Simple changes within dietary subgroups can rapidly improve the nutrient adequacy of the diet of French adults

In healthy pathways of dietary changes, a very rapid reduction of red meat is possible, but specific diet changes are required for full reduction - a graph-based analysis

BACKGROUND

Although reducing meat consumption is becoming increasingly popular in Western countries, such a transition to a sustainable diet can pose some nutritional risks.

OBJECTIVE

We aim to analyze the pathways for reaching a low-meat healthy diet and the changes in other food categories needed to rapidly decrease total red meat consumption.

METHODS

We used a recently developed method based on graph theory to represent all possible pathways of stepwise changes that avoid nutritional deficiencies toward a target healthy diet. Initial and target diets were defined as the daily consumption of 33 food groups. For each sex, three initial diets were taken from the French representative survey INCA3 as the mean observed diet and low (first quintile) and high (fifth quintile) meat consumption. Target diets were identified using multi-criteria optimization to minimize the long-term health risk of chronic diseases while ensuring nutritional adequacy. The Dijkstra algorithm was used to identify the optimal pathways between the initial and target diets, with the aim of reducing meat consumption as quickly as possible and thus minimizing long-term health risks.

RESULTS

Unprocessed red meat was easily minimized in the first steps of the pathways regardless of sex and initial level of meat consumption. However, processed meat could only be decreased later and required prior changes such as increases in fruit, vegetables, and oily fish. During total red meat minimization in females, securing adequate intakes of bioavailable iron had the most substantial impact on the other dietary changes needed.

CONCLUSIONS

Immediate reduction of red meat consumption is possible on the pathway to a healthy diet that avoids any nutrient deficiency. However, early increases in fruit, vegetables, and fish are required before minimizing total red meat early in the diet.

Consumption of foods with the highest nutritional quality, and the lowest greenhouse gas emissions and price, differs between socio-economic groups in the UK population

OBJECTIVE

To establish a baseline understanding of whether consuming food with the highest nutritional quality, lowest greenhouse gas emissions (GHGE) and cost differs between different UK demographic and socio-economic population groups.

DESIGN

Multiple linear regression models were fitted to evaluate the relationship between predictor socio-demographic variables in this study (i.e. sex, ethnic group, age, BMI and level of deprivation) and the response variables (i.e. consumption of items considered most nutritious, with a low GHGE and price, as a proportion of total items consumed).

SETTING

The UK.

PARTICIPANTS

1374 adult (18-65 years) participants from the National Diet and Nutrition Survey latest waves 9-11 (2016-2017 and 2018-2019).

RESULTS

Based on the total energy consumption in a day, the average diet-based GHGE was significantly higher for participants with a higher BMI. Non-white and most deprived participants spent significantly (P < 0·001) less money per total energy consumption. Participants with a BMI between 18·6 and 39·9 kg/m2 and those living in the least deprived areas consumed a significantly (P < 0·001) higher amount of those items considered the most nutritious, with the lowest GHGE and cost per 100 kcal.

CONCLUSIONS

Consumption of food with the highest nutritional quality, lowest GHGE and cost in the UK varies among those with different socio-demographic characteristics, especially the deprivation level of participants. Our analysis endorses the consideration of environmental sustainability and affordability, in addition to the consideration of nutritional quality from a health perspective, to make current dietary guidelines more encompassing and equitable.

Hypothetical impact of the Mexican front-of-pack labeling on intake of critical nutrients and energy

BACKGROUND

Since 2020 in Mexico, front-of-pack warning labels (FOPWL) have been implemented in processed products. Evidence supports warning labels allow consumers to identify unhealthy products. We aimed to evaluate the hypothetical impact of the FOPWL regulation on the Mexican population's intake of critical nutrients and energy, based on the replacement of food and beverages using 4 hypothetical scenarios which represented the phases of the regulation.

