Cardiometabolic disease costs associated with suboptimal diet in the United States: A cost analysis based on a microsimulation model

Nutrition and Physical Activity Interventions for Adults in the General Population: A Position Paper of the Academy of Nutrition and Dietetics and the American Council on Exercise

It is the position of the Academy of Nutrition and Dietetics and the American Council on Exercise that nutrition and physical activity interventions delivered by qualified nutrition and exercise practitioners, within their scopes of practice, can improve lifestyle behaviors and cardiometabolic risk factors for adults in the general population. Effective interventions require client-centered, evidence-based care provided by skilled practitioners using inclusive, dynamic methods, and collaboration with an interprofessional team, as appropriate. Increased access to evidence-based nutrition and physical activity interventions is necessary to improve public health and should be a target for policymakers, health care systems, and practitioners. Adults who attain a nutritious diet and adequate physical activity have improved overall health compared with their counterparts. However, most adults do not meet population recommendations. Qualified nutrition and exercise practitioners can collaborate with clients and interprofessional teams to provide nutrition and physical activity interventions and improve outcomes. However, recent guidelines have identified a need for guidance on best practices for delivering behavioral lifestyle counseling, referring to other practitioners, and improving access to disease prevention services. This Academy of Nutrition and Dietetics Position Paper aims to address common barriers for nutrition and exercise practitioners providing nutrition and physical activity interventions for adults in the general population, and best practices for overcoming these barriers. Collective action from interprofessional practitioners and implementation partners can increase access to high-quality, individualized services to prevent disease and improve health and well-being on a population level. This position was approved in July 2024 and will remain in effect until December 31, 2031.

Global burden and cross-country inequalities in stroke and subtypes attributable to diet from 1990 to 2019

DATA SOURCES

The Global Burden of Diseases, Injuries, and Risk Factors study (GBD) 2019.

BACKGROUND

To describe burden, and to explore cross-country inequalities according to socio-demographic index (SDI) for stroke and subtypes attributable to diet.

METHODS

Death and years lived with disability (YLDs) data and corresponding estimated annual percentage changes (EAPCs) were estimated by year, age, gender, location and SDI. Pearson correlation analysis was performed to evaluate the connections between age-standardized rates (ASRs) of death, YLDs, their EAPCs and SDI. We used ARIMA model to predict the trend. Slope index of inequality (SII) and relative concentration index (RCI) were utilized to quantify the distributive inequalities in the burden of stroke.

RESULTS

A total of 1.74 million deaths (56.17% male) and 5.52 million YLDs (55.27% female) attributable to diet were included in the analysis in 2019.Between 1990 and 2019, the number of global stroke deaths and YLDs related to poor diet increased by 25.96% and 74.76% while ASRs for death and YLDs decreased by 42.29% and 11.34% respectively. The disease burden generally increased with age. The trends varied among stroke subtypes, with ischemic stroke (IS) being the primary cause of YLDs and intracerebral hemorrhage (ICH) being the leading cause of death. Mortality is inversely proportional to SDI (R = -0.45, p < 0.001). In terms of YLDs, countries with different SDIs exhibited no significant difference (p = 0.15), but the SII changed from 38.35 in 1990 to 45.18 in 2019 and the RCI showed 18.27 in 1990 and 24.98 in 2019 for stroke. The highest ASRs for death and YLDs appeared in Mongolia and Vanuatu while the lowest of them appeared in Israel and Belize, respectively. High sodium diets, high red meat consumption, and low fruit diets were the top three contributors to stroke YLDs in 2019.

DISCUSSION

The burden of diet-related stroke and subtypes varied significantly concerning year, age, gender, location and SDI. Countries with higher SDIs exhibited a disproportionately greater burden of stroke and its subtypes in terms of YLDs, and these disparities were found to intensify over time. To reduce disease burden, it is critical to enforce improved dietary practices, with a special emphasis on mortality drop in lower SDI countries and incidence decline in higher SDI countries.

Augmenting the National Nutrition Data System to Promote Diet Sustainability Analyses

Research on sustainable diets has become an important and growing area of the nutrition field, but recent studies have pointed to a lack of sustainability metrics and methods that are hindering research and policy progress. To fill this gap, the White House National Strategy on Hunger, Nutrition, and Health calls for increased funding to improve metrics, data collection, and research to address all domains of sustainability, which include nutrition/health, economic, environmental, and social domains. Commodity recipe databases, such as the Food Commodity Intake Database (FCID), are important tools for conducting diet sustainability analyses because they translate mixed dishes from dietary surveys, such as the National Health and Nutrition Examination Survey (NHANES), into commodity ingredients. These ingredients have been linked to data on environmental impacts and economic costs from other databases, thus facilitating collaboration between nutrition researchers, environmental scientists, economists, and others. These linkages cannot be made with other components of the national nutrition data system, such as the Food Patterns Equivalents Database (FPED), because the disaggregated food groups from them are not relevant for examining environmental impacts. Although the NHANES is conducted on an ongoing basis, and FPED is continually updated, the FCID has not been officially updated since 2010. This severely limits advancements in sustainability research and related policy analyses. In this commentary, we argue that the federal government should promote this diet sustainability work by integrating a commodity recipe database into the national nutrition data system, and updating it on a regular basis, as it does with other component databases.

Engagement in a pilot produce prescription program in rural and urban counties in the Southeast United States

Introduction

In the United States, over one in every ten households experiences food insecurity. Food insecurity is associated with often co-occurring adverse health consequences, including risk for obesity, type 2 diabetes, and hypertension. Within the "Food is Medicine" intervention space, Produce Prescription Programs (PRx) seek to alleviate food insecurity and improve diet and health outcomes by leveraging access to produce through healthcare organizations. Though these programs are burgeoning across the United States, research surrounding their implementation and outreach is limited.

Methods

This study evaluates the implementation, reach, engagement, and retention of a PRx program piloted in two regions of Georgia (US) from 2020 to 2022. The study included 170 people living with one or more cardiometabolic conditions recruited from clinical sites in metropolitan and rural areas. The program provided pre-packaged produce boxes and nutrition education over six months. We examine participants' baseline demographics, food security status, dietary patterns, and loss to follow-up across contexts (metropolitan and rural). We employ regression analyses and model comparison approaches to identify the strongest predictors of loss to follow-up during the pilot period.

Results

In the pilot period of this program, 170 participants enrolled across rural and metropolitan sites. Of these, 100 individuals (59%) remained engaged for the six-month program. While many individuals met the target criteria of living with or at-risk of food insecurity, not all lived with low or very low food security. Metropolitan participants, males, and those with children in the household had significantly higher odds of loss to follow-up compared to rural participants, females, and those without children in the household. No other significant demographic or household differences were observed.

Discussion

This study demonstrates the potential of PRx programs to enhance food and nutrition security and cardiometabolic health in metropolitan and rural clinical settings. Future research should focus on addressing barriers to engagement and expanding the reach, impact, and sustainability of PRx programs across diverse contexts.

National trends in nine key minerals intake (quantity and source) among U.S. adults, 1999 to march 2020

BACKGROUND

Changes in economy and dietary guidelines brought a great shock to diet quality and meal behaviors, but if these transformations have extended to minerals intake and their sources was still poorly understood. It is essential to evaluate time trends in minerals intake and their sources to inform policy makers.

OBJECTIVE

To investigate trends in minerals intake and their sources among U.S. adults.

METHODS

This analysis used dietary data collected by 24-h recalls from U.S. adults (≥ 20 years) in NHANES (1999-March 2020). Minerals intake, age-adjusted percentage of participants meeting recommendations, and minerals sources were calculated among all participants and by population subgroups in each NHANES survey cycle. Weighted linear or logistic regression models were used to examine the statistical significance of time trends.

