Evaluation of a diet quality index based on the probability of adequate nutrient intake (PANDiet) using national French and US dietary surveys

Development and validation of an occurrence-based healthy dietary diversity (ORCHID) score easy to operationalise in dietary prevention interventions in older adults: a French study

Healthy diet and dietary diversity have been associated with healthy ageing. Several scores have been developed to assess dietary diversity or healthy diets in epidemiological studies, but they are not adapted to be used in the context of preventive nutrition interventions. This study aimed to develop an occurrence-based healthy dietary diversity (ORCHID) score easy to implement in the field and to validate it using dietary data from older participants in the latest French food consumption survey (INCA3). The ORCHID score was made of several components representing the consumption occurrences of twenty food groups, in line with French dietary guidelines. The score was then validated using dietary data (namely three 24-h recalls and a food propensity questionnaire) from 696 participants aged 60 years and over in the INCA3 survey. Score validity was evaluated by describing the association of the score with its components, as well as with energy intakes, solid energy density (SED) and the probability of adequate nutrient intakes (assessed by the PANDiet). Higher scores were associated with more points in healthy components such as 'fruits' and 'vegetables' (r = 0·51, and r = 0·54, respectively). The score was positively associated with the PANDiet (r = 0·43) and inversely associated with SED (r = -0·37), while no significant association was found with energy intakes. The ORCHID score was validated as a good proxy of the nutritional quality of French older adults' diets. It could therefore be a useful tool for both public health research and nutrition interventions.

Identification of three dietary groups in French university students and their associations with nutritional quality and environmental impact

Introduction

The student period is associated with changes in eating habits, usually leading to diets of lower nutritional quality. However, some variability may exist in students' dietary patterns. We aimed to describe French students' diets and identify dietary groups that may vary in nutritional quality and environmental impact.

Methods

A representative sample of French students (N = 582) for age, sex and scholarship status completed an online 125-item food frequency questionnaire. The nutritional quality of diets was assessed by a score of adherence to the French nutritional guidelines (sPNNS-GS2 score, ranging from-17 to 11.5) and its environmental impact by greenhouse gas emissions for an isocaloric diet (GHGE). An ascending hierarchical classification analysis on food and beverage intakes led to three dietary groups. Between-group differences in food consumption, dietary indicators and sociodemographic characteristics were investigated using ANOVA models.

Results

The average sPNNS-GS2 score of students' diets was -0.8 ± 2.8, representing a 57% coverage of French nutritional recommendations, and GHGE were 5.4 ± 1.7 kg eCO2/2000 kcal. The three dietary groups were: a healthy diet group (20% of the sample) with the highest nutritional quality and high GHGE, which included older students with a higher level of physical activity; a Western diet group (40%) with the worst nutritional quality and high GHGE, which included more students who lived with their parents; and a frugal diet group (40%) with the lowest energy intake, intermediate nutritional quality, and low GHGE, which included more students who lived alone.

Conclusion

None of the dietary groups optimized both nutritional quality and environmental impact simultaneously, which suggests an apparent incompatibility in the student population between these two sustainability dimensions. These findings emphasize the need for tailored public health policies that acknowledge the diversity of student eating patterns and address specific individual barriers to healthy and sustainable diets.

Diet quality indexes for use during pregnancy: a scoping review

AIMS

High diet quality is related to better health outcomes in general. During pregnancy, a high-quality diet is of paramount importance to promote optimal maternal and neonatal outcomes. This is a scoping review of research available on diet quality indexes (DQIs) for use during pregnancy that summarizes the DQIs in terms of development, country of origin, population used, components, scoring and weighting of components, and evaluation. Furthermore, the DQIs are discussed narratively to inform and direct the development of improved and country-specific DQIs for pregnancy.

METHODS

The EBSCOhost database was used to identify English-language, peer-reviewed articles published between 2000 and 2023, from which 11 publications were identified that describe the development of pregnancy-specific DQIs. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews model.

RESULTS

Almost all DQIs (n = 9 of 11) were developed in high-income countries, using dietary intake data from food frequency questionnaires. Several DQIs (n = 5 of 11) used the US Healthy Eating Index as basis and modified it in various ways. Almost all DQIs included both foods and nutrients as components (n = 9 of 11), with vegetables being the most commonly included component alone (n = 8 of 11) or combined with fruit (n = 2 of 11).

CONCLUSION

Because most DQIs were developed using dietary guidelines, recommendations, and dietary intake data from high-income countries, it is recommended that pregnancy-specific DQIs be developed and validated to reflect the nutrition guidelines for lower-income and culturally diverse countries.

The nature of protein intake as a discriminating factor of diet sustainability: a multi-criteria approach

Animal production is responsible for 56-58% of the GHG emissions and limiting meat consumption would strongly contribute to reducing human health risks in Western countries. This study aimed to investigate the nature of protein intake as a discriminating factor for diets' sustainability. Using data from 29,210 French adults involved in the NutriNet-Santé cohort, we identified clusters according to 23 protein sources. A multicriteria (environmental, economic, nutritional and health) sustainability analysis was then conducted on the identified clusters. The economic analysis focused on both food and protein expenditure structures, using a budget coefficient approach. Relative values of clusters compared to the whole sample were calculated. We identified five clusters: milk-based, meat-based, fast food-based, healthy-fish-based, and healthy-plant-based. We found that the healthy-plant-based and healthy-fish-based clusters were the most sustainable, conciliating the compromise between human health (0.25 and 0.53 respectively for the Health Risk Score) and the protection of the environment (- 62% and - 19% respectively for the pReCiPe indicator). Conversely, the highest environmental impacts (+ 33% for the pReCiPe indicator) and the highest health risk (0.95 for the HRS) were observed for the meat-based cluster, which was associated with the lowest nutritional scores (- 61% for the PNNS-GS2 score). The economic analysis showed that the healthy-plant-based cluster was the one with the highest food budget coefficient (+ 46%), followed by the healthy-fish-based cluster (+ 8%), partly explained by a strong share of organic food in the diet. However, the meat-based cluster spent more of their food budget on their protein intake (+ 13%), while the healthy-plant-based cluster exhibited the lowest expenditure for this intake (- 41%). Our results demonstrate that the nature of protein intake is a discriminating factor in diet sustainability. Also, reducing animal protein consumption would generate co-benefits beyond environmental impacts, by being favorable for health, while reducing the monetary cost associated with protein intake.

The Nutritional Quality of Food Provision at UK Government-Funded Holiday Clubs: A Cross-Sectional Analysis of Energy and Nutrient Content

A large proportion of children are at risk of food insecurity during school holidays in the UK. The government-funded Holiday Activities and Food (HAF) programme provides free holiday clubs offering at least one healthy meal/day to eligible children and adolescents. This study aims at evaluating the nutritional quality of food provision at HAF holiday clubs, particularly hot/cold and vegetarian/non-vegetarian meals. Menu variants (n = 2759) from 49 HAF holiday clubs were assessed for adherence to School Food Standards (SFS) and their notional compositional quality, which was scored utilising a novel nutrient-based meal quality index. The median adherence to SFS across all available menus was 70% (IQR 59-79%). Overall, hot variants scored statistically higher menu quality scores than cold variants for both 5-11y (92.3 (80.7-102.7) vs. 80.4 (69.3-90.6)) and 11-18y (73.5 (62.5-85.8) vs. 58.9 (50.0-70.7)) criteria. Cold and hot menu variants tended to score differentially for quality sub-components. These findings highlight areas for potential future improvement in HAF holiday club provision with a tendency for food provision to appear less ideal for attendees for those aged 11-18. Ensuring that children from low-income households have access to a healthy diet is crucial to reduce UK health inequalities.

Higher adherence to the EAT-Lancet reference diet is associated with higher nutrient adequacy in the NutriNet-Santé cohort : a cross-sectional study

BACKGROUND

In 2019, the EAT-Lancet Commission proposed a planetary and healthy reference diet; however, its nutritional quality has been rarely evaluated.

OBJECTIVE

Across different adherence levels to the EAT-Lancet reference diet, the following were our objectives:1) describe the food and nutritional intakes of the French population, 2) to evaluate the nutrient quality and, 3) investigate the consistency between the French national recommendations and the EAT-Lancet reference diet.

DESIGN

This cross-sectional study was conducted among participants of the NutriNet-Santé cohort and the sample was weighted on the characteristics of the general French population. Adherence to the EAT-Lancet reference diet was estimated using the EAT-Lancet Diet Index (ELD-I). Usual nutrient intakes were obtained using the variance reduction method. We used the estimated average requirements cut-point method to estimate the proportion of participants who meet their respective nutritional requirements. Furthermore, the adequacy of the French food-based dietary recommendations (Programme National Nutrition Santé [PNNS]) according to adherence to the EAT-Lancet reference diet was studied.

RESULTS

The weighted sample was composed of 98,465 participants. Except for bioavailable zinc and vitamin B12, we observed a decrease in the nutrient inadequacy prevalence when the adherence to the EAT-Lancet reference diet increased, particularly for vitamin B9 (Q1=37.8% vs. Q5=5.5%, p=<0.0001) and vitamin C (Q1=59.0% vs. Q5=10.8 %, p=<0.0001). However, inadequacy prevalence remained high in all ELD-I quintiles, particularly for fiber (95.9%), vitamin B1 (70.8%), iodine (48.4%), and magnesium (76.8%). Higher ELD-I score was associated with higher adherence for most components of the PNNS, except for food groups that are not specifically included in the EAT-Lancet reference diet and are typical of the French diet, including alcohol, processed meat, and salt.

