Development of a Semi-Quantitative Food Frequency Questionnaire to Assess the Dietary Intake of a Multi-Ethnic Urban Asian Population

Rationale, Design, and Baseline Characteristics of Participants in the Health@NUS mHealth Augmented Cohort Study Examining Student-to-Work Life Transition: Protocol for a Prospective Cohort Study

BACKGROUND

Integration of mobile health data collection methods into cohort studies enables the collection of intensive longitudinal information, which gives deeper insights into individuals' health and lifestyle behavioral patterns over time, as compared to traditional cohort methods with less frequent data collection. These findings can then fill the gaps that remain in understanding how various lifestyle behaviors interact as students graduate from university and seek employment (student-to-work life transition), where the inability to adapt quickly to a changing environment greatly affects the mental well-being of young adults.

OBJECTIVE

This paper aims to provide an overview of the study methodology and baseline characteristics of participants in Health@NUS, a longitudinal study leveraging mobile health to examine the trajectories of health behaviors, physical health, and well-being, and their diverse determinants, for young adults during the student-to-work life transition.

METHODS

University students were recruited between August 2020 and June 2022 in Singapore. Participants would complete biometric assessments and questionnaires at 3 time points (baseline, 12-, and 24-month follow-up visits) and use a Fitbit smartwatch and smartphone app to continuously collect physical activity, sedentary behavior, sleep, and dietary data over the 2 years. Additionally, up to 12 two-week-long bursts of app-based ecological momentary surveys capturing lifestyle behaviors and well-being would be sent out among the 3 time points.

RESULTS

Interested participants (n=1556) were screened for eligibility, and 776 participants were enrolled in the study between August 2020 and June 2022. Participants were mostly female (441/776, 56.8%), of Chinese ethnicity (741/776, 92%), undergraduate students (759/776, 97.8%), and had a mean BMI of 21.9 (SD 3.3) kg/m2, and a mean age of 22.7 (SD 1.7) years. A substantial proportion were overweight (202/776, 26.1%) or obese (42/776, 5.4%), had indicated poor mental well-being (World Health Organization-5 Well-Being Index ≤50; 291/776, 37.7%), or were at higher risk for psychological distress (Kessler Psychological Distress Scale ≥13; 109/776, 14.1%).

CONCLUSIONS

The findings from this study will provide detailed insights into the determinants and trajectories of health behaviors, health, and well-being during the student-to-work life transition experienced by young adults.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05154227; https://clinicaltrials.gov/study/NCT05154227.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56749.

Plant-Based Meat Analogs and Their Effects on Cardiometabolic Health: An 8-Week Randomized Controlled Trial Comparing Plant-Based Meat Analogs With Their Corresponding Animal-Based Foods

BACKGROUND

With the growing popularity of plant-based meat analogs (PBMAs), an investigation of their effects on health is warranted in an Asian population.

OBJECTIVES

This research investigated the impact of consuming an omnivorous animal-based meat diet (ABMD) compared with a PBMAs diet (PBMD) on cardiometabolic health among adults with elevated risk of diabetes in Singapore.

METHODS

In an 8-wk parallel design randomized controlled trial, participants (n = 89) were instructed to substitute habitual protein-rich foods with fixed quantities of either PBMAs (n = 44) or their corresponding animal-based meats (n = 45; 2.5 servings/d), maintaining intake of other dietary components. Low-density lipoprotein (LDL) cholesterol served as primary outcome, whereas secondary outcomes included other cardiometabolic disease-related risk factors (e.g. glucose and fructosamine), dietary data, and within a subpopulation, ambulatory blood pressure measurements (n = 40) at baseline and postintervention, as well as a 14-d continuous glucose monitor (glucose homeostasis-related outcomes; n = 37).

RESULTS

Data from 82 participants (ABMD: 42 and PBMD: 40) were examined. Using linear mixed-effects model, there were significant interaction (time × treatment) effects for dietary trans-fat (increased in ABMD), dietary fiber, sodium, and potassium (all increased in PBMD; P-interaction <0.001). There were no significant effects on the lipid-lipoprotein profile, including LDL cholesterol. Diastolic blood pressure (DBP) was lower in the PBMD group (P-interaction=0.041), although the nocturnal DBP dip markedly increased in ABMD (+3.2% mean) and was reduced in PBMD (-2.6%; P-interaction=0.017). Fructosamine (P time=0.035) and homeostatic model assessment for β-cell function were improved at week 8 (P time=0.006) in both groups. Glycemic homeostasis was better regulated in the ABMD than PBMD groups as evidenced by interstitial glucose time in range (ABMD median: 94.1% (Q1:87.2%, Q3:96.7%); PBMD: 86.5% (81.7%, 89.4%); P = 0.041). The intervention had no significant effect on the other outcomes examined.

CONCLUSIONS

An 8-wk PBMA diet did not show widespread cardiometabolic health benefits compared with a corresponding meat based diet. Nutritional quality is a key factor to be considered for next generation PBMAs. This trial was registered at https://clinicaltrials.gov/as NCT05446753.

Association of diet quality with hand grip strength weakness and asymmetry in a multi-ethnic Asian cohort

Hand grip strength (HGS) is an important diagnostic tool for sarcopenia and a reliable predictor for age-related chronic diseases and mortality. Interventions in nutrition have been shown as a low-cost strategy to maintain muscular strength and mass. However, there are limited data on the effect of diet on HGS in Southeast Asian populations. This study aims to investigate the association of diet quality with HGS weakness and asymmetry in a multi-ethnic population in Singapore. This cross-sectional study used data from the Singapore Multi-Ethnic Cohort (n = 1547). Dietary data were collected using a validated semi-quantitative FFQ and summarised as the Dietary Quality Index - International (DQI-I). HGS was calculated as the maximum value of six measurements from both hands. HGS weakness and asymmetry were defined using well-recognised criteria. Multivariable linear regression and logistic regression were utilised for continuous and binary outcomes, respectively, adjusting for age, sex, ethnicity, physical activity and smoking status. It was found that the highest quartile of DQI-I was significantly associated with higher HGS (β = 1·11; 95 % CI 0·41, 1·82; Pfor trend < 0·001) and lower odds of HGS asymmetry (OR = 0·71; 95 % CI 0·53, 0·94; Pfor trend = 0·035) and both HGS weakness and asymmetry (OR = 0·50; 95 % CI 0·32, 0·76; Pfor trend = 0·004). Among the different components of DQI-I, only dietary adequacy was significantly associated with higher HGS (Pfor trend < 0·001) and lower odds for both HGS weakness and asymmetry (Pfor trend = 0·006). Our findings support that DQI-I, an indicator of overall diet quality, can be used to provide dietary guidelines for prevention and management of muscle wasting, sarcopenia and frailty.

Singapore's Total Diet Study (2021-2023): Study Design, Methodology, and Relevance to Ensuring Food Safety

A total diet study is often used to evaluate a population's baseline dietary exposure to chemical hazards from across the diet. In 2021-2023, Singapore carried out a TDS, and this article presents an overview of the study design and methodological selections in Singapore's TDS, as well as its relevance to ensuring food safety. A food consumption survey was conducted on Singapore citizens and permanent residents, where food consumption patterns of the Singapore population were identified. The selection of chemical hazards and foods for inclusion in Singapore's TDS, as well as principal considerations on sampling, food preparation, and analytical testing are discussed. Commonly consumed foods by the Singapore population in food categories such as grain and grain-based products, meat and meat products, fish and seafood, vegetables, fruits, milk and dairy products were included in this study, and mean concentrations of chemicals tested in each food category were reported, with food categories possessing higher levels identified. Future work will include dietary exposure assessments for the population and analysis of the contributions by food and cooking method.

Development and Functionality of a Parsimonious Digital Food Frequency Questionnaire for a Clinical Intervention among an Indigenous Population

Nutrition-related chronic diseases are a major problem among Indigenous populations. Appropriate dietary intake assessment tools are needed for nutritional surveillance and intervention; however, tools designed to measure the habitual dietary intake of Indigenous persons are largely lacking. We developed a digital food frequency questionnaire (FFQ) to measure habitual consumption among Australian Aboriginal adults and support personalized nutrition counseling. The primary contributors to energy, select nutrients, and inter-person variation (83 food groups) were identified from nationally representative 24 h recall (24HR) data, and they accounted for >80% of the total intake and inter-person variation of the nutrients of interest. Based on community input, a meal-based FFQ format was adopted, with a main food/beverage list of 81 items and the capacity to report on >300 additional items via the digital platform. The nutrient database was based on the Australian Food and Nutrient Database. Data for the first 60 study participants (70% female; median age: 48 years) were used to assess the FFQ's utility. The participants' median [IQR] reported energy intake (10,042 [6968-12,175] kJ/day) was similar to their median [IQR] estimated energy expenditure (10,197 [8636-11,551] kJ/day). Foods/beverages on the main FFQ list accounted for between 66% and 90% of the participants' reported energy and nutrient intakes; the remainder came from participant-selected extra items. The digital FFQ platform provides a potentially valuable resource for monitoring habitual dietary intake among Aboriginal adults and supporting chronic disease prevention and management interventions.

