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

Evaluating the diet in Germany with two indices focusing on healthy eating and planetary healthy eating using nationwide cross-sectional food intake data from DEGS1 (2008-2011)

PURPOSE

To improve sustainability, adjustments to current diets are necessary. Therefore, limited planetary resources are considered within the healthy reference diet proposed by the EAT-Lancet Commission. The agreement with nationwide food intake was evaluated with two indices which reflect this reference and German food intake recommendations.

METHODS

A healthy eating index (HEI-MON) reflecting the dietary guidelines of the German nutrition society and a planetary healthy eating index (PHEI-MON) reflecting the healthy reference diet were developed, with scores from 0 to 100. Both indices were applied to data from a nationally representative sample of the German population aged 18-79 years for which data from a 53-item food frequency questionnaire are available.

RESULTS

Mean scores for the indices were 53 for HEI-MON and 39 for PHEI-MON. A better adherence to either guideline could be found among women, persons of older age as well as persons with higher education level. The sub-scores for HEI-MON showed high agreement with the recommendations for side dishes, fruit/nuts, (processed) meat and cereals, but low agreement with the recommendations for free sugar and vegetables/legumes. PHEI-MON sub-scores were highest for poultry, fruits and potatoes, and lowest for nuts, red meat and legumes. High scores in one index do not necessarily correspond to high scores in the other index. Individuals with more plantbased diets had higher scores in both indices, while high sugar and meat consumption led to lower scores.

CONCLUSIONS

More plant-based diets are crucial for individual and planetary health. Both indices reflect such diets which consider already health and sustainability aspects. At an individual level, the scores for both indices may differ considerably, but overall there is a huge potential in the population to adapt to a diet more in line with both guidelines.

Is there an "optimal" diet for prevention of inflammatory bowel disease?

Nutritional epidemiological studies have evolved from a focus of single nutrients to diet patterns to capture the protective role of healthy diets on chronic disease development. Similarly, in inflammatory bowel disease (IBD), a healthy diet may be protective against its development in individuals with genetic susceptibility, but the definitions of the optimal diet pattern deserve further exploration. Hence, this review article presents evidence, mainly from prospective cohort studies, for the role of diet quality based on adherence to dietary guidelines, traditional and modern diet patterns in the prevention of IBD. Findings from a limited number of studies on diet quality suggest that high diet quality scores are associated with lower risk of developing Crohn's disease, but the data are inconsistent for ulcerative colitis (UC). There are signals that a Mediterranean diet pattern reduces the risk of Crohn's disease but, again, the data are inconsistent and further studies are much needed. Finally, the evidence is conflicting regarding the role of food additives, with difficulties in the assessment of their intake, namely non-nutritive sweeteners and emulsifiers, precluding accurate assessment of a relationship with IBD risk. In contrast, emerging evidence for a role of ultra-processed food in the development of Crohn's disease but not UC is identified. Given the potential influence of diet quality, a Mediterranean diet and ultra-processed food intake on the risk of Crohn's disease, assessment and implementation of dietary advice for these patients need to be tailored. The search for an optimal diet for UC remains elusive and further research for increasing the evidence in the area is greatly needed.

Assessment of Diet Quality Based on Selected Dietary Quality Indices and Consumption of Specific Food Items of Midwives Working on a Shift Schedule in Wroclaw, Poland

The aim of this study was to assess the quality of diets among midwives working in a shift system and to analyze variations in their dietary habits according to their working hours. In a group of fifty midwives employed in four public hospitals in Wrocław, the HDI-2015, HEI-2015, AHEI-2010, and Mellen's DASH diet index were calculated. The significance of differences in terms of the prevalence of selected dietary habits, meal frequency, average content of selected food items, and the percentage of energy obtained from them was assessed. Over half of the diets of the participants exhibited low adherence to the selected dietary indices. Only the scores on Mellen's DASH diet index were significantly associated with other components of the diet. Diets scoring ≥ 4.5 points were characterized by significantly lower processed meat content, meal frequency, and energy value, as well as lower sugar content and lower dietary energy value, compared to diets scoring < 4.5 points. Regardless of their working hours, the diets of midwives are characterized by low quality. Therefore, it appears essential to introduce targeted educational programs and provide guidance on appropriate dietary models, such as the DASH diet.

Baseline Association between Healthy Eating Index-2015 and Health-Related Quality of Life in Breast Cancer Patients Enrolled in a Randomized Trial

Health-related quality of life (HRQoL) represents one of the most concerning aspects for cancer patients. The Healthy Eating Index (HEI) is an a priori diet quality index directly associated with health outcomes and HRQoL in cancer survivors in North American populations. We evaluated, in a Mediterranean population, the baseline associations between HEI-2015 and HRQoL in 492 women with breast cancer recruited in a DEDiCa lifestyle trial. Dietary data were obtained from 7-day food records; HRQoL was assessed through the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ C30) and the C30 Summary Score (SumSc). Analysis of variance and multivariable linear and log-gamma regression models were performed. Mean and standard deviation for HEI-2015 score was 68.8 ± 11.2; SumSc was 81.5 ± 12.9. Women with lower HEI-2015 score had higher BMI, were more frequently exposed to tobacco smoke and had fewer years of education. Patients with a HEI-2015 score greater than 68.7 (median value) showed a significant increase in SumSc of 4% (p = 0.02). HEI-2015 components also associated with SumSc were beans and greens (β = 1.04; p = 0.02). Weak associations were found for total vegetables and saturated fats. Higher diet quality in breast cancer survivors was associated with higher overall HRQoL in this cross-sectional analysis.

Evaluating Validated Diet Quality Indices Used in Pregnant Women in High-Income Countries: A Systematic Review

CONTEXT

Diet quality indices (DQIs) assess the level of adherence to dietary recommendations and a specified dietary pattern in populations; however, there is limited evidence regarding the construct criteria and validation methodology of DQIs used in pregnant women.

OBJECTIVES

The objectives of this study were to (i) identify and describe characteristics of DQIs that have been validated for use in pregnant women in high-income countries, and (ii) evaluate criteria used to develop DQIs and validation methodologies employed.

DATA SOURCES

CINAHL, Embase, Medline, SCOPUS, and Web of Science were systematically searched for eligible articles published between 1980 and November 2022 that focused on DQIs validated for use in pregnant women from high-income countries.

DATA EXTRACTION

Characteristics, development criteria, and validation methodologies used in the included articles were extracted by one reviewer and checked by a second reviewer.

DATA ANALYSIS

A narrative synthesis and descriptive statistics were used to summarize the review findings. Reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement.

RESULTS

Six articles with 5 validated DQIs were identified. In total, 3777 participants were included - five articles had pregnant women aged 31-50 years and in their second trimester. Food frequency questionnaires were used as the dietary assessment method in all studies, and 3 DQIs were used to assess dietary intake at 1 time point, using 2 different dietary assessment methods. No indices fulfilled preferred features for the DQI development criteria developed by Burggraf et al (2018). Construct validity was assessed by all DQIs, followed by criterion validity (n = 4) and test-retest reliability (n = 2).

CONCLUSION

Limited high-quality validated DQIs for use in pregnant women in high-income countries were identified. Scoring for DQI components were not specific to nutrient requirements for pregnant women. Findings from this review may inform the development of DQIs that evaluate specific dietary requirements and specific food safety considerations applicable to pregnancy.

SYSTEMATIC REVIEW REGISTRATION

https://osf.io/u2hrq.

The association between diet quality and chrononutritional patterns in young adults

PURPOSE

Young adults eat erratically and later in the day which may impact weight and cardiometabolic health. This cross-sectional study examined relationships between chrononutritional patterns and diet quality in two young adult populations: a university and community sample.

METHODS

Three days of dietary data were collected including food images captured using wearable cameras. Chrononutritional variables were extracted: time of first and last eating occasions, caloric midpoint (time at which 50% of daily energy was consumed), number of eating occasions per day, eating window, day-to-day variability of the above metrics, and evening eating (≥20:00h). The Healthy Eating Index for Australian Adults scored diet quality. Statistical analyses controlled for gender, body mass index, and socio-economic status.

RESULTS

No significant associations between chrononutritional patterns and diet quality were found for all participants (n = 95). However, differences in diet quality were found between university (n = 54) and community (n = 41) samples with average diet quality scores of 59.1 (SD 9.7) and 47.3 (SD 14.4), respectively. Of those who extended eating ≥20:00 h, university participants had better diet quality (62.9±SE 2.5 vs. 44.3±SE 2.3, p < 0.001) and discretionary scores (7.9±SE 0.9 vs. 1.6±SE 0.6, p < 0.001) than community participants. University participants consumed predominately healthful dinners and fruit ≥20:00h whereas community participants consumed predominately discretionary foods.

CONCLUSION

For the general young adult population, meal timing needs to be considered. Food choices made by this cohort may be poorer during evenings when the desire for energy-dense nutrient-poor foods is stronger. However, meal timing may be less relevant for young adults who already engage in healthy dietary patterns.

Review of Diet Quality Indices that can be Applied to the Environmental Assessment of Foods and Diets

PURPOSE OF REVIEW

The aim was to identify indices of diet quality and health that could be applied to the environmental assessment of foods in order to provide metrics that collectively assess nutritional, health and environmental dimensions.

RECENT FINDINGS

The review identified five major groups of indices: nutrient-food quantity-based; guideline-based; diversity-based; nutrient quality-based; health-based. Nutrient-food quantity-based and guideline type indices were the most frequently used to evaluate diet quality. Scaled assessment using a nutritional functional unit is the most common integration of diet quality with the environmental analysis of foods. There are fewer indices that measure the heath impacts of foods, but epidemiological dietary risk factors seem a promising approach to integrate diet and health impacts into the environmental assessment of foods. Five groups of nutritional and health indices were identified that can be applied when performing an environmental assessment of foods. This review proposes different methodological insights when doing such assessments to ensure transparency and comparability of the results.