CONCLUSION

In the French context, although issues with the intake of certain nutrients may occur, a diet that remains within the planetary limits as the EAT-Lancet reference diet allows a favorable nutritional quality.

TRIAL REGISTRATION NUMBER

NCT03335644.

Basics of Sustainable Diets and Tools for Assessing Dietary Sustainability: A Primer for Researchers and Policy Actors

Climate change can have economic consequences, affecting the nutritional intake of populations and increasing food insecurity, as it negatively affects diet quality parameters. One way to mitigate these consequences is to change the way we produce and consume our food. A healthy and sustainable diet aims to promote and achieve the physical, mental, and social well-being of the populations at all life stages, while protecting and safeguarding the resources of the planet and preserving biodiversity. Over the past few years, several indexes have been developed to evaluate dietary sustainability, most of them based on the EAT-Lancet reference diet. The present review explains the problems that arise in human nutrition as a result of climate change and presents currently available diet sustainability indexes and their applications and limitations, in an effort to aid researchers and policy actors in identifying aspects that need improvement in the development of relevant indexes. Overall, great heterogeneity exists among the indicators included in the available indexes and their methodology. Furthermore, many indexes do not adequately account for the diets’ environmental impact, whereas others fall short in the economic impact domain, or the ethical aspects of sustainability. The present review reveals that the design of one environmentally friendly diet that is appropriate for all cultures, populations, patients, and geographic locations is a difficult task. For this, the development of sustainable and healthy diet recommendations that are region-specific and culturally specific, and simultaneously encompass all aspects of sustainability, is required.

Plant and Animal Protein Intakes Largely Explain the Nutritional Quality and Health Value of Diets Higher in Plants: A Path Analysis in French Adults

Diets higher in plants are associated with lower risks of chronic diseases. However, animal foods, which are rich in protein, are also rich in some important minerals and vitamins. Using data from a representative survey in France (INCA3, n = 1,125), we used path analyses as a mediation-like approach to decipher the importance of plant and animal proteins in the relationship between the plant-based diet index (PDI) and diet quality. We used three types of diet quality scores, namely, nutrient security, positive nutrient adequacy, and long-term mortality risk of four diet-related diseases (i.e., coronary heart disease, stroke, type 2 diabetes, and colorectal cancer). We identified positive and negative mediations, i.e., changes in plant/animal protein intake that are associated with changes in PDI, and favor or limit the association with the diet quality score. The PDI was positively associated with the risk of long-term mortality but not significantly with nutrient adequacy or nutrient security. A positive mediation by plant protein was found for all diet quality scores (specific indirect effects (SIEs) ranging from 0.04 to 0.10 SD). Conversely, the association between PDI and nutrient adequacy (but not nutrient security) was negatively mediated by animal protein intake (SIE: −0.06 SD). In further detailed models, the association between PDI and diet quality was mainly positively mediated by protein foods from the fruit-vegetables-legumes group (0.01 SD for the nutrient security and 0.02 SD for the nutrient adequacy) and whole grains (0.02 SD for the nutrient adequacy). Our data suggest that the positive impact of plant-based diets on diet quality is largely driven by higher intakes of plant protein foods, especially from fruits-vegetables-legumes and whole grains. Conversely, lower animal protein intake tends to limit the positive impact of plant-based diets on overall positive nutrient adequacy but not security. Protein sources appear critical to healthy plant-based diets.

Sustainability Dimensions of the Mediterranean Diet: A Systematic Review of the Indicators Used and Its Results

The concern about sustainability is growing and the Mediterranean diet has been extensively identified as a promising model, with benefits for human and environmental health. This systematic review aims to identify and describe the indicators that have been used to evaluate the sustainability of the Mediterranean diet and the results from their application. A methodology using PRISMA guidelines was followed, and searches were performed in Web of Science, PubMed, Scopus, and GreenFile. A total of 32 studies assessing the sustainability of the Mediterranean diet were identified. Twenty-five of these studies quantified the environmental impact, 7 studies evaluated the nutritional quality, and 12 studies assessed the daily cost of this dietary pattern. A total of 33 distinct indicators were identified, of which 10 were used to assess the environmental dimension (mainly, carbon, water, and ecological footprint), 8 were used to assess the nutritional dimension (mainly Health score and Nutrient Rich Food Index), 1 was used to assess the economic dimension (dietary cost), and 8 used combined indicators. The remaining 6 indicators for the assessment of sociocultural dimension were only identified in 1 study but were not measured. The Mediterranean diet had a lower environmental impact than Western diets and showed a carbon footprint between 0.9 and 6.88 kg CO2/d per capita, a water footprint between 600 and 5280 m3/d per capita, and an ecological footprint between 2.8 and 53.42 m2/d per capita. With regard to the nutritional dimension, the Mediterranean diet had a high nutritional quality and obtained 122 points on the Health score and ranged between 12.95 and 90.6 points on the Nutrient Rich Food Index. The cost of the Mediterranean diet is similar to other diets and varied between 3.33 and 14.42€/d per capita. These findings show that no uniformity in assessing the MDiet's sustainability exists.

A poor diet quality is associated with more gas-related symptoms and a decreased quality of life in French adults

This study evaluated the association between dietary patterns, Gas-Related Symptoms (GRS) and their impact on quality of life (QoL) in a representative sample (n=936) of the French adult population. During the 2018-2019 "Comportements et Consommations Alimentaires en France" (CCAF) survey (Behaviors and Food Consumption in France), online evaluation of GRS in adult participants was performed using the validated Intestinal Gas Questionnaire (IGQ), which captures the perception of GRS and their impact on QoL via 6 symptom dimensions scores (range 0-100; 100=worse) and a global score (mean of the sum of the 6 symptom dimensions scores). Socio-demographics, lifestyle parameters and dietary habits (7-day e-food diary) were also collected online. Quality of diet was determined using the NRF9.3 score (range 0-900; 900=best). Univariate and multivariate linear regression models were applied to identify factors associated with IGQ global score. K-means was used to identify clusters of subjects based on their dietary records. Data from 936 adults who completed both the IGQ and the food diary showed a mean (SD) IGQ global score of 11.9 (11.2). Younger age and female gender were associated with a higher IGQ global score. Only 7% of subjects reported no symptom at all and nearly 30% of study participants reported a high impact of GRS on their QoL. Two dietary clusters were identified: cluster1, characterized by a higher consumption of fruits and vegetables, lower sugars intake and higher NRF9.3 score and cluster 2, characterized by higher intake of sugars, lower intake in dietary fibers and lower NRF9.3 score. The IGQ global score was lower in cluster1 and higher in cluster2 vs. the total sample average (p<0.001). Prevalence of GRS in the French adult population is high and is associated with impaired QoL and dietary patterns. A change in food habits towards healthier patterns could help reducing the burden of GRS.

Nutritional quality of calorie restricted diets in the CALERIE™ 1 trial

OBJECTIVES

The aim was to determine the nutritional adequacy of calorie restricted (CR) diets during CR interventions up to 12 months.

METHODS

The Comprehensive Assessment of Long-Term Effects of Reducing Intake of Energy (CALERIE™) phase 1 trial consisted of 3 single-site studies to test the feasibility and effectiveness of CR in adults without obesity. After baseline assessments, participants who were randomized to a CR intervention received education and training from registered dietitians on how to follow a healthful CR diet. Food diaries were completed at baseline and during the CR interventions (~6, 9, and 12 months) when participants were self-selecting CR diets. Diaries were analyzed for energy, macronutrients, fiber, 11 vitamins, and 9 minerals. Nutritional adequacy was defined by sex- and age-specific Estimated Average Requirement (EAR) or Adequate Intake (AI) criteria for each nutrient. Diet quality was evaluated using the PANDiet diet quality index.

RESULTS

Eighty-eight CR participants (67% women, age 40 ± 9 y, BMI 27.7 ± 1.5 kg/m²) were included in the analysis. Dietary intake of fiber and most vitamins and minerals increased during CR. More than 90% of participants achieved 100% of EAR or AI during CR for 2 of 4 macronutrients (carbohydrate and protein), 6 of 11 vitamins (A, B1, B2, B3, B6, B12), and 6 of 9 minerals assessed (copper, iron, phosphorus, selenium, sodium, zinc). Nutrients for which <90% of participants achieved adequacy included fiber, omega-3 fatty acids, vitamins B5, B9, C, E, and K, and the minerals calcium, magnesium, and potassium. The PANDiet diet quality index improved from 72.9 ± 6.0% at baseline to 75.7 ± 5.2% during CR (p < 0.0001).

CONCLUSION

Long-term, calorie-restricted diets were nutritionally equal or superior to baseline ad libitum diets among adults without obesity. Our results support modest calorie restriction as a safe strategy to promote healthy aging without compromising nutritional adequacy or diet quality.

