Position of the American Dietetic Association: Total Diet Approach to Communicating Food and Nutrition Information

The South Asian Healthy Lifestyle Intervention (SAHELI) trial: Protocol for a mixed-methods, hybrid effectiveness implementation trial for reducing cardiovascular risk in South Asians in the United States

Intensive lifestyle interventions targeting diet and physical activity are recommended for reducing atherosclerotic cardiovascular disease (ASCVD) risk in adults. However, existing interventions often do not reach immigrant populations because of a mismatch between the social, cultural, and environmental context of immigrants and Western bio behavioral models which underpin evidence-based lifestyle interventions. The South Asian Healthy Lifestyle Intervention (SAHELI) study is a type 1 hybrid design randomized controlled trial aimed at reducing ASCVD risk in South Asian Americans, a group at higher ASCVD risk than whites and other Asian Americans. The objective is to evaluate the clinical effectiveness and implementation potential of a community-based, culturally-adapted lifestyle intervention for South Asian adults. Participants (n = 550) will be randomized to printed healthy lifestyle education materials or SAHELI, a group-based lifestyle change program that includes weekly classes for 16 weeks and 4 booster classes though month 11. SAHELI integrates evidence-based behavior change strategies with culturally-adapted strategies and group motivational interviewing to improve diet, physical activity, and stress management. Follow-up assessments will occur at 6 and 12 months. We hypothesize that the SAHELI intervention group will have greater improvements in clinical ASCVD risk factors (weight, blood pressure, glycated hemoglobin, and lipids), physical activity, and psychosocial outcomes than the print material group at 6- and 12- months. We will use mixed-methods to examine SAHELI's potential for reach, adoption, implementation, and maintenance from the perspective of multiple stakeholders. This study offers the potential to increase the reach and effectiveness of evidence-based lifestyle interventions for South Asian adults at increased risk for ASCVD.

Prevalence of comorbidities in heart failure patients and those treated with cellular therapeutics

Introduction: Changes in our daily living, particularly in work routines, diet, and physical exercise, have influenced a worldwide crisis for life-threatening comorbidities and the likelihood of cardiovascular disease diagnosis. Cardiovascular regenerative medicine researchers continue to investigate new therapeutic approaches and reexamine completed clinical trials to design more effective future studies. As the frequency of cardiovascular disease diagnosis continues to rise, investigations of how to repair and regenerate the failing myocardium remains an essential mission for human health. Areas covered: This review first examines the aging process, the rising rate of comorbidities, and the likelihood of developing heart disease. In the ongoing efforts to recapitulate human health needs in clinical trials, a review of clinical trials involving cellular therapeutics for cardiac repair, with a focus on the patient population and patients' complex medical records, is presented. Expert opinion: The expert opinion first draws attention to the changing demographics of patients diagnosed with diseases that lead to heart failure and focusing on obesity as a primary driver for increased cardiovascular disease. The opinion focuses on the importance of designing preclinical models and experimentation that better mimic the patient population and clinical situations to evaluate the effectiveness of potential future therapeutic interventions.

Effects of meaningful weight loss beyond symptomatic relief in adults with knee osteoarthritis and obesity: a systematic review and meta-analysis

Existing clinical guidelines recommend weight loss for adults with knee osteoarthritis and obesity, but the supporting evidence to date remains inadequate. There is also no pooled data on physical function and quality of life. This study aims to examine the efficacy of weight loss on pain, self-reported disability, physical function and quality of life in adults with knee osteoarthritis and obesity. A systematic database search (from 1990 to June 2017) was conducted, and seven studies were eligible for inclusion. The meta-analyses demonstrated that a 5% to 10% weight loss significantly improved pain (effect size 0.33, 95% confidence intervals 0.17 to 0.48), self-reported disability (effect size 0.42, 95% confidence intervals 0.25 to 0.59) and quality of life (physical) (effect size 0.39, 95% confidence intervals 0.24 to 0.54). The results were based on adults with mean body mass index 33.6 to 36.4 kg m^-2 and mild to moderate knee osteoarthritis. Results for physical function were inconclusive due to the lack of eligible studies and incomprehensive outcome measures used.

Association Between a Healthy Heart Score and the Development of Clinical Cardiovascular Risk Factors Among Women: Potential Role for Primordial Prevention

BACKGROUND

The prevailing efforts for cardiovascular disease (CVD) prevention focused on treatment of common CVD risk factors rather than primordial prevention of risk factors through health behaviors. The previously validated Healthy Heart Score effectively predicted the 20-year risk of CVD in midadulthood; however, it is unknown whether this risk score is associated with clinically relevant CVD risk factors.

METHODS AND RESULTS

We analyzed the association between the Healthy Heart Score and the incidence of clinical CVD risk factors, including diabetes mellitus, hypertension, and hypercholesterolemia among 69 505 US women in the Nurses' Health Study II (NHSII; 1991-2011). The Healthy Heart Score estimates the 20-year CVD risk based on 9 lifestyle factors; thus, a higher score reflected a higher predictive CVD risk. During 20 years, we documented 3275 incident cases of diabetes mellitus, 17 420 of hypertension, and 24 385 of hypercholesterolemia. Women with higher predicted CVD risk based on the Healthy Heart Score (highest quintile versus lowest quintile) had significantly greater risk of each clinical risk factor individually (hazard ratios: 18.1 [95% confidence interval, 14.4-22.7] for diabetes mellitus, 5.10 [4.66-5.57] for hypertension, and 2.57 [2.40-2.75] for hypercholesterolemia). The hazard ratio for developing the high-CVD profile was 52.5 (33.6-82.1). These associations were most pronounced among women who were younger, were nonsmokers, or had optimal weight.

CONCLUSIONS

An absolute 20-year risk of CVD, estimated by the Healthy Heart Score, was strongly associated with the development of CVD clinically relevant risk factors. This risk score may serve as the first step for CVD risk assessment in primordial prevention.

