A narrative review of nutrient based indexes to assess diet quality and the proposed total nutrient index that reflects total dietary exposures

Assessing nutritional adequacy ratios in women with and without binge eating disorder: a comprehensive evaluation

BACKGROUNDS

Bing eating disorder (BED) has been associated with a number of health problems. Remarkably little research has been done to measure dietary intake in people who suffer from binge eating disorder. This study aimed to compare the dietary intake and nutrient adequacy ratio (NAR) between BED individuals and those without BED and also to investigate the association between BED and NAR.

METHODS

In this cross- sectional study, 180 overweight and obese females who aged between 19 and 50 years old and with BMI between 25 and 40 kg/m2 were interviewed. The women were categorized into BED and non- BED groups based on their earned score in Binge Eating Scale (BES) questionnaire. Nutritional adequacy ratio was assessed as Micronutrient adequacy ratio, Macronutrient adequacy ratio and total adequacy ratio (the sum of the previous two) based on last year's dietary intakes collected using a semi-quantitative food frequency questionnaire (FFQ). The odds of binge eating disorder across the nutritional adequacy scores were assessed using multiple logistic regression models. Data were analyzed using SPSS software.

RESULTS

About 41.6% (n = 75) of the subjects were diagnosed with BED. Carbohydrate, saturated fats, sugar levels were significantly higher in women with BED compared to non-BED women (P < 0.05). All vitamins, with the exception of Retinol, and all minerals' levels were significantly lower in BED participants (P < 0.05). Micronutrient adequacy score and total adequacy score differed significantly between individuals with and without BED (P < 0.001) and non- BED group were significantly more nutritional adequate. The odds of having BED were lower in micronutrient, macronutrient adequate individuals (OR = 0.87, 95% CI = 0.78-0.98, P = 0.02), (OR = 0.81, 95% CI = 0.66-0.99, P = 0.049) respectively.

CONCLUSION

Overall, the results demonstrate low intake of key micronutrients and high intake of saturated fatty acids and carbohydrates among binge sufferers. Also, the findings indicate that individuals with BED experience a notably lower nutrient adequacy ratio compared to their peers without the disorder, suggesting that the eating behaviors associated with BED such as high consumption of processed foods and diet with low quality may lead to inadequate intake of vital nutrients.

The Contribution of Free Sugars to Energy Intake in Mid to Late Childhood: Comparisons Between Nutrient and Food Group Intakes and Antecedents of Diets High and Low in Free Sugars

Background/Aims: High intakes of free sugars may have negative effects on health perhaps associated with their effect on nutrient and food group intakes. The primary aim of the study was to compare nutrient and food group intakes between children with habitual high or low intakes of free sugars to identify which foods could be targeted to improve the diets of children consuming excess free sugars. The secondary aim was to assess antecedents for a child being in the high free sugars group compared with the low to identify the age at which an intervention would be most effective. Methods: The Avon Longitudinal Study of Parents and Children collected 3-day food records from children at ages 7, 10, and 13 years. Increments of 5% of energy from free sugars (%E-FS) were calculated. Two groups of children were identified: those consuming ≤15%E-FS each time (Low-FS) and those consuming >20%E-FS each time (High-FS). Their mean daily nutrient and food group intakes were compared at each age using ANOVA. Antecedents of being in these two FS groups were tested using regression models. Results: At each age, 70% of children consumed >15%E-FS with one-third >20%E-FS. Data were available for 4723 children at all three ages, and the diets of the 456 children with Low-FS intakes were compared with 330 children with High-FS intakes at each age. Energy intakes were higher in High-FS than Low-FS at each age, but protein, fat, starch, and fibre intakes were lower. Several micronutrient intakes (e.g., calcium, zinc, selenium, and retinol) were also lower. The High-FS group ate more confectionery and other sweet foods than the Low-FS group as well as six times more sugar-sweetened soft drinks (SSSD) and four times more fruit juice. However, the High-FS group consumed less bread, fat spreads, milk, and vegetables than the Low-FS group. Being in the High-FS group compared with Low-FS group was not associated with maternal education, age, or breastfeeding duration. It was more likely if the child was difficult to feed at 15 months or a picky eater in preschool years and if a dietary pattern low in nutrient-dense core foods and high in nutrient-poor discretionary foods was being consumed at 2 and/or 3 years of age. Conclusions: Children who habitually ate a High-FS diet in mid-late childhood consumed larger amounts of SSSD and fruit juice and less of some core foods than Low-FS consumers. This type of dietary pattern was already evident at 2 years of age and was associated with being a picky eater. To reduce children's intake of free sugars, support for parents to introduce a healthy balanced diet should be provided in the first 2 years of a child's life.