METHODS

Dietary data were collected using a standardized 24-h dietary recall from the 2016 Mexican National Health and Nutrition Survey (n = 4184). To evaluate the hypothetical impact of FOPWL, the nutritional content of critical nutrients in processed products was evaluated according to the Mexican Official Standard 051 (NOM-051). Then, we replaced products with several warning labels (WL) with those with a fewer number of them or with non-processed food. For the replacement, 4 hypothetical scenarios were established: scenario 1: the current consumption of the Mexican Population, scenario 2: the replacement during the first phase of the norm, scenario 3: the replacement in the second phase and scenario 4: the replacement in the last phase. We estimated the means, confidence intervals (CI 95%), and the mean percentage change of energy, saturated fat, trans-fat, added sugars, and sodium intake during the second, third, and the fourth scenarios.

RESULTS

According to the norm, in the second scenario, the majority of the products presented a label for energy (52.6%) whereas in the third (56.4%) and fourth (61.2%) scenarios were for sodium. In contrast, trans-fat was the least labeled nutrient in all the scenarios (from 2.1 to 4.1%). In the fourth scenario, we observed a reduction of the intake of energy intake to 15.4% as well as saturated fat (- 20%, CI 95% - 18.4; - 21.6), trans-fat (- 8.2%, CI 95% - 6.4; - 10.1) and sodium (- 12.7%, CI 95% - 11.3; - 14.1). The most important reduction was observed for added sugars intake (until - 54.1%, CI 95% - 51; - 57.1).

CONCLUSIONS

FOPWL could be an effective strategy to decrease energy consumption and nutrients of concern. If consumers use the FOPWL, it would be an important change in critical nutrients intake. These results support that FOPWL might help the Mexican population to choose healthier nutrition alternatives.

Identifying the most Efficient Detailed Trajectories toward Healthy Diets-A Graph-Based Analysis

BACKGROUND

Much effort has been devoted to defining healthy diets, which could lower the burden of disease and provide targets for populations. However, these target diets are far removed from current diets, so at best, the population is expected to move slowly along a trajectory.

OBJECTIVE

Our aim was to characterize the different possible trajectories toward a target diet and identify the most efficient one for health to point out the first dietary changes being the most urgent to implement.

METHODS

Using graph theory, we have developed a new method to represent in a graph all stepwise change trajectories toward a target healthy diet, with trajectories all avoiding risk of nutrient deficiency. Then, we have identified and characterized the trajectory with the highest value for long-term health. Observed male and female average diets are from the French representative survey INCA3, and target diets were set using multicriteria optimization. The best trajectories were found using the Dijkstra algorithm with the Health risk criteria based on epidemiological data.

RESULTS

Within ∼2.6M diets in the graphs, we found optimal trajectories that were rather similar for males and females regarding the most efficient changes in the first phase of the pathways. In particular, we found that a 1-step increase in the consumption of whole/semirefined bread (60 g) was the first step in all healthiest trajectories. In males, the subsequent decrease in red meat was immediately preceded by increases in legumes.

CONCLUSIONS

We show simple practical dietary changes that can be prioritized along an integral pathway that is the most efficient overall for health when transiting toward a distant healthy diet. We put forward a new method to analyze dietary strategy for public health transition and highlight the first critical steps to prioritize.

Food-Level Analysis to Identify Dietary Choices With the Highest Nutritional Quality and Lowest Greenhouse Gas Emissions and Price

Introduction

Food systems are challenged to provide healthy, sustainable and affordable foods. From a consumer perspective, identifying healthy, sustainable and affordable choices based on individual food products rather than diets could promote better shopping choices.

Objective

To identify foods and drinks with the highest nutritional quality and lowest greenhouse gas emissions (GHGE) and price. We also assessed how a combination of these indicators (e.g., nutritional quality, GHGE and price) for food categories aligned with current United Kingdom dietary recommendations.

Materials and Methods

We performed a secondary analysis of the National Diet and Nutrition Survey (NDNS) nutrient databank year 11 (2018/2019). Spearman correlation coefficients were used to assess the strength of relationships between nutritional quality, environmental impact and/or prices per 100 kcal. In addition, we developed an optimized nutritional quality, GHGE and price score for each food or drink item based on the overall medians for each of these indicators.

