Food-based dietary guidelines: some assumptions tested for The Netherlands

A novel approach to assess diet diversity: a development of the Nutritional Functional Diversity indicator

Background and aims

Diversity is a key element of diet quality. The Food Variety Score (FVS) is used to assess diversity, especially in low- and middle-income countries. It sums up the number of foods consumed ignoring their nutrient content. A more suitable index should combine the number of foods consumed and their nutritional composition. We adapted the Nutritional Functional Diversity indicator (NFD), proposed by ecologists, to measure diversity in the human diet. We compared NFD and FVS evaluating subjects' distributions across quartiles of the two diversity indices. To evaluate which one reflected a higher diet quality, we estimated associations between these two diversity indices and diet quality measures, i.e., the Mediterranean Diet Score (MDS) and the Healthy Eating Index-2015 (HEI-2015). Associations were expressed by odds ratios (OR) and corresponding 95% confidence intervals (CI).

Materials and methods

We used the data of controls only derived from an integrated series of hospital-based case-control cancer studies conducted in different Italian areas. The NFD identifies groups of foods based on a set of nutrients according to a cluster analysis. Some steps are required: creating a food-nutrient matrix; clustering of the Euclidean food-food distance matrix to identify groups of foods with nutritional (dis)similarities; and calculating the NFD as the ratio between the sum of branch lengths of the dendrogram belonging to the number of foods consumed by individuals (i.e., subject-specific diversity) and the sum of all branch lengths of the dendrogram (i.e., maximal diversity).

Results

More than one quarter of individuals (28.4%) were differently classified within quartiles of the two diversity indices. For both indices, increasing the diversity level increased the risk for adhering to MDS (OR for NFD = 11.26; 95% CI: 7.88-16.09, and OR for FVS = 6.80; 95% CI: 4.84-9.54) and to HEI-2015 (OR for NDF = 2.86; 95% CI: 2.39-3.42, and OR for FVS = 2.72; 95% CI: 2.27-3.26). Associations were stronger for NFD.

Conclusion

Our findings showed a greater ability of NFD to assess diet quality quantifying the degree of diversity.

Effects of dietary diversification during pregnancy on birth outcomes in east Gojjam, northwest Ethiopia: A prospective cohort study

Introduction

Adequate nutrient intake during pregnancy is an important key factor affecting fetal growth and birth outcomes, as well as maternal health, as demonstrated by experimental animal studies. However, the few human studies available, especially those conducted in the least developed countries (LDCs), are much less consistent. Therefore, this study aimed to investigate the association between dietary diversification during pregnancy and birth outcomes in Gojjam, Ethiopia.

Methodology

A facility-based prospective cohort study was conducted on 416 pregnant mothers (exposed and non-exposed) from December 2019 to January 2020. Information about the Women's Dietary Diversity Score (WDDS) was collected using the Food and Agricultural Organization's guidelines. Data were collected through interviewer-administered questionnaires and measurements. Log-binomial regression analysis was performed to estimate the relative risk of adverse birth outcomes. Energy, macronutrient, and micronutrient amounts were calculated using the nutrition survey software version 2007. The differences between groups were noticed using analysis of variance. Eta squared was estimated in the current study.

Results

The overall magnitude of low birth weight, preterm birth, and stillbirth in the study area, respectively, was 41%, 38%, and 4%. After adjustment for baseline characteristics, this study revealed that pregnant women in the inadequate WDDS group were at increased risk of LBW (ARR = 6.4; 95% CI: 3.4, 12) and PTD (ARR = 6.3; 95% CI: 3.3, 11.95) as compared with their counterparts but no difference in the occurrence of stillbirth (ARR = 1.08; 95% CI: 0.20, 5.79).

Conclusion

Overall, this study found a large magnitude of low birth weight and preterm birth. Inadequate intake of dietary diversity during pregnancy significantly increased the rate of low birth weight and preterm birth. Thus, we recommend the concerned body to work on improving the feeding practices of pregnant mothers in the study area.

Dietary Diversity Indicators and Their Associations with Dietary Adequacy and Health Outcomes: A Systematic Scoping Review

Dietary diversity has long been recognized as a key component of diet quality and many dietary diversity indicators (DDIs) have been developed. This systematic scoping review aimed to present a comprehensive inventory of DDIs and summarize evidence linking DDIs and dietary adequacy or health outcomes in adolescents and adults. Two search strategies were developed to identify peer-reviewed articles published in English up until June 2018 and were applied to Medline, Web of Science, and Scopus. A 2-stage screening process was used to select the studies to be reviewed. Four types of DDIs were identified among 161 articles, the majority of them belonging to the food group-based indicator type (n = 106 articles). Fifty studies indicated that DDIs were proxies of nutrient adequacy, but there was a lack of evidence about their relation with nutrients to limit. Associations between DDIs and health outcomes were largely inconsistent among 137 studies, especially when the outcomes studied were body weight (n = 60) and noncommunicable diseases (n = 41). We conclude that the ability of DDIs to reflect diet quality was found to be principally limited to micronutrient adequacy and that DDIs do not readily relate to health outcomes. These findings have implications for studies in low- and lower-middle-income economies where DDIs are often used to assess dietary patterns and overall diet quality.

