Healthy Eating Index Diet Quality in Randomized Weight Loss Trials: A Systematic Review

The Effect of Meal Frequency on Body Composition, Biochemical Parameters and Diet Quality in Overweight/Obese Individuals

OBJECTIVES

There is no consensus on the ideal frequency of meals for the prevention and treatment of obesity. While some studies have reported that increasing meal frequency might be beneficial in the treatment of obesity due to its positive effects on glycemic regulation, appetite and diet quality, other studies have reported negative effects. In this study, it was aimed to examine the effect of meal frequency on body composition, anthropometric measurements, some of the biochemical parameters and diet quality in overweight/obese adults.

METHODS

A total of 91 individuals, all overweight/obese, between the ages of 18-64, including 46 consuming 2 main meals (2MMG) and 45 consuming 3 main meals (3MMG) participated in the study. General characteristics and dietary habits of the individuals were obtained with a questionnaire. A 3-day food consumption record was taken to determine their daily energy and nutrient intake and to evaluate their diet quality with the "Healthy Eating Index 2015". Anthropometric measurements of the individuals were performed, body compositions were analyzed and some blood parameters were evaluated.

RESULTS

The median values of body weight, lean body mass (kg), total body water, basal metabolic rate and hip circumference of men in the 3MMG were found to be higher than men in the 2MMG (p < 0.05). The anthropometric measurements and body composition components of women were similar between the two groups (p > 0.05). The renal urea nitrogen and total cholesterol values of women in 2MMG were higher than those of women in the 3MMG. In the regression analysis, a 1-unit increase in the number of main meals was determined to lead to a 9.3 points increase in the total score of HEI 2015.

CONCLUSIONS

Regular consumption of main meals may have positive effects on diet quality, some of the biochemical parameters, basal metabolic rate and body composition in overweight/obese adults. In this group, which is known to have incorrect food preferences in general, it is important to plan the number of meals and the content of these meals correctly.

Diet Quality Changes in a 12-Week Web-Based Physical Activity Intervention without Explicit Dietary Guidance

Lifestyle habits seem interconnected and extant studies suggest that a lifestyle-related modification can impact other related behaviors. For instance, interventions targeting physical activity (PA) could potentially impact dietary patterns and quality. Therefore, we hypothesized that a web-based intervention to increase PA would lead to changes in diet quality without explicit dietary guidance. Our aim was to evaluate changes in diet quality, measured by the Healthy Eating Index 2020 (HEI-2020), following a 12-week web-based PA intervention in adults with obesity. The study consisted of secondary analysis of a 12-week pilot randomized controlled trial, wherein participants (N = 82) were randomized to the Physical Activity for The Heart (PATH) intervention group, which included workout videos and virtual coaching, or a wait-list control group. Diet quality was assessed at baseline and post-intervention using the HEI-2020 based on recalls collected through the Automated Self-Administered 24-h recall (ASA-24) system. Baseline characteristics were similar across groups. Both groups showed small improvements in HEI-2020 total scores after 12 wk (PATH: 65.11 vs. Control: 62.24). Stratification by moderate to vigorous physical activities increase (<60 min. vs. ≥60 min.) revealed greater improvements in specific HEI-2020 components in the ≥60 min group, though overall changes remained modest. The PA intervention led to small improvements in certain diet quality components, suggesting potential interconnectedness between PA and dietary habits. However, overall changes in HEI-2020 scores were modest. Future research with larger samples should explore the effects of PA intervention alone vs. combined with dietary guidance on diet quality in adults with obesity.

Assessing nutrition literacy and nutrition counseling proficiency following an interdisciplinary culinary medicine elective

CONTEXT

Culinary medicine (CM) is a growing field of education that aims to bridge the gap between the clinical need for nutritional counseling and the lack of education on the topic. Healthcare professionals can aid in nutrition-related noncommunicable disease (NCD) prevention by improving a patient's dietary behavior. However, the presence of nutrition education in healthcare curricula is lacking. Early evidence indicates that CM could address this gap.

OBJECTIVES

The objectives of this study are to determine if the provision of an interdisciplinary CM elective will improve student knowledge and confidence with counseling on nutrition and culinary principles, and to improve personal dietary habits of students.

