score of 5-6 points (high adherence) was associated with a statistically significantly 25% lower T2D risk in women (HR: 0.75, 95%CI: 0.61-0.92) and 38% in men (HR: 0.62; 95%CI: 0.53-0.71) compared to those with an index score of 0 points (poor adherence).

CONCLUSION

Adherence to a healthy Nordic food index was found to be inversely associated with risk of T2D, suggesting that regional diets other than the Mediterranean may also be recommended for prevention of T2D.

Contribution of Major Lifestyle Risk Factors for Incident Heart Failure in Older Adults: The Cardiovascular Health Study

OBJECTIVES

The goal of this study was to determine the relative contribution of major lifestyle factors on the development of heart failure (HF) in older adults.

BACKGROUND

HF incurs high morbidity, mortality, and health care costs among adults ≥65 years of age, which is the most rapidly growing segment of the U.S.

METHODS

We prospectively investigated separate and combined associations of lifestyle risk factors with incident HF (1,380 cases) over 21.5 years among 4,490 men and women in the Cardiovascular Health Study, which is a community-based cohort of older adults. Lifestyle factors included 4 dietary patterns (Alternative Healthy Eating Index, Dietary Approaches to Stop Hypertension, an American Heart Association 2020 dietary goals score, and a Biologic pattern, which was constructed using previous knowledge of cardiovascular disease dietary risk factors), 4 physical activity metrics (exercise intensity, walking pace, energy expended in leisure activity, and walking distance), alcohol intake, smoking, and obesity.

RESULTS

No dietary pattern was associated with developing HF (p > 0.05). Walking pace and leisure activity were associated with a 26% and 22% lower risk of HF, respectively (pace >3 mph vs. <2 mph; hazard ratio [HR]: 0.74; 95% confidence interval [CI]: 0.63 to 0.86; leisure activity ≥845 kcal/week vs. <845 kcal/week; HR: 0.78; 95% CI: 0.69 to 0.87). Modest alcohol intake, maintaining a body mass index <30 kg/m(2), and not smoking were also independently associated with a lower risk of HF. Participants with ≥4 healthy lifestyle factors had a 45% (HR: 0.55; 95% CI: 0.42 to 0.74) lower risk of HF. Heterogeneity by age, sex, cardiovascular disease, hypertension medication use, and diabetes was not observed.

CONCLUSIONS

Among older U.S. adults, physical activity, modest alcohol intake, avoiding obesity, and not smoking, but not dietary patterns, were associated with a lower risk of HF.

Greater accordance with the Dietary Approaches to Stop Hypertension dietary pattern is associated with lower diet-related greenhouse gas production but higher dietary costs in the United Kingdom

BACKGROUND

The Dietary Approaches to Stop Hypertension (DASH) diet is a proven way to prevent and control hypertension and other chronic disease. Because the DASH diet emphasizes plant-based foods, including vegetables and grains, adhering to this diet might also bring about environmental benefits, including lower associated production of greenhouse gases (GHGs).

OBJECTIVE

The objective was to examine the interrelation between dietary accordance with the DASH diet and associated GHGs. A secondary aim was to examine the retail cost of diets by level of DASH accordance.

DESIGN

In this cross-sectional study of adults aged 39-79 y from the European Prospective Investigation into Cancer and Nutrition-Norfolk, United Kingdom cohort (n = 24,293), dietary intakes estimated from food-frequency questionnaires were analyzed for their accordance with the 8 DASH food and nutrient-based targets. Associations between DASH accordance, GHGs, and dietary costs were evaluated in regression analyses. Dietary GHGs were estimated with United Kingdom-specific data on carbon dioxide equivalents associated with commodities and foods. Dietary costs were estimated by using national food prices from a United Kingdom-based supermarket comparison website.

RESULTS

Greater accordance with the DASH dietary targets was associated with lower GHGs. Diets in the highest quintile of accordance had a GHG impact of 5.60 compared with 6.71 kg carbon dioxide equivalents/d for least-accordant diets (P < 0.0001). Among the DASH food groups, GHGs were most strongly and positively associated with meat consumption and negatively with whole-grain consumption. In addition, higher accordance with the DASH diet was associated with higher dietary costs, with the mean cost of diets in the top quintile of DASH scores 18% higher than that of diets in the lowest quintile (P < 0.0001).

CONCLUSIONS

Promoting wider uptake of the DASH diet in the United Kingdom may improve population health and reduce diet-related GHGs. However, to make the DASH diet more accessible, food affordability, particularly for lower income groups, will have to be addressed.