Intervention on whole grain with healthy balanced diet to manage childhood obesity (GReat-Child™trial): study protocol for a quasi-experimental trial

Background

The rapid increase in childhood obesity is a serious public health problem, and has led to the development of many interventions. However, no intervention has emphasized whole grains as a strategy to manage childhood obesity. Therefore, this article describes the protocol of a 12-week multi-component, family-based intervention on whole grain, using a healthy balanced diet for managing childhood obesity.

Methods

The GReat-Child trial utilize a quasi-experimental method in which two schools in Kuala Lumpur are assigned to intervention and control groups. The eligibility criteria are overweight/obese children, aged 9 through 11 years, who has no serious co-morbidities. The children who report consuming whole-grain foods in their 3-day diet-recall during the screening will be excluded. The study sample is characterized by anthropometric measurements (weight, height, percentage of body fat and waist circumference), whole grain and nutrient intakes (3-day 24-h diet recalls), and their knowledge, attitudes and practices towards whole grain. The 12-week intervention is comprised of three components addressing behaviour, personal and environmental factors, based on social cognitive theory: (1) individual diet counselling for the parents; (2) six 30-min nutrition education classes and (3) school delivery of whole-grain foods; The control school does not receive any interventions, however, for ethical purposes, a health talk is conducted after the entire GReat-Child Trial is completed.

Conclusion

The GReat-Child trial represents a novel approach to examining the effectiveness of the intervention of whole grain in a healthy balanced diet on managing childhood obesity. We anticipate that this trial will reveal not only whether whole grain intervention will be effective in managing childhood obesity, but also provide greater insights into the acceptance of whole grain among Malaysian children.

A nutrient profiling system for the (re)formulation of a global food and beverage portfolio

Purpose

To describe the Nestlé Nutritional Profiling System (NNPS) developed to guide the reformulation of Nestlé products, and the results of its application in the USA and France.

Design

The NNPS is a category-specific system that calculates nutrient targets per serving as consumed, based on age-adjusted dietary guidelines. Products are aggregated into 32 food categories. The NNPS ensures that excessive amounts of nutrients to limit cannot be compensated for by adding nutrients to encourage. A study was conducted to measure changes in nutrient profiles of the most widely purchased Nestlé products from eight food categories (n = 99) in the USA and France. A comparison was made between the 2009–2010 and 2014–2015 products.

Results

The application of the NNPS between 2009–2010 and 2014–2015 was associated with an overall downwards trend for all nutrients to limit. Sodium and total sugars contents were reduced by up to 22 and 31 %, respectively. Saturated Fatty Acids and total fat reductions were less homogeneous across categories, with children products having larger reductions. Energy per serving was reduced by <10 % in most categories, while serving sizes remained unchanged.

Conclusions

The NNPS sets feasible and yet challenging targets for public health-oriented reformulation of a varied product portfolio; its application was associated with improved nutrient density in eight major food categories in the USA and France. Confirmatory analyses are needed in other countries and food categories; the impact of such a large-scale reformulation on dietary intake and health remains to be investigated.

The growing role of front-of-pack nutrition profile labeling: a consumer perspective on key issues and controversies

Nutrition-related diseases, such as some cancers, heart diseases, and obesity, belong to the most challenging health concerns of our time. Communicating intuitive and simple nutrition information by means of front-of-pack (FOP) nutrition profile signpost labeling is increasingly seen as an essential tool in efforts to combat unhealthy food choices and improve public health. Consequently, much attention in policy and research is given to nutrient profiling methods and the determination of optimal nutrition criteria. Although consumer research on nutrition signpost labeling is now gradually appearing in the literature, the value and meaning of these labeling systems for consumers have received less attention. In the current debate a concise overview is lacking of the consumer perspective, including relevant psychological phenomena, in relation to much debated controversies surrounding these labels and their further development, such as the most effective type of signpost labeling system and varying stakeholder interests. Therefore, this paper aims to critically review the literature in the consumer domain of FOP nutrition labeling in order to illustrate the strengths and weaknesses of this form of nutrition education from a consumer perspective.

Discriminating nutritional quality of foods using the 5-Color nutrition label in the French food market: consistency with nutritional recommendations

Purpose

Our objectives were to assess the performance of the 5-Colour nutrition label (5-CNL) front-of-pack nutrition label based on the Food Standards Agency nutrient profiling system to discriminate nutritional quality of foods currently on the market in France and its consistency with French nutritional recommendations.

Methods

Nutritional composition of 7777 foods available on the French market collected from the web-based collaborative project Open Food Facts were retrieved. Distribution of products across the 5-CNL categories according to food groups, as arranged in supermarket shelves was assessed. Distribution of similar products from different brands in the 5-CNL categories was also assessed. Discriminating performance was considered as the number of color categories present in each food group. In the case of discrepancies between the category allocation and French nutritional recommendations, adaptations of the original score were proposed.

Results

Overall, the distribution of foodstuffs in the 5-CNL categories was consistent with French recommendations: 95.4 % of ‘Fruits and vegetables’, 72.5 % of ‘Cereals and potatoes’ were classified as ‘Green’ or ‘Yellow’ whereas 86.0 % of ‘Sugary snacks’ were classified as ‘Pink’ or ‘Red’. Adaptations to the original FSA score computation model were necessary for beverages, added fats and cheese in order to be consistent with French official nutritional recommendations.

Conclusion

The 5-CNL label displays a high performance in discriminating nutritional quality of foods across food groups, within a food group and for similar products from different brands. Adaptations from the original model were necessary to maintain consistency with French recommendations and high performance of the system.

Electronic supplementary material

The online version of this article (doi:10.1186/s12937-015-0090-4) contains supplementary material, which is available to authorized users.

Overcoming consumer inertia to dietary guidance

Despite 35 y of dietary guidance, there has been no substantial shift in consumer compliance. Consumers report that they seek information on nutrition and healthy eating, but most are not paying attention to dietary recommendations. For guidance to be effective, it must be realistic. Even with increasingly detailed nutrition information and evidence that diet affects health outcomes, convenience and taste remain the strongest determinants of food choices. It is up to health educators to clear up confusion and give consumers control with nutrition messages that are realistic, positive, easy to understand, and actionable without an expectation that consumers will surrender foods they love.