Nutritional Deprivation Index is negatively associated with socio-economic factors in Paraguayan households

The present study aimed to examine the nutritional deprivation of Paraguayan households (measured as households' access to diverse diets) and investigate the association between nutritional deprivation and socio-economic characteristics in a large sample. An extension of Alkire–Foster methodology, a technique widely employed in multidimensional poverty measurement, was used to calculate both the incidence and intensity of nutritional deprivation. The resulting Nutritional Deprivation Index allows us to consider minimum food group requirements that vary by food groups as well as by individual characteristics such as age, sex and activity level. Applying the methodology to a nationally representative sample of households from the 2011–2012 Income and Expenditures Household Survey, the study found that about two in every three Paraguayan households (67 %) were inadequately nourished in at least four (of the total of six) food groups. Although no significant differences were found between rural and urban households, the incidence of multi-dimensionally deprived households generally decreased as income increased. Logistic regression results showed that nutritional deprivation decreased as household income and mother's education increased and increased with household size. Our study concludes that the majority of Paraguayan households is significantly nutritionally deprived across most food groups and suggests that strategies are needed to improve their access to diverse diets, especially among its lower- and middle-income segments.

Effects of multiannual, seasonal unconditional cash transfers on food security and dietary diversity in rural Burkina Faso: the Moderate Acute Malnutrition Out (MAM'Out) cluster-randomized controlled trial

OBJECTIVE

To evaluate the impact of multiannual, seasonal unconditional cash transfers (UCT) provided within the Moderate Acute Malnutrition Out (MAM'Out) research project on households' food security and children's and caregivers' dietary diversity.

DESIGN

A two-arm cluster-randomized controlled trial with sixteen villages in the intervention group and sixteen others in the control group. A monthly allowance of 10 000 XOF was transferred to caregivers of eligible children via a personal mobile phone account from July to November 2013 and 2014.

SETTING

Tapoa province in the eastern region of Burkina Faso.

PARTICIPANTS

Data on household food access (monthly adequate household food provisioning (MAHFP); household food insecurity access scale (HFIAS)) and maternal and child dietary diversity were analysed for 1143 households, 1219 caregivers of reproductive age (15-49 years) and 1247 under-5 children from both intervention and control groups.

RESULTS

The mean women dietary diversity score in intervention caregivers and the mean dietary diversity score (DDS) in intervention children with inadequate minimum DDS at baseline were respectively 7 % (95 % CI 2, 11 %; P = 0·002) and 17 % (95 % CI 11, 23 %; P <0·001) higher compared with the control group. However, no difference was found in the intervention effect on household food security measured with HFIAS (relative risk = 1·03; 95 % CI 0·92, 1·15; P = 0·565) and MAHFP (relative risk = 0·98; 95 % CI 0·96, 1·01; P = 0·426).

CONCLUSIONS

Multiannual, seasonalUCT increased dietary diversity in children and their caregivers. They can be recommended in actions aiming to improve maternal and child diet diversity.

Review of a priori dietary quality indices in relation to their construction criteria

A multitude of indices measure the healthiness of dietary patterns. Because validation results with respect to health outcomes do not sufficiently facilitate the choice of a specific dietary quality index, the decision of which index to use for a particular research objective should be based on other criteria. This review aims to provide guidance on which criteria to focus upon when choosing a dietary index for a specific research question. A review of 57 existing specifications of dietary quality indices was conducted, taking explicitly into account relevant construction criteria explicated in the Organisation for Economic Co-operation and Development handbook on constructing composite indicators. Index construction choices regarding the following criteria were extracted: theoretical framework, indicator selection, normalization and valuation functions, and aggregation methods. Preferable features of dietary indices are discussed, and a summarizing toolbox is provided to help identify indices with the most appropriate construction features for the respective study aim and target region and with regard to the available database. Directions for future efforts in the specification of new diet quality indices are given.

Perspective: Food-Based Dietary Guidelines in Europe-Scientific Concepts, Current Status, and Perspectives

Food-based dietary guidelines (FBDGs) are important tools for nutrition policies and public health. FBDGs provide guidelines on healthy food consumption and are based on scientific evidence. In the past, disease prevention and nutrient recommendations dominated the process of establishing FBDGs. However, scientific advances and social developments such as changing lifestyles, interest in personalized health, and concerns about sustainability require a reorientation of the creation of FBDGs to include a wider range of aspects of dietary behavior. The present review evaluates current European FBDGs with regard to the concepts and aspects used in their derivation, and summarizes the major aspects currently discussed to be considered in future establishment or updates of FBDGs. We identified English information on official European FBDGs through an Internet search (FAO, PubMed, Google) and analyzed the aspects used for their derivation. Furthermore, we searched literature databases (PubMed, Google Scholar) for conceptional considerations dealing with FBDGs. A total of 34 out of 53 European countries were identified as having official FBDGs, and for 15 of these, documents with information on the scientific basis could be identified and described. Subsequently, aspects underlying the derivation of current FBDGs and aspects considered in the literature as important for future FBDGs were discussed. Eight aspects were identified: diet-health relations, nutrient supply, energy supply, dietary habits, sustainability, food-borne contaminants, target group segmentation, and individualization. The first 4 have already been widely applied in existing FBDGs; the others have almost never been taken into account. It remains a future challenge to (re)conceptionalize the development of FBDGs, to operationalize the aspects to be incorporated in their derivation, and to convert concepts into systematic approaches. The current review may assist national expert groups and clarifies the options for future development of local FBDGs.

Seasonality affects dietary diversity of school-age children in northern Ghana

BACKGROUND AND OBJECTIVES

Dietary diversity score (DDS) is relatively easy to measure and is shown to be a very useful indicator of the probability of adequate micronutrient intake. Dietary diversity, however, is usually assessed during a single period and little is known about the effect of seasonality on it. This study investigates whether dietary diversity is influenced by seasonality.