Alone but together: Cloud-based commensality benefits physical and mental health

Cloud-based commensality refers to an eating scenario in which people are eating and videoconferencing with remote co-diners. We report two experiments designed to investigate whether cloud-based commensality can exert a positive effect on individuals' physical and mental health. In Experiment 1, the participants were asked to rate their expectations concerning their feelings when eating in the context of cloud-based commensality or solitary eating and to make food choices in each eating scenario. In Experiment 2, romantic couples were recruited to have meals in different eating scenarios in the laboratory and were asked to rate their emotions and close relationships. The results of the two experiments revealed that when engaging in cloud-based commensality, participants reduced their intake of meat dishes but did not increase their choices of meat dishes compared to solitary eating. Moreover, the results suggest that cloud-based commensality can alleviate negative feelings and promote positive emotions during periods of quarantine or non-quarantine and enhance close relationships for romantic couples. These findings demonstrate that cloud-based commensality is beneficial for individuals' physical and mental health and provide practical implications for utilizing social eating to promote healthy eating.

Higher caffeine consumption is associated with insufficient sleep time in Brazilian adults (CUME study)

We aimed to evaluate the association between caffeine intake and sleep time in Brazilian adults. This cross-sectional study was conducted with 6,356 participants from the Cohort of Universities of Minas Gerais (CUME Study). Data was collected through an online self-report questionnaire. Of the total, 31.9% of the participants had insufficient sleep. Women were found to sleep less than men (64.1 vs. 35.9%; p < 0.001), as well as being more likely to consume higher doses of caffeine (55.2%, p < 0.001). Coffee (35.7%), dark chocolate (25.2%), milk chocolate (15.2%), and diet soda (11.0%) were the foods that more contributed to caffeine intake. Individuals in the highest quartile of caffeine intake (87.0 - 572.0 mg/day) had a 19% higher prevalence of insufficient sleep compared with the lowest quartile (PR: 1.19; 95%CI: 1.08 - 1.31). Future studies are needed to investigate the genetic and hormonal factors involved in the interindividual response in this population.

Development of a Multilingual Web-Based Food Frequency Questionnaire for Adults in Switzerland

Dietary assessment is a major challenge in epidemiological research and is associated with a high time and financial burden. Automated food frequency questionnaires (FFQs) have the potential to rapidly collect dietary intake data in large studies while reducing human error risk during data processing. We developed a semiquantitative, multilingual, electronic FFQ for real-time dietary intake assessment in the Swiss adult population, called "Swiss eFFQ". The iterative development process involved stages of content identification, construction, pretesting, translation, and adaptation of the FFQ. Using 24 h dietary recalls from 2085 participants aged 18-75 years from a nationally representative survey, we conducted a stepwise regression analysis to identify foods contributing to >90% of the variance in intakes of energy and six nutrients. All 118 foods identified in the overall cohort or in any of the Swiss linguistic regions were selected and standardized to define the comprehensive 83-item food list, covering >90% of the intake of key nutrients in the entire study population. Once validated, the Swiss eFFQ can be used to classify individuals based on their habitual diets. The methodology described in this paper enhances the transparency of the Swiss eFFQ and may help researchers to develop multilingual dietary assessment tools for other populations.

Association between nutrition and cognition in a multi-ethnic cohort from Singapore

BACKGROUND

Nutrition, a modifiable risk factor, presents a low-cost prevention strategy to reduce the burden of cognitive impairment and dementia. However, studies examining the effects of dietary patterns on cognition are lacking in multi-ethnic Asian populations. We investigate the association between diet quality, measured with the Alternative Healthy Eating Index (AHEI)-2010, and cognitive impairment in middle-aged and older adults of different ethnicities (Chinese, Malay, Indian) in Singapore.

METHODS

This cross-sectional study (n = 3138; mean age: 50.4 ± 9.8, 58.4% women) was based on data from the Singapore Multi-Ethnic Cohort. Dietary intake collected with a validated semi-quantitative Food Frequency Questionnaire was converted into AHEI-2010 scores. Cognition, assessed with the Mini-Mental State Examination (MMSE), was analysed as a continuous or binary outcome (cognitively impaired or not, using cut-offs of ≥ 24, 26 or 28 for no education, primary school education and secondary school education and above). Multivariable linear and logistic regression models were used to examine associations between AHEI-2010 and cognition, adjusting for covariates.

RESULTS

A total of 988 (31.5%) participants had cognitive impairment. Higher AHEI-2010 scores were significantly associated with higher MMSE scores [β = 0.44; 95% confidence interval (CI) 0.22-0.67 highest vs. lowest quartile; p-trend < 0.001] and lower odds of cognitive impairment [OR 0.69; 95% CI 0.54-0.88; p-trend = 0.01] after adjusting for all the covariates. No significant associations were observed for individual dietary components of the AHEI-2010 with MMSE or cognitive impairment.

CONCLUSION

Healthier dietary patterns were associated with better cognitive function in middle-aged and older Singaporeans. These findings could inform better support to promote healthier dietary patterns in Asian populations.

Adequacy of Nutrient Intake and Malnutrition Risk in Older Adults: Findings from the Diet and Healthy Aging Cohort Study

There is a lack of data on the adequacy of nutrient intake and prevalence of malnutrition risk in Asian populations. The aim was to report on the nutrient intake and prevalence of malnutrition risk in a community sample of older adults in Singapore. Analysis was performed on 738 (n = 206 male, n = 532 male, aged 67.6 ± 6.0 years) adults 60 years and above. Intakes of macro- and micronutrients were evaluated against the Recommended Dietary Allowances (RDAs). Malnutrition risk was assessed using the Nutrition Screening Initiative Determine Your Nutritional Health checklist. It was found that 90.5% older adults exceeded the sugar intake, 68.5% males and 57.1% females exceeded the intake limit for saturated fat, and 33% males had inadequate dietary fiber intake when compared to the RDAs. Inadequate dietary calcium intake was found in 49.5% males and 55.3% females. There were 22.3% of older adults at moderate to high malnutrition risk. Singaporean older adults need to reduce their dietary intakes of sugar and saturated fat and increase their intakes in dietary fiber and calcium. Current findings provide public health awareness on the importance of healthy eating and will facilitate decision making by health promotors to deliver targeted nutrition care programs.

The association between diet quality index-international and inflammatory markers in Iranian overweight and obese women

Objectives

The present study was conducted to evaluate whether there is a link between the diet quality index (DQI) and markers of systemic inflammation in Iranian overweight and obese women.

Methods

This cross-sectional study included 200 Iranian overweight and obese women aged 18-48 years. The DQI-international (DQI-I) comprises four main components: variety, adequacy, moderation, and overall balance. Blood samples were collected in a fasted state to measure inflammatory markers.

Results

After adjusting for age, body mass index (BMI), physical activity, total energy intake, economic status, education, supplement intake, age of starting obesity, and history of body mass loss, a marginally significant negative association was observed between the homeostasis model assessment of insulin resistance (HOMA-IR) and the DQI-I (β: -0.015, 95% CI: -0.03, 0.000; p = 0.061). The results after adjustment showed that DQI-I has a negative association with high-sensitivity C-reactive protein (hs-CRP) concentrations (β: -0.031, 95% CI: -0.104, -0.031; p = 0.023). Furthermore, negative associations were observed between the adequacy component and levels of HOMA-IR (β: -0.025, 95% CI: -0.100, 0.047, p = 0.050) and hs-CRP (β: -0.615, 95% CI: -1.191, -0.020; p = 0.045). In addition, negative associations were found between transforming growth factor-β (TGF-β) and balance score (β: -6.270, 95% CI: -39.211, -3.661, p = 0.020), as well as HOMA-IR (β: -0.080, 95% CI: -0.202, -0.000, p = 0.041) and chemoattractant protein-1 (MCP-1) (β: -0.562, 95% CI: -11.414, -0.282, p = 0.021), with the various component. A marginally significant negative association between galectin 3 (Gal-3) and moderation score (β: -0.451, 95% CI: -1.171, 0.060, p = 0.060) was found. In addition, a marginally significant inverse association was also established between hs-CRP and variety score (β: -0.311, 95% CI: -0.970, 0.001, p = 0.052). The Receiver Operating characteristic (ROC) curve analysis demonstrated that DQI-I might better predict HOMA-IR with a cut point of 3.13 (AUC = 0.698, 0.511-0.699, p = 0.050).

Conclusion

These findings showed that a higher adherence to diet quality and its components could probably be related to lowering the inflammatory markers considerably in overweight and obese women.

Safety, Tolerability, and Pharmacokinetics of β-Cryptoxanthin Supplementation in Healthy Women: A Double-Blind, Randomized, Placebo-Controlled Clinical Trial

BACKGROUND

β-cryptoxanthin is a dietary carotenoid for which there have been few studies on the safety and pharmacokinetics following daily oral supplementation.

METHODS

90 healthy Asian women between 21 and 35 years were randomized into three groups: 3 and 6 mg/day oral β-cryptoxanthin, and placebo. At 2, 4, and 8 weeks of supplementation, plasma carotenoid levels were measured. The effects of β-cryptoxanthin on blood retinoid-dependent gene expression, mood, physical activity and sleep, metabolic parameters, and fecal microbial composition were investigated.

RESULTS

β-cryptoxanthin supplementation for 8 weeks (3 and 6 mg/day) was found to be safe and well tolerated. Plasma β-cryptoxanthin concentration was significantly higher in the 6 mg/day group (9.0 ± 4.1 µmol/L) compared to 3 mg/day group (6.0 ± 2.6 µmol/L) (p < 0.03), and placebo (0.4 ± 0.1 µmol/L) (p < 0.001) after 8 weeks. Plasma all-trans retinol, α-cryptoxanthin, α-carotene, β-carotene, lycopene, lutein, and zeaxanthin levels were not significantly changed. No effects were found on blood retinol-dependent gene expression, mood, physical activity and sleep, metabolic parameters, and fecal microbial composition.