Protective Effects of the Mediterranean Diet on Type 2 Diabetes and Metabolic Syndrome

Several studies provide evidence supporting a beneficial effect from the traditional Mediterranean diet (MedDiet) on the risk of type 2 diabetes mellitus (T2DM) and metabolic syndrome (MetS). This review summarizes the current scientific evidence from epidemiologic studies and clinical trials on the relation between the MedDiet and T2DM and MetS and the possible mechanisms underlying the reported associations. A recent meta-analysis of prospective cohort studies showed that greater adherence to the MedDiet was associated with a significant reduction in the risk of diabetes. The MedDiet has also been found to be beneficial in the prevention of gestational diabetes. Four large prospective studies have observed inverse associations between the MedDiet and MetS or its components. Few randomized controlled trials (RCTs) have evaluated the effect of the MedDiet on T2DM and MetS. Results from the landmark PREvención con DIeta MEDiterránea (PREDIMED) nutrition intervention trial showed that participants assigned to the MedDiet had a significant 30% reduction in the risk of T2DM and that it also promoted the reversion of MetS and its components, hyperglycemia and central obesity. In addition, 5 RCTs showed the beneficial effects of the MedDiet compared with other dietary patterns on glycemic control in patients with T2DM. A recent meta-analysis of RCTs revealed that, compared with a variety of control diets, the MedDiet was associated with beneficial effects on all MetS components. Bioactive components of the MedDiet synergize to affect various metabolic pathways, leading to a reduced cardiometabolic disease risk. The abundance of healthy, nutrient-dense foods that make up the plant-based MedDiet predicts its bioactivity and potential to beneficially influence metabolic pathways that lead to MetS and T2DM, as well as other chronic conditions. Abundant epidemiologic and clinical trial evidence supports the role of the MedDiet on the prevention and management of T2DM and MetS.

Diabetes, diet-health behavior, and obesity

High-quality diets play an important role in diabetes prevention. Appropriate dietary adherence can improve insulin sensitivity and glycemic control, and thus contribute to lifestyle improvement. However, previous research suggests that dietary adherence is arguably among the most difficult cornerstones of diabetes management. The objectives of this study are (1) to estimate whether and to what extent individuals diagnosed with diabetes show significant differences in diet quality [healthy eating index (HEI)] compared to healthy individuals, (2) to quantify whether and to what extent diabetics experience significantly higher outcomes of body mass index (BMI), and (3) to estimate whether and to what extent dietary supplementation impacts diabetes patient's diet quality and/or BMI outcomes. We use data from the 2007-2008 U.S. National Health and Nutrition Examination Survey (NHANES). The NHANES is the primary, randomized, and nationally representative survey used to assess the health and nutritional status in the U.S. We apply propensity score matching (PSM) to account for selection bias and endogeneity between self-reported diet and health behavir (treatment) and BMI outcomes. We control for an individual's BMI as to capture the impact of past dietary behavior in its impact on HEI. Matching results suggest that regular dietary supplement consumption is associated with significant lower BMI outcomes of almost 1 kg/m(2). The close relationship between diabetes and obesity has been at the center of the diet-health policy debate across Canada and the U.S. Knowledge about this linkage may help to improve the understanding of the factors that impact dietary choices and their overall health outcomes, which may lead to a more efficient and effective promotion of dietary guidelines, healthy food choices, and targeted consumer health and lifestyle policies.

Higher diet quality is inversely associated with mortality in African-American women

BACKGROUND

Diet quality has been inversely associated with overall mortality in white populations, but the evidence in African-American populations is limited.

OBJECTIVE

The goal of the present study was to assess diet quality in relation to all-cause mortality in the Black Women's Health Study, a follow-up study of African-American women begun in 1995.

METHODS

Data used in this study were obtained via biennial questionnaires from 1995 to 2011. Based on food-frequency questionnaire data collected in 1995 and 2001, we calculated an index-based diet quality score [Dietary Approaches to Stop Hypertension (DASH)] and derived dietary patterns (prudent and Western) with the use of factor analysis. We followed 37,001 women who were aged 30-69 y and free of cancer, cardiovascular disease, and diabetes at baseline for mortality through 2011. Multivariable Cox regression was used to estimate HRs and 95% CIs. Analyses were conducted in 2014.

RESULTS

Based on a total of 1678 deaths during 16 y of follow-up, higher DASH scores were associated with reduced all-cause mortality (HR: 0.75; 95% CI: 0.63, 0.89 for highest vs. lowest quintiles). The DASH components most strongly associated with lower mortality were high intake of whole grains and low intake of red and processed meat. A Western dietary pattern, characterized by high intake of red and processed meat, was associated with increased all-cause mortality rates (HR: 1.37; 95% CI: 1.17, 1.60 for highest vs. lowest quintiles of score); a prudent dietary pattern was not associated with risk.

CONCLUSION

A DASH-style diet high in intake of whole grains and low in consumption of red meat is associated with reduced mortality rates in healthy African-American women.