METHODS

This was a one-group pretest-posttest quasi-experimental design. First- and second-year osteopathic medical students (OMS) and nurse practitioner students were recruited to participate in a CM elective via email. Participants were excluded if they were not in good academic standing at their respective institutions. Twelve individuals (n=8 medical; n=4 nursing) were enrolled in the course. Participants completed pre- and postcourse surveys to determine changes in nutrition literacy (Nutrition Literacy Assessment Instrument [NLit42]), nutrition counseling proficiency (Nutrition Survey for Family Practitioners), and dietary quality (Automated Self-Administered 24-h dietary assessment tool; ASA24®). A two-sided, paired t test was conducted to determine changes in outcome variables.

RESULTS

All 12 participants completed the precourse assessments, and 8 participants completed the postcourse assessments. Culinary activity attendance was 94.5 %. Participants exhibited a statistically significant increase in their overall nutrition literacy scores after completing the CM elective (p=0.006). Literacy subcategories indicated that the improvement came from the participant's ability to understand household measurements (p=0.005) better. Increases in self-reported proficiency were observed for participants' confidence to counsel on nutrition and prevention/wellness (p=0.02) and macronutrients in health and food safety (p=0.01). No statistically significant changes in the personal dietary pattern or quality were observed.

CONCLUSIONS

The interdisciplinary CM elective improved nutrition literacy and some aspects of counseling proficiency. Although small shifts in dietary variables were observed, the elective did not statistically improve participants' dietary pattern. However, some changes that were observed may lead to clinically relevant outcomes if maintained long-term. These findings are encouraging. Implementing CM as an educational tool could improve healthcare practitioners' ability to understand and counsel patients on nutrition to prevent the nutrition-related NCDs.

Intake of Pistachios as a Nighttime Snack Has Similar Effects on Short- and Longer-Term Glycemic Control Compared with Education to Consume 1-2 Carbohydrate Exchanges in Adults with Prediabetes: A 12-Wk Randomized Crossover Trial

BACKGROUND

Nut intake is associated with better glycemic control and lower cardiovascular disease (CVD) risk. It remains unclear if nut intake timing affects glycemic control and CVD risk factors. Intake of pistachios as a nighttime snack may attenuate morning glucose production and lower fasting plasma glucose (FPG).

OBJECTIVES

We assessed the effects of a nighttime (after dinner and before bedtime) pistachio snack (57 g/d) on glycemic control markers, vascular health, lipids/lipoproteins, and diet quality compared with education to consume 1-2 carbohydrate (CHO) exchanges (usual care) in individuals with prediabetes.

METHODS

A 2-period, randomized crossover trial was conducted. Participants were provided 57 g/d of dry roasted unsalted pistachios (319 kcal; fat 26 g; CHO 16 g; protein 12 g; fiber 6 g) as a nighttime snack or received usual care for 12 wk. Primary (FPG) and secondary outcomes [hemoglobin A1c (HbA1c), insulin, Homeostatic Model Assessment for Insulin Resistance (HOMA-IR), lipids/lipoproteins, vascular health, and Healthy Eating Index-2015 (HEI-2015)] were measured before and after each condition.

RESULTS

A total of 66 participants (50.9 ± 11.6 y, FPG: 106.2 ± 6.4 mg/dL) were randomly assigned, and 51 participants completed the trial. No between-condition differences in FPG {0.9 mg/dL [95% confidence interval (CI): -1.2, 3.1]}, HbA1c, insulin, HOMA-IR, lipids/lipoproteins, blood pressure, or vascular health were observed. The HEI-2015 score was higher after the pistachio condition [6.8 points (95% CI: 1.5, 12.1)] than after usual care driven by higher component scores for seafood and plant proteins [2.0 points (95% CI: 1.0, 2.9)], refined grains [2.3 points (95% CI: 1.1, 3.5)], and the fatty acid ratio [1.7 points (95% CI: 0.0, 3.5)].

CONCLUSIONS

In adults with prediabetes, consuming 57 g/d of pistachios as a nighttime snack increased diet quality but had similar effects on glycemic markers, lipids/lipoproteins, blood pressure, and vascular health compared with the usual care comparator. Pistachios may be a healthful alternative to carbohydrate-rich nighttime snacks to increase alignment with Dietary Guidelines for Americans. This trial was registered at clinicaltrials.gov as NCT04056208.