RESULTS

A total of 48223 U.S. adults were included in this analysis. From 1999 to March 2020, intake of calcium (from 0.94 to 1.02 g/day), magnesium (from 308.07 to 321.85 mg/day), phosphorus (from 1.24 to 1.30 g/day), and sodium (from 3.24 to 3.26 mg/day) from food and beverages (FB) and dietary supplements (DSs) significantly increased, and intake of iron (from 19.17 to 16.38 mg/day), zinc (from 16.45 to 14.19 mg/day), copper (from 1.79 to 1.38 mg/day), and potassium (from 2.65 to 2.50 g/day) from FB + DSs decreased (all FDR < 0.05). Additionally, age-adjusted percentage of participants meeting recommendations for calcium, phosphorus, sodium, and selenium significantly increased, that for iron, potassium, zinc, and copper decreased (all FDR < 0.05). Minerals intake and time trends in minerals intake were highly variable depending on age, gender, race/ethnicity, education, and income. For example, white, higher socioeconomic status participants had a higher minerals intake (e.g. iron, zinc, and copper), but had a greater decrease in minerals intake. Furthermore, the percentage of minerals from milks and DSs decreased, and that from beverages increased.

CONCLUSION

From 1999 to March 2020, both minerals intake and their sources experienced a significant alteration among U.S. adults. Many differences in minerals intake and their food sources across sociodemographic characteristics appeared to narrow over time. Although some improvements were observed, important challenges, such as overconsumption of sodium and underconsumption of potassium, calcium, and magnesium, still remained among U.S. adults.

Caregiver perceptions of a pediatric produce prescription program during the COVID-19 pandemic

Introduction

Produce prescription programs are rapidly expanding as a type of Food is Medicine intervention with prospects for mitigating food insecurity and reducing diet-related health disparities. Gaining insight into participant perspectives on program logistics and perceived impacts is crucial to program success and improvements.

Methods

Between May and June 2021, we conducted individual and small group interviews with 23 caregivers with children aged 1-5 years who participated in a produce prescription program from 2020 to 2021 in Texas, U.S. They were provided with a gift card to a major national grocery retailer to purchase fresh produce. The card was reloaded $60 monthly for 8 months with automatic roll-over of unused funds to the next month. Participants also received nutrition education in the form of two videos. A deductive analysis approach was employed, and NVivo qualitative data analysis software was used to perform coding and to assist with subsequent analyses.

Results

All 23 participants were female, with an average age of 37.5 years, and the majority identified as Hispanic/Latino (83%). About 43% of the families had three or more children. Six themes were generated from interviews. Three of these themes were related to program logistics: (1) ease of program use; (2) participant satisfaction with the incentive; and (3) desire for additional store options. The remaining main themes pertained to program impact: (1) the enhanced ability to purchase produce; (2) the usefulness of the nutrition education; and (3) persistent challenges encountered when preparing the produce for picky eaters and young children.

Conclusion

A pediatric produce prescription program was perceived as logistically easy and a helpful source of financial support for accessing fresh produce. Program features such as card-based incentive system and partnership with major grocery retailer were favored by participants. For future program design, it may be beneficial to consider collaborating with multiple grocery outlets and enhancing the intensity and targeting of nutrition education.

A health technology assessment of personalized nutrition interventions using the EUnetHTA HTA Core Model

OBJECTIVES

Poor nutrition links to chronic diseases, emphasizing the need for optimized diets. The EU-funded project PREVENTOMICS, introduced personalized nutrition to address this. This study aims to perform a health technology assessment (HTA) comparing personalized nutrition interventions developed through this project, with non-personalized nutrition interventions (control) for people with normal weight, overweight, or obesity. The goal is to support decisions about further development and implementation of personalized nutrition.

METHODS

The PREVENTOMICS interventions were evaluated using the European Network for HTA Core Model, which includes a methodological framework that encompasses different domains for value assessment. Information was gathered via [1] different statistical analyses and modeling studies, [2] questions asked of project partners and, [3] other (un)published materials.

RESULTS

Clinical trials of PREVENTOMICS interventions demonstrated different body mass index changes compared to control; differences ranged from -0.80 to 0.20 kg/m2. Long-term outcome predictions showed generally improved health outcomes for the interventions; some appeared cost-effective (e.g., interventions in UK). Ethical concerns around health inequality and the lack of specific legal regulations for personalized nutrition interventions were identified. Choice modeling studies indicated openness to personalized nutrition interventions; decisions were primarily affected by intervention's price.

CONCLUSIONS

PREVENTOMICS clinical trials have shown promising effectiveness with no major safety concerns, although uncertainties about effectiveness exist due to small samples (n=60-264) and short follow-ups (10-16 weeks). Larger, longer trials are needed for robust evidence before implementation could be considered. Among other considerations, developers should explore financing options and collaborate with policymakers to prevent exclusion of specific groups due to information shortages.

Associations between body image, eating behavior, and diet quality

Background: Weight-neutral interventions that promote adaptive eating behaviors are becoming a growing area of practice. Understanding whether adaptive eating behaviors are associated with improved diet quality is essential. Body image may be an important factor in this relationship given its close connection to eating behaviors. Aim: The purpose of this study was to develop an understanding of the relationships between positive and negative body image, adaptive and maladaptive eating behaviors, and diet quality. Methods: We recruited 288 adults 18 years and older who were living in the US using Prolific Academic. Participants completed an online survey including measures of positive and negative body image, adaptive and maladaptive eating behaviors, and a dietary screener questionnaire (DSQ). We ran a hierarchical linear regression and tested whether body image and diet quality were mediated by eating behavior. Results: Body image and maladaptive eating behaviors were not associated with diet quality. Body-food choice congruence (B-FCC), an adaptive eating behavior, was associated with diet quality. B-FCC mediated the relationship of positive and negative body image to diet quality. Conclusions: Our findings provide additional support for weight-neutral or adaptive eating interventions as a mechanism to promote diet quality. Additional research may benefit from exploring indirect effects of body image on diet intake, the relationship between eating behavior and diet quality using qualitative data, and the comparison of weight-neutral or non-diet interventions with traditional behavior change interventions.

"Food Is Medicine" Strategies for Nutrition Security and Cardiometabolic Health Equity: JACC State-of-the-Art Review

"Food Is Medicine" (FIM) represents a spectrum of food-based interventions integrated into health care for patients with specific health conditions and often social needs. Programs include medically tailored meals, groceries, and produce prescriptions, with varying levels of nutrition and culinary education. Supportive advances include expanded care pathways and payment models, e-screening for food and nutrition security, and curricular and accreditation requirements for medical nutrition education. Evidence supports positive effects of FIM on food insecurity, diet quality, glucose control, hypertension, body weight, disease self-management, self-perceived physical and mental health, and cost-effectiveness or cost savings. However, most studies to date are quasiexperimental or pre/post interventions; larger randomized trials are ongoing. New national and local programs and policies are rapidly accelerating FIM within health care. Remaining research gaps require rigorous, iterative evaluation. Successful incorporation of FIM into health care will require multiparty partnerships to assess, optimize, and scale these promising treatments to advance health and health equity.

The Time is Ripe: The Case for Nutrition in Graduate Medical Education in the United States

A poor-quality dietary pattern is a leading risk factor for chronic disease and death in the United States, and the costs of medical care continue to unsustainably rise. Despite this reality, nutrition training for physicians fails to adequately prepare for them to address the complex factors that influence diet-related disease. Expanding nutrition education for physicians-in-training is imperative to equip them for the growing demand of food is medicine services and is also supported by recent policy efforts in the United States as well as the governing bodies of graduate and undergraduate medical education. A multisector approach that links graduate medical education, clinical care delivery innovation, and health and food policy experts provides momentum to advance nutrition education as a core strategy for food is medicine expansion globally.