Diet quality as assessed by the Healthy Eating Index, the Alternate Healthy Eating Index, the Dietary Approaches to Stop Hypertension score, and health outcomes: a systematic review and meta-analysis of cohort studies

Dietary patterns consider synergistic effects compared with isolated foods or nutrients on health outcomes. The aim of this systematic review and meta-analysis was to examine the associations of diet quality as assessed by the Healthy Eating Index (HEI), the Alternate Healthy Eating Index (AHEI), and the Dietary Approaches to Stop Hypertension (DASH) score and the risk of all-cause mortality, cardiovascular mortality or incidence, cancer mortality or incidence, type 2 diabetes mellitus, and neurodegenerative diseases. A literature search was performed using the electronic databases MEDLINE, SCOPUS, and EMBASE with an end date of May 10, 2014. Study-specific risk ratios were pooled using a random effect model by the Cochrane software package Review Manager 5.2. Fifteen cohort studies (34 reports), including 1,020,642 subjects, met the criteria and were included in the meta-analysis. Diets of the highest quality, as assessed by the HEI, AHEI, and DASH score, resulted in a significant risk reduction (RR) for all-cause mortality (RR 0.78, 95% CI 0.76 to 0.80; P<0.00001; I²=61%, 95% CI 20% to 81%), cardiovascular disease (incidence or mortality) (RR 0.78, 95% CI 0.75 to 0.81; P<0.00001; I²=45%, 95% CI 13% to 66%), cancer (incidence or mortality) (RR 0.85, 95% CI 0.82 to 0.88; P<0.00001; I²=77%, 95% CI 68% to 84%), and type 2 diabetes mellitus (RR 0.78, 95% CI 0.72 to 0.85; P<0.00001; I²=74%, 95% CI 52% to 86%). Differences observed for neurodegenerative diseases were not significant. Egger regression tests provided no evidence of publication bias. Diets that score highly on the HEI, AHEI, and DASH are associated with a significant reduction in the risk of all-cause mortality, cardiovascular disease, cancer, and type 2 diabetes mellitus by 22%, 22%, 15%, and 22%, respectively, and therefore is of high public health relevance.

A priori-defined diet quality indexes and risk of type 2 diabetes: the Multiethnic Cohort

AIMS/HYPOTHESIS

Dietary patterns have been associated with the incidence of type 2 diabetes, but little is known about the impact of ethnicity on this relationship. This study evaluated the association between four a priori dietary quality indexes and risk of type 2 diabetes among white individuals, Japanese-Americans and Native Hawaiians in the Hawaii component of the Multiethnic Cohort.

METHODS

After excluding participants with prevalent diabetes and missing values, the analysis included 89,185 participants (11,217 cases of type 2 diabetes). Dietary intake was assessed at baseline with a quantitative food frequency questionnaire designed for use in the relevant ethnic populations. Sex- and ethnicity-specific HRs were calculated for the Healthy Eating Index-2010 (HEI-2010), the Alternative HEI-2010 (AHEI-2010), the Alternate Mediterranean Diet Score (aMED) and the Dietary Approaches to Stop Hypertension (DASH).

RESULTS

We observed significant inverse associations between higher DASH index scores and risk of type 2 diabetes in white men and women, as well as in Japanese-American women and Native Hawaiian men, with respective risk reductions of 37%, 31%, 19% and 21% (in the highest compared with the lowest index category). A higher adherence to the AHEI-2010 and aMED diet was related to a 13-28% lower risk of type 2 diabetes in white participants but not in other ethnic groups. No significant associations with risk of type 2 diabetes were observed for the HEI-2010 index.

CONCLUSIONS/INTERPRETATION

The small ethnic differences in risk of type 2 diabetes associated with scores of a priori-defined dietary patterns may be due to a different consumption pattern of food components and the fact that the original indexes were not based on diets typical for Asians and Pacific Islanders.

Cross-comparison of diet quality indices for predicting chronic disease risk: findings from the Observation of Cardiovascular Risk Factors in Luxembourg (ORISCAV-LUX) study

The scientific community has become increasingly interested in the overall quality of diets rather than in single food-based or single nutrient-based approaches to examine diet-disease relationships. Despite the plethora of indices used to measure diet quality, there still exist questions as to which of these can best predict health outcomes. The present study aimed to compare the ability of five diet quality indices, namely the Recommendation Compliance Index (RCI), Diet Quality Index-International (DQI-I), Dietary Approaches to Stop Hypertension (DASH), Mediterranean Diet Score (MDS), and Dietary Inflammatory Index (DII), to detect changes in chronic disease risk biomarkers. Nutritional data from 1352 participants, aged 18-69 years, of the Luxembourg nationwide cross-sectional ORISCAV-LUX (Observation of Cardiovascular Risk Factors in Luxembourg) study, 2007-8, were used to calculate adherence to the diet quality index. General linear modelling was performed to assess trends in biomarkers according to adherence to different dietary patterns, after adjustment for age, sex, education level, smoking status, physical activity and energy intake. Among the five selected diet quality indices, the MDS exhibited the best ability to detect changes in numerous risk markers and was significantly associated with lower levels of LDL-cholesterol, apo B, diastolic blood pressure, renal function indicators (creatinine and uric acid) and liver enzymes (serum γ-glutamyl-transpeptidase and glutamate-pyruvate transaminase). Compared with other dietary patterns, higher adherence to the Mediterranean diet is associated with a favourable cardiometabolic, hepatic and renal risk profile. Diets congruent with current universally accepted guidelines may be insufficient to prevent chronic diseases. Clinicians and public health decision makers should be aware of needs to improve the current dietary guidelines.

