Nutrition-related issues for the breast cancer survivor

Stay on Track: A Pilot Randomized Control Trial on the Feasibility of a Diet and Exercise Intervention in Patients with Breast Cancer Receiving Radiotherapy

PURPOSE

Among patients with breast cancer undergoing radiotherapy, posttreatment cardiovascular disease and worsened quality of life (QoL) are leading causes of morbidity and mortality. To overcome these negative radiotherapy effects, this prospective, randomized clinical trial pilots a 12-week Stay on Track exercise and diet intervention for overweight patients with nonmetastatic breast cancer undergoing whole-breast radiotherapy.

EXPERIMENTAL DESIGN

The intervention group (n = 22) participated in three personal exercise and dietary counseling sessions, and received three text reminders/week to adhere to recommendations. The control group (n = 22) was administered a diet/exercise information binder. All patients received a Fitbit, and at baseline, 3 months, and 6 months, measurements of biomarkers, dual-energy X-ray absorptiometry scans, QoL and physical activity surveys, and food frequency questionnaires were obtained. A satisfaction survey was administered at 3 months.

RESULTS

Stay on Track was well received, with high rates of adherence and satisfaction. The intervention group showed an increase in self-reported physical activity and preserved QoL, a decrease in body mass index and visceral fat, and higher American Cancer Society/American Institute of Cancer Research dietary adherence. The control participants had reduced QoL, anti-inflammatory markers, and increased metabolic syndrome markers. Both groups had decreased overall body mass. These changes were within group effects. When comparing the intervention and control groups over time, there were notable improvements in dietary adherence in the intervention group.

CONCLUSIONS

Targeted lifestyle interventions during radiotherapy are feasible and could decrease cardiovascular comorbidities in patients with breast cancer. Larger-scale implementation with longer follow-up can better determine interventions that influence cardiometabolic health and QoL.

SIGNIFICANCE

This pilot study examines cardiometabolic benefits of a combined diet and exercise intervention for patients with breast cancer undergoing radiotherapy. The intervention included an activity tracker (FitBit) and text message reminders to promote adherence to lifestyle interventions. Large-scale implementation of such programs may improve cardiometabolic outcomes and overall QoL among patients with breast cancer.

Design and implementation of a standard care programme of therapeutic exercise and education for breast cancer survivors

BACKGROUND

Breast cancer survivors (BCS) face several symptoms and are at higher risk of weight gain following diagnosis. Current literature shows that both exercise and diet play a key role in recovery of BCS. However, there is a gap between current guidelines and the real-world context. The aim of this article is to describe the process behind a free, not-for-profit community-based therapeutic exercise and education programme (TEEP) for BCS in the clinical setting.

METHODS

The "Onco-Health Club" (OHC) consists of therapeutic exercise (TE) intervention aimed at ameliorating cancer-related fatigue (CRF) and improving QoL and physical function. TE is supplemented with nutritional education, providing information about the Mediterranean diet. To this end, patients are recruited from an oncologist and are referred to a physiotherapist and a nutritionist for baseline assessment. TEEP consists of a 3-month intervention, delivered twice a week in a group format with 1 h of TE and 30 min of nutritional education. BCS then have a final assessment and are advised to continue with a healthy lifestyle. Data about referral, compliance and assessment were collected.

RESULTS

From May 2017 to February of 2020, a total of 158 patients were recruited from 8 cohorts and 142 initially started the OHC. From 119 that joined the program, 96 patients were considered to have finished it with good adherence (assistance > 80%). BCS significantly improved their QoL, as well as upper and lower limb's function, and increased their level of physical activity. CRF tended to decrease (p = 0.005).

CONCLUSIONS

This study obtained data on recruitment, compliance, and possible limitations of these kinds of programmes in a real-world context. Further research is needed in order to optimize patient engagement and compliance, as well as to determine the transferability of these programmes in the clinical setting.

TRIAL REGISTRATION

NCT03879096, Registered 18th March 2019. Retrospectively registered.