An Evaluation of Probability of Adequate Nutrient Intake (PANDiet) Scores as a Diet Quality Metric in Irish National Food Consumption Data

Identifying reliable metrics which measure the quality of a diet to promote nutrient adequacy and long-term health is an important step in the development of a sustainable food system. The Probability of Adequate Nutrient Intake (PANDiet) scoring system has been used as a measure of dietary quality in interdisciplinary research in recent years. The aim of the current study is to apply the PANDiet scoring system, and to assess the validity of the score as a metric of nutritional adequacy, within the Irish population. The Irish National Adult Nutrition Survey is a representative database with detailed data on nutrient intakes (18−90 years; n = 1051 valid-reporters; 2008−2010) and biofluid analytes (blood n = 786; urine n = 778). The PANDiet scoring system was expanded to include seven macronutrients, twelve micronutrients, nine minerals, and total energy using an established methodology. PANDiet scores were assessed against the Alternate Healthy Eating Index (AHEI) and Alternate Mediterranean Diet (aMED) food-based scores. The average score for the population (μ) was 63.69 ± 0.23 and ranged from 38.27 to 89.74. Higher PANDiet scores were significantly associated with males, higher educated participants, non-smokers, and low-energy-dense diets (p < 0.001). Females between the ages of 18 and 35 had a significantly lower nutrient adequacy score (μ 59.17). PANDiet scores were significantly correlated with serum folate, riboflavin status, serum vitamin D (p < 0.05) and with AHEI and aMED scores (Rs 0.45 and 0.43, p < 0.0001). The nutritional contribution of food groups varied between genders and low, moderate, and high nutritional adequacy groups. The PANDiet scoring system facilitated a detailed analysis of nutritional adequacy across sub-groups of the population, and is a comprehensive and valid diet quality metric in Irish databases.

Are recent dietary changes observed in the NutriNet-Santé participants healthier and more sustainable?

PURPOSE

While intensive modern food systems have significant unfavourable impacts on health and the environment, new sustainable food consumption trends have been emerging in recent years. This study identified recent dietary trends over a 4-year period in terms of overall dietary patterns and organic foods consumption and associated socio-demographic determinants.

METHODS

Food intakes were assessed among 18,108 participants of the NutriNet-Santé cohort in 2014 and 2018. A food frequency questionnaire was used to estimate organic and conventional food consumption. Change in food consumption, quality of the diet (assessed by the adherence to the French national guidelines), plant-based diet using published scores, organic food intake were evaluated in regard with various socio-demographic factors. The paired student t test to compare dietary intake and the Kruskal-Walllis test to consider socio-demographic characteristics were used.

RESULTS

Consumption of meat and processed meat decreased respectively by 5.09 g/day (SD 51.15) and 1.12 g/day (SD 26.05). The average total consumption of organic products increased by 12% (+ 93 g/day) while consumption of organic fish and seafood (- 1.4 g/day), poultry (- 1 g/day), processed meat (- 0.3 g/day) and meat (- 3.3 g/day) decreased. The dietary towards healthier diets was more pronounced in certain population subgroups. For example, females, young individuals and postgraduate participants were more likely to increase their consumption of healthful plant and animal-based foods, organic foods and to improve the overall nutritional quality of their diets during the follow-up period than their counterparts.

CONCLUSION

Our results indicate a slight inflexion towards healthier and plant-based diets over a 4-year period at least in some segments of the population. A decrease in the consumption of animal products and an increase in the consumption of healthful plant-based foods and organic foods suggests a potential trend towards more sustainable diets among certain subgroups. The environmental impacts of these changes need to be assessed in further works as well as the way to sustain and improve them, in particular those who do not initiate sustainable transition.

Intake of Animal Protein and Dietary Sources in the Colombian Population: Results of the National Nutrition Survey (ENSIN-2015)

BACKGROUND

There is a lack of knowledge in Colombia about dietary intake and sources of animal protein.

DESIGN

Cross-sectional, nationally representative surveys. Setting. Colombia. Participants. n = 32,457 participants aged from 1 to 64 years. The sample analyzed included 21,036 boys and nonpregnant girls, 10,099 adults, and 1,322 pregnant women, 118 of whom were below 18 years of age.

RESULTS

Protein intake was 32.9 g/d (95% CI: 32.4, 33.4) per 1,000 kilocalories. The relative contribution (%) of total protein to the total energy intake/day (acceptable macronutrient distribution) was 13.2% (95% CI: 13.0, 13.3). The acceptable macronutrient distribution (AMDR) for animal protein for those aged 1 to 64 years was 7.8% (95% CI: 7.6, 8.0), with a minimum of 7.1% (95% CI: 6.7, 7.5), which was for children aged from 13 to 17 years, and a maximum of 8.3% (95% CI: 8.1, 8.5), for children aged from 1 to 4 years (P=0.018). For all groups, animal protein made up the majority of total proteins, with 62.6% (95% CI: 61.7, 63.6) for preschoolers, 55.8% (95% CI: 53.2, 58.4) for school-aged children, 54.6% (95% CI: 53.0, 56.1) for adolescents, 58.1% (95% CI: 57.5, 58.7) for adults, and 57.5% (95% CI: 55.2, 59.7) for pregnant women (P=0.027). The three main dietary sources of animal protein were red meat (17.8%), chicken (16.3%), and eggs (10.5%). The sources of vegetal protein were bread-arepa-pasta (20.0%), cereals (19.8%), and legumes (8.2%).

CONCLUSIONS

Protein intake is excessive according to the Recommended Dietary Allowance (RDA), while it is not excessive from the perspective of the AMDR.

A Scoping Review of Indicators for Sustainable Healthy Diets

Introduction: Diets are currently unsustainable in many countries as evidenced by the growing burden of malnutrition, degradation of natural resources, contributions to climate change, and unaffordability of healthy diets. Agreement on what constitutes a healthy and sustainable diet has been debated. In 2019, FAO and WHO published the Sustainable Healthy Diets Guiding Principles, defining what qualifies as a sustainable healthy diet. While valuable, these principles require measurable indicators to support their operationalization. Our scoping review aims to describe how sustainable healthy diets have been assessed in the literature since 2010.

Methods: A search for English-language articles published in peer-reviewed journals was conducted from January 2010 through February 2020 across three databases. Out of the 504 articles initially identified, 103 articles were included. Metadata were extracted from each article on: publication year, country of study, study aims, methods, main data sources, indicators used to assess sustainable healthy diets, reported indicator strengths or limitations, and main study findings. A qualitative content analysis identified major conceptual themes across indicators and their frequency of use.

Findings: From the 103 empirical articles included in our review, 57.3% were published after 2017. Most studies were carried out in high-income countries (74%). Approximately 42% of the articles assessed the sustainability of diets using solely health and environmental indicators; &lt;25% assessed the sustainability of diets across health, environmental, and sociocultural aspects of sustainability. We found a substantial number of unique indicators used for assessing health (n = 82), environmental (n = 117), and sociocultural (n = 43) aspects of diets. These indicators covered concepts related to health outcomes, aspects of diet quality, natural resources, climate change, cultural acceptability, and cost of diets. The preponderance of indicators currently used in research likely poses challenges for stakeholders to identify the most appropriate measures.

Conclusion: Robust indicators for sustainable healthy diets are critical for understanding trends, setting targets, and monitoring progress across national and sub-national levels. Our review highlights the geographical imbalance, the narrow focus on health and environmental aspects, and the lack of common measures used in research. Measures registries could provide the decision-support needed by stakeholders to aid in the indicator selection process.

Development and evaluation of a new dietary index assessing nutrient security by aggregating probabilistic estimates of the risk of nutrient deficiency in two French adult populations

Although micronutrient deficiencies affect 2 billion people worldwide, no index focuses on measuring the risk of overt nutrient deficiency. We aimed to develop an index that could capture the nutrient dimension of nutritional security, a nutrient security index (named SecDiet), and evaluate its apparent validity. The SecDiet (range: 0-1) is based on the square-weighted average of the probabilities that the intake of twelve critical nutrients exceeds the threshold value associated with a risk of overt deficiency. Using adult populations from a French representative survey (INCA3, n 1774) and a large cohort (NutriNet-Santé, n 104 382), the content and construct validity of the SecDiet was evaluated by estimating associations of the SecDiet with its components and with relevant socio-demographic characteristics. The SecDiet was high in the overall population (0·93 (SD 0·09) in INCA3) and markedly skewed towards 1 (i.e. lower risk of insufficient intake). It correlated positively with its twelve components (r 0·17-0·78, all P < 0·001). The SecDiet was associated with monthly income (P = 0·002), perception of financial situation, professional situation, food insufficiency and security statuses (all P < 0·001) in the INCA3 population and with monthly income, professional situation and level of education (all P < 0·001) in the NutriNet-Santé population. Unlike a broader nutrient-based quality index taken as comparison, the SecDiet mean decreased and the tail of its distribution notably extended downwards in at-risk sub-populations, thus revealing its specific sensitivity. The SecDiet could be used to screen sub-groups or study the determinants of nutrient insecurity in large population surveys.

Empirico-inductive and/or hypothetico-deductive methods in food science and nutrition research: which one to favor for a better global health?

Scientific research generally follows two main methods: empirico-inductive (EI), gathering scattered, real-world qualitative/quantitative data to elaborate holistic theories, and the hypothetico-deductive (HD) approach, testing the validity of hypothesized theory in specific conditions, generally according to reductionist methodologies or designs, with the risk of over simplifying the initial complexity empirically perceived in its holistic view. However, in current food and nutrition research, new hypotheses are often elaborated from reductionist data obtained with the HD approach, and aggregated to form (ultra)reductionist theories, with no application of EI observations, limiting the applicability of these hypotheses in real life. This trend and the application of the EI method are illustrated as regards with the global health issue through the examples of food classifications/scoring, clinical studies, the definition of a sustainable diet, the "matrix effect"-related hypothesis, the concept of healthy core metabolism, and obesity prevention within the perspective of social sciences. To be efficient for producing food and nutritional data appropriable by the society, it finally appears that not only both approaches are necessary, starting with the EI method then the HD one, but also a back and forth between the two, this being not always realized, potentially leading to confusion and misunderstanding in society.