Eating Disorders: Cultural Model and Consensus Regarding Food

The cultural model of food was applied to 112 adult patients with eating disorders (PG) and 36 healthy adult women (CG) of similar age. The Free List and Ranking of Foods was used to group foods and verify consensus and cultural aspects. Calories, health, and taste were the dimensions used by the participants to group the foods, and strong consensus was achieved in regard to calories and health. There were, however, inter- and intra-group divergences in regard to these ideas, especially in the PG. The CG used distinct criteria, showing a more complex model.

Performance of a five category front-of-pack labelling system - the 5-colour nutrition label - to differentiate nutritional quality of breakfast cereals in France

BACKGROUND

Breakfast cereals exhibit a wide variability in nutritional quality, and differences are not easily grasped by consumers. A simplified nutritional information system might contribute to help consumers make healthier food choices. A five-category colour label based on the Food Standards Agency Nutrient profiling system (FSA score) has been proposed in France to be implemented on the front-of-pack of foods (the five-colour nutrition label - 5-CNL). Objectives were to evaluate the ability of the 5-CNL to discriminate nutritional quality between types of breakfast cereals, within a category and in equivalent products, as well as its ability to change through product reformulation.

METHODS

Nutritional information was collected through an Internet and supermarket research for N = 433 breakfast cereals (N = 380 complete data included in the analyses). Breakfast cereals were categorized according to common attributes in terms of processing and/or ingredients used. The FSA score and 5-CNL category allocation were computed for each cereal. Nutrient content and FSA score were compared across types of cereals. Distribution within the 5-CNL categories was assessed across types of cereals and for equivalent products. Impact of reformulation (reduction of 5 and 10% in simple sugar, saturated fat and sodium) on the 5-CNL category allocation was compared to original allocation with Bapkhar's tests of homogeneity of marginal distribution.

RESULTS

Variability in nutritional quality of breakfast cereals was high, as reflected by the FSA score (range -7- 22 for a theoretical range of -15-40) and the 5-CNL (all five categories represented). The 5-CNL allowed for discrimination across types of cereals, within categories of breakfast cereals and for equivalent products (at least 3 categories of the 5-CNL represented). Reformulation scenarios allowed for significant change in 5-CNL allocation: 5% reduction in sugar lead to a modification of the label for 4.21% of products while a reduction of 10% of sugar, saturated fat and sodium lead to a modification of the label for 19.2% of products.

CONCLUSION

The 5-CNL adequately discriminates between breakfast cereals. It would therefore be an adequate tool for consumer information on nutritional quality of foods in the French context.

Diet-Related Colorectal Cancer Prevention Beliefs and Dietary Intakes in an Urban Minority Population

In the United States, colorectal cancer (CRC) is the third leading cause of cancer-related death and third most commonly diagnosed cancer among adults. This study is the first to examine the relationship between diet-related beliefs for colorectal cancer prevention and dietary intake among an urban, predominantly Black population (n = 169). More than two-thirds reported diet-related CRC prevention beliefs. Those with diet-related CRC prevention beliefs had healthier intakes for dietary fiber (p = .005), fruit, vegetable, bean (p = .027), red meat (p = .032), vitamin C (p = .039), and cholesterol (p = .045). Most people may already have diet-related CRC prevention beliefs and having them is associated with a more healthful dietary intake.

Application of the British Food Standards Agency nutrient profiling system in a French food composition database

Nutrient profiling systems are powerful tools for public health initiatives, as they aim at categorising foods according to their nutritional quality. The British Food Standards Agency (FSA) nutrient profiling system (FSA score) has been validated in a British food database, but the application of the model in other contexts has not yet been evaluated. The objective of the present study was to assess the application of the British FSA score in a French food composition database. Foods from the French NutriNet-Santé study food composition table were categorised according to their FSA score using the Office of Communication (OfCom) cut-off value (‘healthier’ ≤ 4 for foods and ≤ 1 for beverages; ‘less healthy’ >4 for foods and >1 for beverages) and distribution cut-offs (quintiles for foods, quartiles for beverages). Foods were also categorised according to the food groups used for the French Programme National Nutrition Santé (PNNS) recommendations. Foods were weighted according to their relative consumption in a sample drawn from the NutriNet-Santé study (n 4225), representative of the French population. Classification of foods according to the OfCom cut-offs was consistent with food groups described in the PNNS: 97·8 % of fruit and vegetables, 90·4 % of cereals and potatoes and only 3·8 % of sugary snacks were considered as ‘healthier’. Moreover, variability in the FSA score allowed for a discrimination between subcategories in the same food group, confirming the possibility of using the FSA score as a multiple category system, for example as a basis for front-of-pack nutrition labelling. Application of the FSA score in the French context would adequately complement current public health recommendations.

The Baltic Sea Diet Score: a tool for assessing healthy eating in Nordic countries

OBJECTIVE

The health-related effects of the Nordic diet remain mostly unidentified. We created a Baltic Sea Diet Score (BSDS) for epidemiological research to indicate adherence to a healthy Nordic diet. We examined associations between the score and nutrient intakes that are considered important in promoting public health. We also examined the performance of the BSDS under two different cut-off strategies.

DESIGN

The cross-sectional study included two phases of the National FINRISK 2007 Study. Diet was assessed using a validated FFQ. Food and nutrient intakes were calculated using in-house software. Nine components were selected for the score. Each component was scored according to both sex-specific consumption quartiles (BSDS-Q) and medians (BSDS-M), and summed to give the final score values.

SETTING

A large representative sample of the Finnish population.

SUBJECTS

Men (n 2217) and women (n 2493) aged 25 to 74 years.