METHODS

Two cross-sectional surveys were conducted in two different seasons-dry season (October 2010) and rainy season (May 2011) among the same school-age children (SAC) in two rural schools in northern Ghana. The study population consisted of 228 school-age children. A qualitative 24-hour dietary recall was conducted in both seasons. Based on 13 food groups, a score of 1 was given if a child consumed a food item belonging to a particular food group, else 0. Individual scores were aggregated into DDS for each child. Differences in mean DDS between seasons were compared using linear mixed model analysis.

RESULTS

The dietary pattern of the SAC was commonly plant foods with poor consumption of animal source foods. The mean DDS was significantly higher (P < 0.001) in the rainy season (6.95 ± 0.55) compared to the dry season (6.44 ± 0.55) after adjusting for potential confounders such as age, sex, occupation (household head and mother) and education of household head. The difference in mean DDS between dry and rainy seasons was mainly due to the difference in the consumption of Vitamin A-rich fruits and vegetables between the seasons. While vitamin A-rich fruits (64.0% vs. 0.9%; P < 0.0001) and vitamin A rich dark green leafy vegetables (52.6% vs. 23.3%, P < .0001) were consumed more during the rainy season than the dry season, more children consumed vitamin A-rich deep yellow, orange and red vegetables during the dry season than during the rainy season (73.7% vs. 36.4%, P <0.001).

CONCLUSION

Seasonality has an effect on DDS and may affect the quality of dietary intake of SAC; in such a context, it would be useful to measure DDS in different seasons. Since DDS is a proxy indicator of micronutrient intake, the difference in DDS may reflect in seasonal differences in dietary adequacy and further studies are needed to establish this.

Healthy Food Intake Index (HFII) - Validity and reproducibility in a gestational-diabetes-risk population

Background

The aim was to develop and validate a food-based diet quality index for measuring adherence to the Nordic Nutrition Recommendations (NNR) in a pregnant population with high risk of gestational diabetes (GDM).

Methods

This study is a part of the Finnish Gestational Diabetes Prevention Study (RADIEL), a lifestyle intervention conducted between 2008 and 2014. The 443 pregnant participants (61 % of those invited), were either obese or had a history of GDM. Food frequency questionnaires collected at 1st trimester served for composing the HFII; a sum of 11 food groups (available score range 0–17) with higher scores reflecting higher adherence to the NNR.

Results

The average HFII of the participants was 10.2 (SD 2.8, range 2–17). Factor analysis for the HFII component matrix revealed three factors that explained most of the distribution (59 %) of the HFII. As an evidence of the component relevance 9 out of 11 of the HFII components independently contributed to the total score (item-rest correlation coefficients <0.31). Saturated fatty acids, monounsaturated fatty acids, polyunsaturated fatty acids, sucrose, and fiber intakes (among other nutrients) showed linearity across the HFII categories (P ≤ 0.030 for all nutrients tested); the higher the HFII, the closer the nutrient intake to the recommended intake level. Educational attainment (P = 0.0045), BMI (P = 0.0098), smoking (P = 0.007), and leisure time physical exercise (P = 0.038) showed linearity across the HFII categories. Intra-class correlation coefficient for the HFII was 0.85 (CI 0.79, 0.90).

Conclusions

The HFII components reflect the food guidelines of the NNR, intakes of relevant nutrients, and characteristics known to vary with diet quality. It largely ignores energy intake, its components have independent contribution to the HFII, and it exhibits reproducibility. The main shortcomings are absence of red and processed meat component, and the validation in a selected study population. It is suitable for ranking participants according to the adherence to the NNR in pregnant women at high risk of GDM.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3303-7) contains supplementary material, which is available to authorized users.

Diet quality is inversely related to cardiovascular risk factors in adults

The goal of the study was to determine if there was an association between diet quality and cardiovascular risk factors (CVRF) in adults. NHANES 2001-2008 data were used to compare diet quality, as determined by using 2005 Healthy Eating Index (HEI-2005) scores, and CVRF in adults aged ≥19 y (n = 18,988; 51% men, 50% white, 21% African American, 25% Hispanic American, 4% other). HEI-2005 scores were calculated by using one 24-h dietary recall collected from the participants. Weight and adiposity, blood pressure, and CVRF were measured. Regression analyses were conducted to assess the linear relationship of CVRF and HEI-2005 scores by using appropriate covariates accounting for sample weights and the complex sample design of NHANES. OR were calculated for HEI quartiles and CVRF. BMI (P < 0.0001), waist circumference (WC) (P < 0.0001), diastolic blood pressure (P = 0.0002), C-reactive protein (P = 0.0016), total cholesterol (P = 0.0006), LDL cholesterol (P = 0.0039), and metabolic syndrome (P = 0.0035) were inversely associated with HEI-2005. HDL cholesterol significantly (P = 0.0048) increased across HEI-2005 quartiles. Compared with the lowest HEI-2005 quartile, individuals with the highest diet quality (HEI-2005 quartile 4) were less likely to be overweight or obese (34%) or have elevated WC (35%), elevated blood pressure (26%), metabolic syndrome (35%), and decreased HDL-cholesterol concentrations (21%). Data suggest that diet quality is inversely associated with several CVRF.