Behavioral Lifestyle Intervention Program Using Mobile Application Improves Diet Quality in Adults With Prediabetes (D'LITE Study): A Randomized Controlled Trial

BACKGROUND

Mobile health applications (mHealth apps) are increasingly being used in weight loss interventions. However, evidence on the effects of such interventions on diet quality and their correlation with weight loss is lacking.

OBJECTIVE

The objective of this study was to examine whether changes in the diet quality of adults with prediabetes followed the use of an mHealth-enabled lifestyle intervention, compared with those who did not, and whether these changes correlated with weight loss.

DESIGN

A secondary analysis of a 6-month randomized controlled trial Diabetes Lifestyle Intervention using Technology Empowerment (D'LITE) was conducted, with participants recruited from October 2017 to September 2019.

PARTICIPANTS/SETTING

Community-dwelling adults (n = 148) in Singapore diagnosed with prediabetes and body mass index (BMI) ≥23 were included in this study.

INTERVENTION

Participants were randomized to receive either a 6-month mHealth-enabled lifestyle intervention program (diet and physical activity) or standard care dietary advice.

MAIN OUTCOME MEASURES

Dietary data were collected in the form of 2-day food records at baseline, 3, and 6 months. Changes in Alternate Healthy Eating Index-2010 (AHEI-2010) scores and food groups (servings/day), calculated from the dietary data, and correlation between changes in AHEI-2010 and weight loss at 3 and 6 months, were examined.

STATISTICAL ANALYSES

Between-group comparisons of continuous variables and within-participants variation were performed using longitudinal mixed-effect models, intention-to-treat principles. The models included treatment groups, time (baseline, 3 months, and 6 months), and covariates (age, sex, and BMI), as well as the group × time interactions, as fixed variables and within-participant variation in outcome values as random variable. The random intercept for participants accounted for the dependence of repeated measures. A likelihood ratio test was also conducted to test random effect variance. Spearman correlation test was used to examine correlation between changes in AHEI-2010 scores and weight loss.

RESULTS

There was a significant improvement in overall diet quality as ascertained by the AHEI-2010, by 6.2 points (95% confidence interval [CI], 3.8-8.7; P < 0.001) in the intervention group as compared with the control. The participants in the intervention group had a significantly greater reduction in intake of sugar-sweetened beverages (SSB) by 0.5 servings/day (95% CI, -0.8, -0.2; P < 0.001) and sodium by 726 mg/day (95% CI, -983, -468; P < .001), compared with those receiving standard care. At 3 and 6 months, a significant decrease in SSB (0.8 servings/day; 0.7 servings/day, respectively) and sodium (297 mg/day; 296 mg/day, respectively) intakes were reported compared with baseline intakes. Small positive correlations (r = 0.2; P < 0.05) were observed between changes in AHEI-2010 scores from baseline and percentage weight loss at 3 and 6 months.

CONCLUSION

For adults with prediabetes in Singapore, diet quality can be improved with an mHealth-enabled lifestyle intervention program. A small positive correlation exists between AHEI-2010 scores and weight loss.

One Avocado per Day as Part of Usual Intake Improves Diet Quality: Exploratory Results from a Randomized Controlled Trial

Background

Few clinical trials have evaluated diet quality change as a predictor of intervention effectiveness.

Objectives

The aim of this study was to examine changes in the Healthy Eating Index (HEI)-2015 after a food-based intervention, and assess the associations between HEI-2015 change and intervention effects on cardiometabolic risk-related outcomes.

Methods

The Habitual Diet and Avocado Trial was a 26-wk, multicenter, randomized, controlled parallel-arm study. Participants were 1008 individuals aged ≥25 y with abdominal obesity (females ≥ 35 inches; males ≥ 40 inches). The avocado-supplemented diet group was provided 1 avocado per day, and the habitual diet group maintained their usual diet. Change in diet quality was assessed using the HEI-2015 from a single 24-h recall conducted at 4 time points. Mixed models were used for analysis.