RESULTS

In the age- and energy-adjusted model, adherence to the diet was associated with a higher intake of carbohydrates (E%), and lower intakes of SFA (E%) and alcohol (E%, where E% is percentage of total energy intake; P < 0·01). Furthermore, the intakes of fibre, Fe, vitamins A, C and D, and folate were higher among participants who adhered to the diet (P < 0·05). After further adjustments, the results remained significant (P < 0·05) and did not differ remarkably between BSDS-Q and BSDS-M.

CONCLUSIONS

The BSDS can be used as a measure of a healthy Nordic diet to assess diet-health relationships in public health surveys in Nordic countries.

Prevalence of Obesity: A Public Health Problem Poorly Understood

This review article discusses the Dietary Guidelines for Americans (DGA) in support of a total diet approach to achieving diet and health goals, especially as they relate to the obesity epidemic. However, some scientists and organizations have identified one food, food group, or nutrient as the cause of the obesity epidemic and recommend that simply reducing that food/food group/nutrient will solve the problem. This is simplistic and unlikely to be effective in long term management of the obesity problem. This article also acknowledges discrepancies in the literature and the lack of consensus opinions from systematic reviews. Failure to consider the evidence as a whole can lead to inaccurate reports which may, in turn, adversely influence clinical practice, public policy, and future research. This article also considers where the line should be drawn between individual choice and responsibility and public regulation. Using sugar sweetened beverages as an example, the article considers the lack of a consistent association between added sugars and weight in the literature and calls for policy recommendations that are based on science and emphasizes the need for evidence-based policies rather than policy-based evidence.

Association between energy-dense food consumption at 2 years of age and diet quality at 4 years of age

The present study aimed to evaluate the association between the consumption of energy-dense foods at 2 years of age and the consumption of foods and diet quality at 4 years of age. The sample included 705 children evaluated at 2 and 4 years of age, as part of the population-based birth cohort Generation XXI (Porto, Portugal). Data on sociodemographic and lifestyle factors of both children and mothers were collected by face-to-face interviews. The weight and height of children were measured by trained professionals. Based on FFQ, four energy-dense food groups were defined: soft drinks; sweets; cakes; salty snacks. A healthy eating index was developed using the WHO dietary recommendations for children (2006) aged 4 years. The associations were evaluated through Poisson regression models. After adjustment for maternal age and education, child's carer, child's siblings and child's BMI, higher consumption of energy-dense foods at 2 years of age was found to be associated with higher consumption of the same foods 2 years later. An inverse association was found between the intake ( ≥ median) of soft drinks (incidence rate ratio (IRR) = 0·74, 95 % CI 0·58, 0·95), salty snacks (IRR = 0·80, 95 % CI 0·65, 1·00) and sweets (IRR = 0·73, 95 % CI 0·58, 0·91) at 2 years of age and the consumption of fruit and vegetables at 4 years of age ( ≥ 5 times/d). Weekly and daily consumption of energy-dense foods at 2 years of age was associated with a lower healthy eating score at 4 years of age (IRR = 0·75, 95 % CI 0·58, 0·96; IRR = 0·56, 95 % CI 0·41, 0·77, respectively). The consumption of energy-dense foods at young ages is negatively associated with the diet quality of children a few years later.

The consumption of protein-rich foods in older adults: an exploratory focus group study

OBJECTIVE

Many older adults consume inadequate protein for their needs. This study explored the factors associated with the consumption of high-protein foods in older adults.

METHODS

Participants over the age of 65 years (n = 28) took part in 1 of 4 focus group discussions on meat, fish, eggs, dairy products, nuts, and pulses. Discussions were audio taped, transcribed, and analyzed using thematic analysis.

RESULTS

Numerous and various reasons for the consumption and non-consumption of high-protein foods were reported. Many of these reasons result from reductions in chemosensory, dental and physical abilities, and changes in living situation in the older population, and have impact specifically on high-protein foods because of their often hard, perishable and need-to-be-cooked nature, and high cost.

CONCLUSIONS AND IMPLICATIONS

Further work is required to establish the importance of each of these reasons in relation to protein intakes, to prioritize those of likely greatest impact for increasing intakes.

Adverse outcomes associated with media exposure to contradictory nutrition messages

There is increasing concern that the media present conflicting health information on topics including cancer screening and nutrition. Although scholars have speculated that exposure to this information leads to increased public confusion, less trust in health recommendations, and less engagement in health behaviors, there is a lack of empirical research that directly addresses the role of media exposure to conflicting information. Using data from the Annenberg National Health Communication Survey, this study finds that exposure to conflicting information on the health benefits and risks of, for example, wine, fish, and coffee consumption is associated with confusion about what foods are best to eat and the belief that nutrition scientists keep changing their minds. There is evidence that these beliefs, in turn, may lead people to doubt nutrition and health recommendations more generally-including those that are not rife with contradictory information (e.g., fruit/vegetable consumption, exercise). The implications of these findings for healthy eating campaigns and interventions are discussed.

Interventions to enhance adherence to dietary advice for preventing and managing chronic diseases in adults

BACKGROUND

It has been recognized that poor adherence can be a serious risk to the health and wellbeing of patients, and greater adherence to dietary advice is a critical component in preventing and managing chronic diseases.

OBJECTIVES

To assess the effects of interventions for enhancing adherence to dietary advice for preventing and managing chronic diseases in adults.

SEARCH METHODS

We searched the following electronic databases up to 29 September 2010: The Cochrane Library (issue 9 2010), PubMed, EMBASE (Embase.com), CINAHL (Ebsco) and PsycINFO (PsycNET) with no language restrictions. We also reviewed: a) recent years of relevant conferences, symposium and colloquium proceedings and abstracts; b) web-based registries of clinical trials; and c) the bibliographies of included studies.

SELECTION CRITERIA

We included randomized controlled trials that evaluated interventions enhancing adherence to dietary advice for preventing and managing chronic diseases in adults. Studies were eligible if the primary outcome was the client's adherence to dietary advice. We defined 'client' as an adult participating in a chronic disease prevention or chronic disease management study involving dietary advice.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the eligibility of the studies. They also assessed the risk of bias and extracted data using a modified version of the Cochrane Consumers and Communication Review Group data extraction template. Any discrepancies in judgement were resolved by discussion and consensus, or with a third review author. Because the studies differed widely with respect to interventions, measures of diet adherence, dietary advice, nature of the chronic diseases and duration of interventions and follow-up, we conducted a qualitative analysis. We classified included studies according to the function of the intervention and present results in a narrative table using vote counting for each category of intervention.