Diet quality in U.S. adults eating in senior and community centers: NHANES 2009-2018

BACKGROUND

With advancing age, the worsening of cognitive and physical disabilities may lead older adults to seek help in their daily living activities. Community/senior centers support older adults during aging, offering a wide variety of services, including meal programs. Using data from the National Health and Nutrition Examination Surveys (2009-2018), we aimed to examine whether community/senior center meal programs were associated with an improved nutritional exposure in U.S. adults aged 60 years or older.

METHODS

Nutrient exposure and nutrient-based dietary indexes, including the Diet Quality Score (DQS) and the Food Nutrient Index (FNI) were compared between those eating meals at community/senior centers and the general population. Nutrient intakes were contrasted to the daily nutritional goals from the Dietary Guidelines for Americans.

RESULTS

This study included 6261 participants aged ≥60 years, thereof n = 421 reporting community/senior center meals. The latter were predominantly female and almost 45% were widowed or divorced. Eating at community/senior centers did not result in a better diet quality in crude analyses. After adjustment for potential sociodemographic confounders as well as alcohol, smoking and energy intake, however, sex-specific differences emerged, revealing significantly higher FNI scores in males eating at community/senior centers (adjusted FNI predictions: 61.71 [CI:58.55-64.88] vs 57.64 [CI:56.86-58.41] points).

CONCLUSIONS

Eating at community/senior centers was associated with an improved nutrient exposure in older men, whereas no better diet quality was found in women. Community/senior centers may play a pivotal role when it comes to the diet quality of a particularly vulnerable group of the population.

Eating Egg-Rich Diets and Modeling the Addition of One Daily Egg Reduced Risk of Nutrient Inadequacy among United States Adolescents with and without Food Insecurity

BACKGROUND

Adolescents have the poorest dietary intake throughout their lifespan. Food insecurity worsens these nutritional risks. Eggs are a nutrient-dense strategy to increase nutrient quality.

OBJECTIVES

1) compare usual nutrient intakes, Dietary Reference Intake and protein compliance with recommendations and scores of micronutrient quality; and 2) analyze how adding 1 egg affects adolescents' nutrient profiles, by food security status and egg-rich diets.

METHODS

Dietary data of United States adolescents in the 2007-2018 National Health and Nutrition Examination Survey were analyzed (14-17 y; n = 3633). Egg-rich diet levels were categorized as 1) no eggs, 2) eggs as ingredients in dishes, or 3) primarily egg dishes. Food security status was classified using the United States Household Food Security Survey Module. The National Cancer Institute method was used to estimate usual nutrient intake and nutrient exposure scores [i.e., Food Nutrient Index (FNI) and Total Nutrient Index (TNI)]. Nutrient amounts from 1 medium egg were modeled on existing intakes. Pairwise t-tests determined significant differences.

RESULTS

Over 60% of adolescents risked inadequate intake of calcium, choline, magnesium, vitamin D, and vitamin E regardless of food security status. Food-secure adolescents consuming primarily egg dishes had higher mean usual intakes of lutein + zeaxanthin (1544.1 μg), choline (408.4 mg), vitamin B2 (2.3 mg), selenium (128.6 μg), vitamin D (6 μg), docosahexaenoic acid (70 mg), and protein (89.1 g) than other groups (P < 0.0002). Those who were food secure and consuming eggs as ingredients in dishes demonstrated higher nutrient adequacy for magnesium (scored ∼66 out of 100), potassium (scored 81), and total scores (scored 72 and 69, respectively) for the TNI and FNI; and folate only (scored 92) for the TNI, than those who were food insecure and not consuming eggs (P < 0.0002). Adding 1 egg increased choline and vitamin D usual intakes for some groups and nutrient index scores for all groups (P < 0.0005).

CONCLUSIONS

Adolescents are at substantial nutritional risk that was exacerbated by food insecurity and less egg consumption.