Results

Median nutritional value was highest for fruit and vegetables, whilst median GHGE and price was lower for starchy carbohydrates, fats and items of which consumption should be limited. The relative proportions of foods considered the most nutritious and with a low GHGE and price in each of the food categories, on a per 100 kcal basis, were comparable to the proportions in the Eatwell Guide, except for the proportion of fruits and vegetables being smaller and the proportion of potatoes, bread, rice, pasta, and other starchy carbohydrates being larger in our analysis.

Conclusion

Public health efforts should consider the impact of dietary choices not only in terms of nutritional quality but also in terms of environmental and economic impact. Our food-based analysis shows a large variation in nutritional quality, GHGE and price within and across food categories, which provides consumers with opportunities for “food swaps” that are more nutritious and have lower GHGE and price.

Can Public Health Interventions Change Immediate and Long-Term Dietary Behaviours? Encouraging Evidence from a Pilot Study of the U.K. Change4Life Sugar Swaps Campaign

The aim of this pilot study was to evaluate the effectiveness of the U.K. Change4Life Sugar Swaps campaign for improving nutritional intake in a small sample of families prior to the 2015 nationwide launch. A total of 49 participants from 14 families received information and materials during a two-week intervention period in November 2014 encouraging them to swap high sugar foods and drinks for low sugar alternatives. Daily dietary intake was reported with online food diaries over four stages, each two weeks in length: (i) baseline (no information provided), (ii) intervention when Sugar Swaps materials were accessible, (iii) immediate follow-up, and (iv) one year on from baseline. Data were analysed for sugar, glucose, fructose, sucrose, lactose, fat, saturated fat, carbohydrate, protein, salt, fibre, vitamin C, and energy. During the intervention, significant daily reductions of 32 g sugar, 11 g fat, and 236 kcal for each family member were observed, among others, and 61% of benefits achieved during the intervention period were maintained at immediate follow-up. Encouragingly, for children, reductions in sugar, sucrose, fat, saturated fat, carbohydrate, and energy were observed one year on. The Sugar Swaps Campaign is potentially an effective public health intervention for improving short- and long-term dietary behaviour for the whole family.

Methodological Aspects of Diet Quality Indicators in Childhood: A Mapping Review

Diet quality indicators (DQIns) are tools that aim to assess an individual's overall diet quality. Previous reviews focused mainly on health-related outcomes but did not provide detailed information about components, assessment variables, or important methodological issues for the development and application of DQIns in the pediatric age. The current mapping review aims to provide comprehensive guidance regarding DQIns developed through a priori methodology in children aged ≤14 y that have been applied worldwide. A mapping review was conducted, whereby 1665 original articles describing the development, modifications, and updates of DQIns, published up to June 26, 2020, in English and Spanish, were retrieved. A total of 139 articles were identified and classified into 13 subgroups. There were 10 overall DQIns: Healthy Eating Indexes (n = 25), Dietary Diversity Scores (n = 20), Diet Quality Indexes (n = 16), Food Variety Scores (n = 11), Healthy and Unhealthy Scores (n = 11), Feeding and Eating Indexes (n = 10), Diet Quality Scores (n = 5), Nutritional Adequacy and Micronutrients Indexes (n = 5), Dietary Guidelines Indexes (n = 5), and Other Healthy Diet Indexes (n = 13). Three additional subgroups of dietary and lifestyle indicators found were Mediterranean Diet Indexes (n = 10), Diet-Lifestyle Indexes (n = 5), and Breakfast Quality Indexes (n = 3). This compilation of DQIns will help researchers select the most appropriate tool for future epidemiological studies by considering a careful selection of information about the assessment components, scoring methods, and key methodological issues. The main limitations of this review are that, due to its nature, a risk-of-bias assessment was not performed and the article screening was completed in 2 databases (PubMed/MEDLINE and Scopus). More research is needed to identify health-related outcomes associated with DQIns in the pediatric population, using clearer and more standardized methodological criteria.