Substituting Meat or Dairy Products with Plant-Based Substitutes Has Small and Heterogeneous Effects on Diet Quality and Nutrient Security: A Simulation Study in French Adults (INCA3)

BACKGROUND

Plant-based substitutes are designed to have the same use as animal-based foods in the diet and could therefore assist the transition toward more plant-based diets. However, their nutritional impact has not been characterized.

OBJECTIVES

We assessed and compared the effects of plant-based substitutes on the nutritional quality of the diet.

METHODS

We simulated separately the substitution of meat, milk, and dairy desserts with 96 plant-based substitutes in the diets of 2121 adults (18-79 y old) from the cross-sectional French Third Individual and National Study on Food Consumption Survey (INCA3; 2014-2015). The quality of initial individual diets and the 203,616 substituted diets was evaluated using the Probability of Adequate Nutrient Intake (PANDiet) scoring system, which assesses the probability of adequate (sufficient and not excessive) nutrient intake; also, nutrient security was evaluated using the SecDiet scoring system, which assesses the risk of overt deficiency.

RESULTS

Impacts on PANDiet depended on both the food substituted and the types of substitutes. Soy-based substitutes provided a slight improvement in diet quality (0.8% increase of the PANDiet score when substituting meat), whereas cereal-based substitutes resulted in a 1.1% decrease. Globally, substitutions led to better adequacies for fiber, linoleic acid, α-linolenic acid, vitamin E, folate, and SFAs, but lower adequacies regarding vitamin B-12 and riboflavin, as well as bioavailable zinc and iron when substituting meat, and calcium and iodine when substituting milk/dairy desserts. When they substituted dairy products, calcium-fortified substitutes allowed maintenance of calcium adequacy but there was a higher risk of iodine deficiency when substituting dairy, which may warrant iodine fortification. Substitutions modified the energy share of ultra-processed foods from 29% to 27%-40%, depending on the food substituted and the substitute used.

CONCLUSIONS

Plant-based substitutes had a small effect on overall diet quality and heterogeneous impacts on nutrient adequacy and security. Plant-based substitutes that include legumes appear more nutritionally adequate to substitute animal products than do other substitutes.

Public health potential of guidelines-based dietary scores for non-communicable diseases mortality prevention: simulation study using the Preventable Risk Integrated ModEl (PRIME) model

OBJECTIVE

Dietary indexes measure the adherence of individuals to a set of nutritional recommendations. However, the health gains associated with adherence to various dietary indexes may vary. Our objective was to compare the magnitude of estimated avoided deaths by chronic diseases obtained by improving diet quality in the French population, measured by a variety of dietary indexes.

DESIGN

Simulation study based on observational data.

SETTING

Weighted data from a French population-based cohort study.

PARTICIPANTS

In participants from the NutriNet-Santé cohort, we computed dietary scores reflecting the adherence to various recommendations (Medi-Lite, Healthy Diet Indicator (HDI), Programme National Nutrition Santé/National Nutrition and Health Program - Guidelines Score, Diet Quality Index (DQI), Alternative Healthy Eating Index (AHEI) and the modified Food Standards Agency nutrient profiling system dietary index (FSAm-NPS DI)). Quintiles of the food groups' consumption and dietary intakes were used as input in a simulation model (Preventable Risk Integrated ModEl (PRIME)), yielding the number of delayed or avoided deaths in nutrition-related non-communicable diseases, comparing between very high or very low nutritional quality of the diet and medium nutritional quality.

RESULTS

A modification of dietary intakes from medium quality to very low quality (i.e. from the middle quintile to the quintile with the lowest nutritional quality) was associated with an increased number of deaths ranging from 3485 (95 % uncertainty interval (CI) 4002, 2987) for HDI and 3379 (95 % CI 3881, 2894) for FSAm-NPS DI to 838 (95 % CI 1163, 523) for Medi-Lite. Conversely, a modification of dietary intakes from medium quality to very high quality was associated with a decrease in the number of deaths ranging from 1995 (95 % CI 1676, 2299) for Probability of Adequate Nutrient intake diet, 1986 (95 % CI 1565, 2361) for DQI-International, 1931 (95 % CI 1499, 2316) for FSAm-NPS DI and 858 (95 % CI 499, 1205) for HDI.

CONCLUSIONS

Our results provide some insights as the potential impact of following various dietary guidelines to reduce mortality from nutrition-related diseases.

Organic food consumption and gluten-free diet, is there a link? Results in French adults without coeliac disease

The rising popular belief that gluten is unhealthy has led to growth in gluten avoidance in people without coeliac disease. Little information is available on their dietary profiles and their dietary behaviours. Our aim was to compare the consumption of organic foods between gluten avoiders and non-avoiders, and their places of food purchase. We described their sociodemographic and dietary profiles. The study population included participants of the NutriNet-Santé cohort who completed both a food exclusion questionnaire and an organic semi-quantitative FFQ (n 23 468). Food intake and organic food consumption ratios were compared using multivariable adjusted ANCOVA models. Associations between gluten avoidance and organic food consumption as well as places of food purchase were investigated with multivariable logistic regression. Participants avoiding gluten were more likely to be women and had a healthier dietary profile. Organic food consumption was higher among gluten avoiders (48·50 % of total diet for total avoiders, 17·38 % for non-avoiders). After adjustments for confounders, organic food consumption and purchase in organic stores were positively associated with gluten avoidance: adjusted OR (aOR)Q5 v.Q1 organic food = 4·95; 95 % CI 3·70, 6·63 and aORorganic stores v.supermarkets = 1·82; 95 % CI 1·42, 2·33 for total avoiders. Our study highlights that individuals avoiding gluten are high organic consumers and frequently purchase their foods in organic stores which propose an extended offer of gluten-free food. Further research is needed to determine the underlying common motivations and the temporality of the dietary behaviours of healthy people avoiding gluten.

Contrary to ultra-processed foods, the consumption of unprocessed or minimally processed foods is associated with favorable patterns of protein intake, diet quality and lower cardiometabolic risk in French adults (INCA3)

PURPOSE

While the consumption of ultra-processed foods is steadily increasing, there is a growing interest in more sustainable diets that would include more plant protein. We aimed to study associations between the degree of food processing, patterns of protein intake, diet quality and cardiometabolic risk.

METHODS

Using the NOVA classification, we assessed the proportion of energy from unprocessed/minimally processed foods (MPFp), processed foods (PFp) and ultra-processed foods (UPFp) in the diets of 1774 adults (18-79 years) from the latest cross-sectional French national survey (INCA3, 2014-2015). We studied the associations between MPFp, PFp and UPFp with protein intakes, diet quality (using the PANDiet scoring system, the global (PDI), healthful (hPDI) and unhealthful (uPDI) plant-based diet indices) and risk of cardiometabolic death (using the EpiDiet model).

RESULTS

MPFp was positively associated with animal protein intake and plant protein diversity, whereas PFp was positively associated with plant protein intake and negatively with plant protein diversity. The PANDiet was positively associated with MPFp (β = 0.14, P < 0.0001) but negatively with UPFp (β = - 0.05, P < 0.0001). These associations were modified by adjustment for protein intakes and plant protein diversity. As estimated with comparative risk assessment modeling between extreme tertiles of intake, mortality from cardiometabolic diseases would be decreased with higher MPFp (e.g. by 31% for ischemic heart diseases) and increased with higher UPFp (by 42%) and PFp (by 11%).

CONCLUSIONS

In the French population, in contrast with UPFp, higher MPFp was associated with higher animal protein intake, better plant protein diversity, higher diet quality and markedly lower cardiometabolic risk.

Conservative to disruptive diets for optimizing nutrition, environmental impacts and cost in French adults from the NutriNet-Santé cohort

Improving the sustainability of diets requires the identification of diets that meet the nutritional requirements of populations, promote health, are within planetary boundaries, are affordable and are acceptable. Here we explore the extent to which dimensions of sustainability could be optimally aligned and identify more sustainable dietary solutions, from the most conservative to the most disruptive, among 12,166 participants of the NutriNet-Santé cohort. We aim to concomitantly lower environmental impacts (including greenhouse gas emissions, cumulative energy demand and land occupation), increase organic food consumption and study departure from observed diets (considered as a proxy for acceptability). From the most conservative to the most disruptive scenario, optimized diets were gradually richer in fruits, vegetables and soya-based products and markedly poorer in animal-based foods and fatty and sweet foods. The contribution of animal protein to total protein intake gradually decreased by 12% to 70% of the observed value. The greenhouse gas emissions from food production for the diets gradually decreased across scenarios (as a percentage of observed values) by 36-86%, land occupation for food production by 32-78% and energy demand by 28-72%. Our results offer a benchmark of scenarios of graded dietary changes against graded sustainability improvements.

Development of a Diet Quality Screener for Global Use: Evaluation in a Sample of US Women

BACKGROUND

Valid and efficient tools for measuring and tracking diet quality globally are lacking.

OBJECTIVE

The objective of the study was to develop and evaluate a new tool for rapid and cost-efficient diet quality assessment.