Validation of the Diet Quality Index for Adolescents by comparison with biomarkers, nutrient and food intakes: the HELENA study

Food-based dietary guidelines (FBDG) aim to address the nutritional requirements at population level in order to prevent diseases and promote a healthy lifestyle. Diet quality indices can be used to assess the compliance with these FBDG. The present study aimed to investigate whether the newly developed Diet Quality Index for Adolescents (DQI-A) is a good surrogate measure for adherence to FBDG, and whether adherence to these FBDG effectively leads to better nutrient intakes and nutritional biomarkers in adolescents. Participants included 1804 European adolescents who were recruited in the Healthy Lifestyle in Europe by Nutrition in Adolescence (HELENA) Study. Dietary intake was assessed by two, non-consecutive 24 h recalls. A DQI-A score, considering the components' dietary quality, diversity and equilibrium, was calculated. Associations between the DQI-A and food and nutrient intakes and blood concentration biomarkers were investigated using multilevel regression analysis corrected for centre, age and sex. DQI-A scores were associated with food intake in the expected direction: positive associations with nutrient-dense food items, such as fruits and vegetables, and inverse associations with energy-dense and low-nutritious foods. On the nutrient level, the DQI-A was positively related to the intake of water, fibre and most minerals and vitamins. No association was found between the DQI-A and total fat intake. Furthermore, a positive association was observed with 25-hydroxyvitamin D, holo-transcobalamin and n-3 fatty acid serum levels. The present study has shown good validity of the DQI-A by confirming the expected associations with food and nutrient intakes and some biomarkers in blood.

The Dutch Healthy Diet index (DHD-index): an instrument to measure adherence to the Dutch Guidelines for a Healthy Diet

BACKGROUND

The objective was to develop an index based on the Dutch Guidelines for a healthy Diet of 2006 that reflects dietary quality and to apply it to the Dutch National Food Consumption Survey (DNFCS) to examine the associations with micronutrient intakes.

METHODS

A total of 749 men and women, aged 19-30 years, contributed two 24-hour recalls and additional questionnaires in the DNFCS of 2003. The Dutch Healthy Diet index (DHD-index) includes ten components representing the ten Dutch Guidelines for a Healthy Diet. Per component the score ranges between zero and ten, resulting in a total score between zero (no adherence) and 100 (complete adherence).

RESULTS

The mean ± SD of the DHD-index was 60.4 ± 11.5 for women and 57.8 ± 10.8 for men (P for difference = 0.002). Each component score increased across the sex-specific quintiles of the DHD-index. An inverse association was observed between the sex-specific quintiles of the DHD-index and total energy intake. Calcium, riboflavin, and vitamin E intake decreased with increasing DHD-index, an inverse association which disappeared after energy adjustment. Vitamin C showed a positive association across quintiles, also when adjusted for energy. For folate, iron, magnesium, potassium, thiamin, and vitamin B6 a positive association emerged after adjustment for energy.

CONCLUSIONS

The DHD-index is capable of ranking participants according to their adherence to the Dutch Guidelines for a Healthy Diet by reflecting variation in nine out of ten components that constitute the index when based on two 24-hour recalls. Furthermore, the index showed to be a good measure of nutrient density of diets.

Adolescent weight status and related behavioural factors: web survey of physical activity and nutrition

Purpose. To identify whether non-overweight students were different from their overweight or obese peers with respect to diet, suboptimal meal behaviours, and physical activity using a self-administered web-based survey. Methods. 4097 adolescents living in Alberta, Canada completed Web-SPAN (Web Survey of Physical Activity and Nutrition). Students were classified as overweight or obese, and differences were described in terms of nutrient intakes, physical activity, and meal behaviours. Results. Non-overweight students consumed significantly more carbohydrate and fibre, and significantly less fat and high calorie beverages, and had a higher frequency of consuming breakfast and snacks compared to overweight or obese students. Both non-overweight and overweight students were significantly more active than obese students. Conclusions. This research supports the need to target suboptimal behaviours such as high calorie beverage consumption, fat intake, breakfast skipping, and physical inactivity. School nutrition policies and mandatory physical education for all students may help to improve weight status in adolescents.

Food choices and health during military service: increases in sugar- and fibre-containing foods and changes in anthropometric and clinical risk factors

OBJECTIVE

To analyse changes in food choices, diet-related risk factors and their association during 6 months of military service.

DESIGN

Longitudinal cohort study in Finland, where all men are liable to military service and a clear majority of each age group completes service. Dietary intake data were collected by self-administered questionnaire before and at 6 months of service. Three dietary indices based on food frequencies were developed to characterize the diet: Sugar Index, Fibre Index and Fat Index. Thirteen diet-related risk factors were measured at the beginning and at 6 months of service.

SETTING

Military environment, two geographically distinct garrisons.

SUBJECTS

Male conscripts aged 18-21 years (n 256) performing military service.

RESULTS

During 6 months of service, positive changes concerned more frequent use of fibre-rich foods (P = 0·011), improved body composition (BMI, waist circumference, muscle mass, fat mass and percentage body fat, P ≤ 0·003 for all), decreased systolic blood pressure and increased HDL cholesterol (P < 0·001 for both). Negative changes concerned more frequent use of sugar-rich foods and increased total cholesterol, TAG and blood glucose (P < 0·001 for all). The consumption of fibre-rich foods was inversely associated with anthropometric risk factors at baseline and with sugar-rich foods at both time points.

CONCLUSIONS

Despite more frequent consumption of sweet foods, military service with a unified, nutritionally planned diet, a controlled environment and high physical load has a positive effect on conscripts' health risk factors. The negative changes in blood lipids and glucose may reflect more varied free-time eating.

Food intake in Slovenian adolescents and adherence to the Optimized Mixed Diet: a nationally representative study

Objectives

To investigate the food intake of Slovenian adolescents and to compare it with food-based dietary guidelines developed for children and adolescents, named the Optimized Mixed Diet (OMD). The OMD is a useful tool for the evaluation of food intake of adolescents.

