Ready-to-Eat Cereal Consumption with Total and Cause-Specific Mortality: Prospective Analysis of 367,442 Individuals

Dietary intake of total vegetable, fruit, cereal, soluble and insoluble fiber and risk of all-cause, cardiovascular, and cancer mortality: systematic review and dose-response meta-analysis of prospective cohort studies

Objectives

To conduct a systematic review and meta-analysis of prospective cohort studies to investigate the association between total, vegetable, fruit, cereal, soluble and insoluble fiber intake and risk of all causes, cardiovascular disease (CVD), and cancer mortality and quantitatively assess the dose-response relation.

Methods

Eligible studies were identified by searching PubMed, Embase and Web of science before August 2023. Random effects models were used to calculate summary relative risk (RR) and 95% confidence intervals (CI) and restricted cubic splines to model the linear/non-linear association.

Results

The summary RR for all-cause, CVD and cancer mortality of dietary fiber was 0.90 (95% CI: 0.86,0.93), 0.87 (0.84,0.91), 0.91 (0.88,0.93), respectively. Significant association was observed for all-cause and CVD mortality with fruit, vegetable cereal and soluble fiber intake and cancer mortality with cereal fiber intake. No significant association was found for insoluble fiber, vegetable or fruit fiber intake and cancer mortality. Dose-response analysis showed a significant non-linear relation of dietary fiber intake with all-cause mortality, and linear relation for others.

Conclusions

Higher dietary fiber including different type and food sources of fiber intake were associated with lower risk of mortality. Our findings provide more comprehensive evidence on dietary fiber intake with mortality.

Systematic review registration

https://www.crd.york.ac.uk/prospero, identifier: CRD42022338837.

The Relationship Between Major Food Sources of Fructose and Cardiovascular Outcomes: A Systematic Review and Dose-Response Meta-Analysis of Prospective Studies

There is emerging evidence of associations between intake of sugar-sweetened beverages (SSBs), those that include various forms of added sugar, and increased risk of cardiovascular disease (CVD) but whether consumption of other dietary sources of fructose affects CVD is unclear. In this study, we conducted a meta-analysis to examine potential dose-response relationships between such foods and CVD, coronary heart disease (CHD), and stroke morbidity and mortality. We systematically searched the literature indexed in PubMed, Embase, and the Cochrane Library from the inception of each database to February 10, 2022. We included prospective cohort studies analyzing the association between at least 1 dietary source of fructose and CVD, CHD, and stroke. Based on data from 64 included studies, summary HRs and 95% CIs were calculated for the highest intake category compared with the lowest, and dose-response analyses were performed. Of all fructose sources examined, only SSB intakes showed positive associations with CVD, giving summary HRs per 250 mL/d increase of 1.10 (95% CI: 1.02, 1.17) for CVD, 1.11 (95% CI: 1.05, 1.17) for CHD, 1.08 (95% CI: 1.02, 1.13) for stroke morbidity, and 1.06 (95% CI: 1.02, 1.10) for CVD mortality. Conversely, 3 dietary sources showed protective associations: between fruits and CVD morbidity (HR: 0.97; 95% CI: 0.96, 0.98), fruits and CVD mortality (HR: 0.94; 95% CI: 0.92, 0.97), yogurt and CVD mortality (HR: 0.96; 95% CI: 0.93, 0.99), and breakfast cereals and CVD mortality (HR: 0.80; 95% CI: 0.70, 0.90). All these relationships were linear except for fruit, which was J-shaped: CVD morbidity was the lowest at 200 g/d and there was no protective association above 400 g/d. These findings indicate that the adverse associations between SSBs and CVD, CHD, and stroke morbidity and mortality do not extend to other dietary sources of fructose. The food matrix seemed to modify the association between fructose and cardiovascular outcomes.

Guidance and perspectives on highly processed foods

Guidance from Health Canada to limit highly processed foods (HPF) seeks to ensure that Canadians remain within intake recommendations for nutrients of concern. However, HPF can contribute to dietary requirements of specific populations. The Canadian Nutrition Society and Institute for the Advancement of Food and Nutritional Sciences convened speakers for a Food for Health workshop in 2021 to provide evidence and perspectives from government, industry, and healthcare on reasons for advocating limits and potential unintended consequences of limiting HPF, and implications and necessity of HPF in clinical settings. This paper discusses advantages and disadvantages of HPF explored at this workshop.