Diet, lifestyle, and genetic risk factors for type 2 diabetes: a review from the Nurses' Health Study, Nurses' Health Study 2, and Health Professionals' Follow-up Study

The epidemiological evidence collected from three large US cohorts (Nurses' Health Study, Nurses' Health Study 2, and Health Professionals' Follow-up Study) has yielded important information regarding the roles of overall diet, individual foods and nutrients, physical activity and other lifestyle factors in the development of type 2 diabetes. Excess adiposity is a major risk factor for diabetes, and thus, maintaining a healthy body weight and avoidance of weight gain during adulthood is the cornerstone of diabetes prevention. Independent of body weight, the quality or type of dietary fat and carbohydrate is more crucial than the quantity in determining diabetes risk. Higher consumption of coffee, whole grains, fruits, and nuts is associated with lower risk of diabetes, whereas regular consumption of refined grains, red and processed meats, and sugar-sweetened beverages including fruits juices is associated with increased risk. Dietary patterns rich in fruits and vegetables, whole grains, and nuts and legumes but lower in red and processed meats, refined grains, and sugar-sweetened beverages are consistently associated with diabetes risk, even after adjustment for body mass index. The genome-wide association studies conducted in these cohorts have contributed substantially to the discoveries of novel genetic loci for type 2 diabetes and other metabolic traits, although the identified common variants explain only a small proportion of overall diabetes predisposition. Taken together, these ongoing large cohort studies have provided convincing epidemiologic evidence that a healthy diet, together with regular physical activity, maintenance of a healthy weight, moderate alcohol consumption, and avoidance of sedentary behaviors and smoking would prevent the majority of type 2 diabetes cases.

Adherence in a 1-year whole foods eating pattern intervention with healthy postmenopausal women

OBJECTIVE

To determine the degree of dietary adherence or change in eating patterns, and demographic, psychosocial and study characteristics associated with adherence, in the Comparing Healthy Options in Cooking and Eating (CHOICE) Study.

DESIGN

Randomized controlled trial where women were randomized to one of three eating patterns: (i) Whole Foods, plant-based, macrobiotic-style (n 22); and Moderate Fat with (ii), and without (iii), 10 g of ground flaxseed added daily, which were combined (n 49).

SETTING

A year-long intervention based on social cognitive theory, consisting of twenty-four class sessions involving hands-on cooking classes and behavioural sessions. Monthly 24 h food recalls were obtained and a psychosocial questionnaire was administered at baseline, 6 and 12 months.

SUBJECTS

Healthy, free-living, postmenopausal women.

RESULTS

A non-adherence score measuring all food servings out-of-compliance with eating pattern recommendations was specifically designed for the present study. Non-adherence scores decreased significantly (P < 0·05) in both groups to about 65 % during the adoption phase (first 4 months) and remained so during the 8-month maintenance period. Class attendance of the Moderate Fat group showed a trend towards significance as a predictor of adherence (P = 0·063). None of the other predictors (e.g. demographic and psychosocial factors) in a longitudinal regression model were significant.

CONCLUSIONS

Postmenopausal women were able to adopt and maintain significant changes in their eating patterns, including those on a demanding, near-vegetarian eating plan, suggesting that behavioural interventions with a healthy free-living population can be effective. The non-adherence score developed for the study provides an example of a means for evaluating eating pattern adherence to a dietary intervention.

Diet quality score is a predictor of type 2 diabetes risk in women: the Australian Longitudinal Study on Women's Health

The present study aimed to determine the ability of two diet quality scores to predict the incidence of type 2 diabetes in women. The study population comprised a nationally representative sample of 8370 Australian middle-aged (45-50 years) women participating in the ALSWH (Australian Longitudinal Study on Women's Health), who were free of diabetes and completed FFQ at baseline. The associations between the Australian Recommended Food Score (ARFS) and Dietary Guideline Index (DGI) with type 2 diabetes risk were assessed using multiple logistic regression models, adjusting for sociodemographic characteristics, lifestyle factors and energy intake. During 6 years of follow-up, 311 incident cases of type 2 diabetes were reported. The DGI score was inversely associated with type 2 diabetes risk (OR comparing the highest with the lowest quintile of DGI was 0·51; 95% CI 0·35, 0·76; P for trend = 0·01). There was no statistically significant association between the ARFS and type 2 diabetes risk (OR comparing the highest with the lowest quintile of ARFS was 0·99; 95% CI 0·68, 1·43; P for trend = 0·42). The results of the present prospective study indicate that the DGI score, which assesses compliance with established dietary guidelines, is predictive of type 2 diabetes risk in Australian women. The risk of type 2 diabetes among women in the highest quintile of DGI was approximately 50% lower than that in women in the lowest quintile. The ARFS was not significantly predictive of type 2 diabetes.