Design

All adolescents completed an FFQ at a regional health centre; a subgroup also completed a 3 d weighed dietary protocol at home.

Setting

This study is a part of the first national representative study on the dietary habits of Slovenian adolescents.

Subjects

This cross-sectional study included a representative sample of 2813 Slovenian adolescents entering high school, aged 14–17 years, from all ten geographical regions of Slovenia.

Results

The greatest deviations from the recommended intakes of the main food groups in the OMD were significantly lower intakes of (P < 0·001, mean): vegetables (179 and 163 g/d in boys and girls, respectively), bread/cereals (271 and 226 g/d), potatoes/rice/pasta (212 and 163 g/d); in boys also a significantly lower intake of fruits (mean: 321 g/d, P < 0·001) and a significantly higher intake of meat/meat products (mean: 126 g/d, P < 0·001). Additionally, the results show too high intake of sugar-sweetened beverages and too low intakes of fish and plant oils in both genders.

Conclusions

The food intake pattern of Slovenian adolescents deviates markedly from a healthy eating pattern. Nutrition education and interventions are needed for Slovenian adolescents.

Simple food group diversity indicators predict micronutrient adequacy of women's diets in 5 diverse, resource-poor settings

Women of reproductive age living in resource-poor settings are at high risk of inadequate micronutrient intakes when diets lack diversity and are dominated by staple foods. Yet comparative information on diet quality is scarce and quantitative data on nutrient intakes is expensive and difficult to gather. We assessed the potential of simple indicators of dietary diversity, such as could be generated from large household surveys, to serve as proxy indicators of micronutrient adequacy for population-level assessment. We used 5 existing data sets (from Burkina Faso, Mali, Mozambique, Bangladesh, and the Philippines) with repeat 24-h recalls to construct 8 candidate food group diversity indicators (FGI) and to calculate the mean probability of adequacy (MPA) for 11 micronutrients. FGI varied in food group disaggregation and in minimum consumption required for a food group to count. There were large gaps between intakes and requirements across a range of micronutrients in each site. All 8 FGI were correlated with MPA in all sites; regression analysis confirmed that associations remained when controlling for energy intake. Assessment of dichotomous indicators through receiver-operating characteristic analysis showed moderate predictive strength for the best choice indicators, which varied by site. Simple FGI hold promise as proxy indicators of micronutrient adequacy.

Overall and within-food group diversity are associated with dietary quality in Belgium

OBJECTIVE

To assess the relationship(s) between overall and within-food group diversity and several indices of dietary quality, such as dietary adequacy, moderation and balance, in Belgian adults. Dietary quality indices were derived from the food-based dietary guidelines (FBDG).

DESIGN

Information on food intake was collected with two 24 h recalls.

SETTING

Average overall and within-food group diversity scores and dietary adequacy, moderation and balance scores were calculated.

SUBJECTS

A representative sample (n 3245) of the Belgian population at the age of 15 years and older was randomly selected from the National Register using a multistage stratified procedure.

RESULTS

For both men and women, total dietary diversity score increased with age and smokers had a significantly lower overall diversity score than non- or former smokers. A positive association was found between overall dietary diversity and both dietary adequacy and balance. For most food groups, especially bread and cereals, vegetables, dairy products and spreadable fats, within-food group dietary diversity was positively associated with the fulfillment of the specific recommendation for the intake of that food group. An inverse association was found between dietary diversity within the meat and the energy-dense, nutrient-poor food groups and dietary balance. Diversity within the dairy and spreadable fat group was responsible for the strongest increase in overall dietary adequacy and balance.

CONCLUSIONS

Overall dietary diversity is a useful indicator of dietary quality in Belgium. For some food groups, within-food group dietary diversity is a useful indicator of compliance with the specific FBDG for intake of that food group.

Quality of diet and food choices of Finnish young men: a sociodemographic and health behaviour approach

Objective

Eating habits of Finns have improved dramatically in 40 years. The proportion of fat in the diet has decreased and vegetable and fruit consumption increased. Knowledge of Finnish young men’s dietary habits is limited. The aim was to assess food choices and quality of diet among young men and to analyse how background and health behaviour factors explain it.

Design

In 2007, data on eating habits, sociodemographic background factors and health behaviours of 17–21-year-old men (n 2905) entering military service were collected by self-administrated questionnaire. Two indexes – core food index (CFI) and extra food index (EFI) – were formed to describe daily and redundant snacking-type eating, respectively. Associations of background factors and health behaviours on the indexes were analysed by general linear modelling.

Results

In all, 13 % consumed fruits and berries daily and 8 % consumed vegetables, whereas 24 % consumed pizza and 19 % consumed hamburgers more than once a week. CFI increased with educational level (P < 0·001) and was explained by background and health behaviour (smoking, physical activity and eating breakfast). EFI was inversely associated with BMI (P < 0·001) and explained by health behaviour: (smoking, physical activity, drinking beer and eating breakfast).

Conclusions

These results indicate that in early adulthood, eating habits cluster with other health behaviours among men. In this age group, education is associated with core food but not with extra food eating habits. Furthermore, seasonal variation is seen in both types of eating. When promoting healthy eating, a distinction between core foods and extra foods by using feasible indexes will be helpful in targeting the efforts.