A systematic evaluation of seven different scores representing the EAT-Lancet reference diet and mortality, stroke, and greenhouse gas emissions in three cohorts

Different approaches have been used for translation of the EAT-Lancet reference diet into dietary scores that can be used to assess health and environmental impact. Our aim was to compare the different EAT-Lancet diet scores, and to estimate their associations with all-cause mortality, stroke incidence, and greenhouse gas emissions. We did a systematic review (PROSPERO, CRD42021286597) to identify different scores representing adherence to the EAT-Lancet reference diet. We then qualitatively compared the diet adherence scores, including their ability to group individuals according the EAT-Lancet reference diet recommendations, and quantitatively assessed the associations of the diet scores with health and environmental outcome data in three diverse cohorts: the Danish Diet, Cancer and Health Cohort (DCH; n=52 452), the Swedish Malmö Diet and Cancer Cohort (MDC; n=20 973), and the Mexican Teachers' Cohort (MTC; n=30 151). The DCH and MTC used food frequency questionnaires and the MDC used a modified diet history method to assess dietary intake, which we used to compute EAT-Lancet diet scores and evaluate the associations of scores with hazard of all-cause mortality and stroke. In the MDC, dietary greenhouse gas emission values were summarised for every participant, which we used to predict greenhouse gas emissions associated with varying diet adherence scores on each scoring system. In our review, seven diet scores were identified (Knuppel et al, 2019; Trijsburg et al, 2020; Cacau et al, 2021; Hanley-Cook et al, 2021; Kesse-Guyot et al, 2021; Stubbendorff et al, 2022; and Colizzi et al, 2023). Two of the seven scores (Stubbendorff and Colizzi) were among the most consistent in grouping participants according to the EAT-Lancet reference diet recommendations across cohorts, and higher scores (greater diet adherence) were associated with decreased risk of mortality (in the DCH and MDC), decreased risk of incident stroke (in the DCH and MDC for the Stubbendorff score; and in the DCH for the Colizzi score), and decreased predicted greenhouse gas emissions in the MDC. We conclude that the seven different scores representing the EAT-Lancet reference diet had differences in construction, interpretation, and relation to disease and climate-related outcomes. Two scores generally performed well in our evaluation. Future studies should carefully consider which diet score to use and preferably use multiple scores to assess the robustness of estimations, given that public health and environmental policy rely on these estimates.

Are the 2019 Canada's Food Guide Recommendations on Healthy Food Choices Consistent with the EAT-Lancet Reference Diet from Sustainable Food Systems?

BACKGROUND

The diet proposed by the EAT-Lancet Commission, which supports both health and environmental sustainability, provides an opportunity to assess the sustainability of food-based dietary guidelines.

OBJECTIVES

The primary objective was to assess the alignment of the 2019 Canada's Food Guide (CFG) with the EAT-Lancet diet. To do so, an index assessing adherence to the EAT-Lancet diet was developed and evaluated.

METHODS

Data from 1147 adults were used from the cross-sectional PRÉDicteurs Individuals, Sociaux et Environnementaux (PREDISE) study conducted between 2015 and 2017 in the province of Québec. The EAT-Lancet Dietary Index (EAT-I) was developed to evaluate adherence to the EAT-Lancet diet. Adherence to the 2019 CFG was assessed using the Healthy Eating Food Index (HEFI)-2019. Associations between the HEFI-2019 score and component scores and the EAT-I score were examined using linear regression models.

RESULTS

The mean EAT-I score (/80) in this population was 33.4 points [95% confidence interval (CI): 32.2, 34.6]. EAT-I scores were consistent with expected differences in diet quality between females and males (+6.9 points, 95% CI: 4.8, 9.0) and between adults aged 50-65 y and 18-34 y (+4.3 points, 95% CI: 1.6, 7.0). The mean HEFI-2019 (/80) score was 44.9 points (95% CI: 44.1, 45.7). The HEFI-2019 was strongly associated with the EAT-I (ß = 0.76, 95% CI: 0.72, 0.80). Among the 10 components of the HEFI-2019, components such as the whole-grain foods (ß =4.01, 95% CI: 3.49, 4.52), grain foods ratio (ß =3.65, 95% CI: 3.24, 4.07), plant-based protein foods (ß =2.41, 95% CI: 2.03, 2.78), and fatty acids ratio (ß =3.12, 95% CI: 2.72, 3.51) showed the strongest associations with the EAT-I.

CONCLUSIONS

These results suggest that recommendations in the 2019 CFG are largely coherent with the EAT-Lancet diet underscoring the complementarity and compatibility of the 2019 CFG for sustainability and health promotion purposes.

Prenatal Dietary Patterns and Associations With Weight-Related Pregnancy Outcomes in Hispanic Women With Low Incomes

Background: Dietary patterns during pregnancy may contribute to gestational weight gain (GWG) and birthweight, but there is limited research studying these associations in racial and ethnic minority groups. The objective of this study was to evaluate associations between prenatal dietary patterns and measures of GWG and birthweight in a cohort of culturally diverse Hispanic women with low incomes. Methods: Data were analyzed from 500 mother-infant dyads enrolled in the Starting Early Program, a childhood obesity prevention trial. Diet over the previous year was assessed in the third trimester of pregnancy using an interviewer-administered food frequency questionnaire. Dietary patterns were constructed using the Healthy Eating Index-2015 (HEI-2015) and principal components analysis (PCA) and analyzed as tertiles. GWG and birthweight outcomes were abstracted from medical records. Associations between dietary pattern tertiles and outcomes were assessed by multivariable linear and multinomial logistic regression analyses. Results: Dietary patterns were not associated with measures of GWG or adequacy for gestational age. Greater adherence to the HEI-2015 and a PCA-derived dietary pattern characterized by nutrient-dense foods were associated with higher birthweight z-scores [β: 0.2; 95% confidence interval (CI): 0.04 to 0.4 and β: 0.3; 95% CI: 0.1 to 0.5, respectively], but in sex-specific analyses, these associations were only evident in male infants (β: 0.4; 95% CI: 0.03 to 0.7 and β: 0.3; 95% CI: 0.03 to 0.6, respectively). Conclusions: Among a cohort of culturally diverse Hispanic women, adherence to healthy dietary patterns during pregnancy was modestly positively associated with increased birthweight, with sex-specific associations evident only in male infants.

Three approaches to assessing dietary quality in Mexican adolescents from 2006 to 2018 with data from national health and nutrition surveys

OBJECTIVE

To assess trends in the dietary quality of Mexican adolescents from 2006 to 2018, both overall and by sociodemographic indicators, using adaptations of the EAT-Lancet Planetary Health (PH) recommendations, optimal intake estimated by the Global Burden of Disease (GBD) and 2015 Mexican Dietary Guidelines (MDG) in nationally representative samples.

DESIGN

Using dietary data from a semi-quantitative FFQ, dietary quality indexes were constructed as adaptations of three dietary intake recommendations. Trends in adherence to recommendations were evaluated with multivariate quantile regression models with survey year as the main independent variable and adjusted for age, sex, energy intake, dwelling area, geographical region, household assets condition, and student/non-student status. P values and CI were Bonferroni-corrected.

SETTING

Mexico.

PARTICIPANTS

Non-pregnant or lactating adolescents aged 12-19 years (n 16 520).

RESULTS

Adherence to the PH index was about 40 %, GBD was nearly 35 % and MDG was about 37 %. The lowest adherences were for added sugars, sugar-sweetened beverages, nuts and seeds, red meats, processed meats, and legumes (<28 %). No 2006-2018 trends in total adherence were found in any index. Nevertheless, negative adherence trends were identified for poultry (β = -2·4), and saturated fats (β = -0·93), and positive for unsaturated oils (β = 1·23), in the PH. In MDG, relevant trends were found for plain water (β = 1·63) and foods rich in fats (β = -1·24).

CONCLUSIONS

Mexican adolescents have demonstrated poor dietary quality by these three approaches. Therefore, this population has a high-risk profile for diet-associated chronic diseases. Further research and appropriate public policies are needed.

Modified-Weight Healthy Eating Index-2015 Scores Are More Strongly Associated With Mortality Risk Than Standard Scores

BACKGROUND

Various diet quality scores are consistently and similarly associated with mortality risk. Emerging evidence suggests that individual diet quality components are differentially associated with mortality risk, but it is unclear whether or not modified weights reflective of relative component differences would strengthen mortality associations.

OBJECTIVE

This study examined whether Healthy Eating Index 2015 (HEI-2015) scores with modified (vs standard) component weights are differentially associated with mortality risk.

DESIGN

This was a longitudinal analysis of the National Health and Nutrition Examination Survey III (1988-94) with 23 years of mortality follow-up. The HEI-2015 and modified-weight scores were calculated from one 24-hour recall. The a priori Key Facets HEI was a subset score equivalently weighting fruits, vegetables, whole grains, and seafood and plant proteins. In the least absolute shrinkage and selection operator regression-weighted HEI, components were assigned weights reflecting relative mortality risk associations.

PARTICIPANTS/SETTING

Analyses included 10,789 US adults (aged 20 years and older) who were not pregnant and without prior diabetes, cancer, cardiovascular disease, or chronic kidney disease diagnoses.

MAIN OUTCOME MEASURES

All-cause and cardiovascular disease mortality risk were the primary outcomes examined.

STATISTICAL ANALYSES PERFORMED

Three energy-adjusted HEI scores were assigned to quintiles; covariate-adjusted sex-stratified Cox models with age as the timescale assessed associations between and trends across quintiles of HEI scores and all-cause and cardiovascular disease mortality risk.

RESULTS

Modified-weight HEI scores were associated with 23% to 38% reduced all-cause mortality risk in the highest vs lowest quintile, whereas comparisons were only significant for women (Key Facets P = 0.02 and least absolute shrinkage and selection operator regression-weighted P = 0.001; for men P = 0.06 on both scores), trends across quintiles of modified-weight scores were significant for men and women. The HEI-2015 was not significantly associated with all-cause mortality risk, and none of the scores were associated with cardiovascular disease mortality risk.