The healthy Nordic diet and incidence of Type 2 Diabetes--10-year follow-up

Studies have shown that a diet of healthy foods typical of Nordic countries has a beneficial effect on risk factors for Type 2 Diabetes (T2D), such as obesity and low-grade inflammation. However, longitudinal epidemiological studies examining the association between the healthy Nordic diet and T2D are lacking.

Which diet for prevention of type 2 diabetes? A meta-analysis of prospective studies

No specific diet is recommended to prevent type 2 diabetes. We did a meta-analysis of prospective cohort studies to assess the association between different diets and prevention of type 2 diabetes. We did a comprehensive search of multiple electronic databases (Medline, Scopus, EMBASE, and ISI web of knowledge) until August 2013 using predefined criteria. We included prospective cohort studies that evaluated the role of different diets in type 2 diabetes prevention. Studies were selected by 2 independent reviewers. We did random-effects meta-analyses to determine the relative risk (RR) of incident diabetes associated with healthful dietary patterns. A total of 21,372 cases of incident diabetes, from 18 prospective studies, with 20 cohorts, in 4 world regions were identified. In the random-effect meta-analysis of the 20 cohorts, RR was 0.80 (95 % confidence interval (CI) = 0.74-0.86, P < 0.001), with high heterogeneity (I (2) = 57 %, P = 0.001) and no evidence of publication bias (Egger's test, P = 0.653). Exclusion of two cohorts produced identical RR (0.80, 95 % CI 0.76-0.84), with nonsignificant heterogeneity (I (2) = 9 %). The risk of incident diabetes did not appreciably change considering the geography (USA, Europe, and Asia), the duration of follow-up (≤10 and >10 years), and type of diets (Mediterranean and DASH, Dietary Approaches to Stop Hypertension, diets). There was a difference between at risk and general population (P = 0.0487), but the evidence was limited to two studies only. The results of our study demonstrate that several healthy diets are equally and consistently associated with a 20 % reduced risk of future type 2 diabetes.

Decline in functional capacity is unaffected by diet quality alone or in combination with physical activity among generally healthy older adults with T2D from the NuAge cohort

BACKGROUND

Both diet quality (DQ) and physical activity (PA) have been shown to play a role in the prevention of functional capacity (FC) decline. Because older adults (OA) with T2D are at a higher risk of FC decline compared to their non-diabetic counterparts, our aim was to determine if DQ alone, or combined with PA is associated with FC decline in OA with T2D over a 3-year follow-up in a secondary analysis of the NuAge cohort.

METHODS

In 159 OA with T2D (mean age=75 years), FC change was calculated as the difference in FC scores at T1 and T4 measured by the SMAF (Système de Mesure de l'Autonomie Fonctionnelle). Baseline DQ was calculated from three non-consecutive 24-h dietary recalls collected at T1 using the validated Canadian Healthy Eating Index (C-HEI). PA change was calculated from Physical Activity Scale for the Elderly (PASE) as T4-T1. Associations were evaluated between FC decline and four combinations of variables: C-HEI score < or ≥70 with PASE change < or > median and analyzed by GLM while controlling for covariates.

RESULTS

Neither DQ alone nor DQ combined with PA change were associated with FC decline over follow-up.

CONCLUSIONS

The absence of effect may be explained by characteristics of this healthy sample of OA with T2D who showed relatively good adherence to dietary recommendations (mean C-HEI=70) and were highly functional shown by minimal, clinically non-significant FC decline over 3 years. More research is needed to confirm the role of DQ in preventing FC decline in a larger diabetic sample showing clinically significant FC decline.

Adherence to a Mediterranean diet and risk of diabetes: a systematic review and meta-analysis

OBJECTIVE

Adherence to a Mediterranean diet is associated with significant improvements in health status. However, to date no systematic review and meta-analysis has summarized the effects of Mediterranean diet adherence on the risk of type 2 diabetes mellitus.

DESIGN

Electronic searches for randomized controlled trials and cohort studies were performed in MEDLINE, SCOPUS, EMBASE and the Cochrane Trial Register until 2 April 2014. Pooled effects were calculated by an inverse-variance random-effect meta-analysis using the statistical software Review Manager 5.2 by the Cochrane Collaboration.

SETTING

Meta-analysis of randomized controlled trials and cohort studies.

SUBJECTS

ELIGIBILITY CRITERIA

19+years of age.

RESULTS

One randomized controlled trial and eight prospective cohort studies (122 810 subjects) published between 2007 and 2014 were included for meta-analysis. For highest v. lowest adherence to the Mediterranean diet score, the pooled risk ratio was 0.81 (95 % CI 0.73, 0.90, P<0.0001, I 2=55 %). Sensitivity analysis including only long-term studies confirmed the results of the primary analysis (pooled risk ratio=0.75; 95 % CI 0.68, 0.83, P<0.00001, I 2=0 %). The Egger regression test provided no evidence of substantial publication bias (P=0.254).