DESIGN

Two screener versions were designed using Prime Diet Quality Score (PDQS), one in a 24-hour recall (PDQS-24HR) and another in a 30-day (PDQS-30D) food frequency format. Participants completed two 24-hour diet recalls using the Automated Self-Administered 24-hour Dietary Assessment Tool (ASA24) and 2 web-based diet quality questionnaires 7 to 30 days apart in April and May 2019. Both dichotomous/trichotomous and granular scoring versions were tried for each screener.

PARTICIPANTS/SETTING

The study included 290 nonpregnant, nonlactating US women (mean age ± standard deviation 41 ± 11 years) recruited via Amazon Mechanical Turk.

MAIN OUTCOME MEASURES

The main outcome measures were Spearman rank correlation coefficients and linear regression beta-coefficients between ASA24 nutrient intakes from foods and beverages and PDQS values.

STATISTICAL ANALYSES PERFORMED

The Spearman rank correlation and linear regression were used to evaluate associations of the PDQS values with ASA24 nutrient intakes from food, both crude and energy-adjusted. Correlations were de-attenuated for within-person variation in 24-hour recalls. Wolfe's test was used to compare correlations of the 2 screening instruments (PDQS-24HR and PDQS-30D) with the ASA24. Associations between the ASA24 Healthy Eating Index 2015 and the PDQS values were also evaluated.

RESULTS

Positive, statistically significant rank correlations between the PDQS-24HR values and energy-adjusted nutrients from ASA24 for fiber (r = 0.53), magnesium (r = 0.51), potassium (r = 0.48), vitamin E (r = 0.40), folate (r = 0.37), vitamin C (r = 0.36), vitamin A (r = 0.33), vitamin B6 (r = 0.31), zinc (r = 0.25), and iron (r = 0.21); and inverse correlations for saturated fatty acids (r = -0.19), carbohydrates (r = -0.22), and added sugar (r = -0.34) were observed. Correlations of nutrient intakes assessed by ASA24 with the PDQS-30D were not significantly different from those with the PDQS-24HR. Positive, statistically significant correlations between the ASA24 Healthy Eating Index 2015 and the PDQS-24HR (r = 0.61) and the PDQS-30D (r = 0.60) were also found.

CONCLUSIONS

The results of an initial evaluation of the PDQS-based diet quality screeners are promising. Correlations and associations between the PDQS values and nutrient intakes were of acceptable strength and in the expected directions, and the PDQS values had moderately strong correlations with the total Healthy Eating Index 2015 score. Future work should include evaluating the screeners in other population groups, including men, and piloting it across low- and middle-income countries.

The Habitual Diet of Dutch Adult Patients with Eosinophilic Esophagitis Has Pro-Inflammatory Properties and Low Diet Quality Scores

We determined the nutritional adequacy and overall quality of the diets of adult patients with eosinophilic esophagitis (EoE). Dietary intakes stratified by sex and age were compared to Dietary Reference Values (DRV). Overall diet quality was assessed by two independent Diet-Quality-Indices scores, the PANDiet and DHD-index, and compared to age- and gender-matched subjects from the general population. Lastly, food and nutrient intakes of EoE patients were compared to intakes of the general population. Saturated fat intake was significantly higher and dietary fiber intake significantly lower than the DRV in both males and females. In males, the DRV were not reached for potassium, magnesium, selenium, and vitamins A and D. In females, the DRV were not reached for iron, sodium, potassium, selenium, and vitamins A, B2, C and D. EoE patients had a significantly lower PANDiet and DHD-index compared to the general population, although the relative intake (per 1000 kcal) of vegetables/fruits/olives was significantly higher (yet still up to 65% below the recommended daily amounts) and alcohol intake was significantly lower compared to the general Dutch population. In conclusion, the composition of the habitual diet of adult EoE patients has several pro-inflammatory and thus unfavorable immunomodulatory properties, just as the general Dutch population, and EoE patients had lower overall diet quality scores than the general population. Due to the observational character of this study, further research is needed to explore whether this contributes to the development and progression of EoE.

Adaptation and validity assessment of a diet quality index for patients with type 2 diabetes

PURPOSE

As diet quality indices (DQI) are likely to be influenced by disease background, adapting the existing indices for each disease is crucial. No study has been adapted a DQI for patients with type 2 diabetes. We aimed to adapt healthy eating index and assess its validity for Iranian patients with type 2 diabetes mellitus (T2DM).

METHODS

In this cross-sectional study, the analysis was conducted on 489 adults with T2DM. We adapted HEI and assessed its validity using construct validity. Construct validity was assessed using a 168-item semi-quantitative food-frequency questionnaire (FFQ). General linear model was used to assess associations between adapted HEI scores and demographic characteristics, anthropometric indices, physical activity and food and nutrient intakes.

RESULTS

Adapted HEI were examined on 489 subjects (163 men and 326 women). Findings showed that in older subjects the mean adapted HEI score was greater than the younger ones. However, it was significant only in women (p = 0.01). Women with higher education level obtained the greater score (p < 0.001). The greatest mean score of the adapted HEI score in men was related to non-smokers. The mean score in both genders were raised following the increase in physical activity level (p < 0.05). Moreover, a reduction in the mean score of adapted HEI was observed in men with higher BMI compared to those with the lower one (p = 0.001).

CONCLUSION

Adapted HEI could successfully discriminate diet quality in patients with T2DM. Older and high-educated women were adhered greatly to high quality diets. The adapted DQI linked with greater physical activity level and non-smokers diabetic men with lower BMI.

Estimated dietary pesticide exposure from plant-based foods using NMF-derived profiles in a large sample of French adults

PURPOSE

This study, conducted in participants of the NutriNet-Santé cohort, aims to identify dietary pesticide exposure profiles (derived from Non-negative Matrix Factorization) from conventional and organic foods among a large sample of general population French adults.

METHODS

Organic and conventional dietary intakes were assessed using a self-administered semi-quantitative food frequency questionnaire. Exposure to 25 commonly used pesticides was evaluated using food contamination data from Chemisches und Veterinäruntersuchungsamt Stuttgart accounting for farming system (organic or conventional). Dietary pesticide exposure profiles were identified using Non-Negative Matrix factorization (NMF), especially adapted for non-negative data with excess zeros. The NMF scores were introduced in a hierarchical clustering process.

RESULTS

Overall, the identified clusters (N = 34,193) seemed to be exposed to the same compounds with gradual intensity. Cluster 1 displayed the lowest energy intake and estimated dietary pesticide exposure, high organic food (OF) consumption (23.3%) and a higher proportion of male participants than other groups. Clusters 2 and 5 presented intermediate energy intake, lower OF consumption and intermediate estimated pesticide exposure. Cluster 3 showed high conventional fruits and vegetable (FV) intake, high estimated pesticide exposure, and fewer smokers. Cluster 4 estimated pesticide exposure varied more across compounds than for other clusters, with highest estimated exposures for acetamiprid, azadirachtin, cypermethrin, pyrethrins, spinosad. OF proportion in the diet was the highest (31.5%).

CONCLUSION

Estimated dietary pesticide exposures appeared to vary across the clusters and to be related to OF proportion in the diet.

TRIAL REGISTRATION

Clinical Trial Registry: NCT03335644.

Association between sustainable dietary patterns and body weight, overweight, and obesity risk in the NutriNet-Santé prospective cohort

BACKGROUND

Improving the sustainability of current food systems may prevent future public health, environmental, and social concerns.

OBJECTIVE

Our objective was to investigate the associations between sustainable dietary patterns, assessed using the Sustainable Diet Index (SDI), and the risk of obesity, overweight, and weight gain in French adults, with a prospective design.

METHODS

In 2014, the SDI was computed among 15,626 participants of the NutriNet-Santé study (of whom 76% were women) using data collected within the BioNutriNet project. The SDI ranges from 4 (lowest sustainability) to 20 points and includes 4 subindexes representing the 4 pillars of a sustainable diet. Longitudinal data of weight and height were collected yearly from 2014 to 2018. We used mixed models to estimate the associations between sex-specific quintiles (Qs) of the SDI and weight change and Cox proportional hazard models with different levels of adjustments to assess the association between sex-specific Qs of the SDI and risk of obesity and overweight (mean follow-up time: 2.8 y).

RESULTS

At baseline, a higher percentage of participants with overweight was observed in the first SDI Q, reflecting the lowest sustainable dietary patterns (Q1), than in Q5 (29.83% compared with 12.71%). Compared with Q5, a slight increase (at the population level) of almost 160 g/y was observed in Q1, whereas weight remained relatively stable among participants in other Qs. In total, 281 incident cases of obesity and 777 cases of overweight were identified during the follow-up. Participants in Q1 had a higher risk of obesity and overweight than participants in Q5 (HR comparing Q1 with Q5: 4.03; 95% CI: 2.42, 6.10; P-trend < 0.001; and HR comparing Q1 with Q5: 1.49; 95% CI: 1.13, 1.95; P-trend < 0.001, respectively).

CONCLUSIONS

The findings support a potential protective role for more sustainable diets to prevent the risk of weight gain, overweight, and obesity.This trial was registered at clinicaltrials.gov as NCT03335644.

Plant-Protein Diversity Is Critical to Ensuring the Nutritional Adequacy of Diets When Replacing Animal With Plant Protein: Observed and Modeled Diets of French Adults (INCA3)

BACKGROUND

There is a current trend in Western countries toward increasing the intake of plant protein. A higher plant-protein intake has been associated with nutritional and health benefits, but these may depend on the pattern of plant-protein sources.