CONCLUSIONS

Oral β-cryptoxanthin supplementation over 8 weeks lead to high plasma concentrations of β-cryptoxanthin, with no impact on other carotenoids, and was well tolerated in healthy women.

The relationship between dietary phytochemical index and resting metabolic rate mediated by inflammatory factors in overweight and obese women: a cross-sectional study

Background

Unhealthy dietary patterns are the most important modifiable risk factors for obesity and overweight. This study aimed to examine the relationship between Dietary Phytochemical Index (DPI) and resting metabolic rate (RMR), mediated by inflammatory factors, in overweight and obese women.

Methods

A total of 404 women, aged 18–48 years, were included in the cross-sectional study. DPI was calculated using the 147-item food frequency questionnaire (FFQ). Anthropometric measurements, RMR, and blood biomarkers were assessed using standard protocols.

Results

There was marginally significant association between adherence to DPI and RMR status in the crude model (OR = 1.41, 95% CI 0.94–2.11, P = 0.09). After adjusting for potential confounders, a significant association was seen between the DPI and increase RMR.per.kg (OR = 2.77, 95% CI 0.98–7.82, P = 0.05). Our results indicated that plasminogen activator inhibitor-1 (PAI-1), transforming growth factor (TGF-β), and monocyte chemoattractant protein-1 (MCP-1) had a mediatory effect on the association between RMR and DPI (P > 0.05). Indeed, it was shown that, PAI-1, TGF-β, and MCP-1 destroyed the significance of this association and could be considered as mediating markers. However, no mediating effect was observed for high-sensitivity C reactive protein (hs-CRP).

Conclusions

Adherence to DPI can improve the RMR by reducing levels of inflammatory markers, and may be considered as a treatment for obesity. However, more long-term studies are recommended.

Red, white, and processed meat consumption related to inflammatory and metabolic biomarkers among overweight and obese women

BACKGROUND

Considering that a high meat intake is directly associated with obesity, it is critical to address the relationship between consuming different types of meat with inflammation and metabolism in overweight and obese cohorts. Thus, we evaluated the association between red, white, and processed meat consumption with inflammatory and metabolic biomarkers in overweight and obese women.

METHODS

The current cross-sectional study was conducted on 391 overweight and obese Iranian women. Dietary intake was obtained from a food frequency questionnaire (FFQ) with 147 items. The anthropometric measurements, serum lipid profile, and inflammatory markers were measured by standard protocols. All associations were assessed utilizing one-way analysis of variance (ANOVA), analysis of covariance (ANCOVA), and linear regression models.

RESULTS

In the adjusted model, it was established that higher intake of processed meat had a significant positive association with leptin levels (β: 0.900, 95% CI: 0.031;1.233, p = 0.015). Moreover, after considering the confounders, a significant positive association between processed meat and macrophage inflammatory protein (MCP-1) levels was observed (β: 0.304, 95% CI:0.100;1.596, p = 0.025). Positive significant associations between high-sensitivity C-reactive protein (hs-CRP) (β:0.020, 95% CI:0.000;0.050, P = 0.014) and plasminogen activator inhibitor 1 (PAI-1) (β:0.263, 95% CI:0.112;0.345, p = 0.053) and MCP-1 (β:0.490, 95% CI: 0.175;1.464, p = 0.071) levels with red meat were also shown; while there was a significant negative association between red meat and the homeostasis model assessment of insulin resistance (HOMA-IR) (β: -0.016, 95% CI: -0.022, -0.001, p = 0.033). Furthermore, a significant negative association were established following confounding adjustment between Galectin-3 (Gal-3) (β: -0.110, 95% CI: -0.271;0.000, p = 0.044), MCP-1 (β: -1.933, 95% CI: -3.721;0.192, p = 0.022) and Homeostatic Model Assessment for Insulin Resistance (HOMA-IR) (β: -0.011, 95% CI: -0.020,0.000, p = 0.070) levels with high adherence of white meat intake. In contrast, a significant marginally positive association between PAI-1 levels and high adherence to white meat intake (β: -0.340, 95% CI: -0.751;0.050, p = 0.070) has been shown.

CONCLUSIONS

Higher red and processed meat consumption were positively associated with inflammatory and metabolic markers in overweight and obese women. In contrast, negative relationships between high adherence to white meat and various inflammatory and metabolic parameters were established. Further studies are needed to confirm the causality of these associations and potential mediating pathways.

The interaction between rs 3,807,992 genotypes with the dietary inflammatory index on Leptin, Leptin resistance, and Galectin 3 in obese and overweight women

OBJECTIVE

Obesity is related to increasing leptin and some inflammatory factors that are associated with low-grade inflammation. Moreover, several studies have shown Caveolin-1 (CAV1) genetic variations may be associated with dietary intake. The current study aimed to evaluate the interaction of CAV1 rs3807992 with types of the energy-adjusted dietary inflammatory index (EDII) in leptin, leptin resistance, and Galectin 3, as inflammatory factors.

METHODS

This cross-sectional study was carried out on 363 overweight and obese females. Dietary intake and DII were obtained from a 147-item food frequency questionnaire (FFQ). The CAV-1 genotype was measured using the PCR-RFLP method. Anthropometric values and serum levels of leptin and Galectin 3 were measured by standard methods.

RESULTS

Increased adherence to EDII in the interaction with CAV1 genotypes led to an increase in leptin level 79.15 (mg/l) (β = 79.15, CI = - 1.23,163.94, P = 0.04) in model 3, after controlling for further potential confounders. By contrast, adherence to EDII in the interaction with the genotype including risk alleles showed no significant interaction, even after adjustment in model 3 (β = 0.55, CI = - 0.99, 2.09, P = 0.48). Although, a marginal positive significant interaction was found between EDII and CAV1 genotypes on Galectin 3, after adjustment in model 3 (β = 31.35, CI = 0.13, 77.13, P = 0.05).

CONCLUSIONS

The present study indicates that a high adherence of EDII and CAV1 genotypes containing risk alleles may be a prognostic factor and increase both leptin and Galectin3. However, it seems that the presence of interaction was not on leptin resistance. Further functional studies are necessary to elucidate the exact mechanism.

The association between dietary polyphenol intake and cardiometabolic factors in overweight and obese women: a cross-sectional study

OBJECTIVE

The previous evidence shows that there is an association between total dietary polyphenols intake (DPI) and its subclasses and lower risk of metabolic Syndrome (MetS). This cross-sectional study aims to evaluate associations between DPI and cardiometabolic factors in Iranian women.

METHODS

A total of 404 Iranian women were included in this study. Dietary intakes and polyphenols intakes were measured using a validated semi-quantitative food frequency questionnaire (FFQ) and the Phenol-Explorer database, respectively. Biochemical variables and blood pressure were evaluated using Pars Azmoon kits and mercury sphygmomanometer.

RESULTS

The mean intake of total polyphenol was 2533.96 ± 1223.67 g. While there were significant negative associations between stilbenes and lignans intake and body mass index (BMI) (P-value = 0.04; P-value = 0.02, respectively), beverages containing phenolic acids and hip circumference (HC) (P-value = 0.02), total polyphenols intake and weight to hip ratio (WHR) (P-value = 0.04). Also there was significant negative associations between stilbenes intake and cholesterol (CHOL) level (P-value = 0.03), other polyphenols intake and triglyceride (TG) ((P-value = 0.01), lignan intake and homeostasis model assessment insulin resistance (HOMA-IR) (P-value = 0.03).

CONCLUSION

These findings demonstrated that dietary polyphenols were associated with cardiometabolic factors in Iranian women. Prospective and interventional studies in both genders, different populations and ethnicities need to be conducted to further the knowledge about examine associations between consumption of polyphenols and metabolic component.

Children's and Parents' Marburg Sugar Index (MSI) Values: Are They Comparable?

Studies on children’s nutritional behaviour (CNB) rarely compare children’s answers regarding the frequency of their sugar intake with the respective statements of their parents. Therefore, data from a prevention study were used to analyse this aspect, as well as a potential correlation between Marburg Sugar Index (MSI) values and caries experience of children. The present study based its questionnaire data on CNB and caries data. Pairs of questionnaires filled in separately by children and parents of the participating families were dichotomised by either having completed the diet section entirely (Group A) or in part (Group B). The MSI scores were calculated separately for children and parents. The statistical confidence level was set at α = 0.05 (two-sided). Furthermore, the Pearson correlation coefficient was calculated and tested for “r = 0”. Additionally, a test for equality of the correlations was applied. The number of available questionnaire pairs was 429 in Group A and 400 in Group B. In both groups, significant correlations between children’s and parents’ MSI scores (A: r = 0.301, p < 0.001; B: r = 0.226, p < 0.001) were found. Using Spearman’s Rho, a significant correlation between MSI scores and children’s caries experiences was observed in Group A. MSI scores based on dietary questionnaires can be used to obtain consistent information on children’s CNB provided by the children themselves or their parents. This is true even when the MSI score has to be calculated on the basis of incomplete questionnaires. Questionnaire-based CNB information can improve the effectiveness of individual or group preventive measures supplemented by individually adapted nutritional counselling.

Texture-based differences in eating rate influence energy intake for minimally processed and ultra-processed meals

BACKGROUND

Consumption of ultra-processed foods has been linked with higher energy intakes. Food texture is known to influence eating rate (ER) and energy intake to satiation, yet it remains unclear whether food texture influences energy intakes from minimally processed and ultra-processed meals.

