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Trends in Dietary Carbohydrate, Protein, and Fat Intake and Diet Quality Among US Adults, 1999-2016

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  • Harvard T.H. Chan School of Public Health
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Trends in Dietary Carbohydrate, Protein, and Fat Intake and Diet Quality Among US Adults, 1999-2016

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... Healthful carbohydrates are a critical component of healthy food patterns (2); however, metrics to evaluate carbohydrate quality are not yet fully established (3). Instead, it appears that decisions about carbohydrate quality are sometimes made a priori (4,5). Treated as "lower quality" carbohydrates in some past studies were starchy vegetables, including white potatoes, refined grains, 100% fruit juices, sweetened beverages, and sugars, snacks, and sweets (4,5). ...
... Instead, it appears that decisions about carbohydrate quality are sometimes made a priori (4,5). Treated as "lower quality" carbohydrates in some past studies were starchy vegetables, including white potatoes, refined grains, 100% fruit juices, sweetened beverages, and sugars, snacks, and sweets (4,5). Assigned to "higher quality" carbohydrates were whole grains, legumes, whole fruit, and nonstarchy vegetables, including dark green vegetables and tomatoes (4,5). ...
... Treated as "lower quality" carbohydrates in some past studies were starchy vegetables, including white potatoes, refined grains, 100% fruit juices, sweetened beverages, and sugars, snacks, and sweets (4,5). Assigned to "higher quality" carbohydrates were whole grains, legumes, whole fruit, and nonstarchy vegetables, including dark green vegetables and tomatoes (4,5). ...
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Background Starchy vegetables, including white potatoes, are often categorized as “lower-quality” carbohydrate foods, along with refined grains, 100% fruit juices, sweetened beverages, and sugars, snacks and sweets. Among “higher-quality” carbohydrates are whole grains, non-starchy vegetables, legumes, and whole fruits. Objective To apply multiple nutrient profiling (NP) models of carbohydrate quality to foods containing >40% carbohydrate by dry weight in the USDA Food and Nutrient Database for Dietary Studies (FNDDS 2017-18). Methods Carbohydrate foods in the FNDDS ( n = 2423) were screened using four recent Carbohydrate Quality Indices (CQI) and a new Carbohydrate Food Quality Score (CFQS-4). Cereal products containing >25% whole grains by dry weight were classified as whole grain foods. Results Based on percent items meeting the criteria for 4 CQI scores, legumes, non-starchy and starchy vegetables, whole fruit, and whole grain foods qualified as “high quality” carbohydrate foods. Distribution of mean CFQS-4 values showed that starchy vegetables, including white potatoes placed closer to non-starchy vegetables and fruit than to candy and soda. Conclusion Published a priori determinations of carbohydrate quality do not always correspond to published carbohydrate quality metrics. Based on CQI metrics, specifically designed to assess carbohydrate quality, starchy vegetables, including white potatoes, merit a category reassignment and a more prominent place in dietary guidance.
... Generally, dietary carbohydrates provide almost 50% of total energy and are the main source of energy throughout the day (2). In the past 20 years, total carbohydrate intake during a day has remained stable among U.S. adults, whereas the quality of carbohydrates has slowly increased (7), probably because of dietary guidelines and media publicity based on the evidence of the beneficial effect of high-quality carbohydrates intake. Furthermore, investigators of a few recent studies found that the timing of macronutrient intake, independent of total daily carbohydrate intake, is associated with incidence of obesity (6,(8)(9)(10), dyslipidemia (9,11), hyperglycemia (12), metabolic syndrome (6,10), and mortality (13). ...
... Overall, 27,623 participants were included. NHANES is a stratified and multistage study conducted with a nationally representative sample of the U.S. population (14), the detailed descriptions of which are provided elsewhere (7). The NHANES protocol was approved by the National Center for Health Statistics Research Ethics Review Board, and all participants provided informed consent. ...
... The main exposures were the quantity, quality, and daily timing of carbohydrate intake. The total daily intake of high-and low-quality carbohydrates was calculated with the method described in a previous study (7). The total daily high-quality carbohydrates intake was calculated based on the sum of the intake amount of whole grains, legumes, whole fruits, and nonstarchy vegetables, and the total daily low-quality carbohydrates intake was calculated based on the sum of the intake amount of refined grains, fruit juices, starchy vegetables, and added sugars. ...
Article
OBJECTIVE In this study we investigated the association of the quantity, quality, and timing of carbohydrate intake with all-cause, cardiovascular disease (CVD), and diabetes mortality. RESEARCH DESIGN AND METHODS This secondary data analysis included use of National Health and Nutrition Examination Survey (2003–2014) and National Death Index data from adults (n = 27,623) for examination of the association of total daily and differences in carbohydrate intake with mortality. Participants were categorized into four carbohydrate intake patterns based on the median values of daily high- and low-quality carbohydrate intake. The differences (Δ) in carbohydrate intake between dinner and breakfast were calculated (Δ = dinner − breakfast). Cox regression models were used. RESULTS The participants who consumed more high-quality carbohydrates throughout the day had lower all-cause mortality risk (hazard ratio [HR] 0.88; 95% CI 0.79–0.99), whereas more daily intake of low-quality carbohydrates was related to greater all-cause mortality risk (HR 1.13; 95% CI: 1.01–1.26). Among participants whose daily high- and low-quality carbohydrate intake were both below the median, the participants who consumed more high-quality carbohydrates at dinner had lower CVD (HR 0.70; 95% CI 0.52–0.93) and all-cause mortality (HR 0.82; 95% CI 0.70–0.97) risk; an isocaloric substitution of 1 serving low-quality carbohydrates intake at dinner with high-quality reduced the CVD and all-cause mortality risks by 25% and 19%. There was greater diabetes mortality among the participants who consumed more low-quality carbohydrates at dinner (HR 1.78; 95% CI 1.02–3.11), although their daily high-quality carbohydrate intake was above the median. CONCLUSIONS Consuming more low-quality carbohydrates at dinner was associated with greater diabetes mortality, whereas consuming more high-quality carbohydrates at dinner was associated with lower all-cause and CVD mortality irrespective of the total daily quantity and quality of carbohydrates.
... The primary source of energy from food worldwide is carbohydrates, providing over 50% of the daily energy intake, followed by sources from fat and protein [1]. However, there are substantial differences in the proportion of macronutrient intakes between Asia and Western countries [2,3]. The traditional Chinese diet is characterized by a high intake of carbohydrates and vegetables, as well as moderate intake of animal foods [4]. ...
... Two additional LCD scores were also created: (1) vegetable-based LCD scores were calculated according to the percentage of energy from high-quality carbohydrates, plant protein, and unsaturated fat; (2) meat-based LCD scores were calculated according to the percentage of energy from low-quality carbohydrates, animal protein, and saturated fat (Table S1). Based on the Healthy Eating Index (HEI) 2015, high-quality carbohydrate was defined as a carbohydrate from whole grains, whole fruits, legumes, and non-starchy vegetables, and low-quality carbohydrate as a carbohydrate from refined grains, added sugar, fruit juice, potatoes, and other starchy vegetables [3]. As we found a significant interaction between LCDs and diabetes in all-cause mortality (p for interaction < 0.001), we also conducted pre-specified analyses by diabetes status (Table S2). ...
... The percentage of energy from carbohydrates, fat, and protein in our study were similar with the results of China Health and Nutrition Survey (CHNS) [26]. Notably, the percentage of energy from carbohydrate (especially high-quality carbohydrate) in our study was higher than that reported in the US (total carbohydrate, 57.1% versus 50.5%; high-quality carbohydrate, 10.6% versus 8.6%, respectively), whereas the percentage of energy from animal protein and saturated fat intake was much lower than the US (animal protein, 7.4% versus 10.4%; saturated fat, 4.9% versus 11.9%, respectively) [3]. Moreover, compared with the US, total per capita consumption of meat in Asians was much lower (49.4 kg/year versus 122.8 kg/year), whereas the percentage of energy from fish/sea food consumption was higher (43.5% versus 26.0%) [27]. ...
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The long-term effects of a low-carbohydrate diet (LCD) on mortality, accounting for the quality and source of the carbohydrate, are unclear. Hence, we examined the associations of LCDs with all-cause and cause-specific mortality in a prospective cohort study. A total of 20,206 participants (13.8% diabetes) aged 50+ years were included. Overall, vegetable-based and meat-based LCD scores were calculated based on the percentage of energy as total and subtypes of carbohydrates, fat, and protein. Cox regression analysis was used to calculate hazard ratios (HRs) and 95% confidence intervals (CIs). During 294,848 person-years of follow-up, 4624 deaths occurred, including 3661 and 963 deaths in participants without and with diabetes, respectively. In all participants, overall LCD score was not associated with all-cause and cause-specific mortality, after multivariable adjustment. However, for the highest versus the lowest quartiles of vegetable-based LCD, the adjusted HRs (95%CIs) of all-cause and CVD mortality were 1.16 (1.05–1.27) and 1.39 (1.19–1.62), respectively. The corresponding values for highest versus lowest quartiles of meat-based LCD for all-cause and CVD mortality were 0.89 (0.81–0.97) and 0.81 (0.70–0.93), respectively. Similar associations were found in participants without diabetes. In patients with diabetes, the adjusted HR (95%CI) of CVD mortality for the highest versus the lowest quartiles of vegetable-based LCD was 1.54 (1.11–2.14). Although there were no significant associations with overall LCD score, we found that the vegetable-based LCD score was positively, whereas the meat-based LCD score was negatively, associated with all-cause and CVD mortality in older Asian people.
... Examinations of trends in added sugars intake in the U.S. have been conducted over different time spans and among different age groups, and taken together they provide evidence of significant declines in intake among all age groups over the years 1999-2018 (6)(7)(8)(9)(10)(11)(12), largely driven by reductions in added sugars from sweetened beverages (13,14). Yet despite these declining trends in added sugars, intakes remain above 10% of calories and therefore warrant continued monitoring and examination. ...
... Highest added sugars intakes have been observed among teens and younger adults (12,16,17), and Black individuals and low income groups also tend to have the highest added sugars intakes (11,12,20). Asian individuals tend to have the lowest intakes (20), and White individuals and high income groups tend to show the greatest reductions over time in added sugars intake (7,8). A rigorous examination of added sugars intake would therefore include analyses among various population subgroups in order to reveal any disparities in trends, which would be particularly relevant in the milieu of population-level interventions. ...
... From 2001 to 2018, added sugars intake declined among younger adults (19-50 years) in the U.S., while intake among older adults (51+ years) did not change. The declining trends in added sugars intake we observed are generally consistent with patterns reported in other studies among U.S. adults, encompassing a similar time span from 1999 to 2018 (7,8,(10)(11)(12), and also align with U.S. food disappearance data showing declines in per capita availability of added sugars from 2001 to 2018 (31). Our results also demonstrate that added sugars intake declined across various sociodemographic groups, defined by race and ethnicity and income, similar to observations in other studies (7,8,11,12,19,20). ...
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Research on trends over time in added sugars intake is important to help gain insights into how population intakes change with evolving dietary guidelines and policies on reducing added sugars. The purpose of this study was to provide an analysis of dietary trends in added sugars intakes and sources among U.S. adults from 2001 to 2018, with a focus on variations according to the sociodemographic factors, age, sex, race and ethnicity and income, and the health-related factors, physical activity and body weight. Data from nine consecutive 2 year cycles of the National Health and Nutrition Examination Survey (NHANES) were combined and regression analyses were conducted to test for trends in added sugars intake and sources from 2001 to 2018. Trends were examined in the whole sample (19+ years) and in subsamples stratified by age (19–50, 51+ years), sex, race and ethnicity (Asian, Black, Hispanic, White), household income (poverty income ratio low, medium, high), physical activity level (sedentary, moderate, vigorous) and body weight status (normal, overweight, obese). From 2001 to 2018, added sugars intake (% kcal) decreased significantly ( P < 0.01), from 16.2 to 12.7% among younger adults (19–50 years), mainly due to declines in added sugars from sweetened beverages, which remained the top source. There were no changes in intake among older adults, and by 2018, the 23% difference in intake between younger and older adults that existed in 2001 almost disappeared. Declines in added sugars intake were similar among Black and White individuals, and all income, physical activity and body weight groups. Population-wide reductions in added sugars intake among younger adults over an 18 year time span coincide with the increasing public health focus on reducing added sugars intake. With the updated Nutrition Facts label now displaying added sugars content, it remains to be seen how added sugars intake trends carry forward in the future.
... Most of the previous observational studies about the relationship between fat intake and obesity were cross-sectional studies [11,[14][15][16], or cohort studies [17][18][19][20][21][22][23] that only used the baseline dietary intake or dietary intake change between the baseline survey and a follow-up assessment. In the studies [11,[14][15][16][17]22,23] which only had a dietary assessment at one time, the cumulative and longitudinal effect of dietary fat intake and the effect of change in fat intake could not be estimated. ...