OBJECTIVE

We hypothesized that the diversity of plant foods could be important to nutrient adequacy when increasing plant-protein intake in the diet.

METHODS

Using data on 1341 adults (aged 18-64 y) from a representative French national dietary survey conducted in 2014-2015 (the third Individual and National Study on Food Consumption Survey-INCA3), we studied the links between plant-protein intake, dietary diversity (using various dimensions), and nutrient adequacy [assessed using the PANDiet (Probability of Adequate Nutrient Intake) scoring system, comprising adequacy (AS) and moderation (MS) subscores]. We simulated substituting plant-protein foods for animal-protein foods using different models of plant-protein diversity.

RESULTS

We found that overall diet quality was weakly associated with total and protein diversity and more strongly with plant-protein diversity. Plant-protein intake was inversely associated with animal-protein intake, and positively with the PANDiet and MS, but not with the AS. Plant-protein intake displayed little diversity, mostly taking the form of grains (61% of plant-protein intake), and this diversity was even less marked under a higher plant-protein intake. Finally, modeled substitutions showed that reducing animal-protein intake increased the MS (by 32%) in a similar manner whichever plant protein was used for substitution, whereas it decreased the AS (by 20%) unless using a highly diversified plant-protein mix. These simulated improvements in overall adequacy included marked decreases in adequacy regarding certain nutrients that are typically of animal origin.

CONCLUSIONS

We conclude that in French adults the current pattern of plant-protein intake is hindering the nutritional benefits of a transition toward more plant protein, indicating that the consumption of plant-protein-based foods other than refined grains should be encouraged.

Optimization of the environmental performance of food diets in Peru combining linear programming and life cycle methods

The improvement of diets from a nutritional and health perspective has been a critical policy objective in developing nations for the past few decades. However, the current stress that human populations are exerting on the planet has made it important to assess diets using environmental indicators, such as greenhouse gas (GHG) emissions. Therefore, the main objective of the current study was to propose a methodology in which Life Cycle Assessment results linked to dietary patterns in Peru were combined with nutritional and economic data to optimize diets. For this, a linear programming model was built in which the environmental, nutritional and economic information on a set of 25 dietary patterns in Peru were optimized in order to achieve the environmentally best-performing diet that complies with economic and nutritional standards. The result of the proposed linear program allowed understanding the amount of each individual food product that should be consumed in each city that satisfies all the restrictions included in the model in order to attain the lowest GHG emissions possible. Results demonstrated that GHG reductions in food diets can be attained through optimization. For instance, in the case of Lima the obtained reduction was 6%, lowering the annual per capita footprint linked to food diets to 690 kg CO₂eq, as compared to the current value of 736 kg CO₂eq. From an economic perspective, results show that there are important disparities between cities in terms of increasing or decreasing prices of the market basket. Considering that in most areas of the country food purchase accounts for approximately 50% of household expenditure, it is plausible to assume that food choice is a main carrier to achieve GHG emission mitigations. In this context, the method constitutes a useful tool for policy-makers to push forward joint regulations to improve health-related issues linked to the food diet and food choice together with recommendations to lower the climatic impact of diets.

Diet quality indices for research in low- and middle-income countries: a systematic review

CONTEXT

Dietary intake research has increasingly focused on improving diet quality in low- and middle-income countries (LMICs). Accompanying this is the need for sound metrics to assess diet quality.

OBJECTIVE

This systematic literature review aims to describe existing diet quality indices for general populations and highlights recommendations for developing such indices for food system research in LMICs.

DATA SOURCES

Three electronic databases were searched for papers published between January 2008 and December 2017.

DATA EXTRACTION

Articles published in English and describing the development of an index to measure overall diet quality, irrespective of whether they were for high-income countries or LMICs, were included.

DATA ANALYSIS

Eighty-one indices were identified, over two thirds were based on national dietary guidelines from high-income countries. Of the 3 key diet quality dimensions, "diversity" was included in all 18 indices developed for LMICs, "moderation" was captured by most, and "nutrient adequacy" was included 4 times.

CONCLUSIONS

Indices need to be developed that include all dimensions, include foods and/or food groups rather than nutrients, use an optimal range for individual components in the score, and express the intake of healthy and unhealthy components separately. Importantly, validation of the index should be part of its development.

Programme National Nutrition Santé – guidelines score 2 (PNNS-GS2): development and validation of a diet quality score reflecting the 2017 French dietary guidelines

Following the revision of the French dietary guidelines in 2017, the Programme National Nutrition Santé – guidelines score (PNNS-GS), built upon previous recommendations released in 2001, needed to be updated. This cross-sectional study thus aimed to develop and validate the PNNS-GS2, a predefined food-based dietary index based on the 2017-revised French nutritional guidelines. A total of 80 965 participants recruited among French adults (≥18 years old) in the NutriNet-Santé web-based prospective cohort were included. Collected data included repeated 24 h-dietary records over a 2-year period, sociodemographic and, for 16 938 subjects, clinical and biological data. Weighting and cut-offs of the PNNS-GS2 components were collegially arbitrated by nutrition experts who participated in the 2017 revision of the guidelines. Sociodemographic, nutritional and clinical and biological factors were investigated according to quintiles (Q) of PNNS-GS2 (theoretical ranging −17 to +13·5). Mean PNNS-GS2 was 2·1 (sd3·1) in women and −0·3 (sd3·6) in men. Higher PNNS-GS2 (higher adherence to 2017 dietary guidelines) was positively associated with (mean difference between Q5 and Q1 in women/men) age (+8·4/+4·7 years), education (+3·9/+7·4 % of university level), physical activity (+13·3/+3·5 % of ≥60 min/d) and non-smoking (+9·7/+13·7 %), and was negatively associated with mean blood pressure (−3·0/−2·8 mmHg), plasma LDL-cholesterol (−0·07/−0·06 g/l) and TAG (−0·10/−0·16 g/l) concentrations. Higher PNNS-GS2 was also associated with higher intake of favourable nutrients, e.g.n-3 PUFA (+0·2/+0·2 % of energy intake), fibres (+8·7/+10·7 g) and vitamin C (+36·6/+43·8 mg). Associations between PNNS-GS2 and sociodemographic and nutritional factors arguing for its validation are coherent. Further studies are needed to evaluate its association with mortality and morbidity.

Development and validation of an individual sustainable diet index in the NutriNet-Santé study cohort

In the current context of unsustainable food systems, we aimed to develop and validate an index, the sustainable diet index (SDI), assessing the sustainability of dietary patterns, including multidimensional individual indicators of sustainability. Based on the FAO's definition of sustainable diets, the SDI includes seven indicators categorised into four standardised sub-indexes, respectively, environmental, nutritional, economic and sociocultural. The index (range: 4-20) was obtained by summing the sub-indexes. We computed the SDI for 29 388 participants in the NutriNet-Santé cohort study, estimated its validity and identified potential socio-demographic or lifestyle differences across the SDI quintile. In our sample, the SDI (mean=12·10/20; 95 % CI 12·07, 12·13) was highly correlated to all the sub-indexes that exerted substantial influence on the participants' ranking. The environmental and economical sub-indexes were the most and less correlated with the SDI (Pearson R 2 0·66 and 0·52, respectively). Dietary patterns of participants with a high SDI (considered as more sustainable) were concordant with the already published sustainable diets. Participants with high SDI scores were more often women (24 %), post-secondary graduates (22 %) and vegetarians or vegans (7 %), without obesity (16 %). Finally, the SDI could be a useful tool to easily assess the sustainability-related changes in dietary patterns, estimate the association with long-term health outcomes and help guide future public health policies.

Improvement of diet sustainability with increased level of organic food in the diet: findings from the BioNutriNet cohort

BACKGROUND

Organic food consumption has steadily increased over the past decade in westernized countries.

OBJECTIVE

The aim of this study, based on observational data, was to compare some sustainability features of diets from consumers with varying levels of organic food.

METHODS

The diet sustainability among 29,210 participants of the NutriNet-Santé study was estimated using databases developed within the BioNutriNet project. Four dimensions (nutrition, environment, economy, and toxicology) of diet sustainability were assessed using: 1) nutritional indicators through dietary intakes and dietary scores, and BMI; 2) environmental indicators (greenhouse gas emissions, cumulative energy demand, and land occupation); 3) economic indicators via diet monetary costs; and 4) estimated daily food exposures to 15 pesticides. Adjusted means (95% CI) across weighted quintiles of organic food consumption in the diet were estimated via ANCOVA. Breakdown methods were used to disentangle the contribution of the production system (organic compared with conventional) from the dietary pattern in the variation of diet-related environmental impacts, monetary costs, and pesticide exposure, between the 2 extreme quintiles.

RESULTS

Higher organic food consumption was associated with higher plant-food and lower animal-food consumption, overall nutritional quality (higher dietary scores), and lower BMI. Diet-related greenhouse-gas emissions, cumulative energy demand, and land occupation gradually decreased with increasing organic food consumption, whereas total diet monetary cost increased. Diet exposure to most pesticides decreased across quintiles.

CONCLUSIONS

Diets of high organic food consumers were generally characterized by strong nutritional and environmental benefits. The latter were mostly driven by the low consumption of animal-based foods, whereas the production system was responsible for the higher diet monetary costs, and the overall reduced dietary pesticide exposure.