Benefits of Dietary Management in Breast Cancer Patients: A Systematic Review and Meta-Analysis

The World Cancer Research Fund/American Institute of Cancer Research recommendations include guidance on diet, nutrition, and weight management for people with cancer. However, for women diagnosed with breast cancer there is a lack of comprehensive analyses on the effects of dietary interventions. The purpose of this study was to investigate the impact of changes in dietary behavior and body composition on breast cancer development. A comprehensive and systematic literature search of 12 electronic databases was undertaken on January 27, 2021 to identify randomized controlled trials (RCTs) of dietary interventions for breast cancer. The Cochrane risk bias assessment tool was used to evaluate the quality of the trials identified with the data analyzed by Review Manager 5.3 software. The results showed that dietary interventions probably did not modify servings of fruit (P = 0.08), fat intake (P = 0.10), total cholesterol level (P = 0.82), body weight (P = 0.08), waist circumference (P = 0.15), or waist-to-hip ratio (P = 0.32). However, a significant reduction in body mass index (P = 0.03), and hip circumference (P = 0.03), and improvement in energy intake (P = 0.02), vegetable servings (P < 0.0001), and fiber intake (P < 0.00001) were observed. Future studies should investigate the benefits of exercise in combination with dietary interventions in breast cancer patients.Supplemental data for this article is available online at https://doi.org/10.1080/01635581.2021.1957129.

Self-Reported Changes and Perceived Barriers to Healthy Eating and Physical Activity among Global Breast Cancer Survivors: Results from an Exploratory Online Novel Survey

BACKGROUND

Despite being motivated to improve nutrition and physical activity behaviors, cancer survivors are still burdened by suboptimal dietary intake and low levels of physical activity.

OBJECTIVE

The aim of this study was to assess changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, barriers to eating a healthy diet and staying physically active, and sources for seeking nutrition advice reported by breast cancer survivors.

DESIGN

This was a cross-sectional study.

PARTICIPANTS/SETTING

The study included 315 survivors of breast cancer who were recruited through social media and provided completed responses to an online exploratory survey.

MAIN OUTCOME MEASURES

Self-reported changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, perceived barriers to healthy eating and physical activity, and sources of nutrition advice were measured.

STATISTICAL ANALYSIS

Frequency distribution of nutrition and physical activity behaviors and changes, barriers to healthy eating and physical activity, and sources of nutrition advice were estimated.

RESULTS

About 84.4% of the breast cancer survivors reported at least 1 positive behavior for improving nutrition and physical activity after cancer diagnosis or treatment. Fatigue was the top barrier to both making healthy food choices (72.1%) and staying physically active (65.7%), followed by stress (69.5%) and treatment-related changes in eating habits (eg, change in tastes, loss of appetite, and craving unhealthy food) (31.4% to 48.6%) as barriers to healthy eating, and pain or discomfort (53.7%) as barriers to being physically active. Internet search (74.9%) was the primary source for seeking nutrition advice. Fewer than half reported seeking nutrition advice from health care providers.

CONCLUSIONS

Despite making positive changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, breast cancer survivors experience treatment-related barriers to eating a healthy diet and staying physically active. Our results reinforce the need for developing tailored intervention programs and integrating nutrition into oncology care.

Breast Cancer: A Lifestyle Medicine Approach

Breast cancer is the most common female cancer diagnosis in the United States (excluding skin cancers), and the second leading cause of female cancer death. This article highlights the role that lifestyle plays in primary breast cancer prevention, breast cancer treatment, and tertiary breast cancer prevention. Current data regarding the benefits of a predominantly plant-based diet in combination with physical activity and maintenance of a healthy body weight will be reviewed. The evidenced-based patient-focused recommendations developed by the World Cancer Research Fund/American Institute for Cancer Research will be discussed in the context of an overall lifestyle strategy. It is our hope that this publication empowers clinicians to provide patients with personalized cancer-protective lifestyle prescriptions.

The Effects of Diet and Dietary Interventions on the Quality of Life among Breast Cancer Survivors: A Cross-Sectional Analysis and a Systematic Review of Experimental Studies