Reproducibility and validity of a diet quality index for children assessed using a FFQ

The diet quality index (DQI) for preschool children is a new index developed to reflect compliance with four main food-based dietary guidelines for preschool children in Flanders. The present study investigates: (1) the validity of this index by comparing DQI scores for preschool children with nutrient intakes, both of which were derived from 3 d estimated diet records; (2) the reproducibility of the DQI for preschoolers based on a parentally reported forty-seven-item FFQ DQI, which was repeated after 5 weeks; (3) the relative validity of the FFQ DQI with 3 d record DQI scores as reference. The study sample included 510 and 58 preschoolers (2.5-6.5 years) for validity and reproducibility analyses, respectively. Increasing 3 d record DQI scores were associated with decreasing consumption of added sugars, and increasing intakes of fibre, water, Ca and many micronutrients. Mean FFQ DQI test-retest scores were not significantly different: 72 (sd 11) v. 71 (sd 10) (P = 0.218) out of a maximum of 100. Mean 3 d record DQI score (66 (sd 10)) was significantly lower than mean FFQ DQI (71 (sd 10); P < 0.001). The reproducibility correlation was 0.88. Pearsons correlation (adjusted for within-person variability) between FFQ and 3 d record DQI scores was 0.82. Cross-classification analysis of the FFQ and 3 d record DQI classified 60 % of the subjects in the same category and 3 % in extreme tertiles. Cross-classification of repeated administrations classified 62 % of the subjects in the same category and 3 % in extreme categories. The FFQ-based DQI approach compared well with the 3 d record approach, and it can be used to determine diet quality among preschoolers.

Determinants of diet quality among Canadian adolescents

PURPOSE

Dietary intakes and nutrition behaviours were examined among different diet quality groups of Canadian adolescents.

METHODS

This cross-sectional study included 2850 Alberta and Ontario adolescents aged 14 to 17, who completed a self-administered web-based survey that examined nutrient intakes and meal behaviours (meal frequency and meal consumption away from home).

RESULTS

Mean macronutrient intakes were within Acceptable Macronutrient Distribution Ranges; however, micronutrient intakes and median food group intakes were below recommendations based on Canada's Food Guide to Healthy Eating (CFGHE). Overall diet quality indicated that 43%, 47%, and 10% of students had poor, average, and superior diet quality, respectively. Adolescents with lower diet quality had significantly different intakes of macronutrients and CFGHE-defined "other foods." In terms of diet quality determinants, those with poor diet quality had higher frequencies of suboptimal meal behaviours. Students with poor diet quality consumed breakfast and lunch less frequently than did those with average and superior diet quality.

CONCLUSIONS

Canadian adolescents have low intakes of CFGHE-recommended foods and high intakes of "other foods." Those with poor diet quality had suboptimal macro-nutrient intakes and increased meal skipping and meal consumption away from home. Adherence to CFGHE may promote optimal dietary intakes and improve nutritional behaviours.

The number of index components affects the diagnostic accuracy of a diet quality index: the role of intracorrelation and intercorrelation structure of the components

PURPOSE

The aim of this work was to evaluate whether the number of components influences the diagnostic accuracy of a diet quality index and whether this association is affected by the intercorrelation structure of components and by the association of components with an outcome (intracorrelation).

METHODS

Simulated data were used to develop theoretical indices with various intracorrelation and intercorrelation structures of the components and outcomes. Moreover, dietary intake data of 668 elderly people from the MEDIS (Mediterranean Islands) study were also used to develop a diet index and to test it toward obesity status (outcome).

RESULTS

On the basis of 1,000 simulations, we observed that the diagnostic accuracy of an index increases as the number of components increases, only when the components are not intercorrelated or have low intercorrelation. Moreover, the diagnostic accuracy of an index developed with all components associated with an outcome is higher compared with an index developed by using only some components related to the outcome. Finally, the predictive ability of an isolated component is lower than that of an index developed by using non-intercorrelated or low-intercorrelated components. Real data confirmed the aforementioned findings.

CONCLUSION

Low-intercorrelated or non-intercorrelated components, strongly associated with a particular outcome, should be used in order to obtain an accurate composite index.

Diet quality, nutrition and physical activity among adolescents: the Web-SPAN (Web-Survey of Physical Activity and Nutrition) project

Objective

To assess the overall diet quality of a sample of adolescents living in Alberta, Canada, and evaluate whether diet quality, nutrient intakes, meal behaviours (i.e. meal skipping and consuming meals away from home) and physical activity are related.

Design

A cross-sectional study design. Students completed the self-administered Web-Survey of Physical Activity and Nutrition (Web-SPAN). Students were classified as having poor, average or superior diet quality based on Canada’s Food Guide to Healthy Eating (CFGHE).

Setting

One hundred and thirty-six schools (37 %) within forty-four public and private school boards (75 %) in Alberta, Canada.

Subjects

Grade 7 to 10 Alberta students (n4936) participated in the school-based research.

Results

On average, students met macronutrient requirements; however, micronutrient and fibre intakes were suboptimal. Median CFGHE food group intakes were below recommendations. Those with poor diet quality (42 %) had lower intakes of protein, fibre and low-calorie beverages; higher intakes of carbohydrates, fat and Other Foods (e.g. foods containing mostly sugar, high-salt/fat foods, high-calorie beverages, low-calorie beverages and high-sugar/fat foods); a lower frequency of consuming breakfast and a higher frequency of consuming meals away from home; and a lower level of physical activity when compared with students with either average or superior diet quality.

Conclusions

Alberta adolescents were not meeting minimum CFGHE recommendations, and thus had suboptimal intakes and poor diet quality. Suboptimal nutritional intakes, meal behaviours and physical inactivity were all related to poor diet quality and reflect the need to target these health behaviours in order to improve diet quality and overall health and wellness.