Culinary Medicine: Needs and Strategies for Incorporating Nutrition into Medical Education in the United States

In the past decade, medical education has increasingly incorporated evidence-based lifestyle interventions as primary strategies for preventing and managing noncommunicable diseases. This shift embraces the growing recognition of the significant impact of lifestyle on health outcomes, driving diseases including obesity, diabetes, heart disease, and cancer. Now deemed "food is medicine" (FIM), diet-related interventions witnessed integration into healthcare systems and recognition in the United States' White House Conference on Hunger, Nutrition, and Health in 2023. As FIM gains traction, investigating optimal strategies for team-based education becomes essential. Healthcare teams need the necessary knowledge and tools to effectively administer FIM services and collaborate across disciplines, ultimately enhancing disease prevention, chronic disease management, health quality, value, and overall wellness. Culinary medicine (CM), a vital component of FIM, bridges nutrition education, pragmatic culinary skills, and conventional strategies to improve chronic disease management. CM involves experiential learning, imparts practical skills, and encourages behavior change by addressing food-related determinants of health and promoting equitable access. Teaching kitchens serve as physical or virtual learning spaces and as a didactic and experiential method (skills lab), playing a crucial role by integrating culinary, lifestyle, integrative, and conventional medicine. A growing number of medical schools in the United States and globally offer CM education via diverse methods including interest groups, electives, and specialty tracks, encompassing didactic sessions, hands-on kitchen education, and virtual teaching methods. Given the rising demand for CM programs, this article aims to describe, map, and compare existing CM education types in medical education. It provides actionable recommendations for medical schools to establish and expand CM programs by fostering service-learning partnerships, clinical innovation, and interdisciplinary research. As FIM gains prominence, cultivating a robust foundation of educational strategies is vital to ensure seamless integration into both medical education and collaborative medical practice.

Cost-effectiveness of telehealth-delivered nutrition interventions: a systematic review of randomized controlled trials

CONTEXT

Telehealth-delivered nutrition interventions are effective in practice; however, limited evidence exists regarding their cost-effectiveness.

OBJECTIVE

To evaluate the cost-effectiveness of telehealth-delivered nutrition interventions for improving health outcomes in adults with chronic disease.

DATA SOURCES

PubMed, CENTRAL, CINAHL, and Embase databases were systematically searched from database inception to November 2021. Included studies were randomized controlled trials delivering a telehealth-delivered diet intervention conducted with adults with a chronic disease and that reported on cost-effectiveness or cost-utility analysis outcomes.

DATA EXTRACTION

All studies were independently screened and extracted, and quality was appraised using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist.

DATA ANALYSIS

All extracted data were grouped into subcategories according to their telehealth modality and payer perspective, and were analyzed narratively.

RESULTS

Twelve randomized controlled trials comprising 5 phone-only interventions, 3 mobile health (mHealth), 2 online, and 1 each using a combination of phone-online or phone-mHealth interventions, were included in this review. mHealth interventions were the most cost-effective intervention in all studies. Across all telehealth interventions and cost analyses from health service perspectives, 60% of studies were cost-effective. From a societal perspective, however, 33% of studies reported that the interventions were cost-effective. Of the 10 studies using cost-utility analyses, 3 were cost saving and more effective, making the intervention dominant, 1 study reported no difference in costs or effectiveness, and the remaining 6 studies reported increased cost and effectiveness, meaning payers must decide whether this falls within an acceptable willingness-to-pay threshold for them. Quality of study reporting varied with between 63% to 92%, with an average of 77% of CHEERS items reported.

CONCLUSION

Telehealth-delivered nutrition interventions in chronic disease populations appear to be cost-effective from a health perspective, and particularly mHealth modalities. These findings support telehealth-delivered nutrition care as a clinically beneficial, cost-effective intervention delivery modality.

Impact of Culinary Medicine Course on Confidence and Competence in Diet and Lifestyle Counseling, Interprofessional Communication, and Health Behaviors and Advocacy

Most physicians report inadequate training to provide diet and lifestyle counseling to patients despite its importance to chronic disease prevention and management. To fill the nutrition training gap, elective Culinary Medicine (CM) courses have emerged as an alternative to curriculum reform. We evaluated the impact of an interprofessional CM course for medical and health professional students who experienced the hands-on cooking component in person or a in mixed-mode format (in-person and via Zoom) at the University of Utah from 2019-2023 (n = 84). A factorial ANOVA assessed differences between educational environment and changes between pre- and post-course survey responses related to diet and lifestyle counseling, interprofessional communication, and health behaviors and advocacy. Qualitative comments from post-course surveys were analyzed on a thematic level. Students rated themselves as having greater confidence and competence in diet and lifestyle counseling (p < 0.05) and increased ability to prepare eight healthy meals (p < 0.05). Additionally, a Mann-Whitney two-sample rank-sum test was used to compare data from exit survey responses from medical students who took the CM course (n = 48) and did not take the CM course (n = 297). Medical students who took CM were significantly more likely to agree that they could counsel patients about nutrition (p < 0.05) and physical activity (p < 0.05). CM courses may improve students' confidence to provide diet and lifestyle counseling.

Evaluation of health and economic effects of United States school meal standards consistent with the 2020-2025 dietary guidelines for Americans

BACKGROUND

The current school meal nutrition standards, established in 2010, are not fully aligned with the 2020-2025 Dietary Guideline for Americans (DGA). This study evaluates the potential short-term and long-term health and economic benefits of strengthening the school meal standards on added sugars, sodium, and whole grains to be aligned with current guidelines.

METHODS

We used comparative risk assessment frameworks based on nationally representative data incorporating current demographics, dietary habits, and risk factors of United States children aged 5-18 y from 3 cycles of the National Health and Nutrition Examination Survey (2013-2018). To estimate short-term impact, the model incorporated estimated dietary changes owing to potential new DGA-aligned school meal nutrition standards and the effect of these changes on childhood body mass index (in kg/m2) and blood pressure. To estimate long-term impact, the model further incorporated data on the sustainability of childhood dietary changes into adulthood, and on demographics and risk factors of United States adults, diet-disease associations, and disease-specific national mortality.

RESULTS

In a best-case scenario assuming full school compliance, implementing new DGA-aligned nutritional standards would lower elementary children's BMI by an average 0.14 (95% UI: 0.08-0.20) kg/m2 and systolic blood pressure by 0.13 (95% UI: 0.06-0.19) (95% mm Hg. Later in life, the new standards were estimated to prevent 10,600 [95% uncertainty interval (UI): 4820-16,800) annual deaths from cardiovascular disease (CVD), diabetes, and cancer in adulthood; and save 355,000 (95% UI: 175,000-538,000) disability-adjusted life years and $19.3 (95% UI: 9.35-30.3) B in direct and indirect medical costs each year. Accounting for plausible (incomplete) school compliance, implementation would save an estimated 9110 (95% UI: 2740-15,100) deaths, 302,000 (95% UI: 120,000-479,000) disability-adjusted life years, and $15.9 (95% UI: 4.54-27.2) B in healthcare-related costs per year in later adulthood.

CONCLUSIONS

Stronger school meal nutrition standards on added sugars, sodium, and whole grains aligned with the 2020-2025 DGA recommendations may improve diet, childhood health, and future adult burdens of CVD, diabetes, cancer, and associated economic costs.

Food Insecurity and Diabetes: Overview of Intersections and Potential Dual Solutions

Food insecurity increases the risk of developing diabetes and its complications. In this article, we describe the complex relationship that exists between food insecurity and diabetes and describe potential mechanisms that may underlie this association. We then describe how two different types of interventions, food-is-medicine and federal nutrition assistance programs, may help address both food insecurity and health. Finally, we outline the research, policy, and practice opportunities that exist to address food insecurity and reduce diabetes-related health disparities.