Association between overall quality of macronutrients and incidence of overweight and obesity in the SUN (Seguimiento Universidad de Navarra) cohort

Introduction

Introduction: no previous large prospective studies have assessed the global quality of macronutrients in association with the risk of overweight/obesity. Objective: to prospectively assess the association of an overall macronutrient quality index (MQI) with weight change and the incidence of overweight/obesity in the Seguimiento Universidad de Navarra (SUN) cohort. Methods: the diet of 9,344 Spanish university graduates free of overweight/obesity (mean age: 36.5 [SD, 11.1]) was assessed through a validated 136-item food frequency questionnaire. The MQI was calculated as the sum of the Carbohydrate Quality Index, the Fat Quality Index, and the Healthy Plate Protein Quality Index. Participants were classified into groups (G) according to MQI. Incident overweight/obesity was defined if follow-up questionnaires indicated BMI was ≥ 25 kg/m2. Multiple linear regression models and Cox proportional hazard models were used to assess the average yearly weight change and the risk of overweight/obesity over follow-up time. Results: 2,465 cases of incident overweight/obesity were identified (median follow-up: 10.7 years). Increasing MQI was significantly associated with lower annual weight gain (g): ß coefficient: -99.0, (95 % CI: -173.6 to -24.5) in the G4 vs G1, p for trend = 0.007. In the fully adjusted model the incidences of overweight/obesity in G4 and G1 were 21.7 % (431 cases) and 29.3 % (954 cases), respectively. The adjusted HR was 0.87 (95 % CI, 0.77-0.98, p for trend = 0.036). When we used repeated analyses updating the MQI after 10 years of follow-up, results remained similar. Conclusions: a significant inverse association between a multidimensional MQI and the risk of overweight/obesity was found in this Mediterranean cohort of adults.

Nutrient Intakes in Prostate Cancer Survivors in the United States: A Nationally Representative Study

There are currently more than 3.3 million prostate cancer (PC) survivors in the United States. Conformance with national dietary guidelines and a good diet quality may lower the risk for Gleason grade progression in PC patients. Assessing the nutritional status of PC survivors is thus of paramount importance from a public health nutrition perspective. We used 24-h dietary recall data from the National Health and Nutrition Examination Surveys (NHANES) to systematically estimate nutrient intakes in n = 360 PC survivors (which may be extrapolated to represent n = 1,841,030 PC survivors) aged 70.69 years on average, and contrasted the results to the daily nutritional goals (DNG) in the 2020-2025 Dietary Guidelines for Americans (DGA). Diet quality in PC survivors was found to be generally poor, and the DNG as specified in the DGA were not met for many micronutrients, including calcium, magnesium and potassium. PC survivors had an insufficient intake of many vitamins (including vitamins A, C, D and E), and did not meet the intake recommendations for dietary fiber. Racial disparities in PC were reflected in the lower overall DQ in Non-Hispanic Black participants. Our results reiterate the need for nutritional assessment and counseling to improve DQ in PC patients.

Dietary patterns and periodontitis: A systematic review

The systematic review aimed to investigate the associations between index-based dietary patterns and the risk and severity of periodontitis. Four public databases were searched for relevant published articles. Two independent researchers conducted the study selection, quality assessment, and data extraction. Methodological quality of the selected studies was evaluated using Joanna Briggs Institute Checklists. The review was registered with PROSPERO (CRD42023395049). Twenty-five studies were eligible for this review, including 23 cross-sectional studies and two prospective cohort studies. The most utilized dietary indices were the Healthy Eating Index (HEI), the Mediterranean Diet Score (MDS), and the Dietary Inflammatory Index (DII). The results indicated a positive association between higher diet quality (i.e., higher HEI and MDSs and lower DII scores) and healthier periodontal status. Subgroup meta-analysis for four studies utilizing HEI and CDC/AAP case definition indicates the protective effect of higher HEI scores on the risk of periodontitis (OR [95% CI] = 0.77[0.68, 0.88]) with statistical significance (Z = 3.91 [p < 0.0001]). Dietary assessment was conducted by validated food frequency questionnaires (FFQ) in 52% of the studies and 24-h dietary recalls in 36% of the studies. One study utilized a validated 15-item questionnaire to measure patients' adherence to the Mediterranean Diet (QueMD). The quality assessment showed that all studies were of high quality. High HEI and MDSs and low DII scores were associated with a low risk of periodontitis and better periodontal conditions. The standardized and repeatable diet guidelines might be provided for preventing periodontitis. Future prospective studies and clinical trials are needed to confirm this causal association.