... Most of the previous observational studies about the relationship between fat intake and obesity were cross-sectional studies [11,[14][15][16], or cohort studies [17][18][19][20][21][22][23] that only used the baseline dietary intake or dietary intake change between the baseline survey and a follow-up assessment. In the studies [11,[14][15][16][17]22,23] which only had a dietary assessment at one time, the cumulative and longitudinal effect of dietary fat intake and the effect of change in fat intake could not be estimated. In the cohort studies [18][19][20][21] using dietary assessments at baseline and a follow-up time, the range of the change in fat intake between the baseline and the follow-up time was estimated, but the effect of the fat intake trajectory was not estimated. ...
... The increasing trend in PEF observed in our study is consistent with results of other studies in Asian population [32,33]; however, it is different from results of studies in Western population. Studies in the US adults showed that the PEF decreased from 36.6% in 1971 to 33.7% in 2006 and 33.2% in 2016 [15,16]. Among the Australian population, the PEF declined from 35.3% in 1983 to 31.9% in 1995 and 30.9% in 2012 [14]. ...
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Objectives: This study assessed the associations between long-term trajectories of percentage of energy from fat (PEF) and obesity among Chinese adults. Methods: Longitudinal data collected by the China Health and Nutrition Survey from 1991 to 2015 were analyzed. A body mass index ≥28.0 was defined as general obesity. Participants' baseline PEF levels were categorized as lower than the recommendation of the Chinese Dietary Guideline (<20%), meeting the recommendation (20-30%), and higher than the recommendation (>30%). Patterns of PEF trajectories were identified by latent class trajectory analysis for overall participants and participants in different baseline PEF groups, respectively. Cox proportional hazards regression models with shared frailty were used to estimate associations between PEF and obesity. Results: Data on 13,025 participants with 72,191 visits were analyzed. Four patterns of PEF trajectory were identified for overall participants and participants in three different baseline PEF groups, respectively. Among overall participants, compared with "Baseline Low then Increase Pattern" (from 12% to 20%), participants with "Baseline Normal-Low then Increase-to-High Pattern" (from 20% to 32%) had a higher hazard of obesity (hazard ratio (HR) and 95% confident interval (CI) at 1.18 (1.01-1.37)). Compared with the "Stable Pattern" group (stable at around 18% and 22%, respectively), participants with "Sudden-Increase Pattern" (from 18% to 30%) in the baseline group whose PEF levels were lower than the recommendation and those with "Sudden-Increase then Decrease Pattern" (rapidly increased from 25% to 40%, and then decreased) in the baseline group who met the recommendation had higher hazards of obesity (HRs and 95% CIs being 1.65 (1.13-2.41) and 1.59 (1.03-2.46), respectively). Conclusions: Adults with a trajectory that involved a sudden increase to a high-level PEF had a higher risk of general obesity. People should avoid increasing PEF suddenly.
... Carbohydrate foods (CFs), including grains, starchy roots and tubers, legumes, vegetables, and fruit, account for more than half of the dietary energy in the global food supply [1]. Research suggests that the quality of CFs can impact overall diet quality and health outcomes [2]. However, at present there are no standardized methods for assessing CF quality. ...
... That publication reviewed the current state of CF quality metrics and established several principles for developing a new scoring system for determining CF quality. The present research report advances this work by (1) introducing a more broadly applicable carbohydrate food quality scoring system, known as a Carbohydrate Food Quality Score (CFQS), and by (2) comparing two CFQS models to other measures of nutrient density (i.e., Nutrient-Rich Food (NRF) index, Nutri-Score) and carbohydrate quality (i.e., 10:1:1 carbohydrate:fiber:free sugar model of Liu et al.) [4]. ...
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Existing metrics of carbohydrate food quality have been based, for the most part, on favorable fiber- and free sugar-to-carbohydrate ratios. In these metrics, higher nutritional quality carbohydrate foods are defined as those with >10% fiber and <10% free sugar per 100 g carbohydrate. Although fiber- and sugar-based metrics may help to differentiate the nutritional quality of various types of grain products, they may not aptly capture the nutritional quality of other healthy carbohydrate foods, including beans, legumes, vegetables, and fruits. Carbohydrate food quality metrics need to be applicable across these diverse food groups. This report introduces a new carbohydrate food scoring system known as a Carbohydrate Food Quality Score (CFQS), which supplements the fiber and free sugar components of previous metrics with additional dietary components of public health concern (e.g., sodium, potassium, and whole grains) as identified by the Dietary Guidelines for Americans. Two CFQS models are developed and tested in this study: one that includes four dietary components (CFQS-4: fiber, free sugars, sodium, potassium) and one that considers five dietary components (CFQS-5: fiber, free sugars, sodium, potassium, and whole grains). These models are applied to 2596 carbohydrate foods in the Food and Nutrient Database for Dietary Studies (FNDDS) 2017–2018. Consistent with past studies, the new carbohydrate food scoring system places large percentages of beans, vegetables, and fruits among the top scoring carbohydrate foods. The whole grain component, which only applies to grain foods (N = 1561), identifies ready-to-eat cereals, oatmeal, other cooked cereals, and selected whole grain breads and crackers as higher-quality carbohydrate foods. The new carbohydrate food scoring system shows a high correlation with the Nutrient Rich Food (NRF9.3) index and the Nutri-Score. Metrics of carbohydrate food quality that incorporate whole grains, potassium, and sodium, in addition to sugar and fiber, are strategically aligned with multiple 2020–2025 dietary recommendations and may therefore help with the implementation of present and future dietary guidelines.
... High-quality and low-quality carbohydrates, high-quality and incomplete proteins, high-quality and low-quality fat were among the subtypes of carbohydrates, protein, and fat. Food sources constituting these subtypes are shown in Table 1 (15) . ...
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Objective Dietary transitions in China have undergone rapid changes in over the last three decades. The purpose of this study to describe trends in the macronutrient consumption, the sources of those nutrients, and the diet quality among Chinese adults. Design Longitudinal China Health and Nutrition Survey (CHNS) cohort analysis. Main outcomes are dietary energy intake from total carbohydrate, protein and fat and their subtypes, as well as food sources of carbohydrates, protein, and fat, and the China Dietary Guidelines Index 2018 (CDGI-2018). Setting CHNS (1991, 2000, 2009, 2015). Participants Data from the longitudinal 1991, 2000, 2009, and 2015 China Health and Nutrition Survey (CHNS) of adults aged 18 years or older, who had complete demographic information. Results The estimated mean energy intake from total carbohydrate decreased from 62.6% to 50.6% between 1991 and 2015, while the mean energy intake from total protein increased from 12.6% to just 13.1% and the mean energy intake from total fat significantly increased from 24.0% to 35.8% ( P < 0.001 for trend). Decreases were observed in evaluated mean energy from low-quality carbohydrates (from 53.6% to 41.7%) and incomplete protein (from 9.3% to 7.5%), while increases were seen in estimated mean energy from high-quality protein (from 3.3% to 5.5%), high-quality fat (from 9.1% to 16.7 %), and low-quality fat (from 14.9% to 19.0%). Low-quality carbohydrates, primarily those derived from refined grains, decreased from 52.2% to 36.2%. The diet quality as measured by CDGI-2018 improved, with the estimated mean increasing from 41.7 to 52.4 ( P < 0.01 for trend). Conclusion For Chinese adults, there was a significant change in the macronutrient composition over the previous few decades. The percentage of energy consumed from carbohydrates significantly decreased, however the percentage of energy consumed from total fat significantly increased. Additionally, the diet quality remains suboptimal.
... The NHANES is a stratified, multistage study that uses a nationally representative sample of the population of the U.S.; detailed information regarding this study has been described elsewhere [27]. For all of the participants, a home interview was followed by an examination in a mobile examination center to collect various health-and nutrition-related data. ...
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The timing of food intake can significantly alter the body’s metabolism of nutrient intake and affect the occurrence of chronic diseases. However, whether and how the intake time of dietary fiber could influence mortality risks is largely unknown. This study aims to reveal the association between total dietary fiber intake and fiber intake at different times with all-cause, cancer, and cardiovascular disease (CVD) mortality rates. A total of 31,164 adults who enrolled in the National Health and Nutrition Examination Survey from 2003 to 2014 are included in this study. Dietary fiber intake was measured using 2-day, 24 h dietary recall. The main exposures in this study were the intake of dietary fiber at breakfast, lunch, and dinner via regression analysis of the residual method. The main outcomes were the all-cause, cancer, and CVD mortality rates. Cox proportional hazards regression models were used to evaluate the survival relationship between dietary fiber intake at different times and mortality rates. Among the 31,164 adults, 2915 deaths, including 631 deaths due to cancer and 836 deaths due to CVD, were documented. Firstly, after adjusting for potential confounders, compared to the participants in the lowest quintile of total dietary fiber intake, the participants in the highest quintile of fiber intake had lower all-cause (HR = 0.686, 95% CI: 0.589–0.799, p for trend
... 14,17 Dentro de las principales fuentes de proteína se encuentran los alimentos de origen animal como pollo, carnes rojas, pescado, huevo, lácteos; lo mismo que ciertas verduras y leguminosas cuya fuente es de origen vegetal. 43 Para cubrir las necesidades tanto proteicas como energéticas, es necesario apegarse a las recomendaciones establecidas por el nutriólogo o el personal de salud a cargo. ...
Article
RESUMEN La evidencia ha actualizado las directrices del manejo nutricional en pacientes con enfermedad renal crónica (ERC); sin embargo, recomendaciones como el distanciamiento social derivado de la pandemia por SARS-CoV-2, podría implicar el aumento en la selección de alimentos industrializados, presentando un riesgo para la salud, promoviendo una ganancia de peso corporal no deseado y una mayor ingesta de sodio, potasio o fósforo, ocultos en estos productos. Dentro de las recomendaciones actuales, se sugiere ajustar el consumo de energía, macro y micronutrimentos de acuerdo con el estadio de la enfermedad a través del consumo de frutas, verduras (naturales y congeladas), cereales, leguminosas y alimentos de origen animal, entre otros; al igual que la identificación de fuentes de alimentos que sean seguras, haciendo principal énfasis en el ajuste de fósforo y potasio, así como en la aplicación de distintas técnicas de cocción, permitiendo la implementación de una dieta variada y evitando restricciones innecesarias. Una dieta basada en alimentos mínimamente procesados puede ser implementada durante un periodo de confinamiento, sin que esto implique un riesgo a la salud del paciente con ERC. ABSTRACT The evidence has updated the guidelines on nutritional management in patients with chronic kidney disease (CKD); however, recommendations such as the social distancing derived from the SARS-CoV-2 pandemic could imply an increase in the selection of industrialized foods, presenting a health risk, promoting an undesired body weight gain and a higher intake of sodium, potassium or phosphorus, hidden in these products. Within the current recommendations, it is suggested to adjust the dietary energy, macro, and micronutrients intake according to the stage of the disease through the consumption of fruits, vegetables (natural and frozen), cereals, legumes, and animal protein, among others; as well as in the identification of safe food sources, with the main emphasis on the phosphorus and potassium content, in addition the application of different cooking techniques, allowing the implementation of a varied diet and avoiding unnecessary restrictions. A diet based on minimally processed foods would be implemented during a period of confinement, without this implying a risk to the health of the CKD patient. INTRODUCCIÓN Desde principios del 2020, el mundo ha cambiado radi-calmente debido a la pandemia causada por el nuevo coronavirus, conocido como SARS-CoV-2. Las medidas preventivas han sido drásticas, incluidas las del distan-ciamiento social que ha ensombrecido nuestra dinámica del día a día. Se ha reportado que los riñones son de los principales órganos afectados por este virus, pudiendo desarrollarse lesión renal aguda (LRA) en pacientes hospitalizados en la unidad de cuidados intensivos (UCI) (> 20 % aproxima
... Participants with more than 2.5 h of exercise per week were classified as physically active. Diet quality was assessed by Healthy Eating Index 2015 (HEI−2015) and the methods have been described previously (11). Comorbidity conditions were determined to be diagnosed and/or to take prescribed medications for the disease. ...