MAIN RESULTS

We included 38 studies involving 9445 participants. Among studies that measured diet adherence outcomes between an intervention group and a control/usual care group, 32 out of 123 diet adherence outcomes favoured the intervention group, 4 favoured the control group whereas 62 had no significant difference between groups (assessment was impossible for 25 diet adherence outcomes since data and/or statistical analyses needed for comparison between groups were not provided). Interventions shown to improve at least one diet adherence outcome are: telephone follow-up, video, contract, feedback, nutritional tools and more complex interventions including multiple interventions. However, these interventions also shown no difference in some diet adherence outcomes compared to a control/usual care group making inconclusive results about the most effective intervention to enhance dietary advice. The majority of studies reporting a diet adherence outcome favouring the intervention group compared to the control/usual care group in the short-term also reported no significant effect at later time points. Studies investigating interventions such as a group session, individual session, reminders, restriction and behaviour change techniques reported no diet adherence outcome showing a statistically significant difference favouring the intervention group. Finally, studies were generally of short duration and low quality, and adherence measures varied widely.

AUTHORS' CONCLUSIONS

There is a need for further, long-term, good-quality studies using more standardized and validated measures of adherence to identify the interventions that should be used in practice to enhance adherence to dietary advice in the context of a variety of chronic diseases.

Determinants and consequences of adherence to the dietary approaches to stop hypertension diet in African-American and white adults with high blood pressure: results from the ENCORE trial

BACKGROUND

Although the Dietary Approaches to Stop Hypertension (DASH) diet is an accepted nonpharmacologic treatment for hypertension, little is known about what patient characteristics affect dietary adherence and what level of adherence is needed to reduce blood pressure (BP).

OBJECTIVE

Our aim was to determine what factors predict dietary adherence and the extent to which dietary adherence is necessary to produce clinically meaningful BP reductions.

DESIGN

Ancillary study of the ENCORE (Exercise and Nutrition Interventions for Cardiovascular Health) trial--a 16-week randomized clinical trial of diet and exercise.

PARTICIPANTS/SETTING

Participants included 144 sedentary, overweight, or obese adults (body mass index 25 to 39.9) with high BP (systolic 130 to 159 mm Hg and/or diastolic 85 to 99 mm Hg).

INTERVENTION

Patients were randomized to one of three groups: DASH diet alone, DASH diet plus weight management, and Usual Diet Controls.

MAIN OUTCOMES MEASURES

Our primary outcomes were a composite index of adherence to the DASH diet and clinic BP.

STATISTICAL ANALYSES PERFORMED

General linear models were used to compare treatment groups on post-treatment adherence to the DASH diet. Linear regression was used to examine potential predictors of post-treatment DASH adherence. Analysis of covariance was used to examine the relation of adherence to the DASH diet and BP.

RESULTS

Participants in the DASH diet plus weight management (16.1 systolic BP [SBP]; 95% CI 13.0 to 19.2 mm Hg and 9.9 diastolic BP [DBP]; 95% CI 8.1 to 11.6 mm Hg) and DASH diet alone (11.2 SBP; 95% CI 8.1 to 14.3 mm Hg and 7.5 DBP; 95% CI 5.8 to 9.3 mm Hg) groups showed significant reductions in BP in comparison with Usual Diet Controls participants (3.4 SBP; 95% CI 0.4 to 6.4 mm Hg and DBP 3.8; 95% CI 2.2 to 5.5 mm Hg). Greater post-treatment consumption of DASH foods was noted in both the DASH diet alone (mean = 6.20; 95% CI 5.83 to 6.57) and DASH diet plus weight management groups (mean = 6.23; 95% CI 5.88 to 6.59) compared with Usual Diet Controls (mean = 3.66; 95% CI 3.30 to 4.01; P<0.0001), and greater adherence to the DASH diet was associated with larger reductions in clinic SBP and DBP (P ≤ 0.01). Only ethnicity predicted dietary adherence, with African Americans less adherent to the DASH diet compared with whites (4.68; 95% CI 4.34 to 5.03 vs 5.83; 95% CI 5.50 to 6.11; P<0.001).

CONCLUSIONS

Greater adherence to the DASH diet was associated with larger BP reductions independent of weight loss. African Americans were less likely to be adherent to the DASH dietary eating plan compared with whites, suggesting that culturally sensitive dietary strategies might be needed to improve adherence to the DASH diet.

Measuring Media Exposure to Contradictory Health Information: A Comparative Analysis of Four Potential Measures

There is increasing concern that the news media present conflicting health information on topics including cancer screening and nutrition, yet little is known about whether people notice such content. This study proposes four potential measures of media exposure to contradictory health information, using nutrition as an example (Measures I-IV). The measures varied on two dimensions: (1) content specificity, or whether specific nutrition topics and health consequences were mentioned in the question scripting, and (2) obtrusiveness, or whether "contradictory or conflicting information" was mentioned. Using data from the Annenberg National Health Communication Survey (ANHCS), we evaluated the performance of each measure against a set of validity criteria including nomological, convergent, and face validity. Overall, measure IV, which was moderately content-specific and obtrusive, performed consistently well and may prove most useful to researchers studying media effects of contradictory health information. Future directions and applications are discussed.

The protocol of a randomized controlled trial for playgroup mothers: Reminder on Food, Relaxation, Exercise, and Support for Health (REFRESH) Program

BACKGROUND

Mother's physical activity levels are relatively low, while their energy consumption is generally high resulting in 58% of Australian women over the age of 18 years being overweight or obese. This study aims to confirm if a low-cost, accessible playgroup based intervention program can improve the dietary and physical activity behaviours of mothers with young children.