Impact of intra-category food substitutions on the risk of type 2 diabetes: a modelling study on the pizza category

Advice on replacing unhealthy foods with healthier alternatives within the same food category may be more acceptable and might ease the transition towards a healthy diet. Here, we studied the potential impact of substitutions within the pizza category on the risk of type 2 diabetes (T2D). The study sample consisted of 2510 adults from the INCA2 French national survey. Based on their nutritional characteristics, the 353 pizzas marketed in France were grouped into 100 clusters that were used to run various scenarios of pizza substitutions, which were either isoenergetic (IE) or non-isoenergetic (NIE). We then used a model structurally similar to the Preventable Risk Integrated ModEl to assess the expected rate of change in risk of T2D. Pizzas characterised by a low energy, high vegetable content and whole grain dough were associated with a greater reduction in the risk of T2D. The rates of change in risk of T2D were markedly stronger in men and for NIE substitutions. When the rates of change were estimated in the subsample of pizza consumers, replacing the observed pizzas with the best pizza resulted in a T2D risk reduction of -6·7 % (-8·4 %; -4·9 %, IE) and -8·9 % (-11·2 %; -6·3 %, NIE), assuming that this is their usual diets. The greatest risk reduction induced by an IE substitution of the observed pizza with a mixed dish was similar to that observed with the best pizzas. Overall, this modelling study suggests that healthy swaps within a category can effectively supplement broader dietary changes towards a healthier diet.

Making a Sustainable Diet Acceptable: An Emerging Programming Model With Applications to Schools and Nursing Homes Menus

Background: Food consumption is one of the most important drivers of the relation between human well-being and Earth's ecosystems. The current production level is difficult to sustain without compromising environmental integrity or public health. This calls for a decisive change in food consumption patterns in order to improve nutrition quality while respecting biodiversity and ecosystems. This change will produce some effect only if it is also culturally acceptable, accessible, economically fair and affordable. The design of food plans is traditionally carried out using mathematical optimization models, such as linear programming. This method has proved to be successful in providing nutritionally adequate diets while minimizing their economic and environmental impact. Nevertheless, cultural habits as well as attractiveness and variety of meals is very difficult to deal with, and no fully satisfactory way to include these issues in linear programming has been found. Objective: The aim of this paper is to move from traditional linear programming to a new programming methodology in order to cope also with acceptability in the design of meal plans. Method: Binary integer linear programming is the new modeling paradigm. In the proposed model, meal plans consist of providing the sequence and composition of daily meals over a given period of time and each meal can be composed using dishes from a given set. Therefore, instead of defining just a level of consumption of food groups or food items, the proposed model provides a realistic menu. To cope with sustainability, the energy and nutritional content of each dish is calculated together with its price and environmental impact. Furthermore, acceptability can be explicitly taken into account in a very natural way, that is bounding the daily, weekly, or total repetitions of single dishes and of dishes in the same food groups. Results: The paper reviews three successful studies with increasing complexity considering lunch plans for schools and full-board menus for nursing homes. The case studies show a great reduction of the environmental impact of the meal plans while ensuring an adequate nutritional intake, affordable prices and most importantly the plans are varied and culturally acceptable.

Increasing dietary fibre intake in healthy adults using personalised dietary advice compared with general advice: a single-blind randomised controlled trial

Objective:

A high-fibre diet is associated with a lower risk for diseases. However, few adults meet the dietary fibre recommendation. Therefore, the effects and acceptance of an algorithm-generated personalised dietary advice (PDA) compared with general advice (GA) on fibre intake were investigated.

Design:

A 6-week, single-blind randomised controlled trial with a 3-month follow-up.

Setting:

PDA was based on habitual intake and provided fibre-rich alternatives using a website; GA contained brochures. Dietary intake was assessed at baseline, week 1, week 6 and 3-month follow-up. Both groups evaluated their advice at week 6. All participants had access to PDA from week 7 until 3-month follow-up.

Participants:

Two groups of healthy adults: PDA (n 34) and GA (n 47). For 3-month follow-up analysis, participants were re-divided into visitors (n 52) and non-visitors (n 26) of the PDA.