CONCLUSIONS

Only modified-weight HEI scores were associated with reduced all-cause mortality risk. Findings suggest modified diet quality weighting schemes warrant further examination to determine their replicability.

The Healthy Eating Index-2015 and All-Cause/Cause-Specific Mortality: A Systematic Review and Dose-Response Meta-Analysis

This meta-analysis was undertaken to determine the predictive value of Healthy Eating Index (HEI)-2015 in all-cause, cancer-cause, and cardiovascular disease (CVD)-cause mortality. This review was registered with PROSPERO as CRD42023421585. PubMed and Web of Science were searched for articles published by September 15, 2023. The hazard ratio (HR) was calculated with exact confidence intervals (CIs) of 95%. Statistical heterogeneity among studies was measured by Cochran's Q test (χ2) and the I2 statistic. Eighteen published studies were finally identified in this meta-analysis. The results showed that the HEI-2015 was associated with all-cause mortality either as a categorical variable (HR: 0.80; 95% CI: 0.79, 0.82) or continuous variable (HR: 0.90; 95% CI: 0.88, 0.92). The HEI-2015 was also associated with cancer-cause mortality as categorical variable (HR: 0.81; 95% CI: 0.78, 0.83) or continuous variable (HR:  0.90; 95% CI: 0.81, 0.99). The categorical HEI-2015 was also independently correlated with decreasing CVD-cause mortality (HR: 0.81; 95% CI: 0.75, 0.87). A nonlinear dose-response relation between the HEI-2015 and all-cause mortality was found. In the linear dose-response analysis, the risk of mortality from cancer decreased by 0.42% per 1 score increment of the HEI-2015 and the risk of CVD-cause mortality decreased by 0.51% with the increment of the HEI-2015 per 1 score. Our analysis indicated a significant relationship between the HEI-2015 and all-cause, cancer-cause, and CVD-cause mortality.

Association between adherence to the EAT-Lancet sustainable reference diet and cardiovascular health among European adolescents: the HELENA study

BACKGROUND

The EAT-Lancet Commission proposed a global reference diet to promote healthy diets within planetary boundaries. Studies evaluating the associations between the reference diet with health outcomes among adolescents are scarce. Thus, our aim was to assess the association between adherence to the EAT-Lancet diet and cardiovascular health among European adolescents.

METHODS

Data from the HELENA study were used. Usual dietary intake was assessed using two 24-h dietary recalls and adherence to the EAT-Lancet diet was assessed using the Planetary Health Diet Index (PHDI), a 16-component index that ranges from 0 to 150 points. Cardiovascular health was assessed through the seven-component Ideal Cardiovascular Health (ICH) score: never smoked, eutrophic body mass index, moderate-to-vigorous physical activity, healthy dietary pattern, low blood pressure, low fasting plasma glucose, and low total cholesterol. Total ICH score was categorized into ideal (5-7) and non-ideal (0-4).

RESULTS

A 10-point increment in the PHDI was associated with a lower probability of a non-ideal ICH status (OR 0.84, [95% CI: 0.75, 0.94]) among European adolescents, after adjusting for age, sex, socio-economic status, and total energy intake. Furthermore, a 10-point increment in the PHDI was associated with lower probability of high blood pressure (OR: 0.87 [0.79, 0.96]) and a lower probability of high blood cholesterol (OR: 0.88 [0.78, 0.99]).

CONCLUSION

Our study suggests that a higher PHDI may be associated with a better cardiovascular health status among European adolescents.

Evaluation of Protein Adequacy From Plant-Based Dietary Scenarios in Simulation Studies: A Narrative Review

Although a diet high in plant foods can provide beneficial nutritional outcomes, unbalanced and restrictive plant-based diets may cause nutrient deficiencies. Protein intake from these diets is widely discussed, but the comparison of animal and plant proteins often disregards amino acid composition and digestibility as measurements of protein quality. Poor provision of high-quality protein may result in adverse outcomes, especially for individuals with increased nutrient requirements. Several dietary modeling studies have examined protein adequacy when animal-sourced proteins are replaced with traditional and novel plant proteins, but no review consolidating these findings are available. This narrative review aimed to summarize the approaches of modeling studies for protein intake and protein quality when animal-sourced proteins are replaced with plant foods in diet simulations and examine how these factors vary across age groups. A total of 23 studies using dietary models to predict protein contribution from plant proteins were consolidated and categorized into the following themes-protein intake, protein quality, novel plant-based alternatives, and plant-based diets in special populations. Protein intake from plant-based diet simulations was lower than from diets with animal-sourced foods but met country-specific nutrient requirements. However, protein adequacy from some plant-sourced foods were not met for simulated diets of children and older adults. Reduced amino acid adequacy was observed with increasing intake of plant foods in some scenarios. Protein adequacy was generally dependent on the choice of substitution with legumes, nuts, and seeds providing greater protein intake and quality than cereals. Complete replacement of animal to plant-sourced foods reduced protein adequacy when compared with baseline diets and partial replacements.

Development of a diet quality score and adherence to the Swiss dietary recommendations for vegans

BACKGROUND

Vegan diets have recently gained popularity in Switzerland as well as globally. The aim of the present study was to develop a diet quality score for vegans (DQS-V) based on the Swiss dietary recommendations for vegans.

METHODS

The dataset included 52 healthy vegan adults. Dietary intake data were assessed by three-day weighed food records. Body weight and height were measured, and a venous blood sample for the analysis of vitamin and mineral status was collected. Spearman rank correlation coefficients were used due to not-normally distributed data. Dietary patterns were identified using principal component analysis (PCA).

RESULTS

The DQS-V score (mean ± SD) was 48.9 ± 14.7. Most vegans adhered to the recommended portions of vegetables, vitamin C-rich vegetables, fruits, omega-3-rich nuts, fats and oils, and iodized salt. However, the intake of green leafy vegetables, vitamin C-rich fruits, wholegrains, legumes, nuts and seeds, selenium-rich nuts, zero caloric liquid, and calcium-fortified foods was suboptimal. The sample overconsumed sweet-, salty-, fried foods, and alcohol. The DQS-V had a significantly positive correlation with intakes of fibre, polyunsaturated fatty acids, potassium, zinc, and phosphorus intakes (p's < 0.05) but was negatively correlated with vitamin B12 and niacin intakes (p's < 0.05). Two dietary patterns were derived from PCA: 1) refined grains and sweets and 2) wholegrains and nuts. The correlation between the DQS-V and the first dietary pattern was negative (- 0.41, p = 0.004) and positive for the second dietary pattern (0.37, p = 0.01). The refined grains and sweets dietary pattern was inversely correlated with beta-carotene status (- 0.41, p = 0.004) and vitamin C status (r = - 0.51, p = 0.0002).

CONCLUSION

The newly developed DQS-V provides a single score for estimating diet quality among vegan adults. Further validation studies examining the DQS-V in relation to an independent dietary assessment method and to biomarkers of nutritional intake and status are still needed before the general application of the DQS-V.

Adapting the Planetary Health Diet Index for children and adolescents

BACKGROUND

Tools for measuring adherence to sustainable healthy diets among children and adolescents are lacking.

OBJECTIVE

To advance methods for measuring adherence to sustainable healthy diets among children and adolescents by adapting an existing index, compare scores obtained using the original and adapted versions of the index in a sample of Chilean children, and describe the adapted index association with diet characteristics.

METHODS

The Planetary Health Diet Index (PHDI) was adapted to better reflect children's and adolescents' nutritional requirements. The adapted index (PHDI-C) comprises 16 components with a maximum score of 150 points. PHDI-C was piloted among a sample of 958 Chilean children (3-6 years) using dietary data collected in 2016 through single 24-h recalls. A decision tree and food disaggregation methodology were developed to guide the calculation of scores. Scores obtained using the original and adapted versions of the index were compared. Linear regression models adjusted by child's gender and age were fitted to explore associations between total PHDI-C score, dietary recall characteristics and nutritional composition of children's diets.

RESULTS

PHDI accounted for 75.7% of children's total caloric intake, whereas PHDI-C accounted for 99.6%. PHDI & PHCI-C scores were low among this sample of children; however, mean total score was lower when using PHDI compared to PHDI-C [40.7(12.1) vs 50.1(14.6)]. Children's scores were very low for nuts & peanuts, legumes, dark green vegetables, whole cereals, tubers & potatoes, and added sugars components across both indices, but were higher for dairy products and eggs & white meats components when using the PHDI-C due to adjustments made to ensure nutritional adequacy. Mean total PHDI-C score was significantly lower on weekends and special occasions, and significantly higher when children reported having a special diet (e.g., vegetarian). Total PHDI-C score was negatively associated with total sugars, saturated fats, trans fats, and animal-based protein intake, and positively associated with total protein, plant-based protein, total carbohydrates, and total fibre intake.

CONCLUSIONS

This study provides a replicable method for measuring adherence to sustainable healthy diets among children and adolescents that can be used to monitor trends and measure the effectiveness of actions targeting improving children's diets.

Trade liberalization and nutrition transition: Evidence from China

We examine the impact of trade liberalization on the nutrition transition between 1997 and 2011. Our findings demonstrate that the reduction in tariff rates has had a significant effect on the dietary patterns of both rural and urban residents in the country. With the decrease in tariffs, there has been a noticeable increase in the consumption of animal products (such as meat and aquatic products), vegetables, beans and nuts, as well as packaged and processed foods. Simultaneously, there has been a decrease in the demand for staple foods, fruits, and dairy products. Consequently, there has been an increase in the proportion of overall calories derived from fat and protein, while the proportion from staple foods has declined. As a result, trade liberalization has led to increased food expenditure, while reducing the cost of maintaining a healthy diet. Furthermore, trade liberalization has also contributed to a growing risk of obesity. Additionally, our study identifies rising incomes, specialization in agricultural production, changing food prices, and shifting food preferences as the primary mechanisms of the trade-diet relationship.