OBJECTIVES

We examined the independent and combined effects of food texture and degree of processing on ad libitum food intake. We also investigated whether differences in energy intake during lunch influenced postmeal feelings of satiety and later food intake.

METHODS

In this crossover study, 50 healthy-weight participants [n = 50 (24 men); mean ± SD age: 24.4 ± 3.1 y; BMI: 21.3 ± 1.9 kg/m2] consumed 4 ad libitum lunch meals consisting of "soft minimally processed," "hard minimally processed," "soft ultra-processed," and "hard ultra-processed" components. Meals were matched for total energy served, with some variation in meal energy density (±0.20 kcal/g). Ad libitum food intake (kcal and g) was measured and ER derived using behavioral coding of videos. Subsequent food intake was self-reported by food diary.

RESULTS

There was a main effect of food texture on intake, whereby "hard minimally processed" and "hard ultra-processed" meals were consumed slower overall, produced a 21% and 26% reduction in food weight (g) and energy (kcal) consumed, respectively. Intakes were higher for "soft ultra-processed" and "soft minimally processed" meals (P < 0.001), after correcting for meal pleasantness. The effect of texture on food weight consumed was not influenced by processing levels (weight of food: texture*processing-effect, P = 0.376), but the effect of food texture on energy intake was (energy consumed: texture*processing-effect, P = 0.015). The least energy was consumed from the "hard minimally processed" meal (482.9 kcal; 95% CI: 431.9, 531.0 kcal) and the most from the "soft ultra-processed" meal (789.4 kcal; 95% CI: 725.9, 852.8 kcal; Δ=↓∼300 kcal). Energy intake was lowest when harder texture was combined with the "minimally processed" meals. Total energy intake across the day varied directly with energy intakes of the test meals (Δ15%, P < 0.001).

CONCLUSIONS

Findings suggest that food texture-based differences in ER and meal energy density contribute to observed differences in energy intake between minimally processed and ultra-processed meals.This trial was registered at clinicaltrials.gov as NCT04589221.

Tracking of dietary patterns between pregnancy and 6 years post-pregnancy in a multiethnic Asian cohort: the Growing Up in Singapore Towards healthy Outcomes (GUSTO) study

PURPOSE

Few studies have described adherence to dietary patterns over time in women of childbearing age. This study aims to describe, examine the stability and changes in dietary patterns between pregnancy and 6 years post-pregnancy and the sociodemographic and lifestyle factors influencing the adherence over time.

METHODS

During pregnancy and at 6 years post-pregnancy, 24-h recalls and food frequency questionnaires were collected, respectively, from 709 women. Data on sociodemographic and lifestyle factors were collected via questionnaires. Dietary patterns were identified using principal component analysis and stability assessed using Pearson's correlation coefficients (r) and Cohen's weighted kappa (κ). Associations with sociodemographic characteristics were assessed by multiple logistic regression.

RESULTS

The 'Fruits, Vegetables and Legumes' (FVL) and 'Seafood, Noodle, Soup' (SNS) patterns were identified at both time points, with low correlation for the dietary pattern z scores (r 0.2 and 0.3, respectively) and modest agreement in tertile assignment, suggesting poor stability. An 'unhealthy' pattern was only observed at 6 years post-pregnancy. Women who showed increased adherence to FVL pattern had higher educational attainment and exhibited healthy lifestyle behaviours. Women who had gestational diabetes during pregnancy were less likely to decrease adherence to FVL pattern over time. Women who adhered more closely to the 'unhealthy' pattern at 6 years post-pregnancy tended to be younger, of Malay ethnicity, had lower socioeconomic status, were less physically active and had additional pregnancies.

CONCLUSIONS

Dietary habits of women became less healthy during the transition from pregnancy to 6 years post-pregnancy. However, results should be interpreted with caution due to the different dietary assessment tools used at the two time points.

Acrylamide Contents of Local Snacks in Singapore

Acrylamide is a carcinogen that forms in foods processed at high temperatures. In this study, acrylamide contents of 30 local snacks commonly consumed by the three ethnic groups (Malay, Chinese, and Indian) in Singapore were analysed by using liquid chromatography-tandem mass spectrometry (LC-MS/MS). These snacks were chosen because they were consumed regularly by people of different classes and age groups in Singapore. Our results showed that the average content of acrylamide in Indian snacks (102.23 ng/g) was higher than those in Malay (75.14 ng/g) and Chinese snacks (70.78 ng/g). The high acrylamide levels in several snacks was probably due to the processing methods and the usage of acrylamide-inducing raw materials. Same snacks prepared by different manufacturers contained different levels of acrylamide, suggesting the possibility of acrylamide reduction in these snacks. This study provides an insight into the acrylamide levels of snacks commonly consumed by the three different ethnic groups in Singapore.

Taste of Modern Diets: The Impact of Food Processing on Nutrient Sensing and Dietary Energy Intake

BACKGROUND

Both fresh and processed foods are available in the modern food environment where taste can signal presence of nutrients. However, whether these taste-nutrient relationships are maintained across different degrees of food processing is not well understood, and less is known about the relative contribution of different taste qualities to population energy intakes.

OBJECTIVES

To investigate the association between perceived intensity of 6 taste modalities and a food's nutrient content in the context of food processing and to further examine the relative contribution of different taste clusters to total energy intakes, stratified by weight status.

METHODS

Diet and lifestyle data from the Singapore Multi-Ethnic Cohort Phase 2 (N = 7011; aged 21-75 y) were collected through interviewer-administrated questionnaires. Taste and nutrient profiles for each of the 269 Singaporean foods were derived using a published taste database and food composition table. Each food was then categorized into the NOVA food-processing classification (unprocessed, processed, ultra-processed) to compare the strength of taste-nutrient relationships. Multivariable-adjusted models were used to examine associations between relative consumption of foods from different taste clusters and processing categories, energy intake, and BMI (in kg/m2) within a population cohort.

RESULTS

Sweet taste and mono- and disaccharide content of foods were significantly associated across all processing categories, although this association was weaker among ultra-processed foods (UPFs) (r = 0.42) than among unprocessed foods (r = 0.72). In contrast, associations between fat sensation and fat content (r = 0.74), as well as salt taste and sodium content (r = 0.84), were stronger for UPFs. Individuals who had higher energy intakes or were overweight (BMI >23) derived significantly greater percentage of energy from processed foods rather than UPFs, and this energy was higher from "savory-fatty" and lower from "neutral" tasting foods than those with lower energy intakes and normal weight (all P < 0.001). Eighty percent of individuals' dietary energy was from both "savory-fatty" and "neutral" foods, independent of differences in total energy intake and weight status.

CONCLUSIONS

Taste-nutrient relationships are maintained across different degrees of food processing. Greater consumption of foods that have a high "savory-fatty" taste was associated with increased energy intakes and overweight in the Asian population.

Identification and reproducibility of dietary patterns assessed with a FFQ among women planning pregnancy

OBJECTIVE

To identify a posteriori dietary patterns among women planning pregnancy and assess the reproducibility of these patterns in a subsample using two dietary assessment methods.

DESIGN

A semi-quantitative FFQ was administered to women enrolled in the Singapore PREconception Study of long-Term maternal and child Outcomes study. Dietary patterns from the FFQ were identified using exploratory factor analysis (EFA). In a subsample of women (n 289), 3-d food diaries (3DFD) were also completed and analysed. Reproducibility of the identified patterns was assessed using confirmatory factor analysis (CFA) in the subsample, and goodness of fit of the CFA models was examined using several fit indices. Subsequently, EFA was conducted in the subsample and dietary patterns of the FFQ and the 3DFD were compared.

SETTING

Singapore.

PARTICIPANTS

1007 women planning pregnancy (18-45 years).

RESULTS

Three dietary patterns were identified from the FFQ: the 'Fish, Poultry/Meat and Noodles' pattern was characterised by higher intakes of fish, poultry/meat and noodles in soup; 'Fast Food and Sweetened Beverages' pattern was characterised by higher intakes of fast food, sweetened beverages and fried snacks; 'Bread, Legumes and Dairy' pattern was characterised by higher intakes of buns/ethnic breads, nuts/legumes and dairy products. The comparative fit indices from the CFA models were 0·79 and 0·34 for the FFQ and 3DFD of the subsample, respectively. In the subsample, three similar patterns were identified in the FFQ while only two for the 3DFD.

CONCLUSIONS

Dietary patterns from the FFQ are reproducible within this cohort, providing a basis for future investigations on diet and health outcomes.

Comparison of diet quality of US adults based on primary motivation for following a vegetarian diet: A cross-sectional online study

Adults adopt a vegetarian diet for various motivations, but it is unknown their overall diet quality based on a primary motivation. The purpose of the study was to compare overall diet quality, nutrient intake and related food groups based on primary motivation for following a vegetarian diet. It was hypothesized that vegetarians who chose the diet for health-related motivations would have a higher diet quality based on the Healthy Eating Index (HEI)-2015 scores compared to those following the diet for other motivations. A cross-sectional study was conducted online in the United States. Participants (n = 511) completed an 18-item questionnaire and a 24-hour recall using the Automated Self-Administered 24-hour Dietary Recall (ASA24-2018) and were divided into one of three groups (Health, Animal, Other [family, religious beliefs, or environment]) based on their primary motivation for following a vegetarian diet. Total HEI-2015 scores were determined and Kruskal-Wallis ANOVA on Ranks with a Dunn's Method for all pairwise comparisons (p < 0.05) were conducted. Results showed that total HEI-2015 scores differed among groups (p = 0.022) with the Health group having a higher score than the Other group (70.2 [57.0, 79.1] versus 63.6 [52.2, 77.1], median 25th, 75th) but not the animal rights group (66.5 [55.1, 77.0]). Higher component scores for total protein foods, seafood and plant proteins and fatty acids contributed to the significant difference. Adults who were motivated by health to follow a vegetarian diet had a higher diet quality than those who cited Other as their primary motivation. As motivations may impact diet quality of vegetarians, it is necessary to account for them.