Results:

At week 6, energy intake remained stable in both groups, but fibre intake per 1000 kcal increased non-significantly in both groups (PDA = Δ0·5 ± 2·8; GA = Δ0·8 ± 3·1, P = 0·128). Importantly, a significantly higher percentage of PDA participants adhered to the recommendation compared with week 1 (PDA = 21 % increase; GA = 4 % increase, P ≤ 0·001). PDA participants evaluated the advice significantly better compared with GA participants. At 3-month follow-up, fibre intake increased compared with baseline (visitors = Δ2·2 ± 2·6, P < 0·001; non-visitors = Δ1·5 ± 1·9, P = 0·001), but was insignificantly different between groups. Visitors had a decrease and non-visitors had an increase in energy intake (visitors =Δ − 132 ± 525; non-visitors = Δ109 ± 507, P = 0·055).

Conclusions:

The algorithm-generated PDA was well accepted and stimulated adherence to the recommendations more than GA, indicating to be a suitable and cost-efficient method for improving dietary fibre intake in healthy adults.

Mathematical Optimization to Explore Tomorrow's Sustainable Diets: A Narrative Review

A sustainable diet is, by definition, nutritionally adequate, economically affordable, culturally acceptable, and environmentally respectful. Designing such a diet has to integrate different dimensions of diet sustainability that may not be compatible with each other. Among multicriteria assessment methods, diet optimization is a whole-diet approach that simultaneously combines several metrics for dimensions of diet sustainability. This narrative review based on 67 published studies shows how mathematical diet optimization can help with understanding the relations between the different dimensions of diet sustainability and how it can be properly used to identify sustainable diets. Diet optimization aims to find the optimal combination of foods for a population, a subpopulation, or an individual that fulfills a set of constraints while minimizing or maximizing an objective function. In the studies reviewed, diet optimization was used to examine the links between dimensions of diet sustainability, identify the minimum cost or environmental impact of a nutritionally adequate diet, or identify food combinations able to combine ≥2 sustainability dimensions. If some constraints prove difficult to fulfill, this signals an incompatibility between nutrient recommendations, over-monotonous food-consumption patterns, an inadequate supply of nutrient-rich foods, or an incompatibility with other dimensions. If diet optimization proves successful, it can serve to design nutritionally adequate, culturally acceptable, economically affordable, and environmentally friendly diets. Diet optimization results can help define dietary recommendations, tackle food security issues, and promote sustainable dietary patterns. This review emphasizes the importance of carefully choosing the model parameters (variables, objective function, constraints) and input data and the need for appropriate expertise to correctly interpret and communicate the results. Future research should make improvements in the choice of metrics used to assess each aspect of a sustainable diet, especially the cultural dimension, to improve the practicability of the results.

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.

Modifications in the Consumption of Energy, Sugar, and Saturated Fat among the Mexican Adult Population: Simulation of the Effect When Replacing Processed Foods that Comply with a Front of Package Labeling System

A Mexican Committee of Nutrition Experts (MCNE) from the National Institute of Public Health (INSP), free from conflict of interest, established food content standards to place the front-of-package (FOP) logo on foods that meet these nutrition criteria. The objectives were to simulate the effect on nutrient intake in the Mexican adult population (20–59 years old) after replacing commonly consumed processed foods with those that meet the FOP nutrition-labeling criteria. Twenty-four hour dietary recalls were collected from the 2012 Mexican National Health and Nutrition Survey (n = 2164 adults). A food database from the INSP was used. Weighted medians and 25–75 inter-quartile ranges (IQR) of energy and nutrient intake were calculated for all subjects by sociodemographic characteristics before and after replacing foods. Significant decreases were observed in energy (−5.4%), saturated fatty acids (−18.9%), trans-fatty acids (−20%), total sugar (−36.8%) and sodium (−10.7%) intake and a significant increase in fiber intake (+15.5%) after replacing foods, using the MCNE nutrition criteria. Replacing commonly consumed processed foods in the diet with foods that meet the FOP nutrition-labeling criteria set by the MCNE can lead to improvements in energy and nutrient intake in the Mexican adult population.