There is an ongoing need for solid evidence about the effects of healthy behaviors, and particularly diet, on the quality of life (QoL) among breast cancer survivors. We first conducted a cross-sectional study on 68 Italian stage I-III breast cancer survivors, to investigate the association of adherence to the Mediterranean diet (MD), physical activity and weight status with QoL. Adherence to MD and physical activity was assessed using structured questionnaires. QoL was assessed using the European Organization for the Research and Treatment of Cancer Quality-of-Life tools. We showed that low consumption of red meat and carbonated beverages, daily consumption of wine and high consumption of dishes seasoned with sofrito had beneficial effects on several QoL subscales. By contrast, using olive oil as the main culinary fat, low consumption of commercial sweets and high consumption of nuts were associated with negative effects. Overall, these findings resulted in a null effect of adherence to MD on QoL. Furthermore, we observed better QoL sub-scores among women who performed moderate physical activity (i.e., diarrhea) and those who were underweight/normal weight (i.e., physical functioning and dyspnea) if compared with their counterparts (p-values ≤ 0.003 after correction for multiple comparison). Next, we performed a systematic review of nine experimental studies to summarize whether dietary interventions might improve QoL among breast cancer patients. All the studies demonstrated significant improvements in overall QoL and/or its subscales after the interventions. However, differences in study design, interventions and tools used for QoL assessment did not allow us to provide an overall estimate. Moreover, only a single-arm trial evaluated the effect of an exclusive dietary-based intervention, while others combined dietary recommendations with physical activity and weight loss programs. For these reasons, our study encourages more efforts to improve the robustness of current evidence, through more homogenous tools, larger population-based studies and further randomized controlled trials.

Aspects of Health-Related Factors and Nutritional Care Needs by Survival Stage among Female Cancer Patients in South Korea

PURPOSE

This study examined diet-related problems and needs associated with nutritional care according to survival stage in Korean female cancer survivors.

METHODS

186 outpatients (breast or gynecologic cancer survivors) recruited. Subjects were classified as (1) extended stage (ES, 2-5 years from diagnosis) and (2) long-term stage (LS, ≥5 years from diagnosis). Eating habits, changes in health related factors, nutritional needs, and quality of life were investigated.

RESULTS

43% of ES survivors had diet-related problems (p = .031); ES group reported dyspepsia and LS group reported anorexia/nausea as the major problem. Half of ES survivors had taste change, decreasing amount of intake, and reduced quality of life (p < .05). The LS group had a greater preference for sweet tastes than the ES group. According to their diagnosis, ES survivors with breast cancer gained weight (27.1%), whereas ES survivors with gynecologic cancer lost their body weight (34.5%) significantly. LS breast cancer patients showed great food preference for vegetables, whereas those with gynecologic cancer showed an increased preference for fish, meat and grain. Approximately 90% of survivors demanded nutritional care regarding restricted foods, preventing recurrence, particularly in ES survivors (p < .01). Moreover, main factors for nutritional care needs were body weight control for breast cancer and food environment for gynecologic cancer.

CONCLUSION

Survivors have different aspects of diet-related problems by survival stage as dyspepsia in ES and anorexia in LS. ES stage had changes in dietary patterns and their food consumption have decreased. Most of survivors have demanded nutritional care regardless of survival stage. These features of each stage should be considered to improve their health.

Associations between self-reported post-diagnosis physical activity changes, body weight changes, and psychosocial well-being in breast cancer survivors

PURPOSE

Decreased physical activity and weight gain post-breast cancer diagnosis are associated with negative psychosocial, health, and disease outcomes, but little is known about how these factors interact. The purpose of the present study was to conduct a preliminary examination of the association between post-diagnosis physical activity changes, weight changes, and psychosocial well-being in breast cancer survivors.

METHODS

We examined the association between retrospectively collected, self-reported post-diagnosis changes in physical activity and body weight and post-diagnosis fatigue, anxiety, depression, stress, self-esteem, and health-related quality of life (HRQOL) in breast cancer survivors (N = 1,348) using univariate analyses of covariance with Bonferroni's adjustment.

RESULTS

After adjusting for covariates, maintaining and/or increasing physical activity post-diagnosis was significantly (p < 0.05 for all), independently associated with lower fatigue, anxiety, depression and stress and higher physical self-worth, physical, social, emotional, functional and breast cancer specific well-being and overall HRQOL (effect sizes = 0.23 to 0.60). Maintaining and/or losing weight was significantly (p < 0.05), independently associated with lower fatigue and higher physical self-worth, physical and breast cancer-specific well-being, and overall HRQOL (effect sizes = .28 to 0.87). There were no significant interaction effects between physical activity and body weight changes.

CONCLUSIONS

This study provides preliminary data to suggest that maintaining or increasing physical activity and controlling weight post-diagnosis may be independently, positively associated with psychosocial well-being and HRQOL in breast cancer survivors. In addition, weight management effects may be larger and more outcome-specific while physical activity effects may be more general. Future research is warranted to replicate and confirm these findings.