Menopause as a window of opportunity: the benefits of designing more effective theory-driven behaviour change interventions to promote healthier lifestyle choices at midlife

Menopause is a natural developmental phase that all women go through from their early forties to mid-fifties, marking the transition from the reproductive to the non-reproductive years. This is characterised as the permanent cessation of menses due to progressive ovarian failure. Each woman's experience of the menopause is unique. Biopsychosocial changes occur during this time with some symptoms affecting up to 80 % of women and lasting for 4-5 years from the peri- to post-menopause. Reduced oestrogen may predispose some women to health issues following menopause, such as heart disease, diabetes, stroke and cognitive decline. It is vital to understand how to promote health and well-being to reduce the risk of developing chronic conditions in later life. Increased symptoms and concerns about health during the menopausal transition can be cues to action for some women to actively maintain their health. Menopause represents a window of opportunity to promote health, and to support women to make healthier lifestyle choices, part of the National Institute for Clinical Excellence guidelines for menopause management. Identifying appropriate strategies to change behaviour is less clear. Theories of behaviour change can provide frameworks to gain more insight into the facilitators and barriers to behaviour and can inform the researcher on what needs to change. This information can be used to inform the design, content, implementation and evaluation of a lifestyle intervention. This review paper will explore the impact of menopause on health and well-being generally, and the benefits of designing more effective theory-driven behaviour change interventions for menopause.

Micronutrient intake from three popular diet patterns in the United States: modeled replacement of foods highest in added sugar and sodium using the National Health and Nutrition Examination Survey, 2005-2018

Introduction

Fifty-two percent of adults in the United States reported following a popular diet pattern in 2022, yet there is limited information on daily micronutrient intakes associated with these diet patterns. The objective of the present study was to model the impact on micronutrient intake when foods highest in added sugar and sodium were replaced with healthier alternatives to align with the Dietary Guidelines for Americans recommendations.

Methods

Dietary data were acquired from 34,411 adults ≥ 20 y in the National Health and Nutrition Examination Survey, 2005-2018. The National Cancer Institute methodology was used to estimate usual dietary intake at baseline of 17 micronutrients using information from up to two dietary recalls per person. A food substitution model was used to evaluate the impact on micronutrient intake when three servings of foods highest in added sugar and sodium were substituted with healthier alternatives.

Results

Dietary modeling to replace foods highest in added sugar with healthier alternatives increased the mean intake of fat-soluble vitamins (0.15% for vitamin A to 4.28% for vitamin K), most water-soluble vitamins (0.01% for vitamin B1 to 12.09% for vitamin C), and most minerals (0.01% for sodium to 4.44% for potassium) across all diet patterns. Replacing foods highest in sodium had mixed effects on the mean intake of micronutrients. The intake of most fatsoluble vitamins increased by 1.37-6.53% (particularly vitamin A and D), yet while the intake of some water-soluble vitamins and minerals increased by 0.18-2.64% (particularly vitamin B2, calcium, and iron) others decreased by 0.56-10.38% (notably vitamin B3 and B6, magnesium, sodium, and potassium).

Discussion

Modeled replacement of foods highest in added sugar led to more favorable changes in mean micronutrient intake compared to modeled replacement of foods highest in sodium. Due to the composite nature of mixed dishes that include multiple ingredients, food substitutions may result in both favorable and unfavorable changes in micronutrient intake. These findings highlight the challenges of making singleitem food substitutions to increase micronutrient intake and call for further research to evaluate optimal combinations of replacement foods to maximize the intake of all micronutrients simultaneously.

