Identifying and Estimating Ultraprocessed Food Intake in the US NHANES According to the Nova Classification System of Food Processing.

BACKGROUND: The degree of food processing may be an important dimension of diet in how it relates to health outcomes. A major challenge is standardizing food processing classification systems for commonly used datasets. OBJECTIVES: To standardize and increase transparency in its application, we describe the approach used to classify foods and beverages according to the Nova food processing classification in the 24-h dietary recalls from the 2001-2018 cycles of What We Eat in America (WWEIA), NHANES, and investigate variability and potential for Nova misclassification within WWEIA, NHANES 2017-2018 data via various sensitivity analyses. METHODS: First, we described how the Nova classification system was applied to the 2001-2018 WWEIA, NHANES data using the reference approach. Second, we calculated the percentage energy from Nova groups [1: unprocessed or minimally processed foods, 2: processed culinary ingredients, 3: processed foods, and 4: ultraprocessed foods (UPFs)] for the reference approach using day 1 dietary recall data from non-breastfed participants aged ≥1 y from the 2017-2018 WWEIA, NHANES. We then conducted 4 sensitivity analyses comparing potential alternative approaches (e.g., opting for more vs. less degree of processing for ambiguous items) to the reference approach, to assess how estimates differed. RESULTS: The energy contribution of UPFs using the reference approach was 58.2% ± 0.9% of the total energy; unprocessed or minimally processed foods contributed 27.6% ± 0.7%, processed culinary ingredients contributed 5.2% ± 