Results

The avocado-supplemented diet group had a greater increase in the HEI-2015 (4.74 points; 95% CI: 2.93, 6.55) at 26 wk than the habitual diet group. Compared with the habitual diet group, the avocado-supplemented diet group had greater increases in the following HEI-2015 components from baseline: total vegetables (0.99 points; 95% CI: 0.77, 1.21), fatty acid ratio (2.25 points; 95% CI: 1.74, 2.77), sodium (1.03 points; 95% CI: 0.52, 1.55), refined grains (0.82 points; 95% CI: 0.32, 1.31), and added sugars (0.84 points; 95% CI: 0.49, 1.19). No differences in HEI-2015 improvements were observed by race, ethnicity, study site, body mass index, or age category. In the avocado-supplemented diet compared with the habitual diet group, the HEI-2015 increased in females (6.50 points; 95% CI: 4.39, 8.62) but not in males (0.02 points; 95% CI: -3.44, 3.48). Median HEI-2015 change was not associated with intervention-related changes in cardiometabolic disease risk factors.

Conclusions

Intake of 1 avocado per day for 26 wk in adults with abdominal obesity increased adherence to the Dietary Guidelines for Americans. Changes in diet quality did not predict changes in risk factors for cardiometabolic disease.This trial was registered at clinicaltrials.gov as NCT03528031 (https://clinicaltrials.gov/study/NCT03528031).

Effect of an mHealth weight loss intervention on Healthy Eating Index diet quality: the SMARTER randomised controlled trial

In the few weight loss studies assessing diet quality, improvements have been minimal and recommended calculation methods have not been used. This secondary analysis of a parallel group randomised trial (regsitered: https://clinicaltrials.gov/ct2/show/NCT03367936) assessed whether self-monitoring with feedback (SM + FB) v. self-monitoring alone (SM) improved diet quality. Adults with overweight/obesity (randomised: SM n 251, SM + FB n 251; analysed SM n 170, SM + FB n 186) self-monitored diet, physical activity and weight. Real-time, personalised feedback, delivered via a study-specific app up to three times daily, was based on reported energy, fat and added sugar intake. Healthy Eating Index 2015 (HEI-2015) scores were calculated from 24-hour recalls. Higher scores represent better diet quality. Data were collected August 2018 to March 2021 and analysed spring 2022. The sample was mostly female (78·9 %) and white (85·4 %). At baseline, HEI-2015 total scores and bootstrapped 95 % CI were similar by treatment group (SM + FB: 63·11 (60·41, 65·24); SM: 61·02 (58·72, 62·81)) with similar minimal improvement observed at 6 months (SM + FB: 65·42 (63·30, 67·20); SM: 63·19 (61·22, 64·97)) and 12 months (SM + FB: 63·94 (61·40, 66·29); SM: 63·56 (60·81, 65·42)). Among those who lost ≥ 5 % of baseline weight, HEI-2015 scores improved (baseline: 62·00 (58·94, 64·12); 6 months: 68·02 (65·41, 71·23); 12 months: 65·93 (63·40, 68·61)). There was no effect of the intervention on diet quality change. Clinically meaningful weight loss was related to diet quality improvement. Feedback may need to incorporate more targeted nutritional content.

Implementing multicomponent, eHealth-based behaviour change support within a dietary intervention trial improves adherence to study-related behaviours in healthy young adults

BACKGROUND

Behaviour change science is proposed to improve participant retention and enhance the validity of trials. However, researchers seldom systematically consider and implement behaviour change strategies within trials for this purpose. The objective of this article is to evaluate how an eHealth behaviour change support (BCS) program enhances young adults' adherence to behaviours required within a dietary intervention.

METHODS

The Nine Principles framework was used to develop BCS to implement across both arms of a 10-week randomised parallel-group intervention to enhance adherence to (i) eating healthily and (ii) reporting dietary intake. Key components of the BCS included access to a dietitian-led Facebook group, text reminders, and food delivery. Effectiveness was measured using the following analyses of the 78 participants who completed the study; pre-post change in targeted dietary habits over time using a subscore of the Healthy Diet Habits Index, questionnaire to assess change in perception of barriers to eating healthily over time, Facebook group engagement, and impact evaluation of the BCS. Participants received a dietary reporting score out of 100 to assess adherence across the 10 weeks.

RESULTS

The total Healthy Diet Habits Index subscore out of 16 significantly increased from baseline to week 10 (10.6 ± 2.6 to 11.2 ± 2.6, p value < 0.05), driven primarily by an increase in vegetable consumption. Overall adherence to reporting was high across the 10 weeks, with the total population mean reporting score 90.4 ± 14.6 out of 100. Relatively low Facebook engagement was observed. Adding objects to the environment, prompts/cues and removing reward appeared to be effective components of the BCS for enhancing adherence to the target behaviours.