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To clarify the association of sleep duration with all-cause and cardiovascular mortality, and further estimate the population attributable fraction (PAF) for the 10-year risk of cardiovascular disease (CVD) due to inappropriate sleep duration among US adults, we included data of the National Health and Nutrition Examination Survey (NHANES) from 2005 to 2014 by linkage to the National Death Index until December 31, 2015 in a prospective design. Cox proportional hazards models were used for multivariate longitudinal analyses. The Pooled Cohort Equations methods was adopted to calculate the predicted 10-year CVD risk. In the current study, sleep <5 h or longer than 9 h per day were significantly associated with elevated risks of all-cause mortality, and the multivariable-adjusted HRs across categories were 1.40 (95% CI, 1.14–1.71), 1.12 (95% CI, 0.91–1.38), 1 (reference), 1.35 (95% CI, 1.12–1.63), and 1.74 (95% CI, 1.42–2.12). Similarly, the HRs of cardiovascular mortality across categories were 1.66 (95% CI, 1.02–2.72), 1.15 (95% CI, 0.77–1.73), 1 (reference), 1.55 (95% CI, 1.05–2.29), and 1.81 (95% CI, 1.09–3.02). Under a causal–effect assumption, we estimated that 187 000 CVD events (PAF 1.8%, 0.9% to 2.3%) were attributable to short sleep duration and 947 000 CVD events (PAF 9.2%, 6.4% to 11.6%) were attributable to long sleep duration from 2018 to 2028. This study informed the potential benefit of optimizing the sleep duration for the primary prevention of CVD in a contemporary population.
... A multicountry analysis of trends in diabetes incidence, however, found no temporal relationship between the formal introduction of HbA1c and the decline in diabetes incidence across 21 countries [16]. Although we cannot empirically evaluate specific potential causes, improvements in physical activity [18], decreases in sedentary activity [19], and modest improvements in diet quality [20] may have ameliorated the risk of diabetes at the population level. On the other hand, the prevalence of obesity and severe obesity have continued to increase since 1999 in the United States, particularly among non-White populations [21] and the age-adjusted prevalence of prediabetes has remained relatively constant since 2005 [1], Thus, while the secular decline in LR of diabetes may reflect a positive balance of favorable changes at the population level, it represents nonetheless a crude indicator of the complex interplay between preventive measures, demographic changes, and detection bias. ...
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Background: Both incidence and mortality of diagnosed diabetes have decreased over the past decade. However, the impact of these changes on key metrics of diabetes burden-lifetime risk (LR), years of potential life lost (YPLL), and years spent with diabetes-is unknown. Methods: We used data from 653,811 adults aged ≥18 years from the National Health Interview Survey, a cross-sectional sample of the civilian non-institutionalized population in the United States. LR, YPLL, and years spent with diabetes were estimated from age 18 to 84 by survey period (1997-1999, 2000-2004, 2005-2009, 2010-2014, 2015-2018). The age-specific incidence of diagnosed diabetes and mortality were estimated using Poisson regression. A multistate difference equation accounting for competing risks was used to model each metric. Results: LR and years spent with diabetes initially increased then decreased over the most recent time periods. LR for adults at age 20 increased from 31.7% (95% CI: 31.2-32.1%) in 1997-1999 to 40.7% (40.2-41.1%) in 2005-2009, then decreased to 32.8% (32.4-33.2%) in 2015-2018. Both LR and years spent with diabetes were markedly higher among adults of non-Hispanic Black, Hispanic, and other races compared to non-Hispanic Whites. YPLL significantly decreased over the study period, with the estimated YPLL due to diabetes for an adult aged 20 decreasing from 8.9 (8.7-9.1) in 1997-1999 to 6.2 (6.1-6.4) in 2015-2018 (p = 0.02). Conclusion: In the United States, diabetes burden is declining, but disparities by race/ethnicity remain. LR remains high with approximately one-third of adults estimated to develop diabetes during their lifetime.
... Appropriate distribution of macronutrients with respect to total energy intake (45-65%, 10-35%, and 20-35% for carbohydrates, proteins, and fats, respectively), has been associated with lower risk of chronic diseases and adequate micronutrient intake [19]. However, macronutrient quality is likely to be even more important than macronutrient quantity [20,21]. ...
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Purpose To assess the association between a multi-dimensional Macronutrient Quality Index (MQI) and the risk of cardiovascular disease (CVD) in a Mediterranean cohort. Methods Prospective analyses among 18,418 participants (mean age 36 years, 60.8% women) of the Seguimiento Universidad de Navarra (SUN) cohort. Dietary intake information was obtained through a validated semi-quantitative food-frequency questionnaire (FFQ). The MQI (expressing high-quality macronutrient intake) was calculated based on three previously reported quality indices: the Carbohydrate Quality Index (CQI), the Fat Quality Index (FQI), and the Healthy Plate Protein source Quality Index (HPPQI). Adherence to the Mediterranean diet (MedDiet) and Provegetarian Diet was evaluated using the Trichopoulou index and the score proposed by Martínez-González, respectively. CVD was defined as new-onset stroke, myocardial infarction, or CVD death. Results After a median follow-up time of 14 years (211,744 person-years), 171 cases of CVD were identified. A significant inverse association was found between the MQI and CVD risk with multivariable-adjusted HR for the highest vs. the lowest quartile of 0.60 (95% IC, 0.38–0.96; Ptrend = 0.024). Conclusion In this Mediterranean cohort, we found a significant inverse relationship between a multidimensional MQI (expressing high-quality macronutrient intake) and a lower risk of CVD.
... The World Health Organization (WHO) defines regular physical activity as moderate intensity physical activity at least 150 min per week for adults (2). Healthy diet involves less sodium intake (2), less fat intake (6,7), and more intake of fruits and vegetables (8,9). Regular physical activity and healthy diet can improve blood lipid markers (10,11), lessen blood pressure (11), and improve psychological wellbeing (12). ...
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Background Implementation intention formed by making a specific action plan has been proved effective in improving physical activity (PA) and dietary behavior (DB) for the general, healthy population, but there has been no meta-analysis of their effectiveness for patients with chronic conditions. This research aims to analyze several explanatory factors and overall effect of implementation intention on behavioral and health-related outcomes among community-dwelling patients.Methods We searched CIHNAL (EBSCO), PUBMED, Web of Science, Science Direct, SAGE Online, Springer Link, Taylor & Francis, Scopus, Wiley Online Library, CNKI, and five other databases for eligible studies. Random-effects meta-analysis was conducted to estimate effect sizes of implementation intention on outcomes, including PA, DB, weight, and body mass index. And the eligible studies were assessed by the Cochrane Collaboration's tool for risk of bias assessment. Sensitivity analysis adopted sequential algorithm and the p-curve analysis method.ResultsA total of 54 studies were identified. Significant small effect sizes of the intervention were found for PA [standard mean difference (SMD) 0.24, 95% confidence interval (CI) (0.10, 0.39)] and for the DB outcome [SMD −0.25, 95% CI (−0.34, −0.15)]. In moderation analysis, the intervention was more effective in improving PA for men (p < 0.001), older adults (p = 0.006), and obese/overweight patients with complications (p = 0.048) and when the intervention was delivered by a healthcare provider (p = 0.01).Conclusion Implementation intentions are effective in improving PA and DB for community dwelling patients with chronic conditions. The review provides evidence to support the future application of implementation intention intervention. Besides, the findings from this review offer different directions to enhance the effectiveness of this brief and potential intervention in improving patients' PA and DB.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=160491.
... Protein is one of the three main nutrients that meets the body's energy needs. Between 1999 and 2016, there was an increase in the estimated consumption of protein-source products, which was associated with an increased consumption of poultry, eggs, and soy [63]. Protein requirements change with age and are dependent on the condition of the body. ...
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Sleep is a cyclically occurring, transient, and functional state that is controlled primarily by neurobiological processes. Sleep disorders and insomnia are increasingly being diagnosed at all ages. These are risk factors for depression, mental disorders, coronary heart disease, metabolic syndrome, and/or high blood pressure. A number of factors can negatively affect sleep quality, including the use of stimulants, stress, anxiety, and the use of electronic devices before sleep. A growing body of evidence suggests that nutrition, physical activity, and sleep hygiene can significantly affect the quality of sleep. The aim of this review was to discuss the factors that can affect sleep quality, such as nutrition, stimulants, and physical activity.
... The DI of carbohydrates was found to be higher from sponge gourd (9.38 g/day) whereas lower from cauliflower (1.04 g.day -1 ). The studied vegetables contributed < 1.00% for the dietary DI of carbohydrates compared to the Food Nutritional Board value as reported by Shan et al. (40). Fiber is important because it reduces the risk of chronic disease; it also has gastrointestinal benefits for health. ...
Article
Food security and protection are the most crucial concerns worldwide. However, vegetables may significantly contribute to the macro and micro-nutrients for good health compared to dietary supplements. Eight vegetables of the Larkanadivision, namely spinach (Spinacia oleracea), brinjal (Solanum melongina L.), sponge gourd (Luffa acutangula), lotus root (Lelumbo nucifera), okra (Abelmoschus esculentus), coriander leave (Coriandrum sativum), fenugreek leave (Trigonella foenum graecum), and cauliflower (Brassica oleracea) were studied for their proximate, macro and micro-mineral contents to estimate their importance in human nutrition. The results showed that almost all vegetables contain appreciable amounts of essential nutrients. All the vegetables showed moisture contents of >70.00%. Lotus and sponge gourd have a maximum level of carbohydrates (>10.00%). Fiber was found in the range of 2.70 – 5.10%, with the highest in the okra. Protein and fat were found at < 4.00%, with maximum protein in spinach and fat in fenugreek leaves. The studied vegetables showed maximum levels of K and Ca, followed by Na, Mg, Fe, Zn, and Cu while Cr and Mn were observed to be < 5.00 µg/g. The macro and micro-minerals in the studied vegetables were within the maximum permissible limits recommended by WHO. Moreover, the eight studied vegetables of the Larkana division can also provide up to 1.00% of the required dietary daily intake of macro and micro-nutrients as recommended by the Food and Nutrition Board.
... In addition, the beneficial association of marine n-3 long chain polyunsaturated fatty acids, olive oil, dietary fiber, whole grains, fruit and vegetables with depression risk has been reported in previous studies (Northstone et al., 2018;Bodnar and Wisner, 2005). It is well accepted that beside macronutrients amount, their type and quality may have diverse effects on health status (Shan et al., 2019;Noce et al., 2021;Prentice et al., 2021). ...
Article
Background Macronutrients' quality may impact differently on mental health and quality of life (QOL). This study aimed to investigate the potential relationship between the carbohydrate quality index (CQI), fat quality index (FQI), protein quality index (PQI), the affective mental symptoms and QOL among Iranian adults. Methods The LipoKAP is a cross-sectional study, conducted with 2456 adults in Iran. A validated food frequency questionnaire was used to evaluate usual dietary intakes. A validated Iranian version of the Hospital Anxiety and Depression Scale was used to assess the severity of anxiety and depression. QOL was assessed by EQ-5D. Result In the fully adjusted model, participants in the highest tertile of CQI had lower QOL than those in the lowest tertile (OR = 1.35; 95 % CI: 1.06, 1.73). Individuals in the top tertile of FQI (OR = 0.71; 95 % CI: 0.55, 0.91) and PQI (OR = 0.78; 95 % CI: 0.60; 1.01) were less likely to report lower QOL than those in the bottom tertile. An inverse association was found between PQI and depressive symptoms (OR = 0.72, 95 % CI: 0.55, 0.95), but not for CQI and FQI. Limitations The cross-sectional design of the study and the use of a memory-based dietary tool may limit the generalizability of our findings. Conclusion Higher PQI was associated with lower risk of depressive symptoms and having a low-quality life. Although CQI and FQI were not related to depressive and anxiety symptoms, higher values of FQI were associated with better QOL, while CQI showed an inverse association.
... North America has been appointed as the cradle of the socalled Western diet, characterized by high intakes of refined grains, red and processed meat, pizza and fast food, potato, sweets, sugar, and high-energy beverages. It translates in increased amount of SFA (12%), refined carbohydrates (21% refined grains, fruit juice, and potatoes), and added sugars (14.4%) (31). These dietary features have been associated with poor diet quality and are a primary cause for chronic diseases and mortality in USA (32). ...
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Non-communicable diseases (NCDs) lead to a dramatic burden on morbidity and mortality worldwide. Diet is a modifiable risk factor for NCDs, with Mediterranean Diet (MD) being one of the most effective dietary strategies to reduce diabetes, cardiovascular diseases, and cancer. Nevertheless, MD transferability to non-Mediterranean is challenging and requires a shared path between the scientific community and stakeholders. Therefore, the UNESCO Chair on Health Education and Sustainable Development is fostering a research project—“Planeterranea”—aiming to identify a healthy dietary pattern based on food products available in the different areas of the world with the nutritional properties of MD. This review aimed to collect information about eating habits and native crops in 5 macro-areas (North America, Latin America, Africa, Asia, and Australia). The information was used to develop specific “nutritional pyramids” based on the foods available in the macro-areas presenting the same nutritional properties and health benefits of MD.
... 11,12 Noteworthily, most of these recommendations are based on studies from United States and European populations, who generally have a high consumption of various dairy products (≈600 g/d) and saturated fats (11.5%-11.9% of daily energy intake), whereas little is known about Asian populations including Chinese, who typically have a low dairy intake (≈23.1 g/d), principally milk. [13][14][15] Indeed, as one of the most complex matrix in nature, dairy fat comprises several thousand lipid species. 16 Emerging evidence suggested that milk fat globule phospholipids, a functional component, may have favorable effects on gut health, obesity, and dyslipidemia. ...