Changes in Choline Metabolites and Ceramides in Response to a DASH-Style Diet in Older Adults

This feeding trial evaluated the impact of the Dietary Approaches to Stop Hypertension diet on changes in plasma choline, choline metabolites, and ceramides in obese older adults; 28 adults consumed 3oz (n = 15) or 6oz (n = 13) of beef within a standardized DASH diet for 12 weeks. Plasma choline, betaine, methionine, dimethylglycine (DMG), phosphatidylcholine (PC), lysophosphotidylcholine (LPC), sphingomyelin, trimethylamine-N-oxide (TMAO), L-carnitine, ceramide, and triglycerides were measured in fasted blood samples. Plasma LPC, sphingomyelin, and ceramide species were also quantified. In response to the study diet, with beef intake groups combined, plasma choline decreased by 9.6% (p = 0.012); DMG decreased by 10% (p = 0.042); PC decreased by 51% (p < 0.001); total LPC increased by 281% (p < 0.001); TMAO increased by 26.5% (p < 0.001); total ceramide decreased by 22.1% (p < 0.001); and triglycerides decreased by 18% (p = 0.021). All 20 LPC species measured increased (p < 0.01) with LPC 16:0 having the greatest response. Sphingomyelin 16:0, 18:0, and 18:1 increased (all p < 0.001) by 10.4%, 22.5%, and 24%, respectively. In contrast, we observed that sphingomyelin 24:0 significantly decreased by 10%. Ceramide 22:0 and 24:0 decreased by 27.6% and 10.9% (p < 0.001), respectively, and ceramide 24:1 increased by 36.8% (p = 0.013). Changes in choline and choline metabolites were in association with anthropometric and cardiometabolic outcomes. These findings show the impact of the DASH diet on choline metabolism in older adults and demonstrate the influence of diet to modify circulating LPC, sphingomyelin, and ceramide species.

Nutrition and Physical Activity Interventions Provided by Nutrition and Exercise Practitioners for the General Population: An Evidence-Based Practice Guideline From the Academy of Nutrition and Dietetics and American Council on Exercise

A nutritious diet and adequate physical activity vitally contribute to disease prevention, but most adults do not meet population-based dietary and physical activity recommendations. Qualified nutrition and exercise practitioners can address challenges to adopting healthy lifestyle behaviors by providing consistent, individualized, and evidence-based education and programming within their professional scopes of practice to improve client outcomes. The objective of this evidence-based practice guideline is to inform practice decisions for nutrition and exercise practitioners providing nutrition and physical activity interventions for adults who are healthy or have cardiometabolic risk factors, but no diagnosed disease. Evidence from a systematic review was translated to practice recommendations using an evidence-to-decision framework by an interdisciplinary team of nutrition and exercise practitioners and researchers. This evidence-based practice guideline does not provide specific dietary or physical activity recommendations but rather informs nutrition and exercise practitioners how they may utilize existing guidelines for the general population to individualize programming for a range of clients. This evidence-based practice guideline provides widely applicable recommendation statements and a detailed framework to help practitioners implement the recommendations into practice. Common barriers and facilitators encountered when delivering nutrition and physical activity interventions, such as adherence to professional scopes of practice; methods to support behavior change; and methods to support inclusion, diversity, equity, and access, are discussed. Nutrition and exercise practitioners can consistently provide individualized, practical, and evidence-based interventions by seeking to understand their clients' needs, circumstances, and values and by co-creating interventions with the client and their allied health team.

Informatics for your Gut: at the Interface of Nutrition, the Microbiome, and Technology

BACKGROUND

A significant portion of individuals in the United States and worldwide experience diseases related to or driven by diet. As research surrounding user-centered design and the microbiome grows, movement of the spectrum of translational science from bench to bedside for improvement of human health through nutrition becomes more accessible. In this literature survey, we examined recent literature examining informatics research at the interface of nutrition and the microbiome.

OBJECTIVES

The objective of this survey was to synthesize recent literature describing how technology is being applied to understand health at the interface of nutrition and the microbiome focusing on the perspective of the consumer.

METHODS

A survey of the literature published between January 1, 2021 and October 10, 2022 was performed using the PubMed database and resulting literature was evaluated against inclusion and exclusion criteria.

RESULTS

A total of 139 papers were retrieved and evaluated against inclusion and exclusion criteria. After evaluation, 45 papers were reviewed in depth revealing four major themes: (1) microbiome and diet, (2) usability,(3) reproducibility and rigor, and (4) precision medicine and precision nutrition.

CONCLUSIONS

A review of the relationships between current literature on technology, nutrition and the microbiome, and self-management of dietary patterns was performed. Major themes that emerged from this survey revealed exciting new horizons for consumer management of diet and disease, as well as progress towards elucidating the relationship between diet, the microbiome, and health outcomes. The survey revealed continuing interest in the study of diet-related disease and the microbiome and acknowledgement of needs for data re-use, sharing, and unbiased and rigorous measurement of the microbiome. The literature also showed trends toward enhancing the usability of digital interventions to support consumer health and home management, and consensus building around how precision medicine and precision nutrition may be applied in the future to improve human health outcomes and prevent diet-related disease.

The association between adherence to diet quality index and cardiometabolic risk factors in overweight and obese women: a cross-sectional study

Background

Obesity and overweight status increase the risk of cardiovascular disease. Diet quality can also predict the risk of cardiovascular diseases in obese and overweight patients. Therefore, in this study, we sought to examine the relationship between diet quality index (DQI) and cardiometabolic risk factors in obese and overweight women.

Method

A cross-sectional study was conducted on 197 Iranian women with a Body Mass Index (BMI) > 25, 18-48 years, and recruited from 20 Tehran Health Centers. Nutrition intake and DQI were assessed using a 147-item semi-quantitative food frequency questionnaire (FFQ). Additionally, anthropometric measurements, body composition, biochemical evaluations, and cardiometabolic risk factors were evaluated.

Results

There was an association between DQI and waist-to-hip ratio (WHR), atherogenic index of plasma (AIP), and CHOLINDEX in obese women, after adjusting for potential confounders. Whereas, there were no significant associations of the tertiles of DQI compared with the first tertile in other cardiometabolic risk factors, before and after adjustment.

Conclusion

This study provides evidence that dietary intake and DQI are associated with cardiometabolic risk factors and that dietary modification may be a predictor for reducing WHR, AIP, and CHOLINDEX. However, more research is needed to develop a DQI that reflects changes in cardiometabolic risk factors by considering women's eating habits and patterns.

Individualized diet conversation in primary care: A pilot intervention

BACKGROUND

Most primary care providers do not routinely discuss nutrition and diet with their patients, largely due to lack of time, inadequate resources, and perceived complexity of the topic. This article describes development and implementation of a brief protocol for systematically assessing and discussing diet during routine primary care visits to increase the frequency of these conversations and improve patient health outcomes.

METHODS

The authors developed a protocol for assessing both nutrition and stage of change as well as a guide for engaging in patient-led conversations about nutrition. The protocol was modeled after Screening, Brief Intervention, and Referral to Treatment and informed by the Dietary Guidelines for Americans, the Transtheoretical Model of Behavior Change, and principles of motivational interviewing. It was implemented over three months at a rural health clinic staffed by one NP.

RESULTS

The protocol and conversation guide were easy to use with minimal training and seamlessly incorporated into clinic workflow. The likelihood of making diet changes increased significantly following the diet conversation, with persons who initially scored lower in readiness to change ultimately reporting significantly greater increases.

CONCLUSION

A protocol for assessing diet and engaging patients in a stage of change-appropriate diet conversation can be efficiently integrated into a single primary care visit and increase patients' intent to change their diet. Further investigation is needed to evaluate the protocol more completely and in multiple clinics.

The future of software-controlled cooking

To date, analog methods of cooking such as by grills, cooktops, stoves and microwaves have remained the world's predominant cooking modalities. With the continual evolution of digital technologies, however, laser cooking and 3D food printing may present nutritious, convenient and cost-effective cooking opportunities. Food printing is an application of additive manufacturing that utilizes user-generated models to construct 3D shapes from edible food inks and laser cooking uses high-energy targeted light for high-resolution tailored heating. Using software to combine and cook ingredients allows a chef to more easily control the nutrient content of a meal, which could lead to healthier and more customized meals. With more emphasis on food safety following COVID-19, food prepared with less human handling may lower the risk of foodborne illness and disease transmission. Digital cooking technologies allow an end consumer to take more control of the macro and micro nutrients that they consume on a per meal basis and due to the rapid growth and potential benefits of 3D technology advancements, a 3D printer may become a staple home and industrial cooking device.