Weight change during chemotherapy changes the prognosis in non metastatic breast cancer for the worse

Background

Weight change during chemotherapy is reported to be associated with a worse prognosis in breast cancer patients, both with weight gain and weight loss. However, most studies were conducted prior to the common use of anthracycline-base chemotherapy and on North American populations with a mean BMI classified as overweight. Our study was aimed to evaluate the prognostic value of weight change during anthracycline-based chemotherapy on non metastatic breast cancer (European population) with a long term follow-up.

Methods

Patients included 111 women diagnosed with early stage breast cancer and locally advanced breast cancer who have been treated by anthracycline-based chemotherapy regimen between 1976 and 1989. The relative percent weight variation (WV) between baseline and postchemotherapy treatment was calculated and categorized into either weight change (WV > 5%) or stable (WV < 5%). The median follow-up was 20.4 years [19.4 - 27.6]. Cox proportional hazard models were used to evaluate any potential association of weight change and known prognostic factors with the time to recurrence and overall survival.

Results

Baseline BMI was 24.4 kg/m2 [17.1 - 40.5]. During chemotherapy treatment, 31% of patients presented a notable weight variation which was greater than 5% of their initial weight.

In multivariate analyses, weight change (> 5%) was positively associated with an increased risk of both recurrence (RR 2.28; 95% CI: 1.29-4.03) and death (RR 2.11; 95% CI: 1.21-3.66).

Conclusions

Our results suggest that weight change during breast-cancer chemotherapy treatment may be related to poorer prognosis with higher reccurence and higher mortality in comparison to women who maintained their weight.

A randomized trial of tailoring and motivational interviewing to promote fruit and vegetable consumption for cancer prevention and control

BACKGROUND

Healthful dietary patterns, including eating fruits and vegetables (F&V) and avoiding obesity, may decrease the risk of cancer and other chronic diseases. In addition to promoting health for the general population, a cancer diagnosis may provide a "teachable moment," facilitating the adoption of more healthful eating habits and leading to lower risk of chronic disease and better overall health.

PURPOSE

This study was designed to test the effectiveness of two health communication interventions in increasing F&V consumption and physical activity in a sample of older adults (average age of 66 years), including both colorectal cancer (CRC) survivors and noncolorectal cancer-affected (N-CRC) individuals.

METHODS

CRC survivors and N-CRC individuals were recruited from a population-based case-control study and randomly assigned to four conditions using a 2 x 2 design. We tested two different methods of communicating and promoting health behavior change alone or in combination: tailored print communication (TPC) and brief telephone-based motivational interviewing (TMI).

RESULTS

A significant increase in F&V consumption was found for the combined intervention group in the entire sample (p < 0.05). When stratified by cancer survivor status, the effect was concentrated in the N-CRC subset (p < 0.01) versus CRC survivors. The combined intervention was also found to be most cost-effective for the N-CRC group, with TPC more cost-effective than TMI. For physical activity, none of the interventions produced statistically significant improvements.

CONCLUSIONS

This study indicates that combining tailoring and motivational interviewing may be an effective and cost-effective method for promoting dietary behavior change among older healthy adults. More research is needed to identify the optimal dose and timing for intervention strategies to promote dietary and physical activity change among both CRC survivors and the general population.

Pre-diagnosis body mass index, post-diagnosis weight change, and prognosis among women with early stage breast cancer

OBJECTIVE

We examined the association between body mass index (BMI) around the time of diagnosis, weight change post-diagnosis, and breast cancer prognosis in a prospective cohort study of 1,692 breast cancer survivors.

METHODS

Pre-diagnosis weight, weight at study entry, and height was obtained from mailed questionnaires and then weight change and BMI were calculated. After approximately seven years of follow-up, 207 recurrences, 99 deaths due to breast cancer, and 162 deaths due to any cause were reported. Delayed entry Cox proportional hazard models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI), controlling for treatment and known prognostic factors.

RESULTS

Being obese one year before diagnosis was associated with an increased risk of death from any cause (HR = 1.6; 95% CI: 1.1-2.3) and a suggestion of increased risk of death from breast cancer (HR = 1.6; 95% CI: 0.9-2.7). However, weight gain up to four years after a breast cancer diagnosis was not associated with an increased risk of recurrence or death from any cause nor did moderate weight loss (5-10%) decrease risk of these outcomes. There was some evidence that women who had larger weight losses (>or=10%) between pre-diagnosis and study entry had an increased risk of recurrence (HR = 1.7; 95% CI 1.0-2.6) and death due to any cause (HR = 2.1; 95% CI 1.3-3.4) compared to being weight stable. This elevated risk was more pronounced among women who were obese before diagnosis (BMI >or= 30 kg/m(2)) or who had ER- or PR- tumors.