Healthy lifestyle linked to innate immunity and lipoprotein metabolism: a cross-sectional comparison using untargeted proteomics

This study used untargeted proteomics to compare blood proteomic profiles in two groups of adults that differed widely in lifestyle habits. A total of 52 subjects in the lifestyle group (LIFE) (28 males, 24 females) and 52 in the control group (CON) (27 males, 25 females) participated in this cross-sectional study. Age, education level, marital status, and height did not differ significantly between LIFE and CON groups. The LIFE and CON groups differed markedly in body composition, physical activity patterns, dietary intake patterns, disease risk factor prevalence, blood measures of inflammation, triglycerides, HDL-cholesterol, glucose, and insulin, weight-adjusted leg/back and handgrip strength, and mood states. The proteomics analysis showed strong group differences for 39 of 725 proteins identified in dried blood spot samples. Of these, 18 were downregulated in the LIFE group and collectively indicated a lower innate immune activation signature. A total of 21 proteins were upregulated in the LIFE group and supported greater lipoprotein metabolism and HDL remodeling. Lifestyle-related habits and biomarkers were probed and the variance (> 50%) in proteomic profiles was best explained by group contrasts in indicators of adiposity. This cross-sectional study established that a relatively small number of proteins are associated with good lifestyle habits.

Precision Nutrition: The Hype Is Exceeding the Science and Evidentiary Standards Needed to Inform Public Health Recommendations for Prevention of Chronic Disease

As dietary guidance for populations shifts from preventing deficiency disorders to chronic disease risk reduction, the biology supporting such guidance becomes more complex due to the multifactorial risk profile of disease and inherent population heterogeneity in the diet-disease relationship. Diet is a primary driver of chronic disease risk, and population-based guidance should account for individual responses. Cascading effects on evidentiary standards for population-based guidance are not straightforward. Precision remains a consideration for dietary guidance to prevent deficiency through the identification of population subgroups with unique nutritional needs. Reducing chronic disease through diet requires greater precision in (a) establishing essential nutrient needs throughout the life cycle in both health and disease; (b) considering effects of nutrients and other food substances on metabolic, immunological, inflammatory, and other physiological responses supporting healthy aging; and (c) considering healthy eating behaviors. Herein we provide a template for guiding population-based eating recommendations for reducing chronic diseases in heterogenous populations.

Does Self-Perceived Diet Quality Align with Nutrient Intake? A Cross-Sectional Study Using the Food Nutrient Index and Diet Quality Score

A reliable diet quality (DQ) assessment is critical to empower individuals to improve their dietary choices. Controversies persist as to whether self-perceived DQ is accurate and correlated with actual DQ as assessed by validated nutrient intake indexes. We used National Health and Nutrition Examination Surveys data to examine whether a higher self-perceived DQ was positively associated with a more optimal nutrient intake as reflected by the Food Nutrient Index (FNI) and Diet Quality Score (DQS). Comparative analyses were performed for three self-perceived DQ groups: (I) "excellent or very good" DQ, (II) "good or fair" DQ, and (III) "poor" DQ. The FNI and DQS differed substantially across groups and sexes. FNI scores ranged from 65 to 69 in participants with a self-reported excellent or very good DQ, whereas participants with a self-perceived poor DQ scored significantly lower (53-59). We also observed age- and sex-specific patterns, with the lowest overall FNI scores found in males aged 18-30 years and females aged 31-50 years. DQ intergroup differences were more pronounced in females than in males. Our findings suggest that higher self-perceived DQ is associated with a more optimal nutrient intake and indicate potential helpfulness of self-perceived DQ as a quick and still underexplored indicator with intrinsic limitations.

Shifting towards optimized healthy and sustainable Dutch diets: impact on protein quality

PURPOSE

To reduce the environmental impact of Western diets, a reduction of meat consumption and a substitution by plant-based protein sources is needed. This protein transition will affect the quantity and quality of dietary protein. Therefore, the aim of this study was to evaluate the protein adequacy of diets optimized for nutritional health and diet-related greenhouse gas emission (GHGE).

METHODS

Data from 2150 adult participants of the Dutch National Food Consumption Survey were used, with diet assessed using two non-consecutive 24 h dietary recalls. Utilizable protein of current diets per day was based on meal composition and the Protein Digestibility-Corrected Amino Acid Score and was compared to protein requirements. Optimized diets were derived as linear combinations of current diets that minimized GHGE and maximized the Dutch Healthy Diet 2015 score, with/without constraints to keep dietary change within 33% of current consumption. Protein adequacy was evaluated in both current and optimized diets.

RESULTS

In all age and gender strata, the healthiest diets had higher GHGE, the most sustainable diets had the lowest dietary quality, though higher than current diets, and protein adequacy remained sufficient. When limiting dietary change to 33% of current consumption, in the most promising trade-off diet GHGE was reduced by 12-16%. The current diet provided 1.4-2.2 times the required amount of utilizable protein.