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Background: Omics data may provide a unique opportunity to discover dairy-related biomarkers and their linked cardiovascular health. Methods: Dairy-related lipidomic signatures were discovered in baseline data from a Chinese cohort study (n=2140) and replicated in another Chinese study (n=212). Dairy intake was estimated by a validated food-frequency questionnaire. Lipidomics was profiled by high-coverage liquid chromatography-tandem mass spectrometry. Associations of dairy-related lipids with 6-year changes in cardiovascular risk factors were examined in the discovery cohort, and their causalities were analyzed by 2-sample Mendelian randomization using available genome-wide summary data. Results: Of 350 lipid metabolites, 4 sphingomyelins, namely sphingomyelin (OH) C32:2, sphingomyelin C32:1, sphingomyelin (2OH) C30:2, and sphingomyelin (OH) C38:2, were identified and replicated to be positively associated with total dairy consumption (β=0.130 to 0.148; P<1.43×10-4), but not or weakly with nondairy food items. The score of 4 sphingomyelins showed inverse associations with 6-yr changes in systolic (-2.68 [95% CI, -4.92 to -0.43]; P=0.019), diastolic blood pressures (-1.86 [95% CI, -3.12 to -0.61]; P=0.004), and fasting glucose (-0.25 [95% CI, -0.41 to -0.08]; P=0.003). Mendelian randomization analyses further revealed that genetically inferred sphingomyelin (OH) C32:2 was inversely associated with systolic (-0.57 [95% CI, -0.85 to -0.28]; P=9.16×10-5) and diastolic blood pressures (-0.39 [95% CI, -0.59 to -0.20]; P=7.09×10-5). Conclusions: The beneficial effects of dairy products on cardiovascular health might be mediated through specific sphingomyelins among Chinese with overall low dairy consumption.
... Consumer confusion may result when foods that are affordable, accessible, and acceptable are not the foods recommended as part of HDPs. Of the 50% of dietary energy from carbohydratecontaining foods in the U.S., the main contributors are refined grains (16% of carbohydrates) and added sugars (14% of carbohydrates) (12). These general food categories may not be helpful for describing quality. ...
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This perspective examines the utility of the glycemic index (GI) as a carbohydrate quality indicator to improve Dietary Guidelines for Americans (DGA) adherence and diet quality. Achieving affordable, high-quality dietary patterns can address multiple nutrition and health priorities. Carbohydrate-containing foods make important energy, macronutrient, micronutrient, phytochemical, and bioactive contributions to dietary patterns, thus improving carbohydrate food quality may improve diet quality. Following DGA guidance helps meet nutrient needs, achieve good health, and reduce risk for diet-related non-communicable diseases in healthy people, yet adherence by Americans is low. A simple indicator that identifies high-quality carbohydrate foods and improves food choice may improve DGA adherence, but there is no consensus on a definition. The GI is a measure of the ability of the available carbohydrate in a food to increase blood glucose. The GI is well established in research literature and popular resources, and some have called for including the GI on food labels and in food-based dietary guidelines. The GI has increased understanding about physiological responses to carbohydrate-containing foods, yet its role in food-based dietary guidance and diet quality is unresolved. A one-dimensional indicator like the GI runs the risk of being interpreted to mean foods are “good” or “bad,” and it does not characterize the multiple contributions of carbohydrate-containing foods to diet quality, including nutrient density, a core concept in the DGA. New ways to define and communicate carbohydrate food quality shown to help improve adherence to high-quality dietary patterns such as described in the DGA would benefit public health.
... The NHANES III survey was conducted by the National Center for Health Statistics (NCHS) of the Centers for Disease Control and Prevention (CDC) between 1988 and 1994, which was designed to examine the health and nutritional status of the noninstitutionalized U.S. population (33). It contains two parts of data, interviews and examinations, based on demographic, socioeconomic, dietary, health-related questions, physiological measurements, laboratory tests and other information administered by highly trained medical personnel (34). All procedures were approved by CDC's Institutional Review Board (IRB) and all study subjects provided written informed consent (35). ...
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Background Tryptophan and its metabolites have been found related to various cancers, but the direction of this relationship is still unclear. The purpose of this study is to explore the causal associations of tryptophan and kynurenine with multiple cancers based on the bidirectional Mendelian randomization analysis. Methods The data of a genome-wide association study meta-analysis on 7,824 individuals was used to explore the genetic variants strongly associated with tryptophan and kynurenine. Genetic instruments of four specific cancers were obtained from available summary-level data of 323,590 European participants. Bidirectional Mendelian randomization analysis was conducted to examine possible causality. Sensitivity analysis was performed to test heterogeneity and horizontal pleiotropy. COX regression analysis was conducted to explore associations between dietary tryptophan and cancer mortality in NHANES 1988-1994. Results No evidence of any causal association of tryptophan and kynurenine with the risk of four specific cancers was shown, except for weak correlations were suggested between lung or prostate cancer and kynurenine. Multiple sensitivity analyses generated similar results. Our findings from COX regression analysis were consistent with the above results. Conclusions Our study did not find any causal relationship between tryptophan and kynurenine and multiple cancers. The associations still need further research.
... The NHANES is a nationally representative health survey of the non-institutionalized United States population using a stratified, multistage probability design. Detailed information on NHANES has been previously provided (18). Briefly, adults (aged ≥ 30 years) who participated in NHANES from 2007 to 2014 were selected for this study ( Figure S1). ...
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Although growing evidence suggests that N,N-diethyl- m- toluamide (DEET) has adverse effects on public health, the relationship of DEET with cardiovascular disease (CVD) is still largely unknown. The purpose of this study was, therefore, to evaluate the association between DEET exposure and total and specific CVD among the US adults. In this cross-sectional study, a total of 5,972 participants were selected from the National Health and Nutrition Examination Survey (NHANES) 2007–2014. CVD was defined as a combination of congestive heart failure (CHF), coronary heart disease (CHD), angina, heart attack, or stroke. Logistic regression models were used to evaluate the association between DEET metabolites and the risks of total and specific CVD. Compared to the lowest quartile, 3-(diethylcarbamoyl) benzoic acid (DCBA) in the highest quartile was associated with the increased risks of CVD (odds ratio [OR]: 1.32, 95% CI: 1.03–1.68, P for trend = 0.025) and CHD (OR: 1.57, 95% CI: 1.10–2.25, P for trend = 0.017), after adjustment for potential covariates. Nevertheless, exposure to DCBA was not significantly associated with heart attack, CHF, angina, and stroke. Further studies are required to confirm these findings and identify the underlying mechanisms.
... The ketogenic diet (KD) is an eating pattern characterized by high fat, very low carbohydrate, and adequate protein intake. Americans typically consume roughly half of their energy intake as carbohydrate (Shan et al., 2019) which converts to glucose as the primary substrate for energy metabolism. By reducing carbohydrate intake to < 10% of total energy and increasing fat intake as the primary (65-70%) dietary macronutrient, glucose metabolism is insufficient to support global energy status and the body shifts to ketogenesis for energy production. ...
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Alzheimer’s disease (AD) is a progressive neurodegenerative condition characterized by clinical decline in memory and other cognitive functions. A classic AD neuropathological hallmark includes the accumulation of amyloid-β (Aβ) plaques, which may precede onset of clinical symptoms by over a decade. Efforts to prevent or treat AD frequently emphasize decreasing Aβ through various mechanisms, but such approaches have yet to establish compelling interventions. It is still not understood exactly why Aβ accumulates in AD, but it is hypothesized that Aβ and other downstream pathological events are a result of impaired bioenergetics, which can also manifest prior to cognitive decline. Evidence suggests that individuals with AD and at high risk for AD have functional brain ketone metabolism and ketotherapies (KTs), dietary approaches that produce ketone bodies for energy metabolism, may affect AD pathology by targeting impaired brain bioenergetics. Cognitively normal individuals with elevated brain Aβ, deemed “preclinical AD,” and older adults with peripheral metabolic impairments are ideal candidates to test whether KTs modulate AD biology as they have impaired mitochondrial function, perturbed brain glucose metabolism, and elevated risk for rapid Aβ accumulation and symptomatic AD. Here, we discuss the link between brain bioenergetics and Aβ, as well as the potential for KTs to influence AD risk and progression.
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Alkylresorcinols (ARs) are a naturally occurring homologous series of phenolipids extracted from rye bran which have previously shown antioxidant activity in lipid-containing foods. This study extends previous work to consider their use in low-moisture foods using crackers as a model system. ARs (153 μmol) were capable of inhibiting lipid oxidation reactions based on the delayed generation of lipid hydroperoxides and headspace hexanal compared to a control treatment and were more effective than α-tocopherol which displayed prooxidant behavior. The antioxidant activity of ARs was observed to increase as a function of increasing alkyl chain length, with optimum activity at an alkyl chain length of C23:0; however, ARs were lost at a rate independent of alkyl chain length. A mixture of ARs displayed comparable antioxidant activity to the C23:0 and C25:0 homologs, all of which exerted stronger activity than butylated hydroxytoluene providing an effective alternative to synthetic antioxidants. These findings suggest that ARs are effective antioxidants in low-moisture foods likely because of their hydrophobicity, which allowed them to localize in the lipid phase, the purported site of lipid oxidation in the model cracker system.
Article
Objective: Higher protein intake during weight loss is associated with better health outcomes, but whether this is because of improved diet quality is not known. The purpose of this study was to examine how the change in self-selected protein intake during caloric restriction (CR) alters diet quality and lean body mass (LBM). Methods: In this analysis of pooled data from multiple weight loss trials, 207 adults with overweight or obesity were examined before and during 6 months of CR (approximately 10 food records/person). Body composition was measured by dual-energy x-ray absorptiometry. Diet quality was assessed using the Healthy Eating Index in 2 groups: lower (LP) and higher (HP) protein intake. Results: Participants (mean [SD], 54 [11] years; 29 [4] kg/m2 ) lost 5.0% (5.4%) of weight. Protein intake was 79 (9) g/d (1.0 [0.2] g/kg/d) and 58 (6) g/d (0.8 [0.1] g/kg/d) in the HP and LP groups, respectively (p < 0.05), and there was an attenuated LBM (kilograms) loss in the HP (-0.6% [1.5%]) compared with the LP (-1.2% [1.4%]) group (p < 0.01). The increased Healthy Eating Index score in the HP compared with the LP group was attributed to greater total protein and green vegetable intake and reduced refined grain and added-sugar intake (p < 0.05). Conclusions: Increasing dietary protein during CR improves diet quality and may be another reason for reduced LBM, but it requires further study.
Chapter
Whole grains are consistently identified as an important part of a healthy diet. This article provides an overview of the definitions of whole grains and whole grain foods, recommendations for whole grain intake, and evidence for its health benefits. Specifically, the association between whole grain intake and lower risk of cardiovascular disease, type 2 diabetes, and cancer will be discussed. Additionally, the evidence for associations between whole grain intake and adiposity, blood pressure, inflammation, and the gut microbiota are described as potential mechanisms of action.
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Background & aims Although it is well known dietary factors are closely correlated with bone health, the association between macronutrients intake distribution and bone mineral density (BMD) is still unclear. The aims of this study were to investigate how macronutrients distribution was correlated with BMD, and to evaluate how the substitution between macronutrients could be associated with BMD. Methods We conducted a cross-sectional study based on data from National Health and Nutrition Examination Survey. Dietary recall method was used to assessed the intake of macronutrients. Macronutrient intake distribution including carbohydrate, protein and fat was calculated as percentages of energy intake from total energy. BMD was converted to T-score and low BMD was defined as T-score less than -1.0. The association between the percentages of energy intake from carbohydrate, protein and fat with T-score and risk of low BMD was evaluated using multivariate regression models. Isocaloric substitution analysis was conducted using the multivariate nutrient density method. Results Data form 4447 adults aged 20 years and older who underwent BMD examination were included in this study. Higher percentage of energy intake from carbohydrate was associated with lower T-score (-0.03 [95% CI, -0.05 to -0.01]; P = 0.001) and higher risk of low BMD (1.05 [95% CI, 1.02 to 1.08]; P = 0.003), while higher percentage of energy intake from protein was associated with higher T-score (0.05 [95%CI, 0.01 to 0.08]; P = 0.009) and lower odds of low BMD (0.92 [95%CI, 0.87 to 0.98]; P = 0.007). The percentage of energy intake from fat seemed to be positively correlated with T-score, but the correlation became insignificant after adjusting for metabolism related confounders. Isocaloric substitution analysis showed that only the substitution between carbohydrate and protein was significantly and independently associated with T-score (-0.05 [95%CI, -0.08 to -0.01]; P = 0.01) and the risk of low BMD (1.08 [95%CI, 1.02 to 1.15]; P = 0.008). Conclusions Based on the results from this study, we hypothesized that a high-protein diet coupled with low carbohydrate intake would be beneficiary for prevention of bone loss in adults. However, randomized clinical trials or longitudinal studies are needed to further assessed our findings.