The Initial Dietary Pattern Should Be Considered when Changing Protein Food Portion Sizes to Increase Nutrient Adequacy in French Adults

BACKGROUND

Patterns of protein food intake are undergoing a transition in Western countries, but little is known about how dietary changes to protein intake affect nutrient adequacy of the diet.

OBJECTIVES

Our objective was to identify simple modifications to protein food intake that can gradually increase overall nutrient adequacy.

METHODS

We identified patterns of dietary protein intake in 1678 adults from a representative French national dietary survey. For each individual, we identified the increase in portion size of 1 protein food paired with a decrease in the portion size of another protein food that would best increase nutrient adequacy (using PANDiet probabilistic scoring). Then, such an optimum simple dual change was iterated 20 times for each individual according to 2 scenarios, either by manipulating the intake of foods already consumed [scenario 1 (S1)] or by enabling the introduction of foods consumed by >10% of individuals with the same protein pattern [scenario 2 (S2)].

RESULTS

The optimum stepwise changes to protein intake primarily consisted of reducing portions of deli meats (both scenarios), sandwiches, and cheese (S2), while increasing portions of fatty fish and lean poultry (both scenarios) and legumes (S2). However, these changes differed depending on the initial dietary protein pattern of the individual. For example, in S2, legume intake increased among "poultry" and "fish" eaters only and low-fat meat among "take-away eaters" and "milk drinkers" only. The improvements in overall nutrient adequacy were similar among the different initial dietary patterns, but this was the result of changes to the adequacy of different specific nutrients.

CONCLUSION

Beyond generic changes to protein intake in the entire French adult population, the initial dietary protein pattern is key to identifying the food groups most likely to improve overall nutrient adequacy and the profile of nutrients whose adequacy can easily be increased.

Evaluation of the Effect of a Growing up Milk Lite vs. Cow's Milk on Diet Quality and Dietary Intakes in Early Childhood: The Growing up Milk Lite (GUMLi) Randomised Controlled Trial

scores provide an alternative approach to measuring dietary quality. The Growing Up Milk-Lite (GUMLi) Trial was a multi-centre, double-blinded, randomised controlled trial of children randomised to receive a reduced protein GUM (GUMLi) or unfortified cow's milk (CM). In a secondary analysis of the GUMLi Trial, we used the Probability of Adequate Nutrient Intake (PANDiet) to determine the nutritional adequacy of the diets of participating children living in Auckland. The PANDiet was adapted to the New Zealand Nutrient Reference Values and data from four 24 h Recalls (24HR) collected at months 7, 8, 10, and 11 post-randomisation were used. Differences between randomised groups (GUMLi vs. CM) of the PANDiet and its components were made. Eighty-three Auckland participants were included in the study (GUMLi n = 41 vs. CM n = 42). Total PANDiet scores were significantly higher in the GUMLi group (p < 0.001), indicating better overall nutrient adequacy and diet quality. Dietary intakes of children in both groups met the recommendations for fat, total carbohydrates and most micronutrients; however, protein intakes exceeded recommendations. Consumption of GUMLi was associated with higher nutritional adequacy, with an increased likelihood of meeting nutrient requirements; however, the impact of the family diet and GUMLi on dietary diversity requires further evaluation.

Carbon footprint and nutritional quality of different human dietary choices

Apart from industrial activities, our eating habits also have a significant environmental cost associated with crop cultivation, manufacturing processes, packaging, refrigeration, transport cooking and waste management. In a context of growing social awareness of the role of different dietary choices in the environment, the review of different alternatives on the road to a healthy and sustainable diet should integrate relevant information on the nutritional quality of different eating habits. Since dietary choices have an effect on environmental sustainability and human health, a literature review on different dietary choices has been conducted to determine the differences in carbon footprint and nutritional quality identifying the main hotspots trying to give advice towards the identification of sustainable diets. After applying a set of criteria for reference selection, 21 peer-reviewed studies have been analysed in detail, allowing the comparison of 66 dietary scenarios. We identified that the so-called Mediterranean and Atlantic diets present high nutritional scores and low carbon footprints. On the contrary, the dietary choices identified in northern and Western Europe, as well as in the United States, have the highest carbon footprints, highlighting the contribution of dairy products as a basic source of high-quality nutrients and protein. Broadly speaking, dietary choices rich in vegetables (e.g., vegan, vegetarian as well as Indian and Peruvian) have a better environmental profile than those rich in meat (mainly ruminant meat). In line with these findings, the shift in meat consumption habits from beef and veal to chicken, pork and poultry, the introduction of alternative foods to animal protein (e.g. quinoa) and the consumption of olive oil as a major source of vegetable oil may be compatible with a healthier and more environmentally friendly diet. However, the complete elimination of meat and dairy products from the daily diet may not be feasible in case the supply of some micronutrients (e.g., calcium and vitamin D) is not guaranteed. Limitations were identified in the consulted studies related to the consideration of the different system boundaries, as well as underlying uncertainties related to data sources. Therefore, efforts should be made to develop consistent and agreed-upon methods for estimating both the carbon footprint and nutritional quality scores.

An association between diet quality index for Koreans (DQI-K) and total mortality in Health Examinees Gem (HEXA-G) study

BACKGROUND/OBJECTIVES

Diet quality scores or indices, based on dietary guidelines, are used to summarize dietary intake into a single numeric variable. The aim of this study was to examine the association between the modified diet quality index for Koreans (DQI-K) and mortality among Health Examinees-Gem (HEXA-G) study participants.

SUBJECTS/METHODS

The DQI-K was modified from the original diet quality index. A total of 134,547 participants (45,207 men and 89,340 women) from the HEXA-G study (2004 and 2013) were included. The DQI-K is based on eight components: 1) daily protein intake, 2) percent of energy from fat, 3) percent of energy from saturated fat, 4) daily cholesterol intake, 5) daily whole-grain intake, 6) daily fruit intake, 7) daily vegetable intake, and 8) daily sodium intake. The association between all-cause mortality and the DQI-K was examined using Cox proportional hazard regression models. Hazard ratios and confidence intervals were estimated after adjusting for age, gender, income, smoking status, alcohol drinking, body mass index, and total energy intake.

RESULTS

The total DQI-K score was calculated by summing the scores of the eight components (range 0–9). In the multivariable adjusted models, with good diet quality (score 0–4) as a reference, poor diet quality (score 5–9) was associated with an increased risk of all-cause mortality (hazard ratios = 1.23, 95% confidence intervals = 1.06–1.43). Moreover, a one-unit increase in DQI-K score resulted in a 6% higher mortality risk.

CONCLUSIONS

A poor diet quality DQI-K score was associated with an increased risk of mortality. The DQI-K in the present study may be used to assess the diet quality of Korean adults.

Prospective association between adherence to dietary recommendations and incident depressive symptoms in the French NutriNet-Santé cohort

A posteriorihealthier dietary patterns and several nutrients have been associated with lower risks of depression in various studies; however, evidence is lacking with regard to the prospective association between adherence to nutritional recommendations (food-based and nutrient-based recommendations) and incident depression or depressive symptoms. In this study, we investigate such associations in the NutriNet Santé cohort. The study sample included 26 225 participants (aged 18–86 years) who were initially free of depressive symptoms. Adherence to nutritional recommendations was measured by four scores namely modified French Programme National Nutrition Santé-Guideline Score (mPNNS-GS), Alternative Healthy Eating Index-2010 (AHEI-2010), Probability of Adequate Nutrient Intake Dietary Score (PANDiet) and Diet Quality Index-International (DQI-I), using non-consecutive dietary record data during the first 2 years of follow-up (mean number of recording days=8,sd2). Depressive symptoms were defined by a Center for Epidemiologic Studies Depression Scale (CES-D) score ≥17 for men and ≥23 for women. We used Cox proportional hazards models to estimate hazard ratios and 95 % CI, modelling the dietary scores as standardised continuous variables and as tertiles. Over a mean follow-up of 6 years, we identified 2166 incident cases of depressive symptoms. All dietary scores with the exception of the AHEI-2010 were significantly inversely associated with incident depressive symptoms. In the fully adjusted model, an increase of 1sdin the mPNNS-GS, PANDiet and DQI-I was, respectively, associated with an 8 % (95 % CI 4, 13), 5 % (95 % CI 1, 9) and 9 % (95 % CI 5, 13) reduction in the risk of depressive symptoms. Overall, these findings suggest that diet in accordance with national or international guidelines could have beneficial effects with regard to mental health.

A clear trade-off exists between the theoretical efficiency and acceptability of dietary changes that improve nutrient adequacy during early pregnancy in French women: Combined data from simulated changes modeling and online assessment survey

Background

During pregnancy, the diet of a mother-to-be should be adapted to meet increases in nutrient requirements. We analyzed the theoretical efficiency and acceptability of different types of tailored dietary changes for pregnant women.

Methods

The nutrient adequacy of the diet was evaluated using the PANDiet score, by comparing the nutrient intakes of 344 non-pregnant premenopausal women (18–44y) with dietary reference intakes for the first trimester of pregnancy. Simulations were performed to evaluate the theoretical efficiency of three types of ten successive tailored dietary changes in improving nutrient adequacy, with graded difficulty in implementation. The acceptability (declared intention to use in the diet) of most efficient dietary changes was evaluated during an online randomized study including 115 French pregnant women (22–41y).