METHODS/DESIGN

The current study is a randomized controlled trial lifestyle (nutrition and physical activity) intervention for mothers with children aged between 0 to 5 years attending playgroups in Perth, Western Australia. Nine-hundred participants will be recruited and randomly assigned to the intervention (n = 450) and control (n = 450) groups. The study is based on the Social Cognitive Theory (SCT) and the Transtheoretical Model (TTM), and the Precede-Proceed Framework incorporating goal setting, motivational interviewing, social support and self-efficacy. The six month intervention will include multiple strategies and resources to ensure the engagement and retention of participants. The main strategy is home based and will include a specially designed booklet with dietary and physical activity information, a muscle strength and flexibility exercise chart, a nutrition label reading shopping list and menu planner. The home based strategy will be supported by face-to-face dietary and physical activity workshops in the playgroup setting, posted and emailed bi-monthly newsletters, and monthly Short Message Service (SMS) reminders via mobile phones. Participants in the control group receive no intervention materials. Outcome measures will be assessed using data that will be collected at baseline, six months and 12 months from participants in the control and intervention groups.

DISCUSSION

This trial will add to the evidence base on the recruitment, retention and the impact of community based dietary and physical activity interventions for mothers with young children.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12609000735257.

Ortorexia nervosa: reflexões sobre um novo conceito

Ortorexia nervosa é o termo descrito para o comportamento obsessivo patológico caracterizado pela fixação por saúde alimentar. O quadro ainda não foi oficialmente reconhecido como um transtorno alimentar, mas discute-se o conceito, suas características, interações e sintomas. No presente trabalho foi realizada uma revisão dos vinte e um artigos publicados desde 1997, quando o comportamento da ortorexia nervosa foi inicialmente descrito. Foram apontadas semelhanças e diferenças entre o comportamento alimentar observado na ortorexia nervosa e nos transtornos alimentares mais frequentes (anorexia e bulimia nervosa). Um instrumento foi desen-volvido e validado para detecção do quadro ortoréxico. Os estudos apontam alguns grupos vulneráveis à orto-rexia nervosa: estudantes de medicina, médicos, nutricionistas, pessoas com sintomas de ansiedade, obsessivo-compulsivos e aqueles que supervalorizam o corpo perfeito. A ortorexia nervosa é situada a partir de uma análise dos conceitos de atitude alimentar e alimentação saudável, procurando um foco biopsicossocial para a alimentação adequada e não apenas um foco fisiológico. Não existem estudos investigativos sobre a ortorexia nervosa no Brasil, mas o tema deve ser discutido para alertar os profissionais da área da saúde sobre a existência desse comportamento inadequado e suas possíveis consequências não só para a saúde física e emocional, mas também para a visão de alimentação saudável.

Associations among dietary supplement use and dietary and activity behaviors by sex and race/ethnicity in a representative multiethnic sample of 11th-grade students in Texas

BACKGROUND AND OBJECTIVE

The purpose of this study was to examine associations among dietary supplement use and dietary/activity patterns in a representative sample of adolescents by sex and race/ethnicity, a research area where extant data is limited.

DESIGN/PARTICIPANTS

Cross-sectional, multistage, probability-based sample of 11th graders in Texas during 2004-2005 (n=6,422; 48.8% white/other, 37% Hispanic, and 14.2% African American; 50.6% boys; mean age 16.7 years).

SETTING

Classrooms. MAIN VARIABLES ASSESSED: Dietary supplement use, dietary/activity patterns, and anthropometrics.

STATISTICAL ANALYSES PERFORMED

Multiple logistic regression models (odds ratios [ORs] and 95% confidence intervals [CIs]).

RESULTS

Dietary supplement users reported healthy dietary and physical activity behaviors overall, yet sex- and race/ethnicity-specific differences were seen in associations among specific diet/activity behaviors and supplement use. In whites/others and Hispanics, but not African Americans, supplement use was associated with higher diet quality scores (OR 2.93, 95% CI 1.74 to 4.95 for whites/others; OR 3.93, 95% CI 2.26 to 6.83 for Hispanics), and regular consumption of breakfast (OR 2.27, 95% CI 1.40 to 3.66 for whites/others; OR 1.96, 95% CI 1.11 to 3.46 for Hispanics) and low-fat foods (OR 3.02, 95% CI 1.53 to 5.98 for whites/others; OR 3.59, 95% CI 1.11 to 11.6 for Hispanics). Supplement use was not associated with body mass index or with sedentary behaviors overall, but was associated with less television viewing only in whites/others (OR 0.53, 95% CI 0.33 to 0.84). For physical activity, boys and whites/others showed positive associations between supplement use and all indicators examined, but girls, Hispanics and African Americans showed mixed patterns of associations. Supplement use was associated with higher weight preference only in boys (OR 2.47, 95% CI 1.24 to 4.90), and vegetarian diets only in girls (OR 2.96, 95% CI 1.35 to 6.47).

CONCLUSIONS

Dietary and activity patterns associated with dietary supplement use may vary by sex- and racial/ethnic subpopulation, especially amongst African American youth. These findings together with further research on psychosocial and attitudinal characteristics associated with adolescent supplement use can enhance the development of targeted and tailored health communications about supplement use in adolescent subpopulations.

Whole versus the piecemeal approach to evaluating soy

Soy has been singled out for attention among other legumes as a valuable source of nutrients, phytochemicals, and bioactive compounds. Early epidemiological studies established that whole soy and traditional soy foods were implicated in health-protective effects in Asian populations. The same benefits attributable to soy have not been consistently proven in Western populations that, for various reasons, opt to consume more processed soy foods or various soy components. Soy researchers continue to isolate soy components in search of identifying its salubrious components and whole soy remains relatively underinvestigated despite what we know of the health benefits it may confer to those regularly consuming it. Various dietary guidelines advocate the regular consumption of legumes that tend not to be included in our diets in sufficient quantities. This paper highlights the possibility that whole soy may have a more unique effect on health than a select soy component(s). It explores the rationale for focusing research on whole soy in an attempt to understand it better rather than trying to replicate the health benefits by targeting various soy components, which has been plagued by inconsistent results.