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There is growing evidence that phthalate exposure results in a deteriorated effect on human health, while very few studies directly investigate the relationship of phthalate metabolites with mortality among people with hypertension. We aimed to explore whether exposure to phthalates is associated with cause-specific and all-cause mortality among people with hypertension. This study included 4012 people with hypertension from the National Health and Nutrition Examination Survey from 2003 to 2014. Death information was obtained from the National Death Index until 2015. A total of 577 deaths including 196 deaths due to cardiovascular disease (CVD) and 119 deaths due to cancer were documented. Cox proportional hazards regression models were used to estimate hazard ratios (HR) and 95% confidence intervals (CI). After adjustment for potential covariates, participants exposed to mono-ethyl phthalate (MEP) had a higher risk of cancer mortality (HR, 2.06; 95% CI, 1.07–3.95). Participants exposed to mono-n-butyl phthalate (MnBP) had higher risks of all-cause (HR, 1.83; 95% CI, 1.28–2.60), CVD (HR, 2.19; 95% CI, 1.21–3.95) and cancer mortality (HR, 2.35; 95% CI, 1.07–5.17). Participants exposed to mono-benzyl phthalate (MBzP) had higher risks of all-cause (HR, 2.19; 95% CI, 1.58–3.05) and CVD (HR, 2.36; 95% CI, 1.35–4.13). Participants exposed to di-2-ethylhexylphthalate (DEHP) had a higher risk of all-cause (HR, 1.69; 95% CI, 1.19–2.39). Our findings suggested that higher levels of specific phthalate were significantly associated with increased risks of all-cause, CVD, and cancer mortality among people with hypertension. Further studies are needed to confirm these findings and identify the underlying mechanisms.
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Background Dietary recommendations encourage consuming protein from a variety of plant and animal sources. Evaluating the diet of U.S. adults by level of animal protein (AP) intake can inform dietary assessment and nutrition education. Objective The objective of this cross-sectional study was to estimate percentage of total protein intake from animal sources by U.S. adults to compare diet quality, and intake from USDA Food Patterns (FP) groups by quintiles of AP. Methods One day dietary intake data from adults 20 + years (N = 9,566) in What We Eat in America (WWEIA), NHANES 2015–2018 were used. Proportions of total protein intake from animal and plant sources and the USDA FP groups were estimated from the ingredients in the Food and Nutrient Database for Dietary Studies 2015–2018, then applied to the dietary intakes. The 2015 Healthy Eating Index (HEI) was used as an indicator of diet quality. The USDA FP groups were used to describe contribution of animal and plant foods to total protein intake. Data were analyzed by quintile (Q) of AP protein intake; comparisons were made using pairwise t-tests with adjustments for covariates using survey sample weights. Results were considered significant at P < 0.001. Results Total mean protein intakes ranged from 62 (Q1)-104 grams (Q5) (All comparisons P < 0.001). Total HEI score (possible 100) of Q1 was slightly higher (54.2) (P < 0.001) compared to Q1-Q4 (range: 48.0–50.3), which did not differ significantly from each other. Contributions of plant FP components to total protein intake of Q1 to Q5, respectively were 15% to 1% from nuts/seeds, legumes, and soy products combined; 35 to 10% from grains. Contribution of animal FP components were 19–66% from meat/poultry/seafood, 14–19% dairy, 3–5% eggs. Conclusions Intake of foods considered to be good sources of plant protein was low. Overall diet quality of all adults was suboptimal regardless of plant protein intake.
Article
Diet is a critical risk factor for gastric cancer, and Koreans consume significantly high amounts of carbohydrates. This study examined the association between carbohydrate intake, glycemic index, and glycemic load and the risk of gastric cancer and whether the association varied based on the general risk factors for gastric cancer. We hypothesized that carbohydrate intake, glycemic index, and glycemic load elevated gastric cancer risk and the relationship differed by the gastric cancer risk factors. This was a case-control study with a total of 307 matched pairs aged 20-79 years. Data collection was completed at two hospitals from December 2002 to September 2006. A food frequency questionnaire was applied for dietary assessment. Carbohydrate intake was not related to gastric cancer risk. However, a high glycemic index (odds ratio (OR)= 1.88, 95% confidence interval (95% CI)= 1.18-2.97) and glycemic load (OR= 2.51, 95% CI= 1.53-4.12) were significantly associated with the elevated risk of gastric cancer. When the relationship between glycemic load and gastric cancer risk was stratified by risk factors for gastric cancer, the gastric cancer risk especially increased among men, ≥ 65 years, smokers, drinkers, and people with Helicobacter pylori infection. Although there was no association between carbohydrate consumption and gastric cancer, high glycemic index and glycemic load were associated with the increased gastric cancer risk.
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Food is not just calories; food is information. Food is a complex array of macronutrients, vitamins, minerals, and phytochemicals that upgrade or downgrade our biological software with every bite. The standard American diet lacks essential nutrients and is rich in refined flour, sugar, and inflammatory oils that drive dysbiosis, metabolic dysfunction, and chronic disease. Modern medicine focuses on diagnosing and treating disease with drugs, not creating health. Functional medicine organizes the body into a network of interconnected systems. It focuses on correcting the underlying functional imbalances that drive disease while restoring health using personalized diet, lifestyle, and nutrition interventions.
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Background Restricting dietary sugar is a leading recommendation, but limited biomarkers assessing intake exist. Although 24-h urinary sucrose (U-Suc) and urinary fructose (U-Fruc) excretion has been used with mixed success, collection is burdensome. Aim This study aimed to test the sensitivity of an enzymatic assay of U-Suc and U-Fruc to detect changing added sugar intake using low-burden overnight urine samples in 30 postmenopausal women. Methods Women consumed usual dietary intake during day 1 and usual intake plus a sugar sweetened beverage during day 2. Weighed, photographed food records assessed intake. Enzymatic assay measured U-Suc and U-Fruc from fasting overnight samples; liquid chromatography mass spectrometry (LC-MS) validated U-Suc findings. Results Dietary added sugars increased significantly during day 2 (p < 0.001), but urinary sugars were not significantly increased. Enzymatic assay detected urinary sugars in 75% (U-Suc) and 35% (U-Fruc) of samples. Dietary sucrose was not associated with U-Suc, however dietary fructose was significantly associated with U-Fruc [β = 0.031; p < 0.05] among women with detectable urinary sugars. Participants with detectable U-Fruc consumed more energy from added sugars [12.6% kcal day 1; 21.5% kcal day 2] than participants with undetectable U-Fruc [9.3% kcal day 1; 17.4% kcal day 2], p < 0.05. Using LC-MS, U-Suc predicted sucrose and added sugar intake [β = 0.017, β = 0.013 respectively; both p < 0.05]. Conclusions Urinary sugars measured enzymatically from overnight urine samples were not sensitive biomarkers of changing added sugar intake in postmenopausal women. However, urinary fructose measured by enzymatic assay or LC-MS may differentiate low versus high added sugar consumers.
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Nutrition is a corner stone of diabetes management, and should be regarded as fundamental to achieving blood glucose control. The current advice for nutrition in diabetes management is discussed, with a focus on body weight, macro and micro nutrients, foods and food groups, dietary patterns, and the lifestyle context. More recent evidence on topics such as body weight and dietary patterns indicate flexibility in what can be recommended, which enables patient preference and may aid adherence. Importantly, a healthy diet for those with diabetes is also appropriate to recommend for their families and the general population.
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Background Sustainable plant-, algal-, and fungal-based alternative foods are required to feed the growing human population. The quality of such alternative foods depends not only on the nutrient content, but also on the amino acid composition and protein digestibility. The assessment of protein digestibility is typically considered at the level of ingredients, but these are blended and processed to formulate palatable foods. Scope and approach This review highlights the importance of nutritional quality in alternative foods by focusing on protein digestibility at the level of blends and formulated products. We consider the effects of processing on protein digestibility and the important role of the food matrix. Finally, we consider the colonic fermentation of undigested protein and the role of fiber in alternative foods. Key findings and conclusions Few studies have investigated protein digestibility after the blending and processing of ingredients derived from alternative protein sources or compared protein digestibility between animal-based and alternative food products. We find that processing can increase or decrease the in vitro protein digestibility of alternative foods, or in some cases has no effect. The architecture of the food matrix after processing requires further investigation as a determinant of protein digestibility-related food quality. Furthermore, the mastication of food has a significant impact on its protein digestibility, but most in vitro models do not include this step. To promote the production of beneficial metabolites during colonic fermentation, undigested protein should be accompanied by dietary fiber, even if this partially compromises the digestibility of the protein.
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The association between acrylamide (AA) and the development of cancer has been extensively discussed but the results remained controversial, especially in population studies. Large prospective epidemiological studies on the relationship of AA exposure with cancer mortality were still lacking. Therefore, we aimed to assess the association between AA biomarkers and cancer mortality in adult population from National Health and Nutrition Examination Survey (NHANES) 2003-2014. We followed 3717 participants for an average of 10.3 years. Cox regression models with multivariable adjustments were performed to determine the relationship of acrylamide hemoglobin adduct (HbAA) and glycidamide hemoglobin adduct (HbGA) with cancer mortality. Mediation analysis was conducted to demonstrate the mediated role of low-grade inflammation score (INFLA-score) in this correlation. Compared with the lowest quintile, participants with the highest quintile of HbAA, HbGA and HbAA+HbGA had increased cancer mortality risk, and the hazard ratios(HRs) were 2.07 (95%CI:1.04-4.14) for HbAA, 2.39 (95%CI:1.29-4.43) for HbGA and 2.48 (95%CI:1.28-4.80) for HbAA+HbGA, respectively. And there was a considerable non-linearity association between HbAA and cancer mortality ( p for non-linearity = 0.0139). We further found that increased INFLA-score significantly mediated 71.67% in the effect of HbGA exposure on increased cancer mortality risk. This study demonstrates that hemoglobin biomarkers of AA are positively associated with cancer mortality in adult American population and INFLA-score plays a mediated role in this process. Our findings can raise public awareness of environmental and dietary exposure to acrylamide and remind people to refrain from smoking or having acrylamide-rich foods.
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Context The sleep quality has been related to the risk of diabetes; however, little is known about the prevalence of diabetes in the U.S according to the levels of sleep quality. Objective To examine the joint secular trends of the overall sleep quality and diabetes among US adults from 2005-2006 to 2017-2018. Design Seven cycles of cross-sectional National Health and Nutrition Examination Survey (NHANES) data between 2005-2006 to 2017-2018. Setting Nationally representative population-based data. Participants Nonpregnant adults aged 20 years or older were eligible for the study. Exposures Survey cycle. Main Outcome A healthy sleep score was calculated to represent an overall sleep quality. The estimated prevalence of diabetes and mean levels of fasting plasma glucose (FPG), glycated hemoglobin, and insulin resistance. Results Both the estimated age-standardized prevalence of diabetes and changing trend in prevalence of diabetes varied by the overall sleep quality groups. The highest prevalence of diabetes was consistently observed in the low sleep quality group in each cycle, in which a significantly increasing trend was also noted across cycles (P-trend=0.004). In contrast, the lowest prevalence of diabetes was consistently observed in the high sleep quality group in each cycle, in which no increasing trend over time was observed (P-trend=0.346). Conclusions The overall sleep quality decreased significantly between 2005-2006 and 2017-2018 among US adults. The estimated prevalence of diabetes and related measures only increased in participants with low or medium overall sleep quality but remained stable in participants with high sleep quality.
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Background: Systematic analysis of dietary protein intake may identify demographic groups within the American population that are not meeting the Dietary Reference Intakes (DRIs). Objective: This cross-sectional study analyzed protein intake trends (2001-2014) and evaluated recent conformity to the DRIs (2011-2014) according to age, sex, and race or ethnicity in the US population. Design: Protein intakes and trends during 2-y cycles of NHANES 2001-2014 (n = 57,980; ≥2 y old) were calculated as absolute (grams per day) and relative [grams per kilogram of ideal body weight (IBW) per day] intakes and as a percentage of total energy. Sex and race or ethnicity [Asian, Hispanic, non-Hispanic black (NHB), and non-Hispanic white (NHW)] differences were determined for protein intake and percentage of the population below the Estimated Average Requirement (EAR) and Recommended Dietary Allowance, and above and below the Acceptable Macronutrient Distribution Range (AMDR). Results: Usual protein intakes (mean ± SE) averaged from 55.3 ± 0.9 (children aged 2-3 y) to 88.2 ± 1.1 g/d (adults aged 19-30 y). Protein comprised 14-16% of total energy intakes. Relative protein intakes averaged from 1.10 ± 0.01 (adults aged ≥71 y) to 3.63 ± 0.07 g · kg IBW-1 · d-1 (children aged 2-3 y), and were above the EAR in all demographic groups. Asian and Hispanic populations aged >19 y consumed more relative protein (1.32 ± 0.02 and 1.32 ± 0.02 g · kg IBW-1 · d-1, respectively) than did NHB and NHW (1.18 ± 0.01 g · kg IBW-1 · d-1). Relative protein intakes did not differ by race or ethnicity in the 2-18 y population. Adolescent (aged 14-18 y) females and older (aged ≥71 y) NHB men had the largest population percentages below the EAR (11% and 13%, respectively); <1% of any demographic group had intakes above the AMDR. Conclusions: The majority of the US population exceeds minimum recommendations for protein intake. Protein intake remains well below the upper end of the AMDR, indicating that protein intake, as a percentage of energy intake, is not excessive in the American diet. This trial was registered at www.isrctn.com as ISRCTN76534484.