Review of Validated Methods to Evaluate Diet History in Diet Therapy and Counselling: An Overview and Analysis of Screeners Based on Food-Based Dietary Guidelines

Evidence-based dietetic practice calls for systematically developed assessment methods for nutritional assessment in dietetic counselling and therapy (DCT). Screeners can provide a quick and easy way to determine a client's diet quality and contribute to quality assurance in DCT. The aim of this systematic review was to give a comparative overview of screeners based on national food-based dietary guidelines (FBDGs) and to derive recommendations for developing an FBDG-based screener for DCT. The literature search in PubMed (MEDLINE), embase and Web of Science was conducted between May and July 2022, and updated in March 2023, in accordance with the consensus-based standards for the selection of health measurement instruments (COSMIN). The analysis focused on characteristics of screener design and measurement properties for screener testing. In total, 13 studies on 11 screeners based on FBDGs were included; 7 screeners were targeted to DCT. The content and scoring of screeners were based on the corresponding national FBDGs. The validity and/or reliability of screeners were investigated in 11 studies; responsiveness was not tested for any screener and practicality was considered in all studies. Based on the screeners reviewed, a systematic rationale to develop, enhance and test screeners based on national FBDGs was established.

Aligning Environmental Sustainability, Health Outcomes, and Affordability in Diet Quality: A Systematic Review

Improving diet quality while simultaneously maintaining planetary health is of critical interest globally. Despite the shared motivation, advancement remains slow, and the research community continues to operate in silos, focusing on certain pairings (diet-climate), or with a discipline-specific lens of a sustainable diet, rather than examining their totality. This review aimed to summarize the literature on adherence to a priori defined dietary patterns in consideration of diet quality, metabolic risk factors for noncommunicable diseases (NCDs), environmental impacts, and affordability. A methodology using PRISMA guidelines was followed, and searches were performed in 7 databases as of October 2022. The Appraisal tool for Cross-Sectional Studies (AXIS) and the National Institutes of Health (NIH) quality assessment tool for observational cohort studies were employed for quality appraisal. The evidence was narratively synthesized according to the characteristics of the diet quality metrics. The review includes 24 studies published between 2017-2023. Thirteen distinct diet quality scores were identified, with those measuring adherence to national dietary guidelines the most reported. Thirteen distinct environmental impact indicators were identified, with greenhouse gas emissions (n=23) reported most. All studies reported on body mass index, and 7 studies assessed the cost of adherence. Our results are consistent with previous findings that healthier diets can reduce environmental impacts; however, incongruities between population and planetary health can occur. Hence, the "sustainability" of dietary patterns is dependent on the choice of indicators selected. Further, healthy, lower impact diets can increase financial cost, but may also provide a protective role against the risk of obesity. Given the Global Syndemic, strategies to reduce obesity prevalence should emphasize the win-win opportunities for population and planetary health through dietary change. Research should identify diets that address multiple environmental concerns to curtail burdens potentially transferring, and harmonize this with sociocultural and equity dimensions. This review was registered at PROSPERO as CRD42021238055.

Development of the Norwegian diet index and the Norwegian lifestyle index and evaluation in a national survey

Background

Dietary and lifestyle indices are composite tools that are used to estimate risk of health outcomes.

Objective

We aimed to develop a diet and a lifestyle index assessing adherence to the national guidelines in Norway, and to investigate adherence in a nationwide survey of healthy subjects (Norkost3).

Design

Cut-off values for the indices were based on the Norwegian food based dietary guidelines and national lifestyle guidelines. Adherence was evaluated in the Norkost3 (n = 1,787).

Results

Twelve dietary components were included in the diet index 1) fruit and berries, 2) vegetables, 3) whole grains, 4) unsalted nuts, 5) fish, 6) low-fat dairy products, 7) margarine/oils, 8) red meat, 9) processed meat, 10) foods rich in sugar and fat, 11) drinks with added sugar, and 12) dietary supplements. Each of the components was assigned a value of 0, 0.5 or 1 corresponding to low, intermediate and high adherence, except for plant-based foods, which were assigned a value of 0, 1.5 or 3, providing a composite diet index ranging from 0 to 20 points. The five components in the lifestyle index (i.e. diet, body mass index (BMI), physical activity, tobacco and alcohol) was assigned a value of 0, 0.5 or 1, giving a final score ranging from zero to five points. In Norkost3, 49% (95% CI: 47, 52) of the participants had low adherence to the diet component, whereas only 2% (95% CI: 2, 3) achieved high adherence, although most of the subjects had high educational level. High adherence to the recommendations of BMI, tobacco and alcohol intake was observed in 50% (95% CI: 47, 52), 72% (95% CI: 70, 74) and 68% (95% CI: 66, 70) of the participants, respectively. Due to the lack of data on physical activity, adherence to this component in the lifestyle index is not presented in this study.

Conclusion

The new diet and lifestyle indices assess adherence to the Norwegian food-based dietary guidelines (FBDGs) and other national lifestyle guidelines. In this study, half of the subjects had low diet and lifestyle index scores. There is a need to implement interventions to improve this by focusing on the specific lifestyle components with low adherence.

Quality of diet and odds of metabolic syndrome in Iranian adults: Baseline results from the PERSIAN Kavar cohort study (PKCS)

BACKGROUND AND AIMS

Metabolic Syndrome (MetS) is a major risk factor for cardiovascular diseases and type 2 diabetes mellitus. Diet quality has been associated with multiple chronic diseases. We aimed to investigate the association between the quality of diet and the odds of being diagnosed with MetS.

METHODS AND RESULTS

This study was conducted cross-sectionally on baseline data of 2225 individuals from the PERSIAN Kavar Cohort Study (PKCS). The quality of diet was measured based on the Diet Quality Index - International (DQI-I), using Food Frequency Questionnaires. The association between DQI-I and MetS and its components was measured via logistic regression models in crude and adjusted models. We did not observe any association between DQI-I and MetS in the overall population. However, after adjustment for potential confounders, we found that male participants with higher DQI-I scores had a lower risk of MetS [adjusted odds ratio (OR) 95% confidence interval CI) = 0.62 (0.42-0.93)]. Moreover, analogous trends were observed with respect to some components of MetS, including elevated triglyceride (TG) [crude OR (95% CI) = 0.89 (0.70-0.98); adjusted OR = 0.82 (0.65-0.93)], lowered high-density lipoprotein cholesterol (HDL-c) [crude OR (95% CI) = 0.79 (0.57-0.99); adjusted OR = 0.76 (0.55-0.97)], and abnormal glucose homeostasis [crude OR (95% CI) = 0.80 (0.55-0.94); adjusted OR = 0.73 (0.51-0.91)] only in male participants, both before and after adjustment for potential confounders.

CONCLUSION

In this study, we showed that higher adherence to a high-quality diet was associated with a lower chance of developing MetS in men. Biological gender might be responsible for the observed discrepancies.

Diet Quality Trajectories over Adulthood in a Biracial Urban Sample from the Healthy Aging in Neighborhoods of Diversity across the Life Span Study

Limited investigation has been done on diet quality trajectories over adulthood. The main study objectives were to determine the diet quality group trajectories (GTs) over time and to detect changes in a socio-economically and racially diverse middle-aged cohort. Data from three waves of the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study were used to determine diet quality with group-based trajectory modeling (GBTM). Three quality indices-the Healthy Eating Index (HEI), the Dietary Inflammatory Index (DII), and the Mean Adequacy Ratio (MAR)-were explored. The rate of change in quality over time was determined by mixed-effects regression analysis. Three diet quality GTs, low, middle, and high quality, were identified for each index and confirmed with spaghetti plots. Within each GT, only small changes in diet quality scores were observed, with improvements for the HEI and DII indices and a slight decline in MAR scores. Weighted kappa values revealed that the DII had better agreement with the HEI-2010 and MAR indices compared with the agreement between the HEI-2010 and MAR. Bayesian estimates revealed that the annualized rate of change in diet quality per person across the GTs was similar. There was minimal change in diet quality over time, regardless of the diet quality index used.

The Association between Plant-Based Diets and Dietary Patterns with Cardiometabolic Risk in a Sample of Commercial Taxi Drivers in South Africa

The consumption of unhealthy foods and a sedentary lifestyle predispose individuals to non-communicable diseases. This study investigated the distribution and the association of plant-based diets (PBDs) and dietary patterns in relation to the cardiometabolic risks in commercial taxi drivers. A cross-sectional analysis was conducted among males (≥19 years) who consumed street foods sold by vendors in the Cape Metropole. A validated questionnaire was administered, including a quantified 24 h dietary recall, and fasting blood samples were collected for biochemical analyses. Statistical analyses were performed to investigate the association between dietary habits and cardiometabolic risks, while adjusting for confounding variables. The analytic sample consisted of 189 males with a median age of 38 years. The taxi drivers who ranked in the top-third of the healthy plant-based diet index (hPDI) had a 1–4% lower likelihood of having raised triglycerides (TG). Furthermore, consumption patterns including refined grains and meat conferred a 33% lower likelihood of dysglycaemia (p = 0.049), while fish/seafood, potatoes, and vegetables conferred a 43% greater likelihood of low high-density lipoprotein cholesterol (HDL-C) (p = 0.026) and 44% greater probability of raised low-density lipoprotein cholesterol (LDL-C) (p = 0.027). Consumption patterns, including sugar-sweetened beverages and eggs, conferred a 37% greater probability of hypertension (p = 0.047) and 53% greater likelihood of subclinical inflammation (p = 0.017). These preliminary findings require larger and more elaborate studies to explore the associations between PBDs and dietary patterns in at-risk African populations, with or without sedentary lifestyles, and exposure to unhealthy food environments.

Adherence to the EAT-Lancet diet, genetic susceptibility, and risk of type 2 diabetes in Swedish adults

BACKGROUND AND AIMS

In 2019, the EAT-Lancet Commission proposed a mainly plant-based diet that nurtures human health and supports environmental sustainability. However, its association with type 2 diabetes (T2D) has not been widely studied, and it remains unclear whether genetic susceptibility for T2D can modify this association. The aim was therefore to investigate the association between the EAT-Lancet diet and risk of T2D and assess whether the association differs by the genetic predisposition to T2D.