Food Intake and Food Selection Following Physical Relocation: A Scoping Review

Objectives: To synthesize the current available evidence on the changes in food intake and food selection after physical relocation in non-refugee populations. Methods: The inclusion criteria were studies with a measurement of food selection and/or food intake in non-refugee populations where physical relocation had occurred with self-reported or objective assessment of the neighbourhood physical environment before and after relocation. Databases searched included MEDLINE, EMBASE, CINAHL and SCOPUS from 1946 to August 2022. Results: A total of four articles met the inclusion criteria. Overall, these studies gave longitudinal (n = 2) and cross-sectional (n = 2) evidence to suggest that moving to an urban neighbourhood with more convenience stores, cafés and restaurants around the home was associated with an increase in unhealthy food intake in adult populations. Additional factors such as income, vehicle access, cost, availability and perceptions of the local food environment played a role in shaping food selection and food intake. Conclusion: Four internal migration studies were found. The limited evidence base calls for more research. Future studies should include children and apply appropriate research designs to account for neighbourhood self-selection and concurrent life events. International migration studies should include assessment of neighbourhood physical environments pre- and post-relocation.

Contribution of Snacks to Dietary Intakes Stratified by Race/Ethnicity in the United States

BACKGROUND

Snacking recommendations do not exist, yet snacks contribute substantially to daily energy intakes. While dietary intakes of adults in the United States vary by race/ethnicity, little is known about their snacking patterns. The aim of this study was to assess the quality of snacks stratified by race/ethnicity in adults who participated in the 2011-2018 National Health and Nutrition Examination Survey (NHANES).

METHOD

Dietary data from 18,679 adults older than 19 years were assessed to examine differences in intakes from snacking occasions by self-identified race/ethnicity. Mean intakes were estimated for total snacking occasions, percentage of day, nutrient density per 100 kcals, and the average snack. Healthy Eating Index-2015 (HEI) scores were computed for intakes from total day, snack only, and meals only. Analysis of covariance assessed differences between racial/ethnic groups. US Department of Agriculture food categories determined sources of snack foods. Data were weighted to create a nationally representative sample.

RESULTS

Asians consumed the least amount of daily energy in the form of snacks, while Blacks and Whites consumed the most. Mean intakes of saturated fats and added sugars consumed during snacking occasions were significantly lowest in Asians, and highest in Blacks and Whites. While total and percentage of daily intakes of sodium were lowest in Asians during snacking occasions, they had significantly lowest meal-only HEI sodium subscore, indicating higher sodium consumption of sodium during mealtimes.

CONCLUSIONS

Diet quality of snacks varies significantly by race/ethnicity. These data support the need for development of snacking recommendations with culturally appropriate dietary interventions.

Improving Fruit and Vegetable Accessibility, Purchasing, and Consumption to Advance Nutrition Security and Health Equity in the United States

In recent years, national and local efforts to improve diet and health in the United States have stressed the importance of nutrition security, which emphasizes consistent access to foods and beverages that promote health and prevent disease among all individuals. At the core of this endeavor is fruit and vegetable (FV) consumption, a dietary practice that is integral to attaining and sustaining a healthy diet. Unfortunately, significant inequities in FV accessibility, purchasing, and consumption exist, particularly among populations that are socially and economically disadvantaged. To achieve nutrition and health equity in the United States, the field must center the goal of nutrition security and initiatives that aim to increase FV consumption, specifically, in future work. The International Journal of Environmental Research and Public Health (IJERPH) Special Issue titled "Nutrition and Health Equity: Revisiting the Importance of Fruit and Vegetable Availability, Purchasing, and Consumption" features several scholarly publications from experts conducting timely research on these topics. In this commentary, we (1) summarize the U.S.-based literature on inequities in FV accessibility, purchasing, and consumption, (2) describe how the contributions to this IJERPH special issue can advance nutrition security and health equity, and (3) outline future research questions from our perspective.

Improving Diet Quality in U.S. Adults: A 30-Year Health and Economic Impact Microsimulation

INTRODUCTION

Epidemiologic studies relating health outcomes to dietary patterns captured by diet quality indices have shown better quality scores associated with lower mortality and chronic disease incidence. However, changing chronic disease risk factors only alters population health over time, and initial diet quality systematically varies across the population by sociodemographic status. This study uses microsimulation to examine 30-year impacts of improved diet quality by sociodemographic group.

METHODS

Diet quality across 12 sex-, race/ethnicity-, and education-defined subgroups was estimated from the 2011-2012 National Health and Nutrition Examination Survey. In 2021, the Future Adults (dynamic microsimulation) Model was used to simulate population health and economic outcomes over 30 years for these subgroups and all adults. The modeled pathway was through lowering risk for heart disease by following U.S. Dietary Guidelines.

RESULTS

Diet quality varied across the sociodemographic subgroups, and half of U.S. adults had diet quality that would be classified as poor. Improving U.S. diet quality to that reported for the top 20% in 2 large health professionals' samples could reduce incidence of heart disease by 9.9% (7.6%-13.8% across the 12 sociodemographic groups) after 30 years. Year 30 would also have 37,000 fewer deaths, 694,000 more quality-adjusted life years, and healthcare cost savings of $59.6 billion (2019 U.S. dollars).

CONCLUSIONS

Dynamic microsimulation enables predictions of socially important outcomes of prevention efforts, most of which are many years in the future and beyond the scope of trials. This paper estimates the 30-year population health and economic impact of poor diet quality by sociodemographic group.

Mendelian Randomization Studies on Nutritional Factors and Health Outcomes

Poor diet is a leading cause of morbidity and mortality [...].

US Consumer Identification of the Health Benefits of Dietary Fiber and Consideration of Fiber When Making Food Choices

The purposes of this study were to (1) determine beliefs in the health benefits of dietary fiber, an under-consumed nutrient of public health concern, and (2) determine the relationship between beliefs about dietary fiber and consideration of fiber when making food choices. We conducted a nationally representative within-subject randomized online survey of 42,018 US primary shoppers in May–June 2021. Participants selected health benefits they believed were associated with consumption of fiber from a list of six benefits recognized by the Food and Drug Administration (FDA), one indirect benefit, and one unrelated benefit. Respondents then indicated which nutrients, if any, they considered when making food choices. Respondents selected 1.77 (95% CI = 1.76–1.77) FDA-recognized benefits out of a total six; half (50.6%) of respondents identified zero or one FDA-recognized benefit. The most-cited benefit was “improving bowel movements” (64.4%). Older participants perceived significantly more FDA-recognized fiber benefits. Identification of FDA-recognized benefits increased odds ratios for consideration of fiber during food choice (relative to zero benefits) from 3.0 for one benefit (95% CI = 2.8–3.3) to 14.3 for six benefits (95% CI = 12.4–16.6). Consumers are largely unaware of the many health benefits of dietary fiber, which dramatically decreases the likelihood that they consider this important, under-consumed nutrient during food choice.

Overview of Nutraceuticals and Cardiometabolic Diseases following Socio-Economic Analysis

The importance of functional food and nutraceutical products to deal with cardiometabolic diseases (CMDs) and metabolic syndrome (MetS) has gained attention in the past few years. The aim of this narrative review is to highlight the potential and effectiveness of nutraceutical in the improvement of CMDs and MetS biomarkers, alongside their burden of disease and economic health expenditure. A science database search was conducted between May and June 2021. A total of 35 studies were included in this paper. We included male and female subjects, children, and adults, in good health or with cardiovascular or metabolic disease. CMDs and MetS have gradually become worldwide health problems, becoming two of the major causes of morbidity and mortality in western countries. The results indicate a positive link between daily consumption of nutraceutical products and an improvement in cardiometabolic and anthropometric biomarkers. In this paper we included a wide range of nutraceutical products. Most of them showed promising data, indicating that nutraceuticals could provide a new therapeutic treatment to reduce prevalence and pharmaceutical expenditures attributed to CMDs and MetS. Unfortunately, there is a huge vacuum of data on nutraceutical usage, savings, and burden reduction. Therefore, further clinical and pharmaco-economic research in the field is highly required.