CONCLUSIONS

Greater adherence to a Mediterranean diet is associated with a significant reduction in the risk of diabetes (19 %; moderate quality evidence). These results seem to be clinically relevant for public health, in particular for encouraging a Mediterranean-like dietary pattern for primary prevention of type 2 diabetes mellitus.

Diet-quality scores and risk of hip fractures in elderly urban Chinese in Guangdong, China: a case-control study

This case-control study compared the associations of four widely used diet-quality scoring systems with the risk of hip fractures and assessed their utility in elderly Chinese. We found that individuals avoiding a low-quality diet have a lower risk of hip fractures in elderly Chinese.

INTRODUCTION

Few studies examined the associations of diet-quality scores on bone health, and no studies were available in Asians and compared their validity and utility in a study. We assessed the associations and utility of four widely used diet-quality scoring systems with the risk of hip fractures.

METHODS

A case-control study of 726 patients with hip fractures (diagnosed within 2 weeks) aged 55-80 years and 726 age- (within 3 years) and gender-matched controls was conducted in Guangdong, China (2009-2013). Dietary intake was assessed using a 79-item food frequency questionnaire with face-to-face interviews, and the Healthy Eating Index-2005 (HEI-2005, 12 items), the alternate Healthy Eating Index (aHEI, 8 items), the Diet Quality Index-International (DQI-I, 17 items), and the alternate Mediterranean Diet Score (aMed, 9 items) (the simplest one) were calculated.

RESULTS

All greater values of the diet-quality scores were significantly associated with a similar decreased risk of hip fractures (all p trends <0.001). The multivariate-adjusted odds ratios (ORs) and 95% confidential intervals (95% CIs) comparing the extreme groups of diet-quality scores were 0.29 (0.18, 0.46) (HEI-2005), 0.20 (0.12, 0.33) (aHEI), 0.25 (0.16, 0.39) (DQI-I), and 0.28 (0.18, 0.43) (aMed) in total subjects; and the corresponding ORs ranged from 0.04 to 0.27 for men and from 0.26 to 0.44 for women (all p trends <0.05), respectively.

CONCLUSIONS

Avoiding a low-quality diet is associated with a lower risk of hip fractures, and the aMed score is the best scoring system due to its equivalent performance and simplicity for the user.

Design and development of an instrument to measure overall lifestyle habits for epidemiological research: the Mediterranean Lifestyle (MEDLIFE) index

OBJECTIVE

To design and develop a questionnaire that can account for an individual's adherence to a Mediterranean lifestyle including the assessment of diet and physical activity patterns, as well as social interaction.

DESIGN

The Mediterranean Lifestyle (MEDLIFE) index was created based on the current Spanish Mediterranean food guide pyramid. MEDLIFE is a twenty-eight-item derived index consisting of questions about food consumption (fifteen items), traditional Mediterranean dietary habits (seven items) and physical activity, rest and social interaction habits (six items). Linear regression models and Spearman rank correlation were fitted to assess content validity and internal consistency.

SETTING

A subset of participants in the Aragon Workers' Health Study cohort (Zaragoza, Spain) provided the data for development of MEDLIFE.

SUBJECTS

Participants (n 988) of the Aragon Workers' Health Study cohort in Spain.

RESULTS

Mean MEDLIFE score was 11·3 (sd 2·6; range: 0-28), and the quintile distribution of MEDLIFE score showed a significant association with each of the individual items as well as with specific nutrients and lifestyle indicators (intra-validity). We also quantified MEDLIFE correspondence with previously reported diet quality indices and found significant correlations (ρ range: 0·44-0·53; P<0·001) for the Alternate Healthy Eating Index, the Alternate Mediterranean Diet Index and Mediterranean Diet Adherence Screener.

CONCLUSIONS

MEDLIFE is the first index to include an overall assessment of lifestyle habits. It is expected to be a more holistic tool to measure adherence to the Mediterranean lifestyle in epidemiological studies.

The effect of Mediterranean diet on the development of type 2 diabetes mellitus: a meta-analysis of 10 prospective studies and 136,846 participants

OBJECTIVE

The purpose of this work was to meta-analyze prospective studies that have evaluated the effect of a Mediterranean diet on the development of type 2 diabetes.

MATERIALS/METHODS

PubMed, Embase and the Cochrane Central Register of Controlled Trials databases were searched up to 20 November 2013. English language publications were allocated; 17 original research studies (1 clinical trial, 9 prospective and 7 cross-sectional) were identified. Primary analyses were limited to prospective studies and clinical trials, yielding to a sample of 136,846 participants. A systematic review and a random effects meta-analysis were conducted.

RESULTS

Higher adherence to the Mediterranean diet was associated with 23% reduced risk of developing type 2 diabetes (combined relative risk for upper versus lowest available centile: 0.77; 95% CI: 0.66, 0.89). Subgroup analyses based on region, health status of participants and number of confounders controlling for, showed similar results. Limitations include variations in Mediterranean diet adherence assessment tools, confounders' adjustment, duration of follow up and number of events with diabetes.