METHODS

A total of 24,494 participants from the Malmö Diet and Cancer study were analyzed. Dietary intake was assessed using a modified diet history methodology, and an EAT-Lancet diet index (range from 0 to 42 points) was constructed based on the EAT-Lancet reference diet. National and local registers were used to identify T2D cases during follow-up. Cox proportional hazards regression model was applied to estimate the association between the EAT-Lancet diet index and risk of T2D. Genetic predisposition to T2D was captured based on 116 single nucleotide polymorphisms.

RESULTS

During a median of 24.3 years of follow-up, 4197 (17.1 %) T2D cases were documented. Compared with those with the lowest adherence to the EAT-Lancet diet (≤13 points), participants who had the highest adherence (≥23 points) showed an 18 % (95 % CI: 4 %-30 %) lower risk of T2D (P for trend <0.01). There was no significant multiplicative interaction between genetic predisposition to T2D and the EAT-Lancet diet index (P = 0.59). Also, no significant additive interaction between the genetic risk and the EAT-Lancet diet was seen (P = 0.44). The highest risk was observed among the 22.9 % of the individuals with high genetic risk and low EAT-Lancet diet score (HR = 1.79; 95 % CI: 1.63, 1.96).

CONCLUSIONS

Our findings indicate that high adherence to the EAT-Lancet diet was associated with decreased risk of incident T2D among people with different genetic risks.

Association of diet quality indices with serum and metabolic biomarkers in participants of the ORISCAV-LUX-2 study

PURPOSE

Diet quality is a critical modifiable factor related to health, including the risk of cardiometabolic complications. Rather than assessing the intake of individual food items, it is more meaningful to examine overall dietary patterns. This study investigated the adherence to common dietary indices and their association with serum/metabolic parameters of disease risk.

METHODS

Dietary intakes of the general adult population (n = 1404, 25-79 years) were assessed by a validated food-frequency questionnaire (174 items). The French ANSES-Ciqual food composition database was used to compute nutrient intakes. Seven indicators were calculated to investigate participants' diet quality: the Alternative Healthy Eating Index (AHEI), Dietary Approaches to Stop Hypertension Score (DASH-S), Mediterranean Diet Score (MDS), Diet Quality Index-International (DQI-I), Dietary Inflammatory Index (DII), Dietary Antioxidant Index (DAI), and Naturally Nutrient-Rich Score (NNRS). Various serum/metabolic parameters were used in the validity and association analyses, including markers of inflammation, blood glucose, and blood lipid status.

RESULTS

Following linear regression models adjusted for confounders, the DASH-S was significantly associated with most metabolic parameters (14, e.g., inversely with blood pressure, triglycerides, urinary sodium, uric acid, and positively with serum vitamin D), followed by the DQI-I (13, e.g., total cholesterol, apo-A/B, uric acid, and blood pressure) and the AHEI (11, e.g., apo-A, uric acid, serum vitamin D, diastolic blood pressure and vascular age).

CONCLUSION

Food-group-based indices, including DASH-S, DQI-I, and AHEI, were good predictors for serum/metabolic parameters, while nutrient-based indices, such as the DAI or NNRS, were less related to biological markers and, thus, less suitable to reflect diet quality in a general population.

Effectiveness of diet quality indices in measuring a change in diet quality over time: a systematic review and meta-analysis of randomized controlled trials

CONTEXT

Diet quality indices (DQIs) were developed to score and rank adherence to dietary patterns in observational studies, but their use to measure changes in diet quality in intervention trials is becoming common in the literature.

OBJECTIVE

This systematic review and meta-analysis aimed to assess the effectiveness of DQIs to measure change in diet quality in intervention trials.

DATA SOURCES

MEDLINE, CINAHL, Embase, and the Cochrane Central Register of Controlled Trials databases were searched from January 1994 to June 2020. Two reviewers independently completed full-text screening. Eligible studies were randomized controlled trials that used validated a priori DQIs to measure change in diet quality in adults.

DATA EXTRACTION

Data were extracted by an independent reviewer and reviewed by the research team. Risk of bias was assessed by the Cochrane Collaboration's Risk of Bias 2.0 tool.

DATA ANALYSIS

The 34 included studies (52% of reviewed studies, 0.6% of initially identified studies) used 10 different DQIs, 7 of which were able to measure significant change in diet quality. Meta-analyses of pooled results demonstrated change in the Healthy Eating Index (MD 5.35; 95%CI, 2.74-7.97; P < 0.001) and the Mediterranean Dietary Adherence Screener (MD 1.61; 95%CI, 1.00-2.23; P < 0.001) scores. DQIs were more likely to measure change in diet quality if they reflected the diet pattern being implemented, if the intervention was significantly different from the baseline and control diets, and if the study was adequately powered to detect change.

CONCLUSION

DQIs are responsive to change in diet quality in intervention trials when the index used reflects the dietary changes made and the study is adequately powered. The appropriate selection of a DQI to suitably match dietary changes and study populations is important for future dietary intervention trials.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42020181357.

Development of a Diet Quality Score for Japanese and Comparison With Existing Diet Quality Scores Regarding Inadequacy of Nutrient Intake

BACKGROUND

Few studies have explored optimal diet quality scores in Japan.

OBJECTIVES

We developed a Diet Quality Score for Japanese (DQSJ) and examined the associations of DQSJ and existing diet quality scores with inadequacy of nutrient intake in Japanese adults.

METHODS

Candidate components of the DQSJ were extracted from well-established diet quality scores: Healthy Eating Index-2015 (HEI-2015), Alternate Healthy Eating Index-2010 (AHEI-2010), Alternate Mediterranean Diet score (AMED), and Dietary Approaches to Stop Hypertension (DASH). From candidates, we selected the components of the DQSJ, considering potential health effects of the components (from the Global Burden of Disease Study) and dietary intake in Japan. The DQSJ included 10 components: fruits, vegetables, whole grain, dairy, nuts, legumes, fish, red and processed meat, sugar-sweetened beverages, and sodium. We calculated the DQSJ, HEI-2015, AHEI-2010, AMED, DASH, and Japanese Food Guide Spinning Top score (JFGST) based on 4-d dietary records of 392 Japanese aged 20-69 y. Inadequate intakes of 21 nutrients were assessed using the DRIs for Japanese. Logistic regression was used to examine the prevalence of inadequate nutrient intake according to quartiles of the scores.

RESULTS

All examined scores except the JFGST were moderately to strongly correlated with each other (Spearman correlation coefficients: 0.52-0.84). They were inversely associated with the prevalence of inadequate intake of most nutrients (n = 16 for DQSJ and HEI-2015, n = 13 for AHEI-2010 and DASH, n = 17 for AMED, compared with n = 4 for JFGST). AMED was also positively associated with the prevalence of inadequate sodium intake, whereas no such associations were observed for the other scores.

CONCLUSIONS

Similar to HEI-2015, AHEI-2010, and DASH, the DQSJ was generally associated with the low prevalence of inadequate intake of most nutrients in Japanese adults. Further evaluations against biomarkers and health outcomes are warranted.

Adherence to the EAT-Lancet sustainable reference diet and cardiometabolic risk profile: cross-sectional results from the ELSA-Brasil cohort study

PURPOSE

The EAT-Lancet Commission released a reference sustainable diet to improve human health and respect the planetary boundaries. The Planetary Health Diet Index (PHDI) was developed with the purpose of evaluate the adherence to this reference diet. The aim of the present study was to evaluate the association between adherence to the EAT-Lancet diet with cardiometabolic risk profile.

METHODS

We used the cross-sectional baseline data from 14,155 participants of the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil), a multicenter ongoing cohort study. Dietary data were collected using a 114-item validated food frequency questionnaire. The PHDI was used to assess the adherence to the EAT-Lancet diet. It consists of 16 components and the total score can range from 0 to 150 points. Linear, logistic and quasi-Poisson regression models were built to evaluate the associations between PHDI and the outcomes.

RESULTS

Individuals with higher adherence to EAT-Lancet diet (PHDI, 5th quintile) had lower values for systolic blood pressure (β - 0.84; 95% CI - 1.66: - 0.01), diastolic blood pressure (β - 0.70; 95% CI - 1.24: - 0.15), total cholesterol (β - 3.15; 95% CI - 5.30: - 1.01), LDL-c (β - 4.10; 95% CI - 5.97: -  2.23), and non-HDL-cholesterol (β - 2.57; 95% CI - 4.62: - 0.52). No association was observed for HDL-c, triglycerides and HOMA-IR.

CONCLUSIONS

Our results indicate that higher adherence to the EAT-Lancet diet is associated with lower levels of blood pressure, total cholesterol, LDL-c, and non-HDL-c.

Holistic Framework to Contextualize Dietary Quality Assessment: A Critical Review

Numerous dietary quality indices exist to help quantify overall dietary intake and behaviors associated with positive health outcomes. Most indices focus solely on biomedical factors and nutrient or food intake, and exclude the influence of important social and environmental factors associated with dietary intake. Using the Diet Quality Index- International as one sample index to illustrate our proposed holistic conceptual framework, this critical review seeks to elucidate potential adaptations to dietary quality assessment by considering-in parallel-biomedical, environmental, and social factors. Considering these factors would add context to dietary quality assessment, influencing post-assessment recommendations for use across various populations and circumstances. Additionally, individual and population-level evidence-based practices could be informed by contextual social and environmental factors that influence dietary quality to provide more relevant, reasonable, and beneficial nutritional recommendations.

Measuring food insecurity: An introduction to tools for human biologists and ecologists

OBJECTIVE

Food insecurity is a significant and growing concern undermining the wellbeing of 30% of the global population. Food in/security is a complex construct consisting of four dimensions: availability, access, utilization, and stability, making it challenging to measure. We provide a toolkit human biologists/ecologists can use to advance research on this topic.