CONCLUSION

We found that being obese before breast cancer diagnosis was associated with increased risk of recurrence and poorer survival, corroborating results from previous studies. However, weight gain after diagnosis did not confer additional risk. Body weight pre-diagnosis appears to be the strongest predictor of an adverse breast cancer prognosis.

Plasma and dietary carotenoids are associated with reduced oxidative stress in women previously treated for breast cancer

Dietary carotenoids show numerous biological activities, including antioxidant activity, induction of apoptosis, and inhibition of mammary cell proliferation. Studies examining the role of carotenoid consumption in relation to breast cancer recurrence are limited and report mixed results. We tested the hypothesis that breast cancer survivors with high dietary and plasma carotenoids would show significantly lower levels of oxidative stress than breast cancer survivors with low dietary and plasma carotenoid levels. Two hundred seven postmenopausal breast cancer survivors from the Women's Healthy Eating and Living Study volunteered for this ancillary study. Dietary data were analyzed by the Arizona Food Frequency Questionnaire and plasma carotenoids alpha-carotene, beta-carotene, lutein plus zeaxanthin, lycopene, and beta-cryptoxanthin and quantified with high-performance liquid chromatography, and immunoaffinity chromatography-monoclonal antibody-based ELISAs were used to analyze the urine samples for 8-hydroxy-2'-deoxyguanosine (8-OhdG) and 8-iso-prostaglandin-F2alpha (8-iso-PGF2alpha). The correlations between dietary and plasma carotenoids were 0.34 for beta-carotene, 0.46 for alpha-carotene, 0.39 for beta-cryptoxanthin, 0.27 for lycopene, 0.30 for lutein plus zeaxanthin, and 0.30 for total carotenoids. The 8-OHdG oxidative stress biomarker was significantly reduced at the highest quartile of total plasma carotenoid concentrations (P = 0.001) and 8-iso-PGF2alpha was moderately reduced (P = 0.088). Dietary carotenoid levels were not significantly associated with oxidative, stress indicators, although dietary lycopene and lutein/zeaxanthin were modestly associated with 8-OHdG levels (P = 0.054 and 0.088, respectively). Key findings include a significant inverse association between total plasma carotenoid concentrations and oxidative stress as measured by urinary 8-OHdG and a moderately significant inverse association with 8-iso-PGF2alpha, a protective association that was not shown for dietary carotenoid intake.

Mediterranean diet, olive oil and cancer

Olive oil is an integral ingredient of the "Mediterranean diet" and accumulating evidence suggests that it may have a potential role in lowering the risk of several types of cancers. The mechanisms by which the cancer-preventing effects of olive oil can be performed, however, are not known. We recently hypothesized that a novel molecular explanation concerning the anti-cancer actions of olive oil may relate to the ability of its monounsaturated fatty acid (MUFA) oleic acid (OA; 18:1n-9) to specifically regulate cancer-related oncogenes. Supporting our hypothesis, exogenous supplementation of cultured breast cancer cells with physiological concentrations of OA was found to suppress the overexpression of HER2 (Her-2/neu, erbB-2), a well-characterized oncogene playing a key role in the etiology, progression and response to chemotherapy and endocrine therapy in approximately 20% of breast carcinomas. OA treatment was also found to synergistically enhance the efficacy of trastuzumab, a humanized monoclonal antibody binding with high affinity to the ectodomain (ECD) of the Her2-coded p185(HER2) oncoprotein. Moreover, OA exposure significantly diminished the proteolytic cleavage of the ECD of HER2 and, consequently, its activation status, a crucial molecular event that determines both the aggressive behavior and the response to trastuzumab of Her2-overexpressing breast carcinomas. Our most recent findings further reveal that OA exposure may suppresses HER2 at the transcriptional level by up-regulating the expression of the Ets protein PEA3 -a DNA-binding protein that specifically blocks HER2 promoter activity- in breast, ovarian and stomach cancer cell lines. This anti-HER2 property of OA offers a previously unrecognized molecular mechanism by which olive oil may regulate the malignant behavior of cancer cells. From a clinical perspective, it could provide an effective means of influencing the outcome of Her-2/neu-overexpressing human carcinomas with poor prognosis. Indeed, OA-induced transcriptional repression of HER2 oncogene may represent a novel genomic explanation linking "Mediterranean diet", olive oil and cancer as it seems to equally operate in various types of Her-2/neu-related carcinomas.