Stepwise tailoring and test-retest of reproducibility of an ethnic-specific FFQ to estimate nutrient intakes for South Asians in New Zealand

OBJECTIVE

To develop and test-retest the reproducibility of an ethnic-specific FFQ to estimate nutrient intakes for South Asians (SA) in New Zealand (NZ).

DESIGN

Using culturally appropriate methods, the NZFFQ, a validated dietary assessment tool for NZ adults, was modified to include SA food items by analysing foods consumed by SA participants of the Adult Nutrition Survey, in-person audit of ethnic food stores and a web scan of ethnic food store websites in NZ. This was further refined via three focus group discussions, and the resulting New Zealand South Asian Food Frequency Questionnaire (NZSAFFQ) was tested for reproducibility.

SETTING

Auckland and Dunedin, NZ.

PARTICIPANTS

Twenty-nine and 110 males and females aged 25-59 years of SA ethnicity participated in the focus group discussions and the test-retest, respectively.

RESULTS

The development phase resulted in a SA-specific FFQ comprising of 11 food groups and 180 food items. Test-retest of the NZSAFFQ showed good reproducibility between the two FFQ administrations, 6 months apart. Most reproducibility coefficients were within or higher than the acceptable range of 0·5-0·7. The lowest intraclass correlation coefficients (ICC) were observed for β-carotene (0·47), vitamin B12 (0·50), fructose (0·55), vitamin C (0·57) and selenium (0·58), and the highest ICC were observed for alcohol (0·81), iodine (0·79) and folate (0·77). The ICC for fat ranged from 0·70 for saturated fats to 0·77 for polyunsaturated fats. The ICC for protein and energy were 0·68 and 0·72, respectively.

CONCLUSIONS

The developed FFQ showed good reproducibility to estimate nutrient intakes and warrants the need for validation of the instrument.

Dietary behaviors and patterns of centenarians in Hainan: A cross-sectional study

OBJECTIVES

The aim of this study was to understand the diet-related behaviors of Hainan centenarians and to analyze dietary factors that affect their nutritional status.

METHODS

Data were collected from the China Hainan Centenarian Cohort Study, a full sample survey including questionnaires, physical examinations, and physiologic indices of the centenarian population. The study included 1002 centenarians. The diet-related behaviors were assessed using the food frequency questionnaire; nutritional status was determined according to the Mini Nutritional Assessment - short form scale scores. We used logistic regression models to analyze the main dietary risk factors of malnutrition.

RESULTS

Of all the centenarians, 94.6% maintained regular meals, 80.4% had three meals a day, 53.4% ate each meal until 80% full, 88.7% ate vegetables daily, and 70% drank one to two cups of water daily. Centenarians ate rice-based staple foods; eggs, dairy, legumes, nuts, and poultry were not popular. The main sources of meat were red meat and seafood. None liked fried food, and 19.3% preferred sweet flavors. People with normal nutritional status accounted for 12.3% of the population, whereas those with malnutrition comprised 20.8%. Dietary factors that affected nutritional status included three meals a day (odds ratio [OR], 0.366; 95% confidence interval [CI], 0.173-0.778), tea drinking (OR, 0.236; 95% CI, 0.087-0.641), and the frequency of poultry (OR, 0.261; 95% CI, 0.088-0.771), seafood (OR, 0.247; 95% CI, 0.110-0.554), nuts (OR, 0.381; 95% CI, 0.150-0.965), and pastry (OR, 0.219; 95% CI, 0.080-0.600) consumption.

CONCLUSION

This was the first study on the dietary behaviors and nutritional status of centenarians using survey data. We highlighted the factors affecting nutritional status and provided scientific support for dietary strategies that may improve the nutritional status of the elderly population.

Consumption of Foods With Higher Energy Intake Rates is Associated With Greater Energy Intake, Adiposity, and Cardiovascular Risk Factors in Adults

BACKGROUND

Both high energy density and fast eating rates contribute to excess energy intakes. The energy intake rate (EIR; kcal/min) combines both the energy density (kcal/g) and eating rate (g/min) of a food to quantify the typical rate at which calories of different foods are ingested.

OBJECTIVES

We describe the EIRs of diets in a multi-ethnic Asian population, and examine relationships between the consumption of high-EIR foods and total energy intake, body composition, and cardio-metabolic risk factors.

METHODS

Diet and lifestyle data from the Singapore Multi-Ethnic Cohort 2 (n = 7011; 21-75 y), were collected through interviewer-administrated questionnaires. The EIR for each of the 269 foods was calculated as the product of its eating rate and energy density. Multivariable models were used to examine associations between the relative consumption of foods with higher and lower EIRs and energy intake, body composition, and cardio-metabolic risks, after adjusting for age, sex, ethnicity, education level, physical activity, smoking status, and alcohol drinking status.

RESULTS

Individuals with higher daily energy intakes and with obesity consumed a significantly larger percentage of their energy from high-EIR foods, with a smaller relative intake of lower-EIR foods. Individuals with raised serum cholesterol also consumed a significantly higher proportion of high-EIR foods, whereas those without hypertension consumed a larger percentage of energy intake from low-EIR foods. Individuals classified as having a "very high" dietary EIR had a significantly 1.3 kg higher body weight (95% CI, 0.2-1.5; P = 0.013), 0.4 kg/m2 higher BMI (95% CI, 0.03-0.8; P = 0.037), and 1.2 cm larger waist circumference (95% CI, 0.2-2.2; P = 0.010), and were more likely to have abdominal overweight (OR, 1.3; 95% CI, 1.1-1.5; P < 0.001) than those with a "low" dietary EIR.

CONCLUSIONS

Comparing foods by their EIRs summarizes the combined impact of energy density and eating rate, and may identify foods and dietary patterns that are associated with obesogenic eating styles and higher diet-related cardiovascular disease risk in an Asian population.

Rationale and Methodology of The PopulatION HEalth and Eye Disease PRofile in Elderly Singaporeans Study [PIONEER]

To describe the rationale, design and methodology of a geographically-representative and population-based study investigating the epidemiology, impact, personal and economic burden of age-related eye diseases, declining visual and other sensory systems in Asians aged >60 years in Singapore.PIONEER (The PopulatION HEalth and Eye Disease PRofilE in Elderly Singaporeans Study) is currently a cross-sectional study targeting 3152 Chinese, Malay and Indian adults who are Singapore citizens or permanent residents aged 60 years and older living across Singapore. The study is intended to be longitudinal, with several waves of data planned to be collected in the future. The sampling frame consisted of 7000 names derived from age, gender and ethnicity-stratified random sampling of individuals >60 years. Selected individuals were invited via letters, home visits, and telephone calls for a clinical assessment at the Singapore Eye Research Institute. Individuals with limited mobility were examined in a custom-designed mobile eye clinic. Questionnaires were subsequently administered at participants' homes by trained interviewers in their preferred language. A total of 3,299 participants (from East, West, North and South Singapore) were approached from December 2017 to November 2019. Of these, 953 (28.5%) were deemed ineligible. Out of 2,346 eligible participants, 904 (38.5%) refused, and 1,442 (61.5%) attended our clinical testing protocol, giving an initial response rate of 61.5%. Of these, 1,170 (81%) were cognitively able to complete the questionnaire assessment. The mean age±SD of our participants was 73.8±8.6 years; n=798 (55.3%) were female; and 828 (57.4%) were of Chinese ethnicity. The findings from this study will allow a deeper understanding of the risk factors and impact of aging in Asian populations, particularly in relation to the visual function and other functional system.

Collaborative model of care between Orthopaedics and allied healthcare professionals in knee osteoarthritis (CONNACT): study protocol for an effectiveness-implementation hybrid randomized control trial

Background

Knee Osteoarthritis (OA) is a leading cause of global disability. The Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT) Model of Care (MoC) was developed by optimizing evidence-based non-surgical treatments to deliver value-based care for people with knee OA. The primary aim of this study is to determine the clinical effectiveness of the CONNACT MoC (3 months) compared to usual care. The secondary aims are: a) To determine the cost-effectiveness and b) To develop an evaluation and implementation framework to inform large scale implementation for this MoC.

Methodology

Type 1 Effectiveness-Implementation Hybrid Trial using an explanatory sequential mixed-method approach. The study consists of 3 components. The first component is the pragmatic, parallel-arm, single-blinded randomized control trial. Inclusion criteria are patients with knee OA based on the National Institute of Health and Care Excellence (NICE) criteria with radiographic severity of greater than Kellgren-Lawrence 1, and Knee Injury and OA Outcome Score (KOOS₄) of equal or less than 75. Exclusion criteria include other forms of arthritis, history of previous knee arthroplasty or wheelchair-bound patient. KOOS₄ is the primary outcome measure at 3 months, 6 months and 1 year. Secondary outcomes include KOOS individual subscales, quality of life scoring, functional performance, global, diet and psychological related outcomes. The second component is an economic evaluation of the cost-effectiveness of the CONNACT MoC using a societal perspective. The third component is an implementation and evaluation framework using process evaluation under the RE-AIM framework using a mixed-method approach. Sample size of 100 patients has been calculated.