Potential pitfalls of health claims from a public health nutrition perspective

The European Union is implementing a new regulatory framework for nutrition and health claims (HCs) that will greatly impact the communication of health messages on foodstuffs. In particular, approved HCs will be included in a positive register of generic claims. In the currently available literature, assessment of the relevance of HCs has mainly been related to scientific substantiation, and the issue of relevance in terms of public health has tended to be overlooked. Interestingly, the new regulation states that claims must be well understood by the average consumer. This article delves beyond the issue of scientific substantiation of claims and reviews possible discrepancies between consumer perception/understanding of HCs and the public health nutrition reality, which can confuse or mislead the consumer and ultimately impact public health nutrition. Six pitfalls are described herein and a comprehensive overview of the critical examination of any HC is proposed.

Healthful Eating: Beyond Food, a Global Concept

Producing a definition of healthful eating that expresses adequately the richness and the complexity of the eating experience is challenging. Still, the effort is crucial if one wants to promote behavioural change in the population, as well as a transformation of interventional practices, programs, and policies, and even the agri-food system. We explain that the biological, social, and environmental dimensions of healthful eating, along with the interactions among them, must be addressed. Once these dimensions are considered as a whole, the definition of healthful eating allows the identification of a wide range of strategic interventions to implement such eating. We suggest a continuum of eating quality that could be used to identify, in general, the food habits of persons or groups.

Weight Management Strategies for Recreational Athletes: What Do We Tell Them?

The 2008 Physical Activity Guidelines for Americans provide clear recommendations for health care professionals to share with their patients and clients. The guidelines clearly lay out what the general public needs to do to improve their fitness level and manage their weight. The physical activity guidelines need to be reviewed in conjunction with appropriate dietary advice found in the Dietary Guidelines for Americans. Patients and clients who increase their physical activity to light or moderately active, the recreational athlete, can meet their nutrition needs by consuming a well-balanced, varied diet of nutrient-dense foods. Sports drinks and bars, which are heavily marketed to all levels of athletes and sedentary people, are not necessary for the recreational athlete in most situations and may negatively affect body weight.

Higher Healthy Eating Index-2005 scores associated with reduced symptoms of depression in an urban population: findings from the Healthy Aging in Neighborhoods of Diversity Across the Life Span (HANDLS) study

BACKGROUND

Depression affects more than 15 million Americans in a given year. Compared to physical health, less is known about the affect of diet quality on symptoms of depression.

OBJECTIVE

This study investigated the relationship between diet quality and reported symptoms of depression in a low-income urban population.

SUBJECTS/SETTING

Subjects included 1,118 African-American and white adults, aged 30 to 64 years, living in Baltimore, MD, and represented a subsample of the initial examination and recruitment phase of the Healthy Aging in Neighborhoods of Diversity across the Life Span study.

METHODS

Nutrition data were based on two 24-hour dietary recalls collected by trained interviewers using the US Department of Agriculture Automated Multiple Pass Method. Diet quality was calculated using the US Department of Agriculture Healthy Eating Index (HEI)-2005. Depressive symptoms were assessed by a trained interviewer using the Center for Epidemiologic Studies Depression scale.

STATISTICAL ANALYSIS

Both linear and logistic regression analyses were used to examine whether or not diet quality was associated with depressive symptoms. The dependent variable was depressive symptoms and independent variables included HEI-2005, race, sex, age, education, income, and food-assistance program participation.

RESULTS

Mean HEI-2005 score was 52.17+/-0.40 (out of 100). Mean Center for Epidemiologic Studies Depression scale score was 11.64+/-0.25 (out of 40). Diet quality was significantly associated with reported symptoms of depression. However, income was a significantly stronger predictor of depression compared to diet quality, education, and sex.

CONCLUSIONS

Registered dietitians should be aware of relationships between psychological status and nutritional health when assisting clients to better manage their food choices to improve their overall health and quality of life.

Food consumed away from home can be a part of a healthy and affordable diet

The benefit calculation of the Supplemental Nutrition Assistance Program (SNAP), formerly the Food Stamp Program, is based primarily on results of the Thrifty Food Plan (TFP) developed by the USDA. By using a nonlinear mathematical programming approach, the TFP provides a dietary pattern recommendation that deviates the least from low-income consumers' consumption pattern, meets dietary guidelines, and is economical. The TFP stipulates that all foods should be purchased at stores and prepared at home [food at home (FAH)] and excludes an important part of current consumers' diet, food away from home (FAFH). Our purpose was to evaluate the feasibility and nutritional impact of adding a FAFH dimension into the TFP model framework. Measures of energy density, nutrients and food group composition, and the overall diet quality measured by the Healthy Eating Index 2005 were calculated and compared across the TFP, the TFP with FAFH, and low-income consumers' diet pattern. Our results indicated that considering moderate FAFH in the TFP yielded similar nutrient and food group composition as the original TFP while greatly increasing the practicality and adaptability of the recommended dietary pattern. These findings may be used by nutrition educators to develop healthful FAFH choices for individuals receiving SNAP benefits.

US adolescents and MyPyramid: associations between fast-food consumption and lower likelihood of meeting recommendations

OBJECTIVE

To determine whether fast-food consumption is associated with adolescents' food group intakes and likelihood of meeting recommendations outlined in the MyPyramid Food Guidance System.

DESIGN

Data from two 24-hour recalls collected in What We Eat in America, National Health and Nutrition Examination Survey 2003-2004 were analyzed. Fast-food consumers were divided into tertiles based on the proportion of 2-day energy intake derived from fast food.

SUBJECTS

Adolescent boys and nonpregnant girls aged 12 to 19 years (n=1,956).

STATISTICAL ANALYSES PERFORMED

All statistical analyses included sample weights to account for the survey design. Regression analyses were used to detect associations between fast-food consumption and both food group intakes and percentages of individuals meeting MyPyramid recommendations, and to predict odds of meeting recommendations by fast-food consumption level.