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David S Ludwig and colleagues examine the links between different types of carbohydrates and health © Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to.
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Background: The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of risk factor exposure and attributable burden of disease. By providing estimates over a long time series, this study can monitor risk exposure trends critical to health surveillance and inform policy debates on the importance of addressing risks in context. Methods: We used the comparative risk assessment framework developed for previous iterations of GBD to estimate levels and trends in exposure, attributable deaths, and attributable disability-adjusted life-years (DALYs), by age group, sex, year, and location for 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks from 1990 to 2016. This study included 481 risk-outcome pairs that met the GBD study criteria for convincing or probable evidence of causation. We extracted relative risk (RR) and exposure estimates from 22 717 randomised controlled trials, cohorts, pooled cohorts, household surveys, census data, satellite data, and other sources, according to the GBD 2016 source counting methods. Using the counterfactual scenario of theoretical minimum risk exposure level (TMREL), we estimated the portion of deaths and DALYs that could be attributed to a given risk. Finally, we explored four drivers of trends in attributable burden: population growth, population ageing, trends in risk exposure, and all other factors combined. Findings: Since 1990, exposure increased significantly for 30 risks, did not change significantly for four risks, and decreased significantly for 31 risks. Among risks that are leading causes of burden of disease, child growth failure and household air pollution showed the most significant declines, while metabolic risks, such as body-mass index and high fasting plasma glucose, showed significant increases. In 2016, at Level 3 of the hierarchy, the three leading risk factors in terms of attributable DALYs at the global level for men were smoking (124·1 million DALYs [95% UI 111·2 million to 137·0 million]), high systolic blood pressure (122·2 million DALYs [110·3 million to 133·3 million], and low birthweight and short gestation (83·0 million DALYs [78·3 million to 87·7 million]), and for women, were high systolic blood pressure (89·9 million DALYs [80·9 million to 98·2 million]), high body-mass index (64·8 million DALYs [44·4 million to 87·6 million]), and high fasting plasma glucose (63·8 million DALYs [53·2 million to 76·3 million]). In 2016 in 113 countries, the leading risk factor in terms of attributable DALYs was a metabolic risk factor. Smoking remained among the leading five risk factors for DALYs for 109 countries, while low birthweight and short gestation was the leading risk factor for DALYs in 38 countries, particularly in sub-Saharan Africa and South Asia. In terms of important drivers of change in trends of burden attributable to risk factors, between 2006 and 2016 exposure to risks explains an 9·3% (6·9-11·6) decline in deaths and a 10·8% (8·3-13·1) decrease in DALYs at the global level, while population ageing accounts for 14·9% (12·7-17·5) of deaths and 6·2% (3·9-8·7) of DALYs, and population growth for 12·4% (10·1-14·9) of deaths and 12·4% (10·1-14·9) of DALYs. The largest contribution of trends in risk exposure to disease burden is seen between ages 1 year and 4 years, where a decline of 27·3% (24·9-29·7) of the change in DALYs between 2006 and 2016 can be attributed to declines in exposure to risks. Interpretation: Increasingly detailed understanding of the trends in risk exposure and the RRs for each risk-outcome pair provide insights into both the magnitude of health loss attributable to risks and how modification of risk exposure has contributed to health trends. Metabolic risks warrant particular policy attention, due to their large contribution to global disease burden, increasing trends, and variable patterns across countries at the same level of development. GBD 2016 findings show that, while it has huge potential to improve health, risk modification has played a relatively small part in the past decade. Funding: The Bill & Melinda Gates Foundation, Bloomberg Philanthropies.
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Dietary guidelines suggest consuming a mixed-protein diet, consisting of high-quality animal, dairy, and plant-based foods. However, current data on the distribution and the food sources of protein intake in a free-living, representative sample of US adults are not available. Data from the National Health and Nutrition Examination Survey (NHANES), 2007-2010, were used in these analyses (n = 10,977, age ≥ 19 years). Several US Department of Agriculture (USDA) databases were used to partition the composition of foods consumed into animal, dairy, or plant components. Mean ± SE animal, dairy, and plant protein intakes were determined and deciles of usual intakes were estimated. The percentages of total protein intake derived from animal, dairy, and plant protein were 46%, 16%, and 30%, respectively; 8% of intake could not be classified. Chicken and beef were the primary food sources of animal protein intake. Cheese, reduced-fat milk, and ice cream/dairy desserts were primary sources of dairy protein intake. Yeast breads, rolls/buns, and nuts/seeds were primary sources of plant protein intake. This study provides baseline data for assessing the effectiveness of public health interventions designed to alter the composition of protein foods consumed by the American public.
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Objective To investigate the association between dietary protein sources in early adulthood and risk of breast cancer. Design Prospective cohort study. Setting Health professionals in the United States. Participants 88 803 premenopausal women from the Nurses’ Health Study II who completed a questionnaire on diet in 1991. Main outcome measure Incident cases of invasive breast carcinoma, identified through self report and confirmed by pathology report. Results We documented 2830 cases of breast cancer during 20 years of follow-up. Higher intake of total red meat was associated with an increased risk of breast cancer overall (relative risk 1.22, 95% confidence interval 1.06 to 1.40; Ptrend=0.01, for highest fifth v lowest fifth of intake). However, higher intakes of poultry, fish, eggs, legumes, and nuts were not related to breast cancer overall. When the association was evaluated by menopausal status, higher intake of poultry was associated with a lower risk of breast cancer in postmenopausal women (0.73, 0.58 to 0.91; Ptrend=0.02, for highest fifth v lowest fifth of intake) but not in premenopausal women (0.93, 0.78 to 1.11; Ptrend=0.60, for highest fifth v lowest fifth of intake). In estimating the effects of exchanging different protein sources, substituting one serving/day of legumes for one serving/day of red meat was associated with a 15% lower risk of breast cancer among all women (0.85, 0.73 to 0.98) and a 19% lower risk among premenopausal women (0.81, 0.66 to 0.99). Also, substituting one serving/day of poultry for one serving/day of red meat was associated with a 17% lower risk of breast cancer overall (0.83, 0.72 to 0.96) and a 24% lower risk of postmenopausal breast cancer (0.76, 0.59 to 0.99). Furthermore, substituting one serving/day of combined legumes, nuts, poultry, and fish for one serving/day of red meat was associated with a 14% lower risk of breast cancer overall (0.86, 0.78 to 0.94) and premenopausal breast cancer (0.86, 0.76 to 0.98). Conclusion Higher red meat intake in early adulthood may be a risk factor for breast cancer, and replacing red meat with a combination of legumes, poultry, nuts and fish may reduce the risk of breast cancer.
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In the past couple of decades, evidence from prospective observational studies and clinical trials has converged to support the importance of individual nutrients, foods, and dietary patterns in the prevention and management of type 2 diabetes. The quality of dietary fats and carbohydrates consumed is more crucial than is the quantity of these macronutrients. Diets rich in wholegrains, fruits, vegetables, legumes, and nuts; moderate in alcohol consumption; and lower in refined grains, red or processed meats, and sugar-sweetened beverages have been shown to reduce the risk of diabetes and improve glycaemic control and blood lipids in patients with diabetes. With an emphasis on overall diet quality, several dietary patterns such as Mediterranean, low glycaemic index, moderately low carbohydrate, and vegetarian diets can be tailored to personal and cultural food preferences and appropriate calorie needs for weight control and diabetes prevention and management. Although much progress has been made in development and implementation of evidence-based nutrition recommendations in developed countries, concerted worldwide efforts and policies are warranted to alleviate regional disparities.
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The US Department of Agriculture Automated Multiple-Pass Method (AMPM) is used for collecting 24-h dietary recalls in What We Eat In America, the dietary interview component of the National Health and Nutrition Examination Survey. Because the data have important program and policy applications, it is essential that the validity of the method be tested. The accuracy of the AMPM was evaluated by comparing reported energy intake (EI) with total energy expenditure (TEE) by using the doubly labeled water (DLW) technique. The 524 volunteers, aged 30-69 y, included an equal number of men and women recruited from the Washington, DC, area. Each subject was dosed with DLW on the first day of the 2-wk study period; three 24-h recalls were collected during the 2-wk period by using the AMPM. The first recall was conducted in person, and subsequent recalls were over the telephone. Overall, the subjects underreported EI by 11% compared with TEE. Normal-weight subjects [body mass index (in kg/m(2)) < 25] underreported EI by <3%. By using a linear mixed model, 95% CIs were determined for the ratio of EI to TEE. Approximately 78% of men and 74% of women were classified as acceptable energy reporters (within 95% CI of EI:TEE). Both the percentage by which energy was underreported and the percentage of subjects classified as low energy reporters (<95% CI of EI:TEE) were highest for subjects classified as obese (body mass index > 30). Although the AMPM accurately reported EIs in normal-weight subjects, research is warranted to enhance its accuracy in overweight and obese persons.
Article
Background: Previous systematic reviews and meta-analyses explaining the relationship between carbohydrate quality and health have usually examined a single marker and a limited number of clinical outcomes. We aimed to more precisely quantify the predictive potential of several markers, to determine which markers are most useful, and to establish an evidence base for quantitative recommendations for intakes of dietary fibre. Methods: We did a series of systematic reviews and meta-analyses of prospective studies published from database inception to April 30, 2017, and randomised controlled trials published from database inception to Feb 28, 2018, which reported on indicators of carbohydrate quality and non-communicable disease incidence, mortality, and risk factors. Studies were identified by searches in PubMed, Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials, and by hand searching of previous publications. We excluded prospective studies and trials reporting on participants with a chronic disease, and weight loss trials or trials involving supplements. Searches, data extraction, and bias assessment were duplicated independently. Robustness of pooled estimates from random-effects models was considered with sensitivity analyses, meta-regression, dose-response testing, and subgroup analyses. The GRADE approach was used to assess quality of evidence. Findings: Just under 135 million person-years of data from 185 prospective studies and 58 clinical trials with 4635 adult participants were included in the analyses. Observational data suggest a 15-30% decrease in all-cause and cardiovascular related mortality, and incidence of coronary heart disease, stroke incidence and mortality, type 2 diabetes, and colorectal cancer when comparing the highest dietary fibre consumers with the lowest consumers Clinical trials show significantly lower bodyweight, systolic blood pressure, and total cholesterol when comparing higher with lower intakes of dietary fibre. Risk reduction associated with a range of critical outcomes was greatest when daily intake of dietary fibre was between 25 g and 29 g. Dose-response curves suggested that higher intakes of dietary fibre could confer even greater benefit to protect against cardiovascular diseases, type 2 diabetes, and colorectal and breast cancer. Similar findings for whole grain intake were observed. Smaller or no risk reductions were found with the observational data when comparing the effects of diets characterised by low rather than higher glycaemic index or load. The certainty of evidence for relationships between carbohydrate quality and critical outcomes was graded as moderate for dietary fibre, low to moderate for whole grains, and low to very low for dietary glycaemic index and glycaemic load. Data relating to other dietary exposures are scarce. Interpretation: Findings from prospective studies and clinical trials associated with relatively high intakes of dietary fibre and whole grains were complementary, and striking dose-response evidence indicates that the relationships to several non-communicable diseases could be causal. Implementation of recommendations to increase dietary fibre intake and to replace refined grains with whole grains is expected to benefit human health. A major strength of the study was the ability to examine key indicators of carbohydrate quality in relation to a range of non-communicable disease outcomes from cohort studies and randomised trials in a single study. Our findings are limited to risk reduction in the population at large rather than those with chronic disease. Funding: Health Research Council of New Zealand, WHO, Riddet Centre of Research Excellence, Healthier Lives National Science Challenge, University of Otago, and the Otago Southland Diabetes Research Trust.