Association Between Ultra-Processed Food Intake and All-Cause Mortality: A Systematic Review and Meta-Analysis

Consumption of ultra-processed foods (UPF) has increased worldwide during the last decades because they are hyperpalatable, cheap, and ready-to-consume products. However, uncertainty exists about their impact on health. We conducted a systematic review and meta-analysis evaluating the association of UPF consumption with all-cause mortality risk. Five bibliographic databases were searched for relevant studies. Random effects models were used to calculate pooled relative risks (RRs) and 95% confidence intervals (CIs). Of 6,951 unique citations, 40 unique prospective cohort studies comprising 5,750,133 individuals were included; publication dates ranged from 1984 to 2021. Compared with low consumption, highest consumption of UPF (RR = 1.29, 95% CI: 1.17, 1.42), sugar-sweetened beverages (RR = 1.11, 95% CI, 1.04, 1.18), artificially sweetened beverages (RR = 1.14, 95% CI, 1.05, 1.22), and processed meat/red meat (RR = 1.15, 95% CI, 1.10, 1.21) were significantly associated with increased risk of mortality. However, breakfast cereals were associated with a lower mortality risk (RR = 0.85, 95% CI, 0.79, 0.92). This meta-analysis suggests that high consumption of UPF, sugar-sweetened beverages, artificially sweetened beverages, processed meat, and processed red meat might increase all-cause mortality, while breakfast cereals might decrease it. Future studies are needed to address lack of standardized methods in UPF categorization.

Ready-to-eat cereal fortification: a modelling study on the impact of changing ready-to-eat cereal fortification levels on population intake of nutrients

OBJECTIVE

Ready-to-eat (RTE) cereal is an important source of nutrients in the American diet. Recent regulatory changes to labelling requirements may impact the fortification of RTE cereal. We used an evidence-based approach to optimize the fortification of RTE cereal considering current dietary patterns and nutrition policy.

DESIGN

A US modelling study of cross-sectional data from the National Health and Nutrition Examination Survey (NHANES) 2013-2014. The percentage of the population below the Estimated Average Requirement (EAR) and above the Upper Tolerable Intake Level (UL) was modelled under three scenarios: baseline, zero fortification and optimized fortification.

SETTING

USA.

PARTICIPANTS

Toddlers aged 1-3 years, n 559; children aged 4-12 years, n 1540; adolescents aged 13-18 years, n 992; and adults aged ≥19 years, n 576.

RESULTS

Comparing current with optimized fortification, nutrient/100 g RTE cereal decreased for vitamin A, thiamin, riboflavin, niacin, vitamin B6, folic acid, vitamin B12, Ca and Fe (by 2-82 %). The amount of vitamins C and D increased (by 13 and 50 %, respectively). Among RTE cereal eaters, these changes resulted in modest increases in the percentage of the population aged ≥1 year below the EAR (+0·5 to +11·5 percentage points). Decreases were observed in the percentage of the population above the UL.

CONCLUSIONS

Fortification of RTE cereal can be optimized to provide key nutrients and minimize the percentage of the population below the EAR and above the UL. Dietary intake modelling is useful to ensure that RTE cereal continues to help the population meet their nutrient needs.

Association between Ready-to-Eat Cereal Consumption and Nutrient Intake, Nutritional Adequacy, and Diet Quality in Adults in the National Health and Nutrition Examination Survey 2015-2016

This study examined differences in dietary intake between ready-to-eat cereal eaters and non-eaters in adults from the United States. Participants (n = 5163) from the National Health and Nutrition Examination Survey 2015–2016 were included. One-day dietary recall was used to define ready-to-eat cereal consumption status and estimate dietary intake in eaters and non-eaters. Data from Food Patterns Equivalent Database 2015–2016 were used to compare intakes of food groups by consumption status. Diet quality was assessed by Healthy Eating Index 2015. Nineteen percent of US adults were ready-to-eat cereal eaters; they had a similar level of energy intake as non-eaters, but they had significantly higher intake of dietary fiber, and several vitamins and minerals, such as calcium, iron, magnesium, potassium, zinc, vitamin A, thiamin, riboflavin, niacin, vitamin B₆, folate, vitamin B₁₂, and vitamin D. They were also more likely to meet nutrient recommendations. Compared to non-eaters, ready-to-eat cereal eaters had the same level of added sugar intake but they had significantly higher intake of whole grains, total fruits, and dairy products. The diet quality of ready-to-eat cereal eaters was significantly higher than that of non-eaters. The study supports that ready-to-eat cereal eaters have better dietary intake with a healthier dietary pattern than non-eaters in the United States.

Association between Ready-to-Eat Cereal Consumption and Nutrient Intake, Nutritional Adequacy, and Diet Quality among Infants, Toddlers, and Children in the National Health and Nutrition Examination Survey 2015-2016

Ready-to-eat (RTE) cereal is a popular food among children. However, there are no recent data on the associations between RTE cereal consumption and dietary outcomes in the U.S. Therefore, we sought to investigate how RTE cereal was associated with nutrient and food group intakes and overall dietary quality among children aged 0.5 to 17 years using the latest data from the National Health and Nutrition Examination Survey (NHANES 2015-2016). Thirty-six percent of children reported consuming RTE cereal. RTE cereal eaters consumed the same number of calories as non-eaters but had higher intakes of total carbohydrates, total sugar, fiber, calcium, iron, magnesium, potassium, zinc, vitamin A, thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, and vitamin D, as well as lower intakes of total fat and saturated fat (p ≤ 0.0007). We also found that children who consumed RTE cereal had 29% higher total dairy intake (p < 0.0001) and 61% higher whole grain intake (p < 0.0001). Lastly, children who ate RTE cereal had higher diet quality than the children that did not eat RTE cereal, as shown by Healthy Eating Index 2015 total score (52.6 versus 47.7, p < 0.0001). Therefore, consumption of whole-grain fortified RTE cereals should be encouraged as part of healthy dietary patterns for children.