Dietary quality indices and human health: a review

Indices are composite tools aiming to measure and quantify a variety of clinical conditions, behaviors, attitudes and beliefs that are difficult to be measured quantitatively and accurately. In this review, the methodology used to develop dietary indices and their relationship with health determinants and outcomes is discussed. In brief, the already proposed indices are adequate tools concerning the evaluation of diet quality, but they have shown moderate predictive ability in relation to chronic diseases and health determinants. The aforementioned weaknesses could be attributed to: inappropriate selection of the components (i.e., number or content of dietary information), selection of small number of cut-off points for each component and/or equal contribution of all index items to the calculation of the total score. Nevertheless, dietary indices are important tools to evaluate not only the diet quality, but also the relationship between dietary habits and several health outcomes.

The gap between food-based dietary guidelines and usual food consumption in Belgium, 2004

OBJECTIVE

To evaluate the gap between food-based dietary guidelines (FBDG) and the usual food consumption in Belgium.

DESIGN AND SETTING

Information on food intake was collected with two non-consecutive 24 h recalls, using the validated software package EPIC-SOFT in combination with a self-administered FFQ. Habitual food intake was estimated by the Nusser method. Physical activity was evaluated according to the International Physical Activity Questionnaire.

SUBJECTS

A representative sample of the Belgian population aged 15 years and older was randomly selected from the National Register using a multistage stratified procedure. Dietary information was obtained from 3245 individuals.

RESULTS

Food intakes deviated significantly from the recommendations. In particular, fruit (118 g/d) and vegetable (138 g/d) consumption and intake of dairy and Ca-enriched soya products (159 g/d) were inadequate. Consumption of energy-dense, nutrient-poor foods (soft drinks, alcohol and snacks) was excessive (481 g/d). There were important age and gender differences. Fruit, vegetable and spreadable fat consumption was lowest, while consumption of dairy, starchy and energy-dense, nutrient-poor foods was highest among the youngest age group. Men consumed more animal and starchy foods than women, who consumed more fruits. There were only slight differences by education level.

CONCLUSION

Food intakes differed substantially from the FBDG. Improvement of the Belgian food pattern, in particular among the youngest age group, is necessary for a better prevention of diet-related diseases. In addition, continuous or regular monitoring is crucial to permit trend analyses and to plan effective education or intervention strategies.

An index of diet and eating patterns is a valid measure of diet quality in an Australian population

Diet indices represent an integrated approach to assessing eating patterns and behaviors. The aim of this study was to develop a comprehensive food-based dietary index to reflect adherence to healthy eating recommendations, evaluate the construct validity of the index using nutrient intakes, and evaluate this index in relation to sociodemographic factors, health behaviors, risk factors, and self-assessed health status. Data were analyzed from adult participants of the Australian National Nutrition Survey who completed a 108-item FFQ and a food habits questionnaire (n = 8220). The dietary guideline index (DGI) consisted of 15 items reflecting the dietary guidelines, including dietary indicators of vegetables and legumes, fruit, total cereals, meat and alternatives, total dairy, beverages, sodium, saturated fat, alcoholic beverages, and added sugars. Diet quality was incorporated using indicators relating to whole-grain cereals, lean meat, reduced/low fat dairy, and dietary variety. We investigated associations between the DGI score, sociodemographic factors, health behaviors, chronic disease risk factors, and nutrient intakes. We found associations between the DGI scores and sex, age, income, area-level socioeconomic disadvantage, smoking, physical activity, waist:hip ratio, systolic blood pressure (males only), and self-assessed health status (females only) (all P < 0.05). Higher DGI scores were associated with lower intakes of energy, total fat, and saturated fat and higher intakes of fiber, beta-carotene, vitamin C, folate, calcium, and iron (P < 0.05). This food-based dietary index is able to discriminate across a variety of sociodemographic factors, health behaviors, and self-assessed health and reflects intakes of key nutrients.

A critical review of predefined diet quality scores

The literature on predefined indexes of overall diet quality is reviewed. Their association with nutrient adequacy and health outcome is considered, but our primary interest is in the make-up of the scores. In total, twenty different indexes have been reviewed, four of which have gained most attention, and many others were based on those four. The various scores differ in many respects, such as the items included, the cut-off values used, and the exact method of scoring, indicating that many arbitrary choices have been made. Correlations in intake between dietary components may not be adequately addressed. In general, diet quality scores show an association with mortality or disease risk, but these relations are generally modest. Existing indexes do not predict morbidity or mortality significantly better than individual dietary factors. Although conclusions from the review may provide guidance in the construction of a diet quality score, it is questionable whether a dietary score can be obtained that is a much better predictor of health outcome.

Sources of saturated fatty acids in Belgian adolescents' diet: implications for the development of food-based dietary guidelines

The objectives of the present study are to describe the dietary sources of total fat and of saturated fatty acids (SFA) and to formulate food-based dietary guidelines for SFA in Belgian adolescents. A random sample of 13–18-year-old adolescents was drawn from secondary schools in the region of Ghent. A 7d estimated food record method was used to quantify nutrient and food intake. The average daily SFA intake is 4% above the recommended 10% of the total energy contribution. The most important contributors of SFA on food group level were ‘fats, oils and savoury sauces’, ‘meat and meat products’, ‘sugar, confectionery, sweet fillings and sauces’, ‘cheese’, ‘milk and milk products’ and ‘bread, rusk and breakfast rolls’. On food subgroup level ‘fresh meat’, ‘high-fat margarine’ and ‘high-fat cheese’ had the highest contribution to SFA intake in all adolescents. Adolescents with a low SFA intake (lowest tertile) were compared with adolescents with a high intake (highest tertile). In the lowest tertile the intake of total fat and MUFA was significantly lower than in the highest tertile, while the intake of total carbohydrates, mono- and disaccharides and complex carbohydrates was significantly higher. Overall, the high-fat cheese intake is significantly lower in the lowest tertile, while the fruit intake is higher. The present analysis shows that the nutritional profile of Belgian adolescents could be potentially improved by decreasing the portion sizes of fresh meat (in boys), high-fat margarine, high-fat cheese and reducing intake of commercially prepared baked goods and processed foods, including fast foods.