Consumer acceptance of dairy products with a saturated fatty acid-reduced, monounsaturated fatty acid-enriched content

Agriculture-based reformulation initiatives, including oleic acid-rich lipid supplementation of the dairy cow diet, provide a novel means for reducing intake of saturated fatty acids (SFA) at a population level. In a blinded manner, this study evaluated the consumer acceptance of SFA-reduced, monounsaturated fatty acid-enriched (modified) milk, Cheddar cheese, and butter when compared with control and commercially available comparative samples. The effect of providing nutritional information about the modified cheese was also evaluated. Consumers (n = 115) rated samples for overall liking (appearance, flavor, and texture) using 9-point hedonic scales. Although no significant differences were found between the milk samples, the modified cheese was liked significantly less than a regular-fat commercial alternative for overall liking and liking of specific modalities and had a lower liking of texture score compared with the control cheese. The provision of health information significantly increased the overall liking of the modified cheese compared with tasting the same sample in a blinded manner. Significant differences were evident between the butter samples for overall liking and modalities of liking; all of the samples were significantly more liked than the commercial butter and sunflower oil spread. In conclusion, this study illustrated that consumer acceptance of SFA-reduced, monounsaturated fatty acid-enriched dairy products was dependent on product type. Future research should consider how optimization of the textural properties of fatty acid-modified (and fat-reduced) cheese might enhance consumer acceptance of this product.

Individual Diet Modeling Shows How to Balance the Diet of French Adults with or without Excessive Free Sugar Intakes

Dietary changes needed to achieve nutritional adequacy for 33 nutrients were determined for 1719 adults from a representative French national dietary survey. For each individual, an iso-energy nutritionally adequate diet was generated using diet modeling, staying as close as possible to the observed diet. The French food composition table was completed with free sugar (FS) content. Results were analyzed separately for individuals with FS intakes in their observed diets ≤10% or >10% of their energy intake (named below FS-ACCEPTABLE and FS-EXCESS, respectively). The FS-EXCESS group represented 41% of the total population (average energy intake of 14.2% from FS). Compared with FS-ACCEPTABLE individuals, FS-EXCESS individuals had diets of lower nutritional quality and consumed more energy (2192 vs. 2123 kcal/day), particularly during snacking occasions (258 vs. 131 kcal/day) (all p-values < 0.01). In order to meet nutritional targets, for both FS-ACCEPTABLE and FS-EXCESS individuals, the main dietary changes in optimized diets were significant increases in fresh fruits, starchy foods, water, hot beverages and plain yogurts; and significant decreases in mixed dishes/sandwiches, meat/eggs/fish and cheese. For FS-EXCESS individuals only, the optimization process significantly increased vegetables and significantly decreased sugar-sweetened beverages, sweet products and fruit juices. The diets of French adults with excessive intakes of FS are of lower nutritional quality, but can be optimized via specific dietary changes.

Plant Protein Intake and Dietary Diversity Are Independently Associated with Nutrient Adequacy in French Adults

BACKGROUND

Plant protein intake, which is favorably associated with the intake of many nutrients, is a marker of a healthy diet. However, the higher nutrient adequacy of diets rich in plant protein may also originate from overarching factors associated with more healthful dietary behaviors, such as a greater dietary diversity.

OBJECTIVE

Our main objective was to determine whether the relation between plant protein intake and nutrient adequacy could be explained, at least in part, by an association with overall dietary diversity.

METHODS

We used data from 1330 adults participating in the French Nutrition and Health Survey [Etude Nationale Nutrition Santé (ENNS); 2006-2007]. With the use of global, integrative approaches, we assessed nutrient adequacy [by using the probabilistic PANDiet (Probability of Adequate Nutrient Intake) scoring system] and overall dietary diversity (by using a 100-point score that accounts for the relative number of subgroups consumed in 7 food groups). Linear multivariate modeling was used for the analysis.

RESULTS

We found a positive association between plant protein (but not total or animal protein) intake and dietary diversity (β = 0.08) and a strong positive association between dietary diversity and nutrient adequacy (β = 0.33). However, the association between plant protein intake and nutrient adequacy was not explained by dietary diversity (r = 0.38 and partial r = 0.36, P < 0.0001). In multivariate analysis, nutrient adequacy was positively associated with dietary diversity (β = 0.44) and plant (β = 0.37) and animal (β = 0.15) protein intakes. Associations persisted after adjustment for potential confounders (total energy, energy density, sex, body mass index, income, occupational status, educational level, region, season, and smoking status).