Effects of Hazelnut Consumption on Cardiometabolic Risk Factors and Acceptance: A Systematic Review

Despite being rich sources of monounsaturated fat and a number of vitamins, minerals, and phytonutrients, hazelnuts have received less attention than some other nut types. A qualitative systematic review was carried out to determine the effects of hazelnut consumption on acceptance and markers of cardiometabolic health, including blood lipids and lipoproteins, apolipoproteins A1 and B100, body weight and composition, blood pressure, glycemia, antioxidant status, oxidative stress, inflammation, and endothelial function. In total, 22 intervention studies (25 publications) met our inclusion criteria. The findings indicate some improvements in cardiometabolic risk factors; however, limitations in study design mean interpretation is problematic. The inclusion of hazelnuts in the diet did not adversely affect body weight and composition. Acceptance of hazelnuts remained stable over time confirming nut consumption guidelines are feasible and sustainable. Future studies using more robust study designs in a variety of populations are required to draw more definitive conclusions on the health benefits of hazelnut consumption.

Prevention and Treatment of Cardiometabolic Diseases in Children with Overweight and Obesity: The Future of Healthcare

In this Special Issue we will consider the impact of obesity on health in order to review the latest findings on the risk factors associated with cardiometabolic diseases in children with overweight and obesity as well as to explore the pathogenic mechanisms and potential therapeutic targets. The role of weight-management strategies, including exercise, dietary changes and nutritional education, in preventing obesity-related complications will be considered. The improvement of many obesity-associated complications following bariatric surgery will also be reported. The timely implementation of preventive strategies in pediatric patients with overweight and obesity may ameliorate the future burden of weight-related diseases and the future of healthcare.

US Food Industry Progress Toward Salt Reduction, 2009-2018

Objectives. To determine the extent to which reductions in sodium during the National Salt Reduction Initiative (NSRI) target-setting period (2009-2014) continued after 2014. Methods. We used the NSRI Packaged Food Database, which links products in the top 80% of US packaged food sales to nutrition information, to assess the proportion of products meeting the NSRI targets and the sales-weighted mean sodium density (mg/100 g) of 54 packaged food categories between 2009 and 2018. Results. There was an 8.5% sales-weighted mean reduction in sodium between 2009 and 2018. Most change occurred between 2009 and 2012, with little change in subsequent years. The proportion of packaged foods meeting the 2012 and 2014 targets increased 48% and 45%, respectively, from 2009 to 2012, with no additional improvements through 2018. Conclusions. Food manufacturers reduced sodium in the early years of the NSRI, but progress slowed after 2012. Public Health Implications. The US Food and Drug Administration just released 2.5-year voluntary sodium targets for packaged and restaurant food. Continued assessment of industry progress and further target setting by the Food and Drug Administration is crucial to reducing sodium in the food supply.

Healthy nutrition in secondary prevention after myocardial infarction. What to focus on?

Rationalization of dietary behavior in patients after myocardial infarction is the subject of numerous discussions. Despite the proven preventive effect of a healthy diet and the benefits of certain foods in cardiovascular diseases, this type of intervention is still underused. The aim of this review was to analyze current approaches to modifying the nutrition of patients within the secondary prevention of myocardial infarction. For this, 903 publications from PubMed/MEDLINE database over the past 5 years were studied. The Mediterranean diet demonstrated the highest efficacy and safety in preventing athero-thrombotic events among existing dietary patterns. However, its wide reproducibility in different regions is associated with a number of limitations. Government programs to modify and support a healthy diet beyond the conventional low-cholesterol diet may be promising in secondary prevention, especially if patients are properly monitored and motivated.

Improving the Dietary Intake of Healthcare Workers Through Workplace Dietary Interventions: A Systematic Review and Meta-Analysis

The workplace has been identified as a potential location for dietary intervention delivery due to the amount of time spent and the meals eaten in this setting. It is recommended that interventions are tailored to specific occupational groups, and to date, there is limited synthesis of the evidence relating to healthcare workers. This review characterises and evaluates the effectiveness of dietary interventions in healthcare workers to aid the design and implementation of interventions. The MEDLINE database was searched to September 2020. The reference list of an umbrella review was hand searched for additional titles against inclusion criteria. The search included i) population, ii) intervention and iii) work environment. Studies were assessed for risk of bias. Harvest plots and Forest plots were created to display study quality, direction and size of effect of selected primary (energy, fruit and vegetable and fat intake) and secondary outcomes (weight, body mass index, blood pressure and serum cholesterol levels). Thirty-nine articles assessing thirty-four interventions were eligible for inclusion. Intervention types most commonly used were environmental, educational, educational plus behavioural, and behavioural. Due to the heterogeneity in study design and intervention type, results were largely inconclusive. For dietary outcomes, interventions produced small-moderate favorable changes in fruit, vegetable and fat intake. Decreased fat intake was mainly observed in environmental interventions and increases in fruit and vegetable intake were observed when an educational or/and behavioral component was present. Interventions producing weight loss were mostly non-randomised trials involving education and physical activity. Total and low-density lipoprotein cholesterol decreased in interventions involving physical activity. Meta-analyses revealed significant decreases in energy intake, weight, blood pressure, total cholesterol, and LDL cholesterol in non-randomised trials where data were available. Much more research is needed into strategies to promote diet quality improvement in healthcare workers. Statement of significance: It is recommended that workplace dietary interventions are tailored to specific occupational groups. To our knowledge, this is the first review to examine the effects of dietary workplace interventions in healthcare professionals. Small-moderate favourable changes in fruit and vegetable intake can be achieved when an educational or/and behavioural component is included in the intervention. For weight loss, interventions involving nutrition education and physical activity in addition to a dietary component show benefit. In the studies reviewed, a high level of heterogeneity was evident and insufficient information reported to ascertain potential bias.

Accelerating Evaluation of Financial Incentives for Fruits and Vegetables: A Case for Shared Measures

Food insecurity, or lack of consistent access to enough food, is associated with low intakes of fruits and vegetables (FVs) and higher risk of chronic diseases and disproportionately affects populations with low income. Financial incentives for FVs are supported by the 2018 Farm Bill and United States (U.S.) Department of Agriculture’s Gus Schumacher Nutrition Incentive Program (GusNIP) and aim to increase dietary quality and food security among households participating in the Supplemental Nutrition Assistance Program (SNAP) and with low income. Currently, there is no shared evaluation model for the hundreds of financial incentive projects across the U.S. Despite the fact that a majority of these projects are federally funded and united as a cohort of grantees through GusNIP, it is unclear which models and attributes have the greatest public health impact. We explore the evaluation of financial incentives in the U.S. to demonstrate the need for shared measurement in the future. We describe the process of the GusNIP NTAE, a federally supported initiative, to identify and develop shared measurement to be able to determine the potential impact of financial incentives in the U.S. This commentary discusses the rationale, considerations, and next steps for establishing shared evaluation measures for financial incentives for FVs, to accelerate our understanding of impact, and support evidence-based policymaking.

Lifestyle Medicine and Economics: A Proposal for Research Priorities Informed by a Case Series of Disease Reversal

Chronic disease places an enormous economic burden on both individuals and the healthcare system, and existing fee-for-service models of healthcare prioritize symptom management, medications, and procedures over treating the root causes of disease through changing health behaviors. Value-based care is gaining traction, and there is a need for value-based care models that achieve the quadruple aim of (1) improved population health, (2) enhanced patient experience, (3) reduced healthcare costs, and (4) improved work life and decreased burnout of healthcare providers. Lifestyle medicine (LM) has the potential to achieve these four aims, including promoting health and wellness and reducing healthcare costs; however, the economic outcomes of LM approaches need to be better quantified in research. This paper demonstrates proof of concept by detailing four cases that utilized an intensive, therapeutic lifestyle intervention change (ITLC) to dramatically reverse disease and reduce healthcare costs. In addition, priorities for lifestyle medicine economic research related to the components of quadruple aim are proposed, including conducting rigorously designed research studies to adequately measure the effects of ITLC interventions, modeling the potential economic cost savings enabled by health improvements following lifestyle interventions as compared to usual disease progression and management, and examining the effects of lifestyle medicine implementation upon different payment models.