The protective effect of muesli consumption on diabetes risk: Results from 12 years of follow-up in the Australian Longitudinal Study on Women's Health

Diabetes affects 9.8% of Australian women. Breakfast cereal consumption is potentially protective against diabetes. This study investigated the effects of breakfast cereal consumption on the 12-year risk of developing diabetes among mid-aged participants of the Australian Longitudinal Study of Women's Health (ALSWH). It was hypothesized that any breakfast cereal and higher-fiber breakfast cereals would be protective against the risk of developing diabetes. Data from Survey 3 (S3) to Survey 7 (S7) inclusive, from the 1946-51 ALSWH cohort were analyzed. Dietary data were obtained at S3 and the outcome was incident diabetes between S4-S7. Women were excluded if: they reported existing diabetes or impaired glucose tolerance at S3; dietary data were incomplete; or daily energy intake was <4,500 or >20,000 kJ. Logistic regression with discrete time survival analyses investigated the association between breakfast cereal intake and incident diabetes. Models were adjusted for income, BMI, smoking, physical activity, education, and dietary intakes and included a measure of time. There were 637 incident cases of diabetes. Breakfast cereal intake per se was not associated with incident diabetes (OR: 1.00; P = .98). Muesli consumption on its own (OR: 0.74; P = .00) or as a part of oats-based cereal (OR: 0.84; P = .047) was significantly associated with a decrease in the odds of developing diabetes. No other breakfast cereals were significantly associated with diabetes risk. Among mid-aged Australian women, muesli consumption was associated with a reduction in diabetes risk. This effect may be due to a particular profile of muesli eaters, but the relationship warrants further investigation.

Whole grain consumption and risk of cardiovascular disease, cancer, and all cause and cause specific mortality: systematic review and dose-response meta-analysis of prospective studies

OBJECTIVE

 To quantify the dose-response relation between consumption of whole grain and specific types of grains and the risk of cardiovascular disease, total cancer, and all cause and cause specific mortality.

DATA SOURCES

 PubMed and Embase searched up to 3 April 2016.

STUDY SELECTION

 Prospective studies reporting adjusted relative risk estimates for the association between intake of whole grains or specific types of grains and cardiovascular disease, total cancer, all cause or cause specific mortality.

DATA SYNTHESIS

 Summary relative risks and 95% confidence intervals calculated with a random effects model.

RESULTS

 45 studies (64 publications) were included. The summary relative risks per 90 g/day increase in whole grain intake (90 g is equivalent to three servings-for example, two slices of bread and one bowl of cereal or one and a half pieces of pita bread made from whole grains) was 0.81 (95% confidence interval 0.75 to 0.87; I(2)=9%, n=7 studies) for coronary heart disease, 0.88 (0.75 to 1.03; I(2)=56%, n=6) for stroke, and 0.78 (0.73 to 0.85; I(2)=40%, n=10) for cardiovascular disease, with similar results when studies were stratified by whether the outcome was incidence or mortality. The relative risks for morality were 0.85 (0.80 to 0.91; I(2)=37%, n=6) for total cancer, 0.83 (0.77 to 0.90; I(2)=83%, n=11) for all causes, 0.78 (0.70 to 0.87; I(2)=0%, n=4) for respiratory disease, 0.49 (0.23 to 1.05; I(2)=85%, n=4) for diabetes, 0.74 (0.56 to 0.96; I(2)=0%, n=3) for infectious diseases, 1.15 (0.66 to 2.02; I(2)=79%, n=2) for diseases of the nervous system disease, and 0.78 (0.75 to 0.82; I(2)=0%, n=5) for all non-cardiovascular, non-cancer causes. Reductions in risk were observed up to an intake of 210-225 g/day (seven to seven and a half servings per day) for most of the outcomes. Intakes of specific types of whole grains including whole grain bread, whole grain breakfast cereals, and added bran, as well as total bread and total breakfast cereals were also associated with reduced risks of cardiovascular disease and/or all cause mortality, but there was little evidence of an association with refined grains, white rice, total rice, or total grains.

CONCLUSIONS

 This meta-analysis provides further evidence that whole grain intake is associated with a reduced risk of coronary heart disease, cardiovascular disease, and total cancer, and mortality from all causes, respiratory diseases, infectious diseases, diabetes, and all non-cardiovascular, non-cancer causes. These findings support dietary guidelines that recommend increased intake of whole grain to reduce the risk of chronic diseases and premature mortality.