CONCLUSIONS

Overall dietary diversity is greater in French adults who consume more plant protein. Both plant protein intake and dietary diversity are associated with the nutrient adequacy of the diet. But the plant protein-nutrient adequacy association was not related to the relative overall diversity of the diet.

Drinking Water Intake Is Associated with Higher Diet Quality among French Adults

This study aimed to examine the association between drinking water intake and diet quality, and to analyse the adherence of French men and women to the European Food Safety Authority 2010 Adequate Intake (EFSA AI). A representative sample of French adults (≥18) from the Individual and National Survey on Food Consumption (INCA2) was classified, by sex, into small, medium, and large drinking water consumers. Diet quality was assessed with several nutritional indices (mean adequacy ratio (MAR), mean excess ratio (MER), probability of adequate intakes (PANDiet), and solid energy density (SED)). Of the total sample, 72% of men and 46% of women were below the EFSA AI. This percentage of non-adherence decreased from the small to the large drinking water consumers (from 95% to 34% in men and from 81% to 9% in women). For both sexes, drinking water intake was associated with higher diet quality (greater MAR and PANDiet). This association remained significant independently of socio-economic status for women only. Low drinking water consumers did not compensate with other sources (beverages and food moisture) and a high drinking water intake was not a guarantee for reaching the EFSA AI, meaning that increasing consumption of water should be encouraged in France.

The 5-CNL Front-of-Pack Nutrition Label Appears an Effective Tool to Achieve Food Substitutions towards Healthier Diets across Dietary Profiles

BACKGROUND

Front-of-pack (FOP) nutrition labels are considered helpful tools to help consumers making healthier food choices, thus improving their diet. In France, the implementation of a FOP nutrition label-the 5-Colour Nutrition Label (5-CNL)-is currently under consideration. Our objective was to investigate dietary profiles in a French adult population using the 5-CNL, and to assess its potential impact in improving the diet through substitution of foods.

METHODS AND FINDINGS

Subjects included in the NutriNet-Santé cohort, who had completed three 24-h dietary records were included in this cross-sectional analysis. Mutually exclusive clusters of individuals were identified using the percentage of energy derived from foods of each of the 5-CNL colours as input variables. Three scenarios of substitution of foods for healthier alternative using the 5-CNL were tested. Food group and dietary intakes, socio-demographic and lifestyle data were compared across clusters using ANOVAs or Chi-square tests, as appropriate. We identified three mutually exclusive dietary profiles: 'Healthy' (N = 28 095, 29.3% of the sample), with high consumption of fruit, vegetables, whole cereals and fish; 'Western' (N = 33 386, 34.8%); with high consumption of sweetened beverages, breakfast cereal, cheese, fatty and sugary foods; 'Traditional' (N = 34 461, 35.1%), with high consumption of potatoes, bread, meat and dairy desserts. Overall, substitutions strategies led to an increase in the number of subjects reaching the recommended intakes in energy, macro and micronutrients. Increases were particularly high in the 'Western' pattern for lipids and saturates intakes: from 16.2% reaching the recommended amount for lipids (13.5% for saturates) to 60.6% and 85.7% respectively.

CONCLUSION

The use of the 5-CNL as an indicator of food choice meaningfully characterizes clusters of dietary habits and appears as an effective tool to help improving the nutritional quality of the diet.