Microsimulation Modelling in Food Policy: A Scoping Review of Methodological Aspects

Food policies for the prevention and management of diet-related non-communicable diseases (NCDs) have been increasingly relying on microsimulation models (MSMs) to assess effectiveness. Given the increased uptake of MSMs, this review aims to provide an overview of the characteristics of MSMs that link diets with NCDs. A comprehensive review was conducted in PubMed and Web of Knowledge. Inclusion criteria were: (i) findings from a MSM, (ii) diets, foods or nutrients as main exposure of interest, (iii) NCDs, such as overweight/obesity, type 2 diabetes, coronary heart disease, stroke or cancer as disease outcome for impact assessment. This review included information from 33 studies using MSM in analyzing diet and diverse food policies on NCDs. Hereby, most models employed stochastic, discrete-time, dynamic microsimulation techniques to calculate anticipated (cost-)effectiveness of strategies based on food pricing, food reformulation or dietary (lifestyle) interventions. Currently available models differ in the methodology used for quantifying the effect of the dietary changes on disease, and in the method for modelling disease incidence and mortality. However, all studies provided evidence that the models were sufficiently capturing the close-to-reality situation by justifying their choice of model parameters and validating externally their modelled disease incidence and mortality with observed or predicted event data. With the increasing use of various MSMs, between-model comparisons, facilitated by open access models and good reporting practices, would be important for judging model's accuracy, leading to continued improvement in the methodologies for developing and applying MSMs, and subsequently a better understanding of the results by policymakers.

A STATEMENT OF SIGNIFICANCE

Given the advancement in the application of microsimulation modelling in evaluating food policies and measuring diet-related disease burdens, the present scoping review serves as an exercise to inform future modelling, hereby highlighting the need for transparency in model development, application and dissemination to advance and safeguard accuracy and relevance in modelling efforts.

Healthy Food Prescription Programs and their Impact on Dietary Behavior and Cardiometabolic Risk Factors: A Systematic Review and Meta-Analysis

The enormous burden of diet-related chronic diseases has prompted interest in healthy food prescription programs. Yet, the impact of such programs remains unclear. The aim of this study was to conduct a systematic review of healthy food prescription programs and evaluate their impact on dietary behavior and cardiometabolic parameters by meta-analysis. A systematic search was carried out in Medline, Embase, Scopus, and Cochrane Central Register of Controlled Trials databases since their inception to 3 January, 2020 without language restriction. A systematic search of interventional studies investigating the effect of healthy food prescription on diet quality and/or cardiometabolic risk factors including BMI, systolic (SBP) and diastolic blood pressure (DBP), glycated hemoglobin (HbA1c), or blood lipids was carried out. Thirteen studies were identified for inclusion, most of which were quasi-experimental (pre/post) interventions without a control group (n = 9). Pooled estimates revealed a 22% (95% CI: 12, 32; n = 5 studies, n = 1039 participants; I2 = 97%) increase in fruit and vegetable consumption, corresponding to 0.8 higher daily servings (95% CI: 0.2, 1.4; I2 = 96%). BMI decreased by 0.6 kg/m2 (95% CI: 0.2, 1.1; I2 = 6.4%) and HbA1c by 0.8% (95% CI: 0.1, 1.6; I2 = 92%). No significant change was observed in other cardiometabolic parameters. These findings should be interpreted with caution in light of considerable heterogeneity, methodological limitations of the included studies, and moderate to very low certainty of evidence. Our results support the need for well-designed, large, randomized controlled trials in various settings to further establish the efficacy of healthy food prescription programs on diet quality and cardiometabolic health.

Dietary Insights in Neurological Diseases

PURPOSE OF REVIEW

Dietary interventions may play a role in the pathophysiology of common neurological disorders such as Alzheimer's disease, Parkinson's disease, stroke, migraines, multiple sclerosis, and epilepsy. This article describes the most common and impactful dietary regimens for commonly encountered neurological disorders.

RECENT FINDINGS

Plant-based, low-fat, high-fiber diets, rich in antioxidants and other lifestyle interventions may reduce the burden and disability of common neurological disorders. The ketogenic diet, the diet of choice for the treatment of refractory epilepsy, is such an example. Diverse neurological disorders demonstrate several common pathophysiological mechanisms including increased oxidative stress, neuroinflammation, and disrupted metabolism. Dietary interventions can potentially influence these pathophysiological processes and thus favorably alter clinical outcomes. Adequate dietary choices should be considered as part of a continuum of healthy lifestyle choices.

Cardiometabolic Modification of Amyloid Beta in Alzheimer's Disease Pathology

In recent years, several studies have suggested that cardiometabolic disorders, such as diabetes, obesity, hypertension, and dyslipidemia, share strong connections with the onset of neurodegenerative disorders such as Parkinson’s and Alzheimer’s disease (AD). However, establishing a definitive link between medical disorders with coincident pathophysiologies is difficult due to etiological heterogeneity and underlying comorbidities. For this reason, amyloid β (Aβ), a physiological peptide derived from the sequential proteolysis of amyloid precursor protein (APP), serves as a crucial link that bridges the gap between cardiometabolic and neurodegenerative disorders. Aβ normally regulates neuronal synaptic function and repair; however, the intracellular accumulation of Aβ within the brain has been observed to play a critical role in AD pathology. A portion of Aβ is believed to originate from the brain itself and can readily cross the blood-brain barrier, while the rest resides in peripheral tissues that express APP required for Aβ generation such as the liver, pancreas, kidney, spleen, skin, and lungs. Consequently, numerous organs contribute to the body pool of total circulating Aβ, which can accumulate in the brain and facilitate neurodegeneration. Although the accumulation of Aβ corresponds with the onset of neurodegenerative disorders, the direct function of periphery born Aβ in AD pathophysiology is currently unknown. This review will highlight the contributions of individual cardiometabolic diseases including cardiovascular disease (CVD), type 2 diabetes (T2D), obesity, and non-alcoholic fatty liver disease (NAFLD) in elevating concentrations of circulating Aβ within the brain, as well as discuss the comorbid association of Aβ with AD pathology.

Effects of a Brazilian cardioprotective diet and nuts on cardiometabolic parameters after myocardial infarction: study protocol for a randomized controlled clinical trial

Background

Nut consumption has been related to improvements on cardiometabolic parameters and reduction in the severity of atherosclerosis mainly in primary cardiovascular prevention. The objective of this trial is to evaluate the effects of the Brazilian Cardioprotective Diet (DIetaCArdioprotetoraBrasileira, DICA Br) based on consumption of inexpensive locally accessible foods supplemented or not with mixed nuts on cardiometabolic features in patients with previous myocardial infarction (MI).

Methods

DICA-NUTS study is a national, multicenter, randomized 16-week follow-up clinical trial. Patients over 40 years old with diagnosis of previous MI in the last 2 to 6 months will be recruited (n = 388). A standardized questionnaire will be applied to data collection and blood samples will be obtained. Patients will be allocated in two groups: Group 1: DICA Br supplemented with 30 g/day of mixed nuts (10 g of peanuts, 10 g of cashew, 10 g of Brazil nuts); and Group 2: only DICA Br. The primary outcome will consist of LDL cholesterol means (in mg/dL) after 16 weeks of intervention. Secondary outcomes will consist of other markers of lipid profile, glycemic profile, and anthropometric data.

Discussion

It is expected that DICA Br supplemented with mixed nuts have superior beneficial effects on cardiometabolic parameters in patients after a MI, when compared to DICA Br.

Trial registration

ClinicalTrials.gov Identifier NCT03728127. First register: November 1, 2018; Last update: June 16, 2021. World Health Organization Universal Trial Number (WHO-UTN): U1111-1259-8105.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05494-0.