Discussion

CONNACT MoC is a complex intervention. In line with the MRC guidance for developing and evaluating complex interventions, a pilot feasibility study was completed and a comprehensive approach including an RCT, economic evaluation and process evaluation is described in this study protocol. Results from this study will help clinicians, healthcare administrators and policymakers guide the sustainable and effective implementation of the CONNACT MoC for knee OA and serve as a basis for similar multidisciplinary MoC for chronic degenerative musculoskeletal conditions to be developed.

Trial registration

Clinicaltrials.gov Identifier: NCT03809975. Registered January 182,019.

Validity and reliability of a simplified food frequency questionnaire: a cross sectional study among physical health examination adults in southwest region of China

Background

In China, many people are regarded suitable for participating in regular physical examination for diagnosis and prevention of diseases. Some simplified food frequency questionnaires have been designed and used; however, the accuracy of the questionnaire is absent. This study aimed to examine the reliability and validity of simplified food frequency questionnaire (SFFQ) used among adults undergoing physical examination in southwest region of China.

Methods

This was a cross-sectional study conducted among physical health examination adults in the Southwest region of China. A total of 239 participants aged 20–65 were included from February 2019 to June 2019. The performance of SFFQ was evaluated by means of a three-day 24-h dietary record (3R24). The relative validity and agreement was assessed by Pearson’s correlation and intra-class correlation coefficients (ICC), respectively.

Results

The median energy-adjusted ICC of food groups between SFFQ2 and SFFQ1 was 0.59 (range: 0.49–0.73) and the ICC of nutrients was 0.47(range: 0.39–0.76). The Pearson correlation showed a valid comparisons between SFFQ1 and 3R24, ranging from -0.086 to 0.93 for food and 0.21 to 0.71 for nutrition, respectively. The energy-adjustment slightly increased the correlation coefficients.

Conclusions

The reliability and validity of SFFQ was acceptable, and it could be an appropriate dietary assessment tool for the future epidemiological studies conducted among physical health examination adults of southwest China.

Trial registration

CHiCTR, ChiCTR1900020934, Registered 22 January 2019, https://www.chictr.org.cn/edit.aspx?pid=35414&htm=4.

Collaborative model of care between Orthopaedics and allied healthcare professionals trial (CONNACT) - a feasibility study in patients with knee osteoarthritis using a mixed method approach

Background

Osteoarthritis is a leading cause of global disability resulting in significant morbidity and cost to the healthcare system. Current guidelines recommend lifestyle changes such exercises and weight loss as first line treatment prior to surgical consideration. Our current model of care is inefficient with suboptimal allied health intervention for effective behaviour changes. A 12-week community based, individualized, multidisciplinary new model of care for knee osteoarthritis was developed in light of current deficiencies.

Methods

The primary aim of this study was to determine the feasibility of a full randomized controlled trial evaluating this new model of care using pre-defined progression criteria. The secondary aim was to optimize the intervention and study design through a process evaluation. A pilot exploratory, parallel arm, single blinded randomized trial design using a mixed method approach was utilized. Progression criteria for a full trial including key domains of patient recruitment and retention, outcome measure acceptability and improvement, adverse events were developed. The primary outcome measure was the Knee Injury and Osteoarthritis Outcome Score (KOOS) at baseline and 12-weeks. Secondary outcomes included quality of life, functional and psychological assessments. Semi-structured interviews were conducted with the patients at 12-weeks.

Results

20 patients (3 males, 17 females) were randomized (10 intervention, 10 control). Intervention arm patients reported better improvements in their knee function, quality of life, psychological outcome, dietary improvement and weight loss compared to the control arm at 12-weeks. Semi-structured interviews revealed several themes pertaining to feasibility and intervention optimization. 5 out of the 6 progression criteria’s domains were met (recruitment criteria not met).

Conclusion

This pilot has demonstrated the feasibility of a full randomized control trial investigating the potential effectiveness of the new proposed model of care for knee osteoarthritis using pre-defined progression criteria and process evaluation. Results from the qualitative study were used to modify and improve the intervention content, delivery model and study design for a large effectiveness-implementation hybrid randomized control trial that is currently underway.

Trial registration

Retrospectively registered on 18 January 2019 at http://clinicaltrial.gov ID: NCT03809975.

The Cardio-Med survey tool: development and pilot validation of a FFQ in a multicultural cardiology cohort

OBJECTIVE

(i) Describe the development of a multipurpose Cardio-Med survey tool (CMST) comprising a semi-quantitative FFQ designed to measure dietary intake in multicultural patients with or at high risk of CVD and (ii) report pilot evaluation of test-retest reliability and validity of the FFQ in measuring energy and nutrient intakes.

DESIGN

The CMST was developed to identify CVD risk factors and assess diet quality over 1 year using an FFQ. Design of the ninety-three-item FFQ involved developing food portion photographs, and a list of foods appropriate for the Australian multicultural population allowing the capture of adherence to a Mediterranean diet pattern. The FFQ was administered twice, 2 weeks apart to assess test-retest reliability, whilst validity was assessed by comparison of the FFQ with a 3-d food record (3DFR).

SETTING

The Northern Hospital and St Vincent's Hospital, Melbourne, Australia.

PARTICIPANTS

Thirty-eight participants aged 34-81 years with CVD or at high risk.

RESULTS

Test-retest reliability of the FFQ was good: intraclass correlation coefficient (ICC) ranged from 0·52 (Na) to 0·88 (alcohol) (mean 0·79), with energy and 70 % of measured nutrients being above 0·75. Validity was moderate: ICC ranged from 0·08 (Na) to 0·94 (alcohol) (mean 0·59), with energy and 85 % of measured nutrients being above 0·5. Bland-Altman plots demonstrated good levels of agreement between the FFQ and 3DFR for carbohydrates, protein, alcohol, vitamin D and Na.

CONCLUSIONS

The CMST FFQ demonstrated good test-retest reliability and moderate validity for measuring dietary energy and nutrients in a multicultural Australian cardiology population.

Environment-Wide Association Study (En WAS) of Prenatal and Perinatal Factors Associated With Autistic Traits: A Population-Based Study

A combination of genetic and environmental factors contributes to the origins of autism spectrum disorder (ASD). While a number of studies have described specific environmental factors associating with emerging ASD, studies that compare and contrast multiple environmental factors in the same study are lacking. Thus, the goal of this study was to perform a prospective, data-driven environmental-wide association study of pre- and perinatal factors associated with the later development of autistic symptoms in childhood. The participants included 3891 6-year-old children from a birth cohort with pre- and perinatal data. Autistic symptoms were measured using the Social Responsiveness Scale in all children. Prior to any analyses, the sample was randomly split into a discovery set (2920) and a test set (921). Multiple linear regression analyses were performed for each of 920 variables, correcting for six of the most common covariates in epidemiological studies. We found 111 different pre- and perinatal factors associated with autistic traits during childhood. In secondary analyses where we controlled for parental psychopathology, 23 variables in the domains of family and interpersonal relationships were associated with the development of autistic symptoms during childhood. In conclusion, a data-driven approach was used to identify a number of pre- and perinatal risk factors associating with higher childhood autistic symptoms. These factors include measures of parental psychopathology and family and interpersonal relationships. These measures could potentially be used for the early identification of those at increased risk to develop ASD. LAY SUMMARY: A combination of genetic and environmental factors contributes to the development of autism spectrum disorder (ASD). Each environmental factor may affect the risk of ASD. In a study on 6-year-old children, a number of pre- and perinatal risk factors were identified that are associated with autistic symptoms in childhood. These factors include measures of parental psychopathology and family and interpersonal relationships. These variables could potentially serve as markers to identify those at increased risk to develop ASD or autistic symptoms. Autism Res 2020, 13: 1582-1600. © 2020 International Society for Autism Research, Wiley Periodicals, Inc.

Development, validation and utilisation of dish-based dietary assessment tools: a scoping review

Objective:

To summarise the existing evidence of development, validation and current status of utilisation of dish-based dietary assessment tools.

Design:

Scoping review.

Setting:

Systematic search using PubMed and Web of Science.

Results:

We identified twelve tools from seventy-four eligible publications. They were developed for Koreans (n 4), Bangladeshis (n 2), Iranians (n 1), Indians/Malays/Chinese (n 1), Japanese (n 3) and Chinese Americans (n 1). Most tools (10/12) were composed of a dish-based FFQ. Although the development process of a dish list varied among the tools, six studies classified mixed dishes based on the similarity of their characteristics such as food ingredients and cooking methods. Tools were validated against self-reported dietary information (n 9) and concentration biomarkers (n 1). In the eight studies assessing the differences between the tool and a reference, the mean (or median) intake of energy significantly differed in five studies, and 26–83 % of nutrients significantly differed in eight studies. Correlation coefficients for energy ranged from 0·15 to 0·87 across the thirteen studies, and the median correlation coefficients for nutrients ranged from 0·12 to 0·77. Dish-based dietary assessment tools were used in fifty-nine studies mainly to assess diet–disease relationships in target populations.

Conclusions:

Dish-based dietary assessment tools have exclusively been developed and used for Asian-origin populations. Further validation studies, particularly biomarker-based studies, are needed to assess the applicability of tools.