The Role of Avocados in Maternal Diets during the Periconceptional Period, Pregnancy, and Lactation

Maternal nutrition plays a crucial role in influencing fertility, fetal development, birth outcomes, and breast milk composition. During the critical window of time from conception through the initiation of complementary feeding, the nutrition of the mother is the nutrition of the offspring—and a mother’s dietary choices can affect both the early health status and lifelong disease risk of the offspring. Most health expert recommendations and government-sponsored dietary guidelines agree that a healthy diet for children and adults (including those who are pregnant and/or lactating) should include an abundance of nutrient-rich foods such as fruits and vegetables. These foods should contain a variety of essential nutrients as well as other compounds that are associated with lower disease risk such as fiber and bioactives. However, the number and amounts of nutrients varies considerably among fruits and vegetables, and not all fruit and vegetable options are considered “nutrient-rich”. Avocados are unique among fruits and vegetables in that, by weight, they contain much higher amounts of the key nutrients folate and potassium, which are normally under-consumed in maternal diets. Avocados also contain higher amounts of several non-essential compounds, such as fiber, monounsaturated fats, and lipid-soluble antioxidants, which have all been linked to improvements in maternal health, birth outcomes and/or breast milk quality. The objective of this report is to review the evidence that avocados may be a unique nutrition source for pregnant and lactating women and, thus, should be considered for inclusion in future dietary recommendations for expecting and new mothers.

'Change4Life Smart Swaps': quasi-experimental evaluation of a natural experiment

Objective

To evaluate the impact on food purchasing behaviour of the ‘Change4Life Smart Swaps’ campaign to encourage families to make small changes to lower-fat or lower-sugar versions of commonly eaten foods and drinks.

Design

Quasi-experimental study comparing the proportion of swaps made by an intervention group (267 families who had signed up to the ‘Smart Swaps’ campaign promoted through various media, including television and radio advertising in early 2014) and a comparison group (135 families resident in Wales, signed up for ‘Change4Life’ materials, but not directly exposed to the ‘Smart Swaps’ campaign). During weeks 1, 2 and 3 of the campaign participants were asked to record their purchases of dairy products, carbonated drinks and breakfast cereals, using a mobile phone app questionnaire, when making a purchase within the category.

Setting

England and Wales.

Subjects

Families registered with ‘Change4Life’.

Results

In weeks 2 and 3 a significantly higher percentage of the intervention group had made ‘smart swaps’ than the comparison group. After week 3, 58 % of participants had swapped to a lower-fat dairy product compared with 26 % of the comparison group (P<0·001), 32 % of the intervention group had purchased a lower-sugar drink compared with 19 % of the comparison group (P=0·01), and 24 % had made a change to a lower-sugar cereal compared with 12 % of the comparison group (P=0·009).

Conclusions

In the short term a national campaign to change purchase habits towards healthier products may have some merit but the sustainability of change requires further investigation.

Pregnancy Requires Major Changes in the Quality of the Diet for Nutritional Adequacy: Simulations in the French and the United States Populations

BACKGROUND

Maternal nutrition is critical to the health of both mother and offspring, but there is a paucity of data on the nutritional adequacy of diets during pregnancy.

OBJECTIVE

Our objective was to identify to what extent pregnancy reduces the nutritional adequacy of the expecting mother's diet and if this nutritional gap can be resolved by simple quantitative or qualitative changes in the diet.

MATERIALS AND METHODS

We evaluated the observed overall nutritional adequacy of diets of French and American women of childbearing age participating in ENNS (n = 344) and NHANES (n = 563) using the probabilistic approach of the PANDiet system, resulting in a 100-point score. Then, we simulated the changes in the PANDiet scores of women of childbearing age who would remain on their diet during pregnancy. Finally, by either increasing the quantity of consumed foods or using eleven snacks recommended during pregnancy, we simulated the effect of a 150-kcal increase in the energy intake of French women.

RESULTS

Observed PANDiet scores were equal to 59.3 ± 7.0 and 58.8 ± 9.3 points respectively in France and in the US. Simulation of pregnancy for women of childbearing age led to a decrease in nutritional adequacy for key nutrients during pregnancy and resulted in reducing PANDiet scores by 3.3 ± 0.1 and 3.7 ± 0.1 points in France and in the US. Simulated 150-kcal increases in energy intake proved to be only partially effective in filling the gap both when the quantity of food consumed was increased and when recommended snacks were used.

CONCLUSIONS

The decrease in nutritional adequacy induced by pregnancy cannot be addressed by simply following generic dietary guidelines.