Post-diagnosis weight gain and breast cancer recurrence in women with early stage breast cancer

PURPOSE

To examine whether weight gain after diagnosis of breast cancer affects the risk of breast cancer recurrence.

PATIENT AND METHODS

Patients included 3215 women diagnosed with early stage breast cancer (Stage I >1 cm., II, and IIIA) who were enrolled either in an observational cohort of breast cancer survivors or were part of the comparison group of a dietary intervention trial to prevent breast cancer recurrence. We computed weight change from 1 year prior to diagnosis to study enrollment. Delayed entry Cox proportional hazards models were used to evaluate associations of categories of weight change with time to recurrence, controlling for known prognostic factors.

RESULTS

Neither moderate (5-10%) nor large (> 10%) weight gain (HR 0.8, 95% CI, 0.6-1.1; HR 0.9, 95% CI, 0.7-1.2, respectively) after breast cancer diagnosis was associated with an increased risk of breast cancer recurrence in the early years post-diagnosis (median time of 73.7 months from diagnosis).

CONCLUSION

Our research provides evidence that weight gain commonly seen in the first several years following a breast cancer diagnosis does not increase a woman's risk for breast cancer recurrence in the first 5-7 years post-diagnosis. However, this research does not address the effects of weight gain on overall survival or on the risk of other new cancers, other prognostic outcomes of concern to the breast cancer survivor.

Diet among breast cancer survivors and healthy women. The Norwegian Women and Cancer Study

OBJECTIVE

To compare the diet and lifestyle in breast cancer survivors and healthy women.

DESIGN

Cross-sectional study in the population-based Norwegian Women and Cancer cohort study, using a postal questionnaire on diet, lifestyle and health.

SETTING

Nation-wide, population-based study.

SUBJECTS

Women aged 41-70 years. Prevalent breast cancer cases (314 short-term with 1-5 years since diagnosis, 352 long-term with >5 years since diagnosis) were identified by linkage to the Norwegian Cancer Registry. The comparison group consisted of 54,314 women.

INTERVENTIONS

Analyses of variance, with post hoc Bonferroni tests when significant differences were found.

RESULTS

Overall there were few differences in the diet of the three groups. Short-term survivors ate more fruits and vegetables than healthy women (P<0.0001), and consumed more of nutrients associated with fruit and vegetables (fibre, mono- and disaccharides, folate, vitamin C and potassium). Short-term breast cancer survivors also had a higher use of dietary supplements and a lower level of physical activity, but did not differ from healthy women on other lifestyle factors. The long-time survivors did not differ from any of the other groups.

CONCLUSION

Diet and lifestyle is generally similar between breast cancer survivors and healthy women, especially more than 5 years after diagnosis.

Concept of a nutritious food: toward a nutrient density score

The American diet is said to be increasingly energy-rich but nutrient-poor. To help improve the nutrient-to-energy ratio, the 2005 Dietary Guidelines for Americans recommend that consumers replace some foods in their diets with more nutrient-dense options. Such dietary guidance presupposes the existence of a nutrient density standard. However, a review of the literature shows that the concept of a nutritious food is not based on any consistent standards or criteria. In many cases, healthful foods are defined by the absence of problematic ingredients-fat, sugar, and sodium-rather than by the presence of any beneficial nutrients they might contain. Past attempts to quantify the nutrient density of foods have been based on a variety of calories-to-nutrient scores, nutrients-per-calorie indexes, and nutrient-to-nutrient ratios. The naturally nutrient rich (NNR) score, which is based on mean percentage daily values (DVs) for 14 nutrients in 2000 kcal food, can be used to assign nutrient density values to foods within and across food groups. Use of the NNR score allows consumers to identify and select nutrient-dense foods while permitting some flexibility where the discretionary calories are concerned. This approach has implications for food labeling, nutritional policy making, and consumer education. The Food and Drug Administration has considered approving nutrient claims based on the ratio of a beneficial nutrient to the food's energy content, as opposed to a specified minimum amount of a nutrient per serving size. Given the current dietary trends, the nutrient density approach can be a valuable tool for nutrition education and dietary guidance.