METHODS

We review the strengths and limitations of common tools used to measure food access and utilization, the two dimensions most proximate to people's lived experience, and emphasize tools that provide data needed to best link food security with human biological outcomes. We also discuss methods that provide contextual data human biologists/ecologists will find useful for study design, ensuring instrument validity, and improving data quality.

RESULTS

Food access is principally measured using experience-based instruments that emphasize economic access. Social access, such as food sharing, is under-studied and we recommend using social network analysis to explore this dimension. In terms of utilization, emphasis has been on food choice measured as dietary diversity. Food preparation and intrahousehold distribution, also part of the utilization dimension, are less studied and standardized instruments for measuring both are lacking. The embodiment of food insecurity has focused on child growth, although a growing literature addresses adult mental wellbeing and chronic and infectious disease risk.

CONCLUSIONS

We see the potential to expand outcomes to include reproductive and immune function, physical activity, and the gut microbiome. Human biologists/ecologists are well-positioned to advance understanding of the human health impacts of food insecurity and provide data to support intervention efforts.

Comparison of Four Dietary Pattern Indices in Australian Baby Boomers: Findings from the Busselton Healthy Ageing Study

The assessment of dietary patterns comprehensively represents the totality of the diet, an important risk factor for many chronic diseases. This study aimed to characterise and compare four dietary pattern indices in middle-aged Australian adults. In 3458 participants (55% female) from the Busselton Healthy Ageing Study (Phase Two), a validated food frequency questionnaire was used to capture dietary data between 2016 and 2022. Four dietary patterns [Australian Dietary Guideline Index 2013 (DGI-2013); the Mediterranean Diet Index (MedDiet); the Literature-based Mediterranean Diet Index (Lit-MedDiet); and the EAT-Lancet Index], were calculated and compared by measuring total and sub-component scores, and concordance (𝜌c). Cross-sectional associations between the dietary indices and demographic, lifestyle, and medical conditions were modelled with linear regression and restricted cubic splines. Participants had the highest standardised scores for the DGI-2013 followed by the EAT-Lancet Index and the MedDiet, with the lowest standardised scores observed for the Lit-MedDiet. The DGI-2013 had the lowest agreement with the other scores (𝜌c ≤ 0.47). These findings indicate that the diets included in this Australian cohort align more closely with the Australian Dietary Guidelines than with the other international dietary patterns, likely due to the wide variation of individual food group weightings in the construction of these indices.

Comparison and convergent validity of five Mediterranean dietary indexes applied to Brazilian adults and older adults: data from a population-based study (2015 ISA-Nutrition)

Different dietary indexes are proposed to investigate adherence to the Mediterranean diet (MD). However, they are based on different methodologies, and limited research has compared them to each other, particularly in non-Mediterranean populations. We aimed to compare five indexes intended to measure adherence to the MD. The sample was composed of adults and older adults (n 1187) from 2015 ISA-Nutrition, a cross-sectional population-based study in São Paulo, SP, Brazil. Dietary data obtained through two 24-h dietary recalls (24HDR) from which the Mediterranean diet scale (MDS), Mediterranean diet Score (MedDietscore), Mediterranean dietary pattern (MDP), Mediterranean Adequacy Index (MAI) and Mediterranean-Style Dietary Pattern Score (MSDPS) were calculated. The correlations and agreements between them were analysed by Spearman's correlation and linearly weighted Cohen's Kappa coefficients, respectively. Confirmatory factor analyses (CFAs) were applied to investigate their convergent validity. The highest correlations were found between MDP and MAI (r = 0⋅76; 95% CI 0⋅74-0⋅79) and between MDP and MDS (r = 0⋅72; 95% CI 0⋅69-0⋅75). The greatest agreements observed were moderate, between MDP v. MAI (κ = 0⋅57, P < 0⋅001) and MDP v. MDS (κ = 0⋅48, P < 0⋅001). The goodness-of-fit of CFA for MedDietscore (RMSEA = 0⋅033, 90% CI 0⋅02-0⋅042; SRMR = 0⋅042) and MSDPS (RMSEA = 0⋅028, 90% CI 0⋅019-0⋅037; SRMR = 0⋅031) had acceptable values for absolute fit indices. Vegetables, olive oil, MUFA:SFA ratio and cereals with legumes were more relevant to characterise the MD (factor loadings ≥0⋅50). The MDS, MAI and MDP classified the population similarly, but the MedDietscore showed better performances in evaluating adherence to the MD. These results provided guidance for the most appropriate Mediterranean dietary index to be applied in non-Mediterranean populations.

Measuring Adherence to Sustainable Healthy Diets: A Scoping Review of Dietary Metrics

Comprehensive metrics that provide a measure of dietary patterns at global and national levels are needed to inform and assess the effectiveness of policy actions that promote sustainable healthy diets. In 2019, the Food and Agriculture Organization of the United Nations and the World Health Organization reported 16 guiding principles of sustainable healthy diets, but it is still unknown how these principles are considered in dietary metrics. This scoping review aimed to explore how principles of sustainable healthy diets are considered in dietary metrics used worldwide. Forty-eight food-based, investigator-defined dietary pattern metrics assessing diet quality in free-living, healthy populations at the individual or household level were assessed against the 16 guiding principles of sustainable healthy diets, which was used as a theoretical framework. A strong adherence of the metrics to health-related guiding principles was found. Metrics had a weak adherence to principles related to environmental and sociocultural aspects of diets, except for the principle related to diets being culturally appropriate. No existing dietary metric captures all principles of sustainable healthy diets. Notably, the significance food processing, environmental, and sociocultural aspects of diets are generally understated. This likely reflects the lack of focus on these aspects in current dietary guidelines, which highlights the importance of including these emerging topics in future dietary recommendations. The absence of quantitative metrics that comprehensively measure sustainable healthy diets limits the body of evidence that would otherwise inform national and international guideline developments. Our findings can help grow the quantity and quality of the body of evidence available to inform policy activities to realize 2030 Sustainable Development Goals of multiple United Nations. Adv Nutr 2022;x:xx.

Differences in Cost-Effectiveness of Adherence to Nutritional Recommendations: Why, Where, and What?

Cost-effectiveness analysis of diets may comprise an important tool to promote food security; however, studies show divergent evidence regarding the relationship between diet quality and cost in diverse populations. Thus, this study assesses differences in cost-effectiveness ratios regarding adherence to nutritional recommendations using data representative of the population level in Sao Paulo municipality, Brazil. Information from adolescents and adult individuals (n = 1742) was used to estimate diet quality and cost in 2015. Differences in cost-effectiveness ratios were investigated through application of two diet quality indexes and exploration of individuals' personal and contextual characteristics. Results indicated that higher diet cost was associated with higher adherence to nutritional recommendations at the national level and inversely associated with adherence to international recommendations. Purchasing foods in street markets was linked to healthier diets at lower costs, and protein consumption was associated with higher diet cost regardless of diet quality; however, diet quality was linked to type of protein consumed by individuals. Differences in cost-effectiveness ratios were attributable to methodological choices in measuring dietary quality (why); individuals' personal and contextual characteristics, in particular, access to retail equipment (where); and certain food choices (what). Therefore, cost-effectiveness analyses should be tailored to policy goals and local environments to ensure proper assessment of nutrition programs and to foster improvements in nutritional diet quality at lower cost.

Ultra-processed food consumption and associations with biomarkers of nutrition and inflammation in pregnancy: The Norwegian Environmental Biobank

Background

A high consumption of ultra-processed foods (UPFs) is often associated with low nutritional quality, but data on associations with biomarkers are scarce. We aimed to explore associations between UPF intake, diet quality, and concentrations of biomarkers of nutrition and inflammation measured in mid-pregnancy.

Methods

This cross-sectional study included n = 2,984 pregnant women recruited during 2002-2008 in the Norwegian Mother, Father, and Child Cohort Study (MoBa). Concentrations of C-reactive protein (CRP) and 21 nutritional biomarkers including carotenes (α-carotene, β-carotene, γ-carotene, α-cryptoxanthin, β-cryptoxanthin, lutein, lycopene), vitamins [α-tocopherol, γ-tocopherol, 25-hydroxyvitamin D (25-OH-D), retinol], creatinine, elements (K, Na, Co, Cu, Mn, Mo, Se, Zn), and ferritin (Fe) were measured in blood and urine collected in mid-pregnancy. Habitual diet in pregnancy was assessed using a validated semi-quantitative food frequency questionnaire. We calculated the relative (%) energy contribution of UPF to overall intake according to the NOVA classification. We also applied a diet quality index (DQI) adapted to assess adherence to Norwegian dietary guidelines (DQI; min-max: 0-110, higher score meaning higher adherence). We present summary statistics for biomarker concentrations and explored associations between UPF intake or the DQI and measured biomarkers using adjusted linear, logistic, and generalized additive regression models.

Results

Ultra-processed food intake was positively associated with biomarker concentrations of vitamin E (γ-tocopherol), creatinine, K, and Na [βs: 5.6 to 17% increase in biomarker concentration per interquartile range (IQR) increase in UPF intake] and negatively associated with carotenoids (α-carotene, β-carotene, γ-carotene, α-cryptoxanthin, β-cryptoxanthin, lutein, lycopene), vitamin A, Mo, and Se (βs: -2.1 to -18%). Inversely, high diet quality (i.e., the DQI) was positively associated with concentrations of carotenoids, vitamins [vitamin A (retinol) and D (25-OH-D)], and Se (β: 1.5 to 25%) and negatively associated with vitamin E (γ-tocopherol), creatinine, and Na (β: -4.8 to -8.3%). A weak, positive association was found between UPF and CRP (β: 5.4%, 95% CI 0.12-11%).

Conclusion

High UPF intake was associated with reduced concentrations of nutrition biomarkers in mid-pregnancy. Associations in the opposite direction were found with high adherence to the Norwegian dietary guidelines, suggesting that the two dietary scoring systems capture diet quality in a mirrored manner in this population.