CONCLUSIONS

The presented results are of major public health importance, since no consensus exists concerning the best anti-diabetic diet. Mediterranean diet could, if appropriately adjusted to reflect local food availability and individual's needs, constitute a beneficial nutritional choice for the primary prevention of diabetes.

Mediterranean diet and health: food effects on gut microbiota and disease control

The Mediterranean diet (MD) is considered one of the healthiest dietary models. Many of the characteristic components of the MD have functional features with positive effects on health and wellness. The MD adherence, calculated through various computational scores, can lead to a reduction of the incidence of major diseases (e.g., cancers, metabolic and cardiovascular syndromes, neurodegenerative diseases, type 2 diabetes and allergy). Furthermore, eating habits are the main significant determinants of the microbial multiplicity of the gut, and dietary components influence both microbial populations and their metabolic activities from the early stages of life. For this purpose, we present a study proposal relying on the generation of individual gut microbiota maps from MD-aware children/adolescents. The maps, based on meta-omics approaches, may be considered as new tools, acting as a systems biology-based proof of evidence to evaluate MD effects on gut microbiota homeostasis. Data integration of food metabotypes and gut microbiota “enterotypes” may allow one to interpret MD adherence and its effects on health in a new way, employable for the design of targeted diets and nutraceutical interventions in childcare and clinical management of food-related diseases, whose onset has been significantly shifted early in life.

A provegetarian food pattern and reduction in total mortality in the Prevención con Dieta Mediterránea (PREDIMED) study

BACKGROUND

Vegetarian diets have been associated with reduced mortality. Because a pure vegetarian diet might not easily be embraced by many individuals, consuming preferentially plant-derived foods would be a more easily understood message. A provegetarian food pattern (FP) emphasizing preference for plant-derived foods might reduce all-cause mortality.

OBJECTIVE

The objective was to identify the association between an a priori-defined provegetarian FP and all-cause mortality.

DESIGN

We followed 7216 participants (57% women; mean age: 67 y) at high cardiovascular risk for a median of 4.8 y. A validated 137-item semiquantitative food-frequency questionnaire was administered at baseline and yearly thereafter. Fruit, vegetables, nuts, cereals, legumes, olive oil, and potatoes were positively weighted. Added animal fats, eggs, fish, dairy products, and meats or meat products were negatively weighted. Energy-adjusted quintiles were used to assign points to build the provegetarian FP (range: 12-60 points). Deaths were confirmed by review of medical records and the National Death Index.

RESULTS

There were 323 deaths during the follow-up period (76 from cardiovascular causes, 130 from cancer, 117 for noncancer, noncardiovascular causes). Higher baseline conformity with the provegetarian FP was associated with lower mortality (multivariable-adjusted HR for ≥ 40 compared with <30 points: 0.59; 95% CI: 0.40, 0.88). Similar results were found with the use of updated information on diet (RR: 0.59; 95% CI: 0.39, 0.89).

CONCLUSIONS

Among omnivorous subjects at high cardiovascular risk, better conformity with an FP that emphasized plant-derived foods was associated with a reduced risk of all-cause mortality. This trial was registered at www.controlled-trials.com as ISRCTN35739639.

Diet quality is associated with leisure-time physical activity in individuals at cardiometabolic risk

OBJECTIVES

We investigated whether diet quality was associated with leisure-time physical activity (LTPA) and television viewing and the associations of these variables with traditional cardiovascular risk factors and novel biomarkers in individuals at cardiometabolic risk.

METHODS

A total of 193 prediabetic adults (63.7% women, mean age 54.1 years), screened for a diabetes prevention program in Brazil, participated in this cross-sectional study. Clinical data and blood samples were collected for several determinations. Twenty-four-hour recalls were used to calculate the Healthy Eating Index (HEI) adapted to Brazilian dietary habits and the International Physical Activity Questionnaire to assess physical activity level. Analysis of covariance with adjustments for age and body mass index (BMI) was employed to test associations across categories of LTPA and television viewing.

RESULTS

Stratifying according to LTPA categories, the most active subset (≥150 minutes/week) showed better HEI scores after adjustments (64.6 ± 11.0, 65.1 ± 10.3, and 68.6 ± 10.8, p = 0.02) and significant higher values of dark green and orange vegetables but not of whole grains (p = 0.06). Active individuals had lower BMI, waist circumference, inflammatory markers, and better insulin sensitivity (p < 0.05). Individuals at the highest category of television viewing had higher age-adjusted BMI (32.0 ± 6.2, 30.7 ± 6.0, and 28.8 ± 4.7 hours/week; p = 0.01) than the others. Time watching television was inversely associated with homeostasis model assessment (HOMA-IR) and C-reactive protein (CRP; p < 0.01) after adjustments but not with lipids and HEI score. Comparisons of individuals with healthy habits (better diet and higher physical activity [PA]), with those with unhealthy habits revealing better anthropometric and cardiometabolic profiles in the former group.