Article
Background: The Healthy Eating Index (HEI), a diet quality index that measures alignment with the Dietary Guidelines for Americans, was updated with the 2015-2020 Dietary Guidelines for Americans. Objective and design: To evaluate the psychometric properties of the HEI-2015, eight questions were examined: five relevant to construct validity, two related to reliability, and one to assess criterion validity. Data sources: Three data sources were used: exemplary menus (n=4), National Health and Nutrition Examination Survey 2011-2012 (N=7,935), and the National Institutes of Health-AARP (formally known as the American Association of Retired Persons) Diet and Health Study (N=422,928). Statistical analyses: Exemplary menus: Scores were calculated using the population ratio method. National Health and Nutrition Examination Survey 2011-2012: Means and standard errors were estimated using the Markov Chain Monte Carlo approach. Analyses were stratified to compare groups (with t tests and analysis of variance). Principal components analysis examined the number of dimensions. Pearson correlations were estimated between components, energy, and Cronbach's coefficient alpha. National Institutes of Health-AARP Diet and Health Study: Adjusted Cox proportional hazards models were used to examine scores and mortality outcomes. Results: For construct validity, the HEI-2015 yielded high scores for exemplary menus as four menus received high scores (87.8 to 100). The mean score for National Health and Nutrition Examination Survey was 56.6, and the first to 99th percentile were 32.6 to 81.2, respectively, supporting sufficient variation. Among smokers, the mean score was significantly lower than among nonsmokers (53.3 and 59.7, respectively) (P<0.01), demonstrating differentiation between groups. The correlation between diet quality and diet quantity was low (all <0.25) supporting these elements being independent. The components demonstrated multidimensionality when examined with a scree plot (at least four dimensions). For reliability, most of the intercorrelations among the components were low to moderate (0.01 to 0.49) with a few exceptions, and the standardized Cronbach's alpha was .67. For criterion validity, the highest vs the lowest quintile of HEI-2015 scores were associated with a 13% to 23% decreased risk of all-cause, cancer, and cardiovascular disease mortality. Conclusions: The results demonstrated evidence supportive of construct validity, reliability, and criterion validity. The HEI-2015 can be used to examine diet quality relative to the 2015-2020 Dietary Guidelines for Americans.
Article
Introduction Several studies have measured health outcomes in the United States, but none have provided a comprehensive assessment of patterns of health by state. Objective To use the results of the Global Burden of Disease Study (GBD) to report trends in the burden of diseases, injuries, and risk factors at the state level from 1990 to 2016. Design and Setting A systematic analysis of published studies and available data sources estimates the burden of disease by age, sex, geography, and year. Main Outcomes and Measures Prevalence, incidence, mortality, life expectancy, healthy life expectancy (HALE), years of life lost (YLLs) due to premature mortality, years lived with disability (YLDs), and disability-adjusted life-years (DALYs) for 333 causes and 84 risk factors with 95% uncertainty intervals (UIs) were computed. Results Between 1990 and 2016, overall death rates in the United States declined from 745.2 (95% UI, 740.6 to 749.8) per 100 000 persons to 578.0 (95% UI, 569.4 to 587.1) per 100 000 persons. The probability of death among adults aged 20 to 55 years declined in 31 states and Washington, DC from 1990 to 2016. In 2016, Hawaii had the highest life expectancy at birth (81.3 years) and Mississippi had the lowest (74.7 years), a 6.6-year difference. Minnesota had the highest HALE at birth (70.3 years), and West Virginia had the lowest (63.8 years), a 6.5-year difference. The leading causes of DALYs in the United States for 1990 and 2016 were ischemic heart disease and lung cancer, while the third leading cause in 1990 was low back pain, and the third leading cause in 2016 was chronic obstructive pulmonary disease. Opioid use disorders moved from the 11th leading cause of DALYs in 1990 to the 7th leading cause in 2016, representing a 74.5% (95% UI, 42.8% to 93.9%) change. In 2016, each of the following 6 risks individually accounted for more than 5% of risk-attributable DALYs: tobacco consumption, high body mass index (BMI), poor diet, alcohol and drug use, high fasting plasma glucose, and high blood pressure. Across all US states, the top risk factors in terms of attributable DALYs were due to 1 of the 3 following causes: tobacco consumption (32 states), high BMI (10 states), or alcohol and drug use (8 states). Conclusions and Relevance There are wide differences in the burden of disease at the state level. Specific diseases and risk factors, such as drug use disorders, high BMI, poor diet, high fasting plasma glucose level, and alcohol use disorders are increasing and warrant increased attention. These data can be used to inform national health priorities for research, clinical care, and policy.
Article
In this Minireview, we provide an epidemiologist's perspective on the debate and recent advances in determining the relationship between diet and cardiovascular health. We conclude that, in order to reduce the global burden of cardiovascular disease, there should be a greater emphasis on improving overall diet quality and food sources of macronutrients, such as dietary fats and carbohydrates. In addition, building a strong evidence base through high-quality intervention and observational studies is crucial for effective policy changes, which can greatly improve the food environment and population health. In this Minireview, Pan et al. provide a nutritional epidemiologic perspective on the recent debate and advances in determining the relationship between diet and cardiovascular health. To reduce the global cardiovascular disease burden, high-quality intervention and observational studies are needed to inform policies to improve overall diet quality and dietary sources of fats and carbohydrates.
Article
Cardiovascular disease (CVD) is the leading global cause of death, accounting for 17.3 million deaths per year. Preventive treatment that reduces CVD by even a small percentage can substantially reduce, nationally and globally, the number of people who develop CVD and the costs of caring for them. This American Heart Association presidential advisory on dietary fats and CVD reviews and discusses the scientific evidence, including the most recent studies, on the effects of dietary saturated fat intake and its replacement by other types of fats and carbohydrates on CVD. In summary, randomized controlled trials that lowered intake of dietary saturated fat and replaced it with polyunsaturated vegetable oil reduced CVD by ≈30%, similar to the reduction achieved by statin treatment. Prospective observational studies in many populations showed that lower intake of saturated fat coupled with higher intake of polyunsaturated and monounsaturated fat is associated with lower rates of CVD and of other major causes of death and all-cause mortality. In contrast, replacement of saturated fat with mostly refined carbohydrates and sugars is not associated with lower rates of CVD and did not reduce CVD in clinical trials. Replacement of saturated with unsaturated fats lowers low-density lipoprotein cholesterol, a cause of atherosclerosis, linking biological evidence with incidence of CVD in populations and in clinical trials. Taking into consideration the totality of the scientific evidence, satisfying rigorous criteria for causality, we conclude strongly that lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, will lower the incidence of CVD. This recommended shift from saturated to unsaturated fats should occur simultaneously in an overall healthful dietary pattern such as DASH (Dietary Approaches to Stop Hypertension) or the Mediterranean diet as emphasized by the 2013 American Heart Association/American College of Cardiology lifestyle guidelines and the 2015 to 2020 Dietary Guidelines for Americans.
Article
Importance: Defining what represents a macronutritionally balanced diet remains an open question and a high priority in nutrition research. Although the amount of protein may have specific effects, from a broader dietary perspective, the choice of protein sources will inevitably influence other components of diet and may be a critical determinant for the health outcome. Objective: To examine the associations of animal and plant protein intake with the risk for mortality. Design, setting, and participants: This prospective cohort study of US health care professionals included 131 342 participants from the Nurses' Health Study (1980 to end of follow-up on June 1, 2012) and Health Professionals Follow-up Study (1986 to end of follow-up on January 31, 2012). Animal and plant protein intake was assessed by regularly updated validated food frequency questionnaires. Data were analyzed from June 20, 2014, to January 18, 2016. Main outcomes and measures: Hazard ratios (HRs) for all-cause and cause-specific mortality. Results: Of the 131 342 participants, 85 013 were women (64.7%) and 46 329 were men (35.3%) (mean [SD] age, 49 [9] years). The median protein intake, as assessed by percentage of energy, was 14% for animal protein (5th-95th percentile, 9%-22%) and 4% for plant protein (5th-95th percentile, 2%-6%). After adjusting for major lifestyle and dietary risk factors, animal protein intake was weakly associated with higher mortality, particularly cardiovascular mortality (HR, 1.08 per 10% energy increment; 95% CI, 1.01-1.16; P for trend = .04), whereas plant protein was associated with lower mortality (HR, 0.90 per 3% energy increment; 95% CI, 0.86-0.95; P for trend < .001). These associations were confined to participants with at least 1 unhealthy lifestyle factor based on smoking, heavy alcohol intake, overweight or obesity, and physical inactivity, but not evident among those without any of these risk factors. Replacing animal protein of various origins with plant protein was associated with lower mortality. In particular, the HRs for all-cause mortality were 0.66 (95% CI, 0.59-0.75) when 3% of energy from plant protein was substituted for an equivalent amount of protein from processed red meat, 0.88 (95% CI, 0.84-0.92) from unprocessed red meat, and 0.81 (95% CI, 0.75-0.88) from egg. Conclusions and relevance: High animal protein intake was positively associated with mortality and high plant protein intake was inversely associated with mortality, especially among individuals with at least 1 lifestyle risk factor. Substitution of plant protein for animal protein, especially that from processed red meat, was associated with lower mortality, suggesting the importance of protein source.
Article
Importance: Most studies of US dietary trends have evaluated major macronutrients or only a few dietary factors. Understanding trends in summary measures of diet quality for multiple individual foods and nutrients, and the corresponding disparities among population subgroups, is crucial to identify challenges and opportunities to improve dietary intake for all US adults. Objective: To characterize trends in overall diet quality and multiple dietary components related to major diseases among US adults, including by age, sex, race/ethnicity, education, and income. Design, setting, and participants: Repeated cross-sectional investigation using 24-hour dietary recalls in nationally representative samples including 33 932 noninstitutionalized US adults aged 20 years or older from 7 National Health and Nutrition Examination Survey (NHANES) cycles (1999-2012). The sample size per cycle ranged from 4237 to 5762. Exposures: Calendar year and population sociodemographic subgroups. Main outcomes and measures: Survey-weighted, energy-adjusted mean consumption and proportion meeting targets of the American Heart Association (AHA) 2020 continuous diet scores, AHA score components (primary: total fruits and vegetables, whole grains, fish and shellfish, sugar-sweetened beverages, and sodium; secondary: nuts, seeds, and legumes, processed meat, and saturated fat), and other individual food groups and nutrients. Results: Several overall dietary improvements were identified (P < .01 for trend for each). The AHA primary diet score (maximum of 50 points) improved from 19.0 to 21.2 (an improvement of 11.6%). The AHA secondary diet score (maximum of 80 points) improved from 35.1 to 38.5 (an improvement of 9.7%). Changes were attributable to increased consumption between 1999-2000 and 2011-2012 of whole grains (0.43 servings/d; 95% CI, 0.34-0.53 servings/d) and nuts or seeds (0.25 servings/d; 95% CI, 0.18-0.34 servings/d) (fish and shellfish intake also increased slightly) and to decreased consumption of sugar-sweetened beverages (0.49 servings/d; 95% CI, 0.28-0.70 servings/d). No significant trend was observed for other score components, including total fruits and vegetables, processed meat, saturated fat, or sodium. The estimated percentage of US adults with poor diets (defined as <40% adherence to the primary AHA diet score components) declined from 55.9% to 45.6%, whereas the percentage with intermediate diets (defined as 40% to 79.9% adherence to the primary AHA diet score components) increased from 43.5% to 52.9%. Other dietary trends included increased consumption of whole fruit (0.15 servings/d; 95% CI, 0.05-0.26 servings/d) and decreased consumption of 100% fruit juice (0.11 servings/d; 95% CI, 0.04-0.18 servings/d). Disparities in diet quality were observed by race/ethnicity, education, and income level; for example, the estimated percentage of non-Hispanic white adults with a poor diet significantly declined (53.9% to 42.8%), whereas similar improvements were not observed for non-Hispanic black or Mexican American adults. There was little evidence of reductions in these disparities and some evidence of worsening by income level. Conclusions and relevance: In nationally representative US surveys conducted between 1999 and 2012, several improvements in self-reported dietary habits were identified, with additional findings suggesting persistent or worsening disparities based on race/ethnicity, education level, and income level. These findings may inform discussions on emerging successes, areas for greater attention, and corresponding opportunities to improve the diets of individuals living in the United States.
Article
During 1971-2000, the prevalence of obesity in the United States increased from 14.5% to 30.9%.¹ Unhealthy diets and sedentary behaviors have been identified as the primary causes of deaths attributable to obesity.² Evaluating trends in dietary intake is an important step in understanding the factors that contribute to the increase in obesity. To assess trends in intake of energy (i.e., kilocalories [kcals]), protein, carbohydrate, total fat, and saturated fat during 1971-2000, CDC analyzed data from four National Health and Nutrition Examination Surveys (NHANES): NHANES I (conducted during 1971-1974), NHANES II (1976-1980), NHANES III (1988-1994), and NHANES 1999-2000. This report summarizes the results of that analysis, which indicate that, during 1971-2000, mean energy intake in kcals increased, mean percentage of kcals from carbohydrate increased, and mean percentage of kcals from total fat and saturated fat decreased (Figures 1 and 2). An expert advisory committee appointed by the U.S. Department of Health and Human Services and the U.S. Department of Agriculture (USDA) is conducting a review of the Dietary Guidelines for Americans.³ Revised guidelines will be published in 2005.