CONCLUSION

Using a behaviour change framework to support the design of randomised trials is a promising way to enhance participant adherence to study requirements that are typically considered burdensome, such as dietary reporting. It also enables researchers to identify and replicate effective components of BCS, including behaviour change techniques and modes of delivery. Further research into the use of different behaviour change frameworks for this purpose is warranted.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04869163; https://clinicaltrials.gov/ct2/show/NCT04869163 . (03/05/2021).

Healthy Eating Index Diet Quality in Randomized Weight Loss Trials: A Systematic Review

BACKGROUND

Weight loss interventions focus on dietary and physical activity changes to induce weight loss. Both through weight loss and independent of it, diet quality is important for reducing chronic disease risk. However, whether and how diet quality changes over the course of a behavioral intervention is unclear.

OBJECTIVE

To systematically review the evidence from randomized controlled trials on the effect of behavioral interventions on diet quality as defined by the Healthy Eating Index (HEI) among adults with overweight and obesity.

METHODS

PubMed, Ebscohost CINAHL, Embase, OVID APA PsycInfo, Scopus, and Web of Science were searched through May 2021. Inclusion criteria comprised randomized controlled trial design, a primary or secondary aim of weight loss, a sample of US adults with overweight or obesity, measurement using the HEI-2005, 2010, or 2015, and assessment of the time by treatment effect. Interventions must have included behavioral components and lasted at least 3 months. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool. The systematic review protocol was published on Open Science Framework.

RESULTS

Of 3,707 citations retrieved, 18 studies met inclusion criteria. A wide array of behavioral interventions were assessed, including in-person and mobile health interventions as well as those prescribing intake of specific foods. Risk of bias in the included studies primarily arose from the measurement of the outcome variable. Sample sizes ranged from 34 to 413 participants. Nine studies used multiple dietary recalls, with few using the recommended method of Healthy Eating Index calculation. Changes in diet quality ranged from no improvement to a 20-point improvement. More often, improvement was in the 4- to 7-point range.

CONCLUSIONS

The evidence for the efficacy of behavioral weight loss interventions for improving diet quality among adults with overweight and obesity is limited. Modest improvements in HEI scores were observed in the reviewed studies.

Effects of a Web-Based Weight Loss Program on the Healthy Eating Index-NVS in Adults with Overweight or Obesity and the Association with Dietary, Anthropometric and Cardiometabolic Variables: A Randomized Controlled Clinical Trial

This randomized, controlled clinical trial examined the impact of a web-based weight loss intervention on diet quality. Furthermore, it was investigated whether corresponding changes in diet quality were associated with changes in measures of cardiovascular risk profile. Individuals with a body mass index (BMI) of 27.5 to 34.9 kg/m2 and an age of 18 to 65 y were assigned to either an interactive and fully automated web-based weight loss program focusing on dietary energy density (intervention) or a non-interactive web-based weight loss program (control). Examinations were performed at baseline (t0), after the 12-week web-based intervention (t1), and after an additional 6 (t2) and 12 months (t3). Based on a dietary record, the Healthy Eating Index-NVS (HEI-NVS) was calculated and analyzed using a robust linear mixed model. In addition, bootstrapped correlations were performed independently of study group to examine associations between change in HEI-NVS and change in dietary, anthropometric, and cardiometabolic variables. A total of n = 153 participants with a mean BMI of 30.71 kg/m2 (SD 2.13) and an average age of 48.92 y (SD 11.17) were included in the study. HEI-NVS improved significantly in the intervention group from baseline (t0) to t2 (p = 0.003) and to t3 (p = 0.037), whereby the course was significantly different up to t2 (p = 0.013) and not significantly different up to t3 (p = 0.054) compared to the control group. Independent of study group, there was a significant negative association between change in HEI-NVS and dietary energy density. A higher total score in HEI-NVS did not correlate with improvements in cardiovascular risk profile. The interactive and fully automated web-based weight loss program improved diet quality. Independent of study group, changes in HEI-NVS correlated with changes in energy density, but there was no association between improvements in HEI-NVS and improvements in cardiovascular risk profile.