Biomarkers of intake for tropical fruits

Consumption of fruit and vegetable is a key component of a healthy and sustainable diet. However, their accurate dietary assessment remains a challenge. Due to errors in self-reporting methods, the available dietary information is usually biased. Biomarkers of intake constitute objective tools to better reflect the usual or recent consumption of different foods, including fruits and vegetables. Partners of The Food Biomarker Alliance (FoodBall) Project have undertaken the task of reviewing the available literature on putative biomarkers of tropical fruit intake. The identified candidate biomarkers were subject to validation evaluation using eight biological and chemical criteria. This publication presents the current knowledge on intake biomarkers for 17 tropical fruits including banana, mango, and avocado as the most widely consumed ones. Candidate biomarkers were found only for banana, avocado, and watermelon. An array of banana-derived metabolites has been reported in human biofluids, among which 5-hydroxyindole-acetic acid, dopamine sulfate, methoxyeugenol glucuronide, salsolinol sulfate, 6-hydroxy-1-methyl-1,2,3,4-tetrahydro-β-carboline-sulfate, and other catecholamine metabolites. Their validation is still at an early stage, with insufficient data on dose-response relationship. Perseitol and mannoheptulose have recently been reported as candidate biomarkers for avocado intake, while the amino acid citrulline has been associated with watermelon intake. Additionally, the examination of food composition data revealed some highly specific phytochemicals, which metabolites after absorption may be further studied as putative BFI for one or several tropical fruits. To make the field move forward, untargeted metabolomics, as a data-driven explorative approach, will have to be applied in both intervention and observational studies to discover putative BFIs, while their full validation and the establishment of dose-response calibration curves will require quantification methods at a later stage.

Contribution of foods to absolute nutrient intake and between-person variations of nutrient intake in Korean preschoolers

BACKGROUND/OBJECTIVES

The aim of this study was to analyze specific foods influencing absolute nutrient intake and between-person variations of nutrient intake among Korean preschoolers.

SUBJECTS/METHODS

This study included 2,766 participants aged 1–5 years in the 2009–2013 Korea National Health and Nutrition Examination Surveys. Dietary data were obtained from a 24-h dietary recall method. Major food sources of absolute nutrient intake were evaluated based on percent contribution of each food. To assess the contribution of specific foods to between-person variations in nutrient intake, stepwise multiple regressions were performed and cumulative R² was used.

RESULTS

White rice and milk were main food sources of energy, protein, carbohydrate, phosphorus, iron, potassium, thiamin, riboflavin, and niacin. The percentage of fat contributed by milk was 21.3% which was the highest, followed by pork, soybean oil, and egg. White rice accounted for 25% and 40% of total variability in total energy and carbohydrate intakes, respectively. About 39% of variation in calcium intake was explained by milk while 40% of variation in phosphorous intake was explained by cheese. The top 10 foods contributing to between-person variations in nutrient intakes were similar with food items that mainly contributed to absolute nutrient intakes. The number of foods explaining 90% of absolute amounts of nutrient intakes varied from 28 for vitamin A to 80 for iron.

CONCLUSIONS

This study identified specific foods that contributed to absolute nutrient intakes and between-person variations in nutrient intakes among Korean preschoolers. Our findings can be used to develop dietary assessment tools and establish food-based dietary guidelines for young children.

The association between total antioxidant capacity and resting metabolic rate (RMR) / respiratory quotient (RQ) in overweight and obese woman

OBJECTIVE

The effect of total antioxidant capacity on resting metabolic rate (RMR) and respiratory quotient (RQ) of overweight and obese woman has been debated globally. Total Antioxidant Capacity may have an independent effect on resting metabolic rate and respiratory quotient.

METHODS AND MATERIALS

A study population of 263 aged 18-50 years participated in this cross-sectional study from the communities of Tehran based on cluster sampling. Dietary intake assessed by using a semi quantitative food frequency questionnaire (FFQ) Demographic questions. Anthropometrics measurements for each participant were done. Dietary total antioxidant capacity (DTAC) was calculated by the 147-item food frequency questionnaire (FFQ) and FRAP assay. Resting metabolic rate and respiratory quotient was measured by Indirect calorimetry.

RESULTS

The mean DTAC of the study participants was 1251.8 (SD 893.60). There was a statistically significant relationship between dietary total antioxidant capacity (DTAC) and respiratory quotient (P > 0.013). People with high dietary total antioxidant capacity have tended to show a lower RQ than those with a lower one. There was a significant correlation between DTAC and RQ for both the adjusted model for age, total energy intake, BMI, physical activity, higher DTAC diet and the crude model which were (β = 0.011; SE = 0.005; CI = -0.021_0) and (β = -3.143E-6; SE = 0; CI = 0), respectively. However, we found no correlation between the DTAC and RMR/FFM-RES (P < 0.49). Also, a significantly higher relationship was demonstrated between dietary total antioxidant capacity and intake vegetables (P ≤ 0.006), fruits (P ≤ 0.009), white meet (P ≤ 0.03) and dairy products (P ≤ 0.005).

CONCLUSION

RQ is correlated with total antioxidant capacity. Increased intake of high DTAC foods may result in weight loss maintenance. This result may suggest a beneficial role of higher-DTAC diets in the prevention of obesity.

Structural Equation Modeling on Effects of Community Empowerment and Supplementary Feeding on Health Status and Nutritional Status of Pregnant Women

Introduction: rates of health problems related to a chronic lack of energy in pregnant women in Indonesia remain prevalence. This study aimed to develop community empowerment and supplementary feeding on health status and nutritional status among pregnant women.Methods: the sample included 189 pregnant women living in the six villages in the Jember District. The research used a cluster random sampling technique. The variables included community empowerment, supplementary feeding, health status, and nutritional status of pregnant women. Data analysis was performed using structural equation modeling (SEM) with parameter data estimation using software (Analysis of Moment Structures (AMOS) version 21).Results: estimations of the direct effects were as follows: community empowerment on health status  (0.224), supplementary feeding on health status (0.169), health status on nutritional status of pregnant women (0.001), community empowerment on nutritional status of pregnant women (2.857), supplementary feeding on nutritional status of pregnant women (-0.537), community empowerment on nutritional status of pregnant women through health status (0.000), supplementary feeding on nutritional status of pregnant women through health status (0.000), community empowerment on health status (0.224), supplementary feeding on health status (0.169).Conclusion: community empowerment remains an important key in improving the engagement of women in maternal health issues. Combined intervention with supplementary feeding based on locality may improve the health outcomes.

An investigation of prepregnancy body mass index, ethnicity and health-related quality of life as predictors of breastfeeding exclusivity during early postpartum period: Cross sectional survey

BACKGROUND

Identifying and understanding the determinants of breastfeeding exclusivity during early postpartum period are crucial for sustainable breastfeeding. Few researchers have examined the association among prepregnancy body mass index, ethnicity and exclusive breastfeeding. As a result, whether or not these factors exhibit different relationship patterns across body mass index groups remains unclear.

OBJECTIVES

This study was performed to: (1) test the relationships among prepregnancy body mass index, ethnicity, health-related quality of life, maternal and obstetric characteristics and exclusive breastfeeding; and (2) compare the relationships among these study variables for two body mass index groups.

DESIGN

Exploratory cross-sectional research design.

SETTING

Two postnatal wards of a university-affiliated hospital.

PARTICIPANTS

A total of 715 postpartum multi-ethnic women in Singapore.

METHODS

We used structural equation modelling with multigroup analysis to examine our hypothetical model, which integrated the concepts of breastfeeding initiation and health-related quality of life conceptual models. A 12-item short form health survey was used to assess the health-related quality of life.

RESULTS

The structural equation modelling showed that women with following factors were significantly less likely to initiate exclusive breastfeeding: being Chinese (β = -0.10, p <  0.05), having high body mass index (β = -0.11, p <  0.01), living with low household income (β = -0.08, p <  0.05) and exhibiting poor health-related quality of life scores (β = 0.17, p <  0.001). Multigroup analysis showed no difference (critical ratio = 0.061) between the parameter estimates of health-related quality of life on exclusive breastfeeding in the two body mass index groups. Health-related quality of life (β = 0.17, p <  0.001) and monthly household incomes (β = -0.11, p < 0.05) were the only significant factors in the normal body mass index group. All structural equation modelling values satisfactorily fitted the data (Goodness of Fit Index = 0.937-0.954, Incremental Fit Index = 0.937-0.945, Tucker-Lewis Index = 0.906-0.917, Comparative Fit Index = 0.936-0.942 and Root Means Square Error of Approximation = 0.027-0.040).

CONCLUSIONS

Enhancing postpartum health-related quality of life and prepregnancy weight management are crucial to initiate exclusive breastfeeding. Our findings can guide the development of promising health promotion strategies among Chinese women with low household income.

Dietary Folate Intake Is Negatively Associated with Excess Body Weight in Brazilian Graduates and Postgraduates (CUME Project)

Folate, vitamin B6, and vitamin B12 intake can be important regulators for obesity development. Thus, we investigated the possible association between the intake of these vitamins and the excess body weight or obesity prevalence in the participants of the Cohort of Universities in Minas Gerais (CUME project). This study analyzed cross-sectional data of 2695 graduates and postgraduates from universities in the state of Minas Gerais (801 men, 1894 women, ages 36.2 ± 9.4). The first step consisted of collecting data online, and the second step consisted of blood collecting in the subsample living in the city of Viçosa and its region (Minas Gerais). Excess body weight and obesity prevalence were 38.1% and 10.1%, respectively. Inadequate intake of folate, B6, and B12 were 12, 6.3, and 11.1%, respectively. Beans/lentils and French bread presented the highest contribution to folate intake (23.45% and 10.01%, respectively). Those individuals in the third tertile for folate intake (≥511.12 μg/d) had a lower excess body weight [prevalence ratio (PR): 0.79, confidence interval (CI): 0.71⁻0.8] and obesity prevalence (PR: 0.60, CI: 0.45⁻0.78). These associations were maintained when the sample was categorized by sex. In addition, serum folate was positively associated with dietary folate (p for trend = 0.032) and negatively associated with serum homocysteine (p for trend = 0.003) in the subsample. Dietary folate intake was negatively associated with excess body weight and obesity in CUME participants, indicating the relevance of this vitamin dietary assessment.