Sustainable Diets for Cardiovascular Disease Prevention and Management

PURPOSE OF REVIEW

Healthy dietary patterns are recommended for prevention of cardiovascular disease, which remains the leading cause of morbidity and mortality globally. In this review, we discuss dietary patterns that are not only optimal for CVD prevention and management but also sustainable in maximizing health, environmental, and economic benefits.

RECENT FINDINGS

The growing literature on sustainable diets in the context of environmental sustainability includes subtopics of climate change, land use, biodiversity loss, freshwater use, and reactive nitrogen emissions. Similarly, economic sustainability, beyond the retail cost of food, extends to healthcare costs and the economic costs of environmental destruction related to current agricultural practices and food choices. Dietary patterns that are high in plant foods and low in animal foods could maximize health, environmental, and economic benefits; however, questions remain about how to best promote these patterns to achieve wider adoption in an environmentally and economically sustainable way.

Dietary management of cardiovascular risk including type 2 diabetes

PURPOSE OF REVIEW

Recent changes or confirmations linking patterns of eating and specific dietary interventions in the management of cardiovascular risk factors including associations with prevalent and incident type 2 diabetes.

RECENT FINDINGS

Recently published guidance for dietary management of cardiovascular risk and type 2 diabetes have mostly common features. Major findings include a trend to replace strict quantitative advice on nutrients with qualitative advice on food consumption with exceptions for diabetes, global advice to increase intake of plant foods, confirmation to substitute mono and polyunsaturated oils for saturated and trans fats, new advisory on supplemental omega-3 intake, less limitation on dairy foods and fermented dairy foods encouraged, reduced emphasis on specific cholesterol-rich foods allowing greater consumption of eggs except for people with diabetes, processed meat consumption limited allowing modest intake of lean red meat, distinguishing between 'healthy' and 'unhealthy' carbohydrates including sugars, and maintaining advice on healthy bodyweight, reducing salt intake and encouraging water as preferred beverage.

SUMMARY

The new guidance for healthier patterns of food consumption supported by evidence is more readily understood by health practitioners and translatable to consumers and patients.

Cardiometabolic Changes in Response to a Calorie-Restricted DASH Diet in Obese Older Adults

Objective: To examine the response of a calorie-restricted Dietary Approaches to Stop Hypertension diet on indicators of cardiometabolic health in a cohort of sedentary obese older adults. Design: This was a controlled-feeding trial with a parallel design. Each participant consumed either 3 oz (85 g; n = 15) or 6 oz (170.1 g; n = 13) of lean fresh beef within a standardized calorie-restricted DASH-like diet for 12-weeks. Fasted blood samples were collected and used to measure conventional biomarkers of cardiovascular, metabolic and inflammatory health. Participants: Caucasian older (70.8 years), obese (BMI: 32 ± 6.9 kg/m²; WC: 101 ± 16.4 cm) females (n = 17) and males (n = 11) from the rural community of Brookings, South Dakota. Results: 28 participants completed the 12-week feeding trial, with no differences (p > 0.05) among the biomarkers of cardiometabolic health between the 3 and 6 oz beef intake groups. However, when the beef intake groups were combined, all biomarkers changed concentration in response to the intervention diet. Total cholesterol (p < 0.001), LDL-C (p = 0.004), HDL-C (p < 0.0001), insulin (p = 0.014), glucose (p = 0.008), HOMA-IR (p < 0.05), IL-12 (p < 0.001), and CRP (p = 0.006) all decreased in response to the study diet. IGF-1 (p < 0.001) and IL-8 (p = 0.005) increased in response to the intervention. Correlations among cardiometabolic biomarkers and body composition measures were observed. By study end, the decrease in insulin (R ² = 0.22; P = 0.012) and HOMA-IR (R ² = 0.22; P = 0.01) was positively correlated with the decrease in waist circumference. The increase in IGF-1 was significantly correlated with the decrease in waist circumference (R ² = 0.21; p = 0.014). The increase in IGF-1 was significantly correlated with the increase in sit-to-stand (R ² = 0.21; p = 0.016). The increase in IL-8 was significantly correlated with decreases in total cholesterol (R ² = 0.24; P = 0.008), LDL-C (R ² = 0.17; P = 0.031) and glucose (R ² = 0.44; P = 0.0001). Conclusions: These findings suggest that a DASH-like diet with restricted calories may potentially improve biomarkers of cardiometabolic health in sedentary obese older adults. These results also point to interrelationships between body composition changes and changes in cardiometabolic biomarkers. Lastly, regardless of meat intake amount, positive impacts on cardiometabolic biomarkers were observed in this cohort of older adults with an obese phenotype.

Linking metabolic dysfunction with cardiovascular diseases: Brn-3b/POU4F2 transcription factor in cardiometabolic tissues in health and disease

Metabolic and cardiovascular diseases are highly prevalent and chronic conditions that are closely linked by complex molecular and pathological changes. Such adverse effects often arise from changes in the expression of genes that control essential cellular functions, but the factors that drive such effects are not fully understood. Since tissue-specific transcription factors control the expression of multiple genes, which affect cell fate under different conditions, then identifying such regulators can provide valuable insight into the molecular basis of such diseases. This review explores emerging evidence that supports novel and important roles for the POU4F2/Brn-3b transcription factor (TF) in controlling cellular genes that regulate cardiometabolic function. Brn-3b is expressed in insulin-responsive metabolic tissues (e.g. skeletal muscle and adipose tissue) and is important for normal function because constitutive Brn-3b-knockout (KO) mice develop profound metabolic dysfunction (hyperglycaemia; insulin resistance). Brn-3b is highly expressed in the developing hearts, with lower levels in adult hearts. However, Brn-3b is re-expressed in adult cardiomyocytes following haemodynamic stress or injury and is necessary for adaptive cardiac responses, particularly in male hearts, because male Brn-3b KO mice develop adverse remodelling and reduced cardiac function. As a TF, Brn-3b regulates the expression of multiple target genes, including GLUT4, GSK3β, sonic hedgehog (SHH), cyclin D1 and CDK4, which have known functions in controlling metabolic processes but also participate in cardiac responses to stress or injury. Therefore, loss of Brn-3b and the resultant alterations in the expression of such genes could potentially provide the link between metabolic dysfunctions with adverse cardiovascular responses, which is seen in Brn-3b KO mutants. Since the loss of Brn-3b is associated with obesity, type II diabetes (T2DM) and altered cardiac responses to stress, this regulator may provide a new and important link for understanding how pathological changes arise in such endemic diseases.

Impact of Multidisciplinary Stroke Post-Acute Care on Cost and Functional Status: A Prospective Study Based on Propensity Score Matching

Few papers discuss how the economic burden of patients with stroke receiving rehabilitation courses is related to post-acute care (PAC) programs. This is the first study to explore the economic burden of stroke patients receiving PAC rehabilitation and to evaluate the impact of multidisciplinary PAC programs on cost and functional status simultaneously. A total of 910 patients with stroke between March 2014 and October 2018 were separated into a PAC group (at two medical centers) and a non-PAC group (at three regional hospitals and one district hospital) by using propensity score matching (1:1). A cost-illness approach was employed to identify the cost categories for analysis in this study according to various perspectives. Total direct medical cost in the per-diem-based PAC cohort was statistically lower than that in the fee-for-service-based non-PAC cohort (p < 0.001) and annual per-patient economic burden of stroke patients receiving PAC rehabilitation is approximately US $354.3 million (in 2019, NT $30.5 = US $1). Additionally, the PAC cohort had statistical improvement in functional status vis-à-vis the non-PAC cohort and total score of each functional status before rehabilitation and was also statistically significant with its total score after one-year rehabilitation training (p < 0.001). Early stroke rehabilitation is important for restoring health, confidence, and safe-care abilities in these patients. Compared to the current stroke rehabilitation system, PAC rehabilitation shortened the waiting time for transfer to the rehabilitation ward and it was indicated as an efficient policy for treatment of stroke in saving medical cost and improving functional status.