Two approaches to derive a proposal for added sugars intake for German children and adolescents

Objective:

Intake of sugars is restricted in most international food guides. However, in recent recommendations quantified limits of added sugars intake have not been given, although deemed necessary by those who criticised the recommendations.

Design:

Two approaches to derive a scientifically based quantified limit of added sugars intake for German children and adolescents are suggested. For the first dietary survey approach, 5120 three-day weighed dietary records from the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) Study were used. Added sugars intakes in records of high vs. low dietary quality, measured by a nutrient intake score, were compared. For the second approach, a total dietary concept for German children and adolescents developed and evaluated by the Research Institute of Child Nutrition – the Optimised Mixed Diet – was used.

Results:

Whereas in the latter dietary concept an added sugars intake of about 6% of energy intake is tolerated, the dietary survey approach resulted in only small differences between high and low dietary quality, with a median added sugars intake of 12% of energy in records with high dietary quality.

Conclusions:

A reasonable dietary quality is possible within higher ranges of added sugars intake than derived from the dietary concept approach. Therefore we suggest a range of intake of added sugars for German children and adolescents, from 6% to 12% of energy.

Food-based dietary guidelines can be developed and tested using linear programming analysis

Effective food-based dietary guidelines (FBDGs) are required to combat micronutrient deficiencies. This study aimed to develop a rigorous approach for designing population-specific FBDGs. A 4-phase approach based on linear programming analysis was used to design, test, and refine the FBDGs. This was illustrated for Malawian children. In phase I, the objective function minimized the difference in the energy contributed by different food groups between modeled and observed diets for 16 observed diet types, while preferentially selecting foods most often consumed. Constraints ensured nutrient adequacy and diet palatability. In phase II, the meal/snack patterns of the phase I modeled diets were examined to develop season-specific FBDGs. In phase III, the robustness of these FBDGs, for ensuring a nutritionally adequate diet, was tested. The objective function, in this analysis, minimized selected nutrient levels in the modeled diets (i.e., chose the "worst-case scenario"), while respecting the FBDGs, palatability, and energy constraints. The FBDGs were refined in phase IV. In the Malawian example used to illustrate our approach, the FBDGs promoted daily consumption of maize flour, small dry fish (>or=20 g), leaf relish, and 2-3 snacks. The last mentioned included mangoes, in the food-shortage season, and pumpkin in the food-plenty season. In addition, legume relish was recommended in the food-shortage season. The approach presented here can be used to design and then test the robustness of FBDGs for meeting nutrient recommendations.

Why combine diet and physical activity in the same international research society?

Research in diet and physical activity in the U.S. started in very different traditions, with behavioral science input being uneven in their development. Investigators and policy makers in Europe have recognized the complementarity of diet and physical activity and incorporated them both under the label Public Health Nutrition. Joining these disciplines internationally offers the opportunity to benefit all, since the problems addressed are human, not specific to any one country.

In regard to why combine diet and physical activity, at the biological level, there is reason to believe that diet and physical activity working in concert can remodel physiological structures and processes toward healthful ends. The diet and physical activity behaviors themselves vary in characteristics and are similar in others. The behavioral science components of these two disciplines face similar problems, and can learn from the advances made by the other, in the areas of measurement, correlates and intervention. By working together, knowledge will be enhanced from uncovering complementary and interactive relationships between diet and physical activity, and in relation to disease risks, that may result in designing more effective and efficient interventions and policies.

Since the behavioral sciences are at a disadvantage in comparison to the biological sciences in terms of scientific advances and thereby capturing the popular imagination for solutions to health problems, we must redouble our efforts to enhance funding for behavioral research in regard to diet and physical activity and to make the research advances necessary to prevent the medicalizing of essentially social and behavioral problems. Nutrition and physical activity should most effectively do this together.

Operationalizing Dietary Diversity: A Review of Measurement Issues and Research Priorities

Dietary diversity (DD) is universally recognized as a key component of healthy diets. There is still, however, a lack of consensus on how to measure and operationalize DD. This article reviews published literature on DD, with a focus on the conceptual and operational issues related to its measurement in developing countries. Findings from studies of the association between DD and individual nutrient adequacy, child growth and/or household socioeconomic factors are summarized. DD is usually measured using a simple count of foods or food groups over a given reference period, but a number of different groupings, classification systems and reference periods have been used. This limits comparability and generalizability of findings. The few studies that have validated DD against nutrient adequacy in developing countries confirm the well-documented positive association observed in developed countries. A consistent positive association between dietary diversity and child growth is also found in a number of countries. Evidence from a multicountry analysis suggests that household-level DD diversity is strongly associated with household per capita income and energy availability, suggesting that DD could be a useful indicator of food security. The nutritional contribution of animal foods to nutrient adequacy is indisputable, but the independent role of animal foods relative to overall dietary quality for child growth and nutrition remains poorly understood. DD is clearly a promising measurement tool, but additional research is required to improve and harmonize measurement approaches and indicators. Validation studies are also needed to test the usefulness of DD indicators for various purposes and in different contexts.