Article
For almost 50 y, the US National Health and Nutrition Examination Survey (NHANES) has measured the caloric consumption, and body heights and weights of Americans. The aim of this study was to determine, based on that data, how macronutrient consumption patterns and the weight and body mass index in the US adult population have evolved since the 1960s. We conducted the first comprehensive analysis of the NHANES data, documenting how macronutrient consumption patterns and the weight and body mass index in the US adult population have evolved since the 1960s. Americans in general have been following the nutrition advice that the American Heart Association and the US Departments of Agriculture and Health and Human Services have been issuing for more than 40 y: Consumption of fats has dropped from 45% to 34% with a corresponding increase in carbohydrate consumption from 39% to 51% of total caloric intake. In addition, from 1971 to 2011, average weight and body mass index have increased dramatically, with the percentage of overweight or obese Americans increasing from 42% in 1971 to 66% in 2011. Since 1971, the shift in macronutrient share from fat to carbohydrate is primarily due to an increase in absolute consumption of carbohydrate as opposed to a change in total fat consumption. General adherence to recommendations to reduce fat consumption has coincided with a substantial increase in obesity. Copyright © 2015 Elsevier Inc. All rights reserved.
Article
Importance: Many changes in the economy, policies related to nutrition, and food processing have occurred within the United States since 2000, and the net effect on dietary quality is not clear. These changes may have affected various socioeconomic groups differentially. Objective: To investigate trends in dietary quality from 1999 to 2010 in the US adult population and within socioeconomic subgroups. Design, setting, and participants: Nationally representative sample of 29 124 adults aged 20 to 85 years from the US 1999 to 2010 National Health and Nutrition Examination Survey. Main outcomes and measures: The Alternate Healthy Eating Index 2010 (AHEI-2010), an 11-dimension score (range, 0-10 for each component score and 0-110 for the total score), was used to measure dietary quality. A higher AHEI-2010 score indicated a more healthful diet. Results: The energy-adjusted mean of the AHEI-2010 increased from 39.9 in 1999 to 2000 to 46.8 in 2009 to 2010 (linear trend P < .001). Reduction in trans fat intake accounted for more than half of this improvement. The AHEI-2010 component score increased by 0.9 points for sugar-sweetened beverages and fruit juice (reflecting decreased consumption), 0.7 points for whole fruit, 0.5 points for whole grains, 0.5 points for polyunsaturated fatty acids, and 0.4 points for nuts and legumes over the 12-year period (all linear trend P < .001). Family income and education level were positively associated with total AHEI-2010, and the gap between low and high socioeconomic status widened over time, from 3.9 points in 1999 to 2000 to 7.8 points in 2009 to 2010 (interaction P = .01). Conclusions and relevance: Although a steady improvement in AHEI-2010 was observed across the 12-year period, the overall dietary quality remains poor. Better dietary quality was associated with higher socioeconomic status, and the gap widened with time. Future efforts to improve nutrition should address these disparities.
Article
The imperative to address the national obesity epidemic has stimulated efforts to develop accurate dietary assessment methods suitable for large-scale applications. This study evaluated the performance of the USDA Automated Multiple- Pass Method (AMPM), the computerized dietary recall designed for the National Health and Nutrition Examination Survey dietary survey, and 2 epidemiological methods (the Block food-frequency questionnaire (Block) and National Cancer Institute's Diet History Questionnaire (DHQ)) using doubly labeled water (DLW) total energy expenditure (TEE) and 14-d estimated food record (FR) absolute nutrient intake as criterion measures. Twenty highly motivated, normal-weight-stable, premenopausal women participated in a free-living study that included 2 unannounced AMPM recalls and completion of the Block and DHQ. AMPM and FR total energy intake (TEI) did not differ significantly from DLW TEE (AMPM: 8982 6 2625 kJ; FR: 8416 6 2217; DLW: 8905 6 1881 (mean 6 SD)). Conversely, the questionnaires underestimated TEI by ;28% (Block: 6365 6 2193; DHQ: 6215 6 1976; P , 0.0001 vs. DLW). Pearson correlation coefficients for DLW TEE with each dietary method TEI showed a stronger linear relation for AMPM (r ¼ 0.53; P ¼ 0.02) and FR (r ¼ 0.41; P ¼ 0.07) than for the Block (r ¼ 0.25; P ¼ 0.29) and DHQ (r ¼ 0.15; P ¼ 0.53). Most mean absolute FR nutrient intakes were closely approximated by the AMPM but were significantly underestimated by the questionnaires. In highly motivated premenopausal women, the AMPM provides valid measures of group total energy and nutrient intake whereas the Block and DHQ yield underestimations. J. Nutr. 136: 2594-2599, 2006.
Article
With the exception of fish, few major dietary protein sources have been studied in relation to the development of coronary heart disease (CHD). Our objective was to examine the relation between foods that are major dietary protein sources and incident CHD. We prospectively followed 84,136 women aged 30 to 55 years in the Nurses' Health Study with no known cancer, diabetes mellitus, angina, myocardial infarction, stroke, or other cardiovascular disease. Diet was assessed by a standardized and validated questionnaire and updated every 4 years. During 26 years of follow-up, we documented 2210 incident nonfatal infarctions and 952 deaths from CHD. In multivariable analyses including age, smoking, and other risk factors, higher intakes of red meat, red meat excluding processed meat, and high-fat dairy were significantly associated with elevated risk of CHD. Higher intakes of poultry, fish, and nuts were significantly associated with lower risk. In a model controlling statistically for energy intake, 1 serving per day of nuts was associated with a 30% (95% confidence interval, 17% to 42%) lower risk of CHD compared with 1 serving per day of red meat. Similarly, compared with 1 serving per day of red meat, a lower risk was associated with 1 serving per day of low-fat dairy (13%; 95% confidence interval, 6% to 19%), poultry (19%; 95% confidence interval, 3% to 33%), and fish (24%; 95% confidence interval, 6% to 39%). These data suggest that high red meat intake increases risk of CHD and that CHD risk may be reduced importantly by shifting sources of protein in the US diet.
Article
This document details the procedures and recommendations of the Goals and Metrics Committee of the Strategic Planning Task Force of the American Heart Association, which developed the 2020 Impact Goals for the organization. The committee was charged with defining a new concept, cardiovascular health, and determining the metrics needed to monitor it over time. Ideal cardiovascular health, a concept well supported in the literature, is defined by the presence of both ideal health behaviors (nonsmoking, body mass index <25 kg/m(2), physical activity at goal levels, and pursuit of a diet consistent with current guideline recommendations) and ideal health factors (untreated total cholesterol <200 mg/dL, untreated blood pressure <120/<80 mm Hg, and fasting blood glucose <100 mg/dL). Appropriate levels for children are also provided. With the use of levels that span the entire range of the same metrics, cardiovascular health status for the whole population is defined as poor, intermediate, or ideal. These metrics will be monitored to determine the changing prevalence of cardiovascular health status and define achievement of the Impact Goal. In addition, the committee recommends goals for further reductions in cardiovascular disease and stroke mortality. Thus, the committee recommends the following Impact Goals: "By 2020, to improve the cardiovascular health of all Americans by 20% while reducing deaths from cardiovascular diseases and stroke by 20%." These goals will require new strategic directions for the American Heart Association in its research, clinical, public health, and advocacy programs for cardiovascular health promotion and disease prevention in the next decade and beyond.
Article
Some weight loss diets promote protein intake; however, the association of protein with disease is unclear. In 1986, 29,017 postmenopausal Iowa women without cancer, coronary heart disease (CHD), or diabetes were followed prospectively for 15 years for cancer incidence and mortality from CHD, cancer, and all causes. Mailed questionnaires assessed dietary, lifestyle, and medical information. Nutrient density models estimated risk ratios from a simulated substitution of total and type of dietary protein for carbohydrate and of vegetable for animal protein. The authors identified 4,843 new cancers, 739 CHD deaths, 1,676 cancer deaths, and 3,978 total deaths. Among women in the highest intake quintile, CHD mortality decreased by 30% from an isoenergetic substitution of vegetable protein for carbohydrate (95% confidence interval (CI): 0.49, 0.99) and of vegetable for animal protein (95% CI: 0.51, 0.98), following multivariable adjustment. Although no association was observed with any outcome when animal protein was substituted for carbohydrate, CHD mortality was associated with red meats (risk ratio = 1.44, 95% CI: 1.06, 1.94) and dairy products (risk ratio = 1.41, 95% CI: 1.07, 1.86) when substituted for servings per 1,000 kcal (4.2 MJ) of carbohydrate foods. Long-term adherence to high-protein diets, without discrimination toward protein source, may have potentially adverse health consequences.
Article
The imperative to address the national obesity epidemic has stimulated efforts to develop accurate dietary assessment methods suitable for large-scale applications. This study evaluated the performance of the USDA Automated Multiple-Pass Method (AMPM), the computerized dietary recall designed for the National Health and Nutrition Examination Survey dietary survey, and 2 epidemiological methods [the Block food-frequency questionnaire (Block) and National Cancer Institute's Diet History Questionnaire (DHQ)] using doubly labeled water (DLW) total energy expenditure (TEE) and 14-d estimated food record (FR) absolute nutrient intake as criterion measures. Twenty highly motivated, normal-weight-stable, premenopausal women participated in a free-living study that included 2 unannounced AMPM recalls and completion of the Block and DHQ. AMPM and FR total energy intake (TEI) did not differ significantly from DLW TEE [AMPM: 8982 +/- 2625 kJ; FR: 8416 +/- 2217; DLW: 8905 +/- 1881 (mean +/- SD)]. Conversely, the questionnaires underestimated TEI by approximately 28% (Block: 6365 +/- 2193; DHQ: 6215 +/- 1976; P < 0.0001 vs. DLW). Pearson correlation coefficients for DLW TEE with each dietary method TEI showed a stronger linear relation for AMPM (r = 0.53; P = 0.02) and FR (r = 0.41; P = 0.07) than for the Block (r = 0.25; P = 0.29) and DHQ (r = 0.15; P = 0.53). Most mean absolute FR nutrient intakes were closely approximated by the AMPM but were significantly underestimated by the questionnaires. In highly motivated premenopausal women, the AMPM provides valid measures of group total energy and nutrient intake whereas the Block and DHQ yield underestimations.
Article
We propose a new statistical method that uses information from two 24-hour recalls to estimate usual intake of episodically consumed foods. The method developed at the National Cancer Institute (NCI) accommodates the large number of nonconsumption days that occur with foods by separating the probability of consumption from the consumption-day amount, using a two-part model. Covariates, such as sex, age, race, or information from a food frequency questionnaire, may supplement the information from two or more 24-hour recalls using correlated mixed model regression. The model allows for correlation between the probability of consuming a food on a single day and the consumption-day amount. Percentiles of the distribution of usual intake are computed from the estimated model parameters. The Eating at America's Table Study data are used to illustrate the method to estimate the distribution of usual intake for whole grains and dark-green vegetables for men and women and the distribution of usual intakes of whole grains by educational level among men. A simulation study indicates that the NCI method leads to substantial improvement over existing methods for estimating the distribution of usual intake of foods. The NCI method provides distinct advantages over previously proposed methods by accounting for the correlation between probability of consumption and amount consumed and by incorporating covariate information. Researchers interested in estimating the distribution of usual intakes of foods for a population or subpopulation are advised to work with a statistician and incorporate the NCI method in analyses.
Article
This article examines how faith in science led physicians and patients to embrace the low-fat diet for heart disease prevention and weight loss. Scientific studies dating from the late 1940s showed a correlation between high-fat diets and high-cholesterol levels, suggesting that a low-fat diet might prevent heart disease in high-risk patients. By the 1960s, the low-fat diet began to be touted not just for high-risk heart patients, but as good for the whole nation. After 1980, the low-fat approach became an overarching ideology, promoted by physicians, the federal government, the food industry, and the popular health media. Many Americans subscribed to the ideology of low fat, even though there was no clear evidence that it prevented heart disease or promoted weight loss. Ironically, in the same decades that the low-fat approach assumed ideological status, Americans in the aggregate were getting fatter, leading to what many called an obesity epidemic. Nevertheless, the low-fat ideology had such a hold on Americans that skeptics were dismissed. Only recently has evidence of a paradigm shift begun to surface, first with the challenge of the low-carbohydrate diet and then, with a more moderate approach, reflecting recent scientific knowledge about fats.
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