Getting the food list 'right': an approach for the development of nutrition-relevant food lists for household consumption and expenditure surveys

OBJECTIVE

The present paper aimed to demonstrate how 24 h dietary recall data can be used to generate a nutrition-relevant food list for household consumption and expenditure surveys (HCES) using contribution analysis and stepwise regression.

DESIGN

The analysis used data from the 2011/12 Bangladesh Integrated Household Survey (BIHS), which is nationally representative of rural Bangladesh. A total of 325 primary sampling units (PSU=village) were surveyed through a two-stage stratified sampling approach. The household food consumption module used for the analysis consisted of a 24 h open dietary recall in which the female member in charge of preparing and serving food was asked about foods and quantities consumed by the whole household.

SETTING

Rural Bangladesh.ParticipantsA total of 6500 households.

RESULTS

The original 24 h open dietary recall data in the BIHS were comprised of 288 individual foods that were grouped into ninety-four similar food groups. Contribution analysis and stepwise regression were based on nutrients of public health interest in Bangladesh (energy, protein, fat, Fe, Zn, vitamin A). These steps revealed that a list of fifty-nine food items captures approximately 90 % of the total intake and up to 90 % of the between-person variation for the key nutrients based on the diets of the population.

CONCLUSIONS

The study illustrates how 24 h open dietary recall data can be used to generate a country-specific nutrition-relevant food list that could be integrated into an HCES consumption module to enable more accurate and comprehensive household-level food and nutrient analyses.

Relative validity and reproducibility of dietary quality scores from a short diet screener in a multi-ethnic Asian population

Objective

Short screeners for assessing dietary quality are lacking in Asia. We recently developed a short thirty-seven-item diet screener (DS). The present study aimed to evaluate reproducibility and relative validity of the DS in assessing a priori dietary quality indices (DQI; i.e. the Alternative Healthy Eating Index-2010 (AHEI-2010), alternate Mediterranean Diet (aMed) and Dietary Approaches to Stop Hypertension (DASH) diet) and intakes of selected foods.

Design

DS administration and biomarker measurement took place twice within a 4-month interval. A 163-item FFQ was administered one month after the second DS administration.

Setting

Singapore, a multi-ethnic urban Asian country.

Subjects

Singapore residents (n 161) aged 18–79 years, of Chinese, Malay and Indian ethnicity.

Results

Reproducibility coefficients for the two DS were 0·71 (DQI) and 0·65 (food groups). Correlations (ρ) between mean DS and FFQ DQI scores were 0·51 (AHEI-2010), 0·50 (aMed) and 0·61 (DASH; all P<0·05). Cohen’s weighted kappa indicated moderate agreement between the two measures (κw=0·48–0·58). DS DQI scores were associated with concentrations of β-cryptoxanthin (AHEI-2010, ρ=0·26; P<0·05), odd-chain SFA (aMed, ρ=0·24; DASH, ρ=0·25; both P<0·05), and enterolactone, total carotenoids, PUFA and α-linolenic acid (all scores, ρ=0·17–0·30; all P<0·05). Scores were not associated with isoflavone or long-chain n-3 PUFA concentrations.

Conclusions

A short screener can be used to assess DQI with good reproducibility and relative validity compared with a longer FFQ in an Asian population.

Development of a Food Frequency Questionnaire for Brazilian athletes

AIM

Until recently most dietary survey methods have been developed for non-athletic populations. In this study, we aimed to develop a Food Frequency Questionnaire (FFQ) to assess the regular dietary intake of Brazilian athletes.

METHODS

We interviewed 141 athletes (23.36 ± 7.77 years old) for their dietary intake using 24-hour recalls. After grouping conceptually similar food items into 113 food items, percentage contribution analysis and stepwise regression models were used to highlight foods contributing to at least 90% of the between-person variability of key nutrients.

RESULTS

The developed FFQ contained 59 foods which were important predictors of the variance in nutrient intake. Vitamin C and pyridoxine had the lowest number of selected foods. Conversely, 13 food items were required to explain the between-person variation for energy, carbohydrate and magnesium intake.

CONCLUSIONS

Using a multiple regression analysis we developed a 59-food item questionnaire, which includes culturally specific food items and may represent an important dietary tool to analyse athletic populations. Reproducibility and validity of this FFQ will be verified in future research.

Use of dietary indices to control for diet in human gut microbiota studies

BACKGROUND

Environmental factors have a large influence on the composition of the human gut microbiota. One of the most influential and well-studied is host diet. To assess and interpret the impact of non-dietary factors on the gut microbiota, we endeavoured to determine the most appropriate method to summarise community variation attributable to dietary effects. Dietary habits are multidimensional with internal correlations. This complexity can be simplified by using dietary indices that quantify dietary variance in a single measure and offer a means of controlling for diet in microbiota studies. However, to date, the applicability of different dietary indices to gut microbiota studies has not been assessed. Here, we use food frequency questionnaire (FFQ) data from members of the TwinsUK cohort to create three different dietary measures applicable in western-diet populations: The Healthy Eating Index (HEI), the Mediterranean Diet Score (MDS) and the Healthy Food Diversity index (HFD-Index). We validate and compare these three indices to determine which best summarises dietary influences on gut microbiota composition.

RESULTS

All three indices were independently validated using established measures of health, and all were significantly associated with microbiota measures; the HEI had the highest t values in models of alpha diversity measures, and had the highest number of associations with microbial taxa. Beta diversity analyses showed the HEI explained the greatest variance of microbiota composition. In paired tests between twins discordant for dietary index score, the HEI was associated with the greatest variation of taxa and twin dissimilarity.

CONCLUSIONS

We find that the HEI explains the most variance in, and has the strongest association with, gut microbiota composition in a western (UK) population, suggesting that it may be the best summary measure to capture gut microbiota variance attributable to habitual diet in comparable populations.

The relationship of dietary fish intake to diabetic retinopathy and retinal vascular caliber in patients with type 2 diabetes

In this cross-sectional study, we evaluated the association of dietary fish intake with varying severity of diabetic retinopathy (DR) and retinal vascular caliber in Asians with type 2 diabetes mellitus. 357 Asians (median age: 58 years; 31% women; 78% Chinese) were recruited from a tertiary eye care institution in Singapore. Fish consumption was evaluated using a validated food frequency questionnaire. Digital retinal photographs assessed for DR severity and retinal vascular caliber. Ordered logistic and linear regression models were used to investigate the association of fish intake with DR severity and vascular caliber. Increasing frequency of fish consumption was significantly associated with lower odds of having severe DR (odds ratio [OR] = 0.91, 95% CI: 0.84–0.99 per 1-unit increase of fish intake; P = 0.038). Among those with no retinopathy, persons in quartile 4 fish intake had a wider retinal vascular caliber for arteriolar (β = 22.27 µm, 95% CI: 12.64–31.90; P-trend < 0.001) and venular (β = 32.00 µm, 95% CI: 17.56–46.43; P-trend < 0.001), than those in quartile 1 fish intake. Persons with higher fish intake had a decreased likelihood of having severe DR. In diabetics without retinopathy, higher fish intake was associated with wider retinal vascular caliber. Future research is needed to reinforce the direction of the casualty.

Relative Validity and Reproducibility of a Food Frequency Questionnaire for Assessing Dietary Intakes in a Multi-Ethnic Asian Population Using 24-h Dietary Recalls and Biomarkers

The assessment of diets in multi-ethnic cosmopolitan settings is challenging. A semi-quantitative 163-item food frequency questionnaire (FFQ) was developed for the adult Singapore population, and this study aimed to assess its reproducibility and relative validity against 24-h dietary recalls (24 h DR) and biomarkers. The FFQ was administered twice within a six-month interval in 161 adults (59 Chinese, 46 Malay, and 56 Indian). Fasting plasma, overnight urine, and 24 h DR were collected after one month and five months. Intra-class correlation coefficients between the two FFQ were above 0.70 for most foods and nutrients. The median correlation coefficient between energy-adjusted deattenuated FFQ and 24 h DR nutrient intakes was 0.40 for FFQ1 and 0.39 for FFQ2, highest for calcium and iron, and lowest for energy and carbohydrates. Significant associations were observed between urinary isoflavones and soy protein intake (r = 0.46), serum carotenoids and fruit and vegetable intake (r = 0.34), plasma eicosapentaenoic acid and docosahexaenoic acid (EPA + DHA) and fish/seafood intake (r = 0.36), and plasma odd chain saturated fatty acids (SFA) and dairy fat intake (r = 0.25). Associations between plasma EPA + DHA and fish/seafood intake were consistent across ethnic groups (r = 0.28–0.49), while differences were observed for other associations. FFQ assessment of dietary intakes in modern cosmopolitan populations remains feasible for the purpose of ranking individuals’ dietary exposures in epidemiological studies.