RESULTS

Fast-food consumption was associated negatively with MyPyramid fruit and milk group intakes (boys and girls) and positively with discretionary energy and solid fats (girls only). Negative associations were also found between fast-food consumption and percentages of adolescents meeting recommendations for milk (boys), fruits (girls), and vegetables and discretionary energy (boys and girls). Compared with those consuming no fast food, adolescents in the highest tertile of energy from fast food were less likely to meet recommendations for vegetables (odds ratio [OR]=0.16, 95% confidence interval [CI]: 0.05 to 0.52 for boys; OR=0.18, 95% CI: 0.04 to 0.79 for girls) and discretionary energy (OR=0.41, 95% CI: 0.22 to 0.77 for boys; OR=0.04, 95% CI: 0.01 to 0.24 for girls). No relationships were found between fast-food consumption and grains, meat/beans, and oils.

CONCLUSIONS

Adolescents' intakes, whether containing fast food or not, need improvement. Fast food is one factor that impacts adolescents' intake of MyPyramid groups and their likelihood of meeting recommendations. Awareness of fast-food's role in discrepancies between adolescent intakes and MyPyramid recommendations can aid professionals in designing effective strategies to improve adolescents' diets.

Diet- and body size-related attitudes and behaviors associated with vitamin supplement use in a representative sample of fourth-grade students in Texas

OBJECTIVE

To examine diet- and body size-related attitudes and behaviors associated with supplement use in a representative sample of fourth-grade students in Texas.

DESIGN

Cross-sectional data from the School Physical Activity and Nutrition study, a probability-based sample of schoolchildren. Children completed a questionnaire that assessed supplement use, food choices, diet-related attitudes, and physical activity; height and weight were measured.

SETTING

School classrooms.

PARTICIPANTS

Representative sample of fourth-grade students in Texas (n = 5967; mean age = 9.7 years standard error of the mean [SEM] = .03 years, 46% Hispanic, 11% African-American).

MAIN OUTCOME MEASURES

Previous day vitamin supplement consumption, diet- and body size-related attitudes, food choices, demographic factors, and physical activity.

ANALYSIS

Multivariable logistic regression models, P < .05.

RESULTS

The prevalence of supplement use was 29%. Supplement intake was associated with physical activity. Girls who used supplements were more likely to report positive body image and greater interest in trying new food. Relative to nonusers, supplement users were less likely to perceive that they always ate healthful food, although supplement use was associated with more healthful food choices in boys and girls (P < .001).

CONCLUSIONS AND IMPLICATIONS

The widespread use of supplements and clustering of supplement use with healthful diet and greater physical activity in fourth graders suggest that supplement use be closely investigated in studies of diet-disease precursor relations and lifestyle factors in children.

Food intake patterns may explain the high prevalence of cardiovascular risk factors among Iranian women

Some cardiovascular risk factors are more prevalent in Middle Eastern countries than in other parts of the world. Lifestyle-related factors, including diet, might account for this discrepancy. We aimed to identify the association between food intake patterns and cardiovascular risk factors among Iranian adult women. We studied 486 apparently healthy Iranian women aged 40-60 y. We used a Willett-format FFQ for collecting dietary data. Fasting plasma glucose (FPG) concentrations, lipid profiles, and blood pressure were measured. Diabetes was defined as FPG > or = 6.93 mmol/L; dyslipidemia was based on Adult Treatment Panel III and hypertension on Joint National Committee VI recommendations. The presence of at least 1 risk factor and at least 2 risk factors of the 3 major risk factors for cardiovascular disease (hypertension, dyslipidemia, and diabetes) was also evaluated. We identified 3 major eating patterns (healthy, Western, and Iranian). After controlling for potential confounders, subjects in the top quintile of the healthy dietary pattern were less likely to have dyslipidemia [odds ratio (OR), 0.36; 95% CI, 0.19-0.53], hypertension (OR, 0.33; 95% CI, 0.17-0.60), at least 1 (OR, 0.30; 95% CI, 0.18-0.58), and at least 2 risk factors (OR, 0.39; 95% CI, 0.20-0.77) compared with the lowest quintile. In contrast, those with greater adherence to the Western dietary pattern had greater odds for cardiovascular risk factors (OR, 2.59-3.11; P < 0.05). The Iranian dietary pattern was significantly associated with dyslipidemia (OR, 1.73; 95% CI, 1.02-2.99) and at least 1 risk factor (OR, 1.89; 95% CI, 1.05-3.20). The major dietary patterns and diabetes were not associated. Eating patterns of this Middle Eastern population might explain the higher prevalence of some cardiovascular risk factors in this region. However, our findings need to be confirmed in other Middle Eastern countries.

Should Canadians eat according to the traditional Mediterranean diet pyramid or Canada’s food guide?

Eating well with Canada’s food guide (CFG) was developed by Health Canada as an education tool to encourage the Canadian public to have eating habits that meet nutrient needs, promote health, and reduce the risk of nutrition-related chronic disease. It was developed in the Canadian context and reflects the food supply available to Canadians, as well as food choices made by Canadians. There are other dietary patterns that are consistent with health such as the traditional Mediterranean diet (TMD), which has gained popularity in Canada. The potentially different food choices that Canadians could make if they were to follow one guide over the other might significantly influence population health. Although the two guides differ in their recommendations for red wine, fats, and meat and meat alternatives, they both promote a diet rich in grains, fruits, and vegetables. The CFG may have some advantages over the TMD for Canadians, such as focusing on vitamin D and recommending limited alcoholic beverage intake. Some shortcomings of the CFG compared with the TMD are the grouping of animal proteins with nuts, seeds, and legumes into a single category, and not recommending limits for red meat consumption. If Canadians following the CFG were to choose whole grains and vegetarian options from the meat and alternatives category more often, the CFG may be preferable to TMD for Canadians. The TMD is an alternative to the CFG for Canadians if sources of vitamin D are included in the diet and wine consumption is limited or is imbibed in moderation.