Results

Modifying the amount consumed of foods (type-1) did not modify the food repertoire and resulted in the smallest theoretical efficiency (increase in the PANDiet score of 9.8±0.2 points), but changes were the most acceptable (probability of the intention to use: 0.30–0.78). Conversely, replacing food items by items from the same group or eaten at the same time (type-3) broadened the food repertoire (3.6±1.3 food subgroups added) and resulted in the greatest theoretical efficiency (+23.9±0.3) but changes were the least acceptable (0.07–0.23). Replacing food items within the same subgroup (type-2) slightly broadened the food repertoire (+8.0±1.3 foods) and resulted in moderate theoretical efficiency (+14.8±0.2) and intermediate acceptability (0.11–0.35).

Conclusion

A clear trade-off exists between the theoretical efficiency and acceptability of dietary changes, with a graded broadening of the food repertoire.

Patterns of Protein Food Intake Are Associated with Nutrient Adequacy in the General French Adult Population

Protein food intake appears to partially structure dietary patterns, as most current emergent diets (e.g., vegetarian and flexitarian) can be described according to their levels of specific protein sources. However, few data are available on dietary protein patterns in the general population and their association with nutrient adequacy. Based on protein food intake data concerning 1678 adults from a representative French national dietary survey, and non-negative-matrix factorization followed by cluster analysis, we were able to identify distinctive dietary protein patterns and compare their nutrient adequacy (using PANDiet probabilistic scoring). The findings revealed eight patterns that clearly discriminate protein intakes and were characterized by the intakes of one or more specific protein foods: ‘Processed meat’, ‘Poultry’, ‘Pork’, ‘Traditional’, ‘Milk’, ‘Take-away’, ‘Beef’ and ‘Fish’. ‘Fish eaters’ and ‘Milk drinkers’ had the highest overall nutrient adequacy, whereas that of ‘Pork’ and ‘Take-away eaters’ was the lowest. Nutrient adequacy could often be accounted for by the characteristics of the food contributing to protein intake: ‘Meat eaters’ had high probability of adequacy for iron and zinc, for example. We concluded that protein patterns constitute strong elements in the background structure of the dietary intake and are associated with the nutrient profile that they convey.

Environmental Impacts of Plant-Based Diets: How Does Organic Food Consumption Contribute to Environmental Sustainability?

Background

Studies investigating diet-related environmental impacts have rarely considered the production method of the foods consumed. The objective of the present study, based on the NutriNet-Santé cohort, was to investigate the relationship between a provegetarian score and diet-related environmental impacts. We also evaluated potential effect modifications on the association between a provegetarian score and the environmental impacts of organic food consumption.

Methods

Food intake and organic food consumption ratios were obtained from 34,442 French adults using a food frequency questionnaire, which included information on organic food consumption for each group. To characterize the overall structure of the diets, a provegetarian score was used to identify preferences for plant-based products as opposed to animal-based products. Moreover, three environmental indicators were used to assess diet-related environmental impacts: greenhouse gas (GHG) emissions, cumulative energy demand (CED), and land occupation. Environmental impacts were assessed using production life cycle assessment (LCA) at the farm level. Associations between provegetarian score quintiles, the level of organic food consumption, and environmental indicators were analyzed using ANCOVAs adjusted for energy, sex, and age.

Results

Participants with diets rich in plant-based foods (fifth quintile) were more likely to be older urban dwellers, to hold a higher degree in education, and to be characterized by an overall healthier lifestyle and diet. A higher provegetarian score was associated with lower environmental impacts (GHG emissions_Q5vsQ1 = 838/1,664 kg CO_2eq/year, -49.6%, P < 0.0001; CED_Q5vsQ1 = 4,853/6,775 MJ/year, -26.9%, P < 0.0001; land occupation_Q5vsQ1 = 2,420/4,138 m²/year, -41.5%, P < 0.0001). Organic food consumption was also an important modulator of the relationship between provegetarian dietary patterns and environmental impacts but only among participants with diets rich in plant-based products.

Conclusion

Future field studies should endeavor to integrate all the components of a sustainable diet, i.e., both diet composition and production methods.

Improving diet sustainability through evolution of food choices: review of epidemiological studies on the environmental impact of diets

The Food and Agriculture Organization defines sustainable diets as nutritionally adequate, safe, healthy, culturally acceptable, economically affordable diets that have little environmental impact. This review summarizes the studies assessing, at the individual level, both the environmental impact and the nutritional quality or healthiness of self-selected diets. Reductions in meat consumption and energy intake were identified as primary factors for reducing diet-related greenhouse gas emissions. The choice of foods to replace meat, however, was crucial, with some isocaloric substitutions possibly increasing total diet greenhouse gas emissions. Moreover, nutritional adequacy was rarely or only partially assessed, thereby compromising the assessment of diet sustainability. Furthermore, high nutritional quality was not necessarily associated with affordability or lower environmental impact. Hence, when identifying sustainable diets, each dimension needs to be assessed by relevant indicators. Finally, some nonvegetarian self-selected diets consumed by a substantial fraction of the population showed good compatibility with the nutritional, environmental, affordability, and acceptability dimensions. Altogether, the reviewed studies revealed the scarcity of standardized nationally representative data for food prices and environmental indicators and suggest that diet sustainability might be increased without drastic dietary changes.

Changes in diet quality during a 12 month weight loss randomised controlled trial

Background

Reductions in energy intake are seen in weight loss trials, but whether this occurs with improvements to diet quality (DQ) is less established. The aim of this study was to evaluate changes in diet quality in a sample of volunteers in a weight loss trial.

Methods

This was a secondary analysis of dietary data from a lifestyle intervention trial (the HealthTrack study) which advised on dietary guidelines. The trial ran for 12 months with three treatment groups: control (general advice C), intervention (individualised advice, I), and intervention plus a supplement of walnuts (IW). Both the published a priori diet quality score (APDQS, maximum score 164) and a study specific Diet Quality Tracker (DQT, maximum score 44) indicated compliance to dietary advice. DQ scores calculated at 0, 3months and 12months were evaluated using two-way RMANOVA, one-way ANOVA and one-way RMANOVA. Changes in intakes of food groups and nutrients were analysed using Kruskal-Wallis and Friedman’s tests.

Results

There were no differences between groups at baseline, but at 3months IW recorded higher DQ scores (APDQS:96 ± 10; DQT:22 ± 5, P < 1 × 10⁻³ for both) compared to I (APDQS:91 ± 13, P < 1 × 10⁻³; DQT:21 ± 4, P < 1 × 10⁻²) and C (APDQS:87 ± 12, P < 5 × 10⁻²; DQT:19 ± 4, P > 5 × 10⁻²), and a higher consumption of nuts at 3 months (P < 1 × 10⁻³), and 12months (P < 1 × 10⁻²). All groups reported decreased intakes of discretionary foods/beverages assessed by the DQT (P < 1 × 10⁻³ for IW and I; P < 1 × 10⁻² for C). The APDQS showed this as reduced intakes of grain based desserts (P < 1 × 10⁻³ at 3 and 12months), and salty snacks at 12months (P < 1 × 10⁻³ for IW and I; P < 5 × 10⁻² for C). Intakes of monounsaturated and saturated fatty acids were lowest, and polyunsaturated fatty acids highest for IW (P < 1 × 10⁻³), resulting in a higher dietary polyunsaturated:saturated fat ratio (P < 1 × 10⁻³).

Conclusions

Lifestyle intervention addressing dietary guidelines can lead to significant reductions in consumption of discretionary foods and saturated fat, but individualised advice may have a greater impact on improving overall DQ regardless of DQI used. Providing a healthy food supplement may help assure higher DQ and where the food is walnuts, produce commensurate differences in dietary fatty acid profiles.

Trial registration

ANZCTRN 12614000581662. Date of registration: 30th May 2014.

Electronic supplementary material

The online version of this article (doi:10.1186/s40795-017-0157-z) contains supplementary material, which is available to authorized users.

The EVIDENT diet quality index is associated with cardiovascular risk and arterial stiffness in adults

Background

We aimed to simplify information from food frequency questionnaires (FFQs) in a single parameter that allows for rapid identification of quality of patient diet and its relationship to cardiovascular risk and pulse wave velocity (PWV).

Methods

The sample from the EVIDENT study, consisting of 1553 subjects (aged 20–80 years) with no cardiovascular disease selected by random sampling among those attending primary care clinics, was used. The EVIDENT diet index (range 0–100) was calculated based on the results of a FFQ. Evaluation of dietary habits also included adherence to the Mediterranean diet (MD). Cardiovascular risk was estimated, and carotid-femoral pulse wave velocity was measured.

Results

Mean subject age was 54.9 ± 13.8 years, and 60.3% of subjects were female. The mean value of the EVIDENT diet index was 52.1 ± 3.2 points. Subjects in the third tertile (the highest score) had the greatest adherence to MD and the highest energy intake, with greater amounts of carbohydrates, protein, and fiber. The best cut-off point of the EVIDENT diet index for predicting good adherence to the MD is 52.3 (0.71 sensitivity, 0.61 specificity). In a multiple regression analysis, after a complete adjustment, it was estimated that for each one-point increase in the EVIDENT diet index, cardiovascular risk (CVR), blood-pressure, waist circumference, and PWV decreased by 0.14, 0.43, 0.24, and 0.09 respectively (p < 0.05, all).

Conclusions

The diet quality index developed is associated to CVR and its components, and also with arterial stiffness, as measured with PWV. This index is also a good predictor of adherence to MD.