CONCLUSION

Diet quality assessed by the HEI adapted for Brazilian eating habits attained significance in differentiating more active from inactive at-risk individuals during leisure time. Time watching television, as a surrogate of sedentary behavior, is not useful to detect unhealthy diet quality. LTPA is indicative of better cardiometabolic profile reflected by lipid and inflammatory markers and index of insulin resistance.

Prevention and management of type 2 diabetes: dietary components and nutritional strategies

In the past couple of decades, evidence from prospective observational studies and clinical trials has converged to support the importance of individual nutrients, foods, and dietary patterns in the prevention and management of type 2 diabetes. The quality of dietary fats and carbohydrates consumed is more crucial than is the quantity of these macronutrients. Diets rich in wholegrains, fruits, vegetables, legumes, and nuts; moderate in alcohol consumption; and lower in refined grains, red or processed meats, and sugar-sweetened beverages have been shown to reduce the risk of diabetes and improve glycaemic control and blood lipids in patients with diabetes. With an emphasis on overall diet quality, several dietary patterns such as Mediterranean, low glycaemic index, moderately low carbohydrate, and vegetarian diets can be tailored to personal and cultural food preferences and appropriate calorie needs for weight control and diabetes prevention and management. Although much progress has been made in development and implementation of evidence-based nutrition recommendations in developed countries, concerted worldwide efforts and policies are warranted to alleviate regional disparities.

Evaluation of the reliability and validity of the Brazilian Healthy Eating Index Revised

OBJECTIVE

Evaluate validity and reliability of the Brazilian Healthy Eating Index Revised according to the psychometric properties.

METHODS

Cross-sectional study of a random sample of 2,375 individuals of both sexes, aged 12 or older from the city of São Paulo, Southeastern Brazil, drawn from the Health Survey carried out in 2003. Information on the population characteristics was acquired using a questionnaire. Food intake was obtained using 24h Recall, used to calculate the Brazilian Healthy Eating Index Revised (BHEI-R). The following aspects were evaluated: (1) content validity, by comparing the components with the Dietary Guidelines for the Brazilian Population; (2) construct validity, factor analysis using principal components method and verifying whether the index can measure diet quality regardless of energy intake; (3) discriminating validity; and (4) the reliability of the BHEI-R by analyzing the internal consistency of the items using Cronbach's alpha coefficient.

RESULTS

The correlations between the component scores and energy intake were weak (r < 0.30). Principal component analysis indicated the presence of four factors with eigenvalues > 1 that represented 67% of the index variance. The discriminating validity of the BHEI-R was observed by comparing the individuals by sex and smoking habit, and identifying statistically significant differences between the means of the components of the BHEI-R and the final score. The Cronbach's alpha value (α = 0.7) indicated the presence of internal consistency between the components of the BHEI-R. The SoFAAS component followed by the total fruit component and whole fruit component presented greater correlation with the final index scores.

CONCLUSIONS

The Brazilian Healthy Eating Index Revised showed itself to be reliable and structurally valid when used to evaluate and monitor the diet quality of Brazilians.

Racial/ethnic disparities in association between dietary quality and incident diabetes in postmenopausal women in the United States: the Women's Health Initiative 1993-2005

OBJECTIVE

To examine the association of dietary quality and risk of incident diabetes overall and by race/ethnicity among postmenopausal women enrolled in the Women's Health Initiative (WHI).

RESEARCH METHODS AND PROCEDURES

The WHI recruited 161,808 postmenopausal women between 1993 and 1998, and followed them until 2005. Incident diabetes was determined annually over an average of 7.6 years from enrollment. At baseline, all participants completed a Food Frequency Questionnaire (FFQ). Dietary quality was assessed by the Alternate Healthy Eating Index (AHEI), calculated from the baseline FFQ responses.

RESULTS

There were 10,307 incident cases of self-reported treated diabetes over 1,172,761 person-years of follow-up. Most participants did not meet the AHEI dietary goals; that is, only 0.1% of women met or exceeded the recommended consumption of vegetables, and few (17.3%) met or exceeded the recommended level for total fiber. After adjusting for potential confounders, women in the highest quintile of the AHEI score were 24% less likely to develop diabetes relative to women in the lowest quintile of AHEI [hazard ratio (HR)=0.76 (95% CI: 0.70-0.82)]. This association was observed in Whites [HR=0.74 (95% CI: 0.68-0.82)] and Hispanics [HR=0.68 (95% CI: 0.46-0.99)], but not in Blacks [HR=0.85 (95% CI: 0.69-1.05)] or Asians [HR=0.88 (95% CI: 0.57-1.38)].

CONCLUSION

These findings support a protective role of healthful eating choices in reducing the risk of developing diabetes, after adjusting for other lifestyle factors, in White and Hispanic postmenopausal women. Future studies are needed to investigate the relationship between dietary quality and risk of diabetes among Blacks and Asians in relationship to other lifestyle factors.