Diet quality indices and their associations with all-cause mortality, CVD and type 2 diabetes mellitus: an umbrella review

Numerous observational studies have investigated associations between diet indices and health outcomes. Our aim was to systematically synthesise data that was previously summarised separately for each diet index in one umbrella review of all diet indices with sufficient evidence gained in systematic reviews and to assess the quality and strength of evidence for selected health outcomes. The MEDLINE, EMBASE and Scopus databases were systematically searched following the PRISMA guidelines through October 2021 for systematic reviews of observational studies investigating associations between adherence to diet indices and selected health outcomes (all-cause mortality, CVD incidence or mortality, type 2 diabetes mellitus incidence or mortality). Methodological quality and quality of evidence were assessed using the AMSTAR 2 and NutriGrade tools. The inclusion criteria were met by seven systematic reviews, entirely based on prospective cohort studies and reviewing five different diet indices - alternate healthy eating index (AHEI), dietary approaches to stop hypertension (DASH), dietary inflammatory index (DII), healthy eating index (HEI) and Mediterranean diet (MedDiet). All seven included systematic reviews showed that greater adherence to these diet indices reduces the risks of all-cause mortality, CVD incidence and mortality and type 2 diabetes mellitus incidence. Moderate meta-evidence was presented for AHEI and DASH for all outcomes, also for DII for all-cause mortality, CVD mortality and incidence, MedDiet for all-cause mortality and for HEI for CVD incidence and mortality. Our umbrella review provides further evidence for AHEI, DASH, DII and HEI diet indices to be used as predictors of selected health outcomes.

Three food pattern-based indices diagnose lactating women's nutritional inadequacies in Argentina: A clinimetric approach using diet quality indicators and breast milk biomarkers

Diet is a health foundation that supports breastfeeding and enables lactating women's recovery. This study aimed to develop 3 valid diet adherence indices by clinimetric contrast with different parameters. We hypothesize that the 3 diet adherence-based indices are positively correlated with diet quality and milk biomarkers and directly related to calcium, fiber, and energy intake. A cross-sectional study recorded food frequency, anthropometric and dietary measures, and milk analysis to estimate correlations, sensitivity, and specificity (n = 284). Three reliable indices agreed by >75% with food frequency: macronutritional (MDI), phytochemical (PDI), and energetic (EDI), which correlated positively to the Fat Quality Index and Minimum Dietary Diversity for Women. MDI and EDI correlated negatively to the Healthy Plant-Based Diet Index (H-PBDI), whereas PDI correlated positively. MDI correlated positively to the protein-to-carbohydrate ratio, whereas EDI correlated negatively. Inadequate intakes of calcium, fiber, and energy were indicated by MDI <19, PDI <19, and EDI ≥19, respectively, in a sensitive and specific manner. Body fat was therefore positively associated with EDI. MDI was associated with increased protein and superoxide anion in milk, depending on its high protein-to-carbohydrate ratio and low H-PBDI. These indices allowed us to assess diet to diagnose maternal malnutrition promptly. Index validity was supported by significant dietary correlations and biological responsiveness. MDI and EDI promoted breast bioactivity and body adiposity, respectively, whereas PDI represented a healthier option.

Towards healthier and more sustainable diets in the Australian context: comparison of current diets with the Australian Dietary Guidelines and the EAT-Lancet Planetary Health Diet

BACKGROUND

There is increasing focus on moving populations towards healthier and more environmentally sustainable dietary patterns. The Australian Dietary Guidelines provide dietary patterns that promote health and wellbeing. It is unclear how these guidelines align with the more recently published global recommendations of the EAT-Lancet Planetary Health Reference Diet, and how Australian diets compare to both sets of recommendations.

METHODS

Data from one 24-h recall collected for the 2011-13 National Nutrition and Physical Activity Survey were analysed for 5,920 adults aged 19-50 years. Subgroups of this population were identified by diet quality and lower or higher consumption of foods often considered to be environmentally intensive (higher animal meat and dairy foods) or associated with healthiness (higher vegetables and lower discretionary choices). Food group and nutrient composition of Australian diets were compared to diets modelled on the Australian Dietary Guidelines and Planetary Health Reference Diet. The environmental impacts of diets were estimated using an index of combined metrics.

RESULTS

Compared with the Planetary Health Reference Diet, the Australian Dietary Guidelines contained more servings of the vegetable, dairy and alternatives, fruit, and discretionary choices. The amount of meat and alternatives was higher in the Planetary Health Reference Diet than Australian Dietary Guidelines due to the inclusion of more plant-based meat alternatives. The average Australian diet contained two to almost four times the Australian Dietary Guidelines and Planetary Health Reference Diet maximum recommended intake of discretionary choices, and provided inadequate amounts of the vegetables, cereals, unsaturated fats and meats and alternatives food groups, primarily due to lower intakes of plant-based alternatives. The average Australian diet also contained less dairy and alternatives than the Australian Dietary Guidelines. In the average Australian diet, red meat and poultry contributed 73% to the total servings of meat and alternatives compared to 33% and 10% for the Australian Dietary Guidelines and Planetary Health Reference Diet respectively. The modelled Australian Dietary Guidelines diet met the relevant nutrient reference value for all 22 nutrients examined, whereas the Planetary Health Reference Diet contained an inadequate amount of calcium. The environmental impact scores of the Planetary Health Reference Diet and Australian Dietary Guidelines were 31% and 46% lower than the average Australian diet.

CONCLUSIONS

Significant changes are required for Australians' dietary intake to align more closely with national and global dietary recommendations for health and environmental sustainability.

Mediterranean Diet and White Matter Hyperintensity Change over Time in Cognitively Intact Adults

Current evidence on the impact of Mediterranean diet (MeDi) on white matter hyperintensity (WMH) trajectory is scarce. This study aims to examine whether greater adherence to MeDi is associated with less accumulation of WMH. This population-based longitudinal study included 183 cognitively intact adults aged 20−80 years. The MeDi score was obtained from a self-reported food frequency questionnaire; WMH was assessed by 3T MRI. Multivariable linear regression was used to estimate the effect of MeDi on WMH change. Covariates included socio-demographic factors and brain markers. Moderation effects by age, gender, and race/ethnicity were examined, followed by stratification analyses. Among all participants, WMH increased from baseline to follow-up (mean difference [follow-up-baseline] [standard deviation] = 0.31 [0.48], p < 0.001). MeDi adherence was negatively associated with the increase in WMH (β = −0.014, 95% CI = −0.026−−0.001, p = 0.034), adjusting for all covariates. The association between MeDi and WMH change was moderated by age (young group = reference, p-interaction[middle-aged × MeDi] = 0.075, p-interaction[older × MeDi] = 0.037). The association between MeDi and WMH change was observed among the young group (β = −0.035, 95% CI = −0.058−−0.013, p = 0.003), but not among other age groups. Moderation effects by gender and race/ethnicity did not reach significance. Greater adherence to MeDi was associated with a lesser increase in WMH over time. Following a healthy diet, especially at younger age, may help to maintain a healthy brain.

Diet cost and quality using the Healthy Eating Index-2015 in adults from urban and rural areas of Mexico

OBJECTIVE

To assess the association between diet cost and quality by place of residence.

DESIGN

We analysed cross-sectional data of the National Health and Nutrition Survey-2012. Diet cost was estimated by linking dietary data, obtained from a 7-d SFFQ, with municipality food prices, which were derived from a national expenditure survey. Diet quality was assessed using the Healthy Eating Index-2015 (HEI-2015). Association between quintiles of diet cost and HEI-2015 was assessed using linear regression analysis.

SETTINGS

Mexico.

PARTICIPANTS

2438 adults (18-59 years).

RESULTS

Diet cost was positively associated with diet quality (HEI-2015) in urban but not in rural areas. Compared with quintile (Q1) of cost, the increment in diet quality score was 1·17 (95 % CI -0·06, 4·33) for Q2, 2·14 (95 % CI -0·06, 4·33) for Q3, 4·70 (95 % CI 2·62, 6·79) for Q4 and 6·34 (95 % CI 4·20, 8·49) for Q5 (P-trend < 0·001). Individuals in rural v. urban areas on average have higher quality diets at lower cost with higher intakes of whole grains and beans and lower intakes of Na, added sugars and saturated fats. Living in the South, being indigenous and having low socio-economic status were also associated with higher quality diets.

CONCLUSIONS

Diet cost was positively associated with diet quality, but only in urban areas. Further studies are needed to understand the relation between diet cost and quality in rural areas. To improve overall diet quality in Mexico, strategies that aim to reduce the cost of high-quality diets should consider the heterogeneity by place of residence.

Impacts of Self-Efficacy on Food and Dietary Choices during the First COVID-19 Lockdown in China

The COVID-19 pandemic has caused a global public health emergency, increasing the prevalence of emotional distress, and potentially leading to altered diet behavior. Self-efficacy measures various aspects of perceiving and understanding emotions. The present study was carried out with the objective of understanding the effect of emotional self-efficacy on dietary behavior and quality. It also shed light on which elements contributed to the link between food-related behavior and perceived dietary quality during the first lockdown of the COVID-19 pandemic. Based on the factor analysis of nineteen food groups, choices, consumption, and socioeconomic status were examined in a sample of 441 Chinese participants. Multiple linear regression examined the association between food consumption, dietary quality, and self-efficacy. Contrary to prior research, the intake of salty snacks and alcoholic beverages dropped by 3.3% and 2.8%, respectively, during the first lockdown. Emotional self-efficacy negatively mediated the relationship between socioeconomic status and dietary quality. In conclusion, emotional self-efficacy is a well-established tool for evaluating how Chinese people cope with negative emotions. As an individual's dietary quality was affected during the imposed lockdown, the present study offers valuable insight into psychosocial factors that may contribute to health disparities by advocating for organized nutritional support in future epidemic-related quarantines.

Development of a metric Healthy Eating Index-2015 and comparison with the Healthy Eating Index-2015 for the evaluation of dietary quality

Background

Diet quality indices can provide important information about relationships between diet and health independent of energy balance. The Healthy Eating Index-2015 (HEI-2015) is widely used and has been extensively evaluated. However, due to imperial units the HEI-2015 is difficult to apply in countries with metric systems. Our objective was to develop a metric version of the HEI-2015 and compare it to the original. The metric Healthy Eating Index-2015 (mHEI-2015) is intended to simplify the application of a dietary quality index in countries using the metric system.