CONCLUSION

These results suggest that a realistic aim for the next decade might be to reduce diet-related GHGE to 12-16% of the current levels without compromising protein adequacy and diet quality. To achieve global targets, upstream food system transformations are needed with subsequent dietary changes.

Protein-to-carbohydrate ratio is informative of diet quality and associates with all-cause mortality: Findings from the National Health and Nutrition Examination Survey (2007-2014)

Background

Dietary protein and carbohydrate intake and health outcomes have received extensive attention in recent years. However, the nutritional context in which these associations occur is less studied.

Objectives

We aimed to examine the dietary context associating protein-to-carbohydrate ratio and all-cause mortality in US adults.

Methods

Data from 17,814 adults enrolled in the 2007-2014 NHANES was analyzed. Information on mortality was obtained from the US mortality registry updated in December 2015. Diet quality was assessed using the Healthy Eating Index (HEI) and Total Nutrients Index (TNI). ANCOVA was used to test the mean differences in HEI and TNI scores across %E P:C quintiles. Linear regression examined the association of HEI and TNI with %E P:C. Cox proportional hazards regression evaluated the association between %E P:C and all-cause mortality. A restricted cubic spline examined the non-linear relationship between %E P:C and death.

Results

Low %E P:C was associated with lower HEI and TNI scores while higher %E P:C was associated with healthier HEI and TNI scores. HEI and TNI were positively associated with %E P:C (β = 0.22, 95% CI: 0.19-0.25, and β = 0.16, 95% CI: 0.14-0.18), respectively. Low %E P:C was associated with an increased risk of death from all-cause. The higher HRs (95% CIs) of all-cause mortality were 1.97(1.46-2.65), and 7.35 (2.57-21.03) in the second quintile for the age-sex-ethnicity model, and the fully adjusted model, respectively. There was a significant reverse U-shape relationship between %E P:C and all-cause mortality with P, non-linearity < 0.001.

Conclusion

This study indicates that a low %E P:C that gives emphasis to unhealthy foods increases the risk of death. Hence, it would be useful to consider the complete diet associated with protein intake when making dietary recommendations for populations.

The Total Nutrient Index is a Useful Measure for Assessing Total Micronutrient Exposures Among US Adults

BACKGROUND

Most dietary indices reflect foods and beverages and do not include exposures from dietary supplements (DS) that provide substantial amounts of micronutrients. A nutrient-based approach that captures total intake inclusive of DS can strengthen exposure assessment.

OBJECTIVES

We examined the construct and criterion validity of the Total Nutrient Index (TNI) among US adults (≥19 years; nonpregnant or lactating).

METHODS

The TNI includes 8 underconsumed micronutrients identified by the Dietary Guidelines for Americans: calcium; magnesium; potassium; choline; and vitamins A, C, D, and E. The TNI is expressed as a percentage of the RDA or Adequate Intake to compute micronutrient component scores; the mean of the component scores yields the TNI score, ranging from 0-100. Data from exemplary menus and the 2003-2006 (≥19 years; n = 8861) and 2011-2014 NHANES (≥19 years; n = 9954) were employed. Exemplary menus were used to determine whether the TNI yielded high scores from dietary sources (women, 31-50 years; men ≥ 70 years). TNI scores were correlated with Healthy Eating Index (HEI) 2015 overall and component scores for dairy, fruits, and vegetables; TNI component scores for vitamins A, C, D, and E were correlated with respective biomarker data. TNI scores were compared between groups with known differences in nutrient intake based on the literature.

RESULTS

The TNI yielded high scores on exemplary menus (84.8-93.3/100) and was moderately correlated (r = 0.48) with the HEI-2015. Mean TNI scores were significantly different for DS users (83.5) compared with nonusers (67.1); nonsmokers (76.8) compared with smokers (70.3); and those living with food security (76.6) compared with food insecurity (69.1). Correlations of TNI vitamin component scores with available biomarkers ranged from 0.12 (α-tocopherol) to 0.36 (serum 25-hydroxyvitamin D), and were significantly higher than correlations obtained from the diet alone.

CONCLUSIONS

The evaluation of validity supports that the TNI is a useful construct to assess total micronutrient exposures of underconsumed micronutrients among US adults.