Methods

We developed a metric database logic following the methodology of the HEI-2015, which allows the application to metric databases and was applied to Food Patterns Equivalents Database (FPED). The HEI-2015 was calculated for the National Health and Nutrition Examination Survey (NHANES) 2017-2018 and the scoring standards for each component of the mHEI-2015 was calibrated against it. For the assessment of agreement between indices, HEI-2015 and mHEI-2015 were calculated for NHANES 2015-2016 and a Bland–Altman plot was created.

Results

Healthy Eating Index-2015 and mHEI-2015 for the NHANES 2015-2016 averaged 52.5 ± 13.5 and 52.6 ± 13.2, respectively. The total scores as well as component scores of the indices were strongly correlated. The Bland–Altman plot revealed a high agreement of the total scores. An illustrated analysis of six different menu plans showed only minor differences between the HEI-2015 and mHEI-2015 component scores.

Conclusion

The mHEI-2015 allows for superior analysis of metric dietary data to better examine the relationship between chronic diseases and diet. The streamlined metric methodology enables straightforward application to metric food databases and thus the development of country-specific indices.

Diet quality and physical or comprehensive frailty among older adults

PURPOSE

While the association between diet quality and mortality has been previously demonstrated, the association between frailty and diet quality has not been evaluated well. This study aimed to investigate the association between diet quality and prevalence of both physical and comprehensive frailty, using two validated tools, in a community-based cohort of older adults.

METHODS

We conducted cross-sectional analyses using baseline data of 7022 participants aged ≥ 65 years in the Kyoto-Kameoka study. Diet quality was assessed by calculating the adherence scores to the Japanese Food Guide Spinning Top using a validated questionnaire; the participants were stratified into quartile groups based on these scores. Physical and comprehensive frailty was assessed using the Fried phenotype model-based Frailty Screening Index and the Kihon Checklist, respectively. Multivariable logistic regression and the restricted cubic spline model were used to calculate odds ratios (ORs) and their 95% confidence intervals (CIs) for associations between adherence scores and frailty prevalence.

RESULTS

Higher adherence scores signified a higher intake of vitamin C, vegetables, dairy products, and fruits. Physical and comprehensive frailty prevalence was 14.2 and 35.8%, respectively. In a multivariable adjusted model, compared with the bottom adherence score quartile, the top quartile was associated with lower ORs of physical (OR 0.64; 95% CI 0.52-0.80) and comprehensive frailty (OR 0.60; 95% CI 0.51-0.71). These relationships were similar to results in the spline model.

CONCLUSIONS

This study shows an inverse dose-response relationship between diet quality and prevalence of both physical and comprehensive frailty in older adults.

Is dietary intake of advanced glycation end products associated with mortality among adults with diabetes?

BACKGROUND AND AIMS

Prior studies suggest a positive association between dietary AGEs and adverse health outcomes but have not well-characterized AGEs intake and its association with mortality in a general adult population in the United States.

METHODS AND RESULTS

We included 5474 adults with diabetes from the 2003 to 2018 National Health and Nutrition Examination Survey, a nationally representative sample of the non-institutionalized civilian population in the United States. Concordance to dietary guidelines (Healthy Eating Index 2015 [HEI-2015]) and intake of the AGE Nϵ-(carboxymethyl)lysine (CML) were estimated using an existing database and two 24-h food recalls. Multivariable Cox regression evaluated the association between AGEs intake and all-cause mortality. A secondary analysis measured CML, Nϵ-(1-carboxyethyl)lysine (CEL), and Nδ-(5-hydro-5-methyl-4-imidazolon-2-yl)-ornithine (MGH1) from an alternative database. Higher AGEs intake was associated with lower concordance to dietary guidelines (Means and standard errors of HEI-2015 score, by quartiles of AGEs intake: Q1 = 55.2 ± 0.6, Q2 = 54.1 ± 0.5, Q3 = 52.1 ± 0.5, Q4 = 49.0 ± 0.5; p < 0.001). There were 743 deaths among 3884 adults in the mortality analysis (mean follow-up = 3.8 years). AGEs intake was not significantly associated with all-cause mortality (Q2 vs. Q1: Hazard Ratio [HR] = 0.91 [0.69-1.21], Q3 vs. Q1: HR = 0.90 [0.63-1.27], Q4 vs. Q1: HR = 1.16 [0.84-1.60]). Results were similar in secondary analyses.

CONCLUSION

While dietary AGEs intake was associated with concordance to dietary guidelines, it was not significantly associated with all-cause mortality among adults with diabetes. Further research may consider other health outcomes as well as the evaluating specific contribution of dietary AGEs to overall AGEs burden.

Equal Weighting of the Healthy Eating Index-2010 Components May Not be Appropriate for Pregnancy

BACKGROUND

Adherence to the Dietary Guidelines for Americans is often assessed using the Healthy Eating Index (HEI). The HEI total score reflects overall diet quality, with all aspects equally important. Using the traditional weighting scheme for the HEI, all components are generally weighted equally in the total score. However, there is limited empirical basis for applying the traditional weighting for pregnancy specifically.

OBJECTIVES

We aimed to assess associations between the 12 HEI-2010 component scores and select pregnancy outcomes.

METHODS

The Nulliparous Pregnancy Outcomes Study: Monitoring Mothers-to-Be was a prospective pregnancy cohort (US multicenter, 2010-2013). Participants enrolled in the study between 6 and 13 weeks of gestation. An FFQ assessed usual dietary intake 3 months prior to pregnancy (n = 7880). Scores for the HEI-2010 components were assigned using prespecified standards based on densities (standard units per 1000 kcal) of relevant food groups for most components, a ratio (PUFAs and MUFAs to SFAs) for fatty acids, and the contribution to total energy for empty calories. Using binomial regression, we estimated risk differences between each component score and cases of small-for-gestational age (SGA) birth, preterm birth, preeclampsia, and gestational diabetes, controlling for total energy and scores for the other HEI-2010 components.

RESULTS

Higher scores for greens and beans and total vegetables were associated with fewer cases of SGA birth, preterm birth, and preeclampsia. For instance, every 1-unit increase in the greens and beans score was associated with 1.2 fewer SGA infants (95% CI, 0.7-1.7), 0.7 fewer preterm births (95% CI, 0.3-1.1), and 0.7 fewer preeclampsia cases (95% CI, 0.2-1.1) per 100 deliveries. For gestational diabetes, the associations were null.

CONCLUSIONS

Vegetable-rich diets were associated with fewer cases of SGA birth, preterm birth, and preeclampsia, controlling for overall diet quality. Examination of the equal weighting of the HEI components (and underlying guidance) is needed for pregnancy.

A Guide to Dietary Pattern-Microbiome Data Integration

The human gut microbiome is linked to metabolic and cardiovascular disease risk. Dietary modulation of the human gut microbiome offers an attractive pathway to manipulate the microbiome to prevent microbiome-related disease. However, this promise has not been realized. The complex system of diet and microbiome interactions is poorly understood. Integrating observational human diet and microbiome data can help researchers and clinicians untangle the complex systems of interactions that predict how the microbiome will change in response to foods. The use of dietary patterns to assess diet-microbiome relations holds promise to identify interesting associations and result in findings that can directly translate into actionable dietary intake recommendations and eating plans. In this article, we first highlight the complexity inherent in both dietary and microbiome data and introduce the approaches generally used to explore diet and microbiome simultaneously in observational studies. Second, we review the food group and dietary pattern-microbiome literature focusing on dietary complexity-moving beyond nutrients. Our review identified a substantial and growing body of literature that explores links between the microbiome and dietary patterns. However, there was very little standardization of dietary collection and assessment methods across studies. The 54 studies identified in this review used ≥7 different methods to assess diet. Coupled with the variation in final dietary parameters calculated from dietary data (e.g., dietary indices, dietary patterns, food groups, etc.), few studies with shared methods and assessment techniques were available for comparison. Third, we highlight the similarities between dietary and microbiome data structures and present the possibility that multivariate and compositional methods, developed initially for microbiome data, could have utility when applied to dietary data. Finally, we summarize the current state of the art for diet-microbiome data integration and highlight ways dietary data could be paired with microbiome data in future studies to improve the detection of diet-microbiome signals.

The AHA Recommendations for a Healthy Diet and Ultra-Processed Foods: Building a New Diet Quality Index

The American Heart Association (AHA) has developed the concept of “ideal cardiovascular health” (ICH), a seven-component score, which includes health dietary metrics. Higher ultra-processed foods intake is related with several cardiometabolic and cardiovascular diseases. We propose to develop and validate the Cardiovascular Health Diet Index (CHDI), a diet quality index that combines the AHA's recommendations of a healthy diet for cardiovascular health and ultra-processed foods. We used dietary data obtained through a 114-item FFQ from 14,779 participants of the Brazilian Longitudinal Study of Adults Health (ELSA-Brasil). The CHDI had 11 components and a total score ranging from 0 to 110 points. Validation and reliability analyses were performed, including principal component analyses, association with selected nutrients, means differences between groups (for example, smokers vs. non-smokers), Cronbach's alpha, and linear regression analyses between CHDI and overall dietary quality. The mean CHDI was 57.1 points (95% CI 47.9:66.0). The CHDI had four dimensions; in addition, it was associated with nutrients related to cardiovascular health, and the points were significantly (p < 0.001) lower in smokers (52.1) than in non-smokers (57.8). Cronbach's alpha value was 0.50. After age and sex adjustment, the CHDI score remained associated with a higher overall dietary quality (β 0.87, 95%CI 0.84:0.89, p < 0.001). The CHDI proved to be valid and reliable for use, in addition to being associated with higher overall dietary quality. The use of CHDI is expected to assess the population's compliance with dietary recommendations for promoting cardiovascular health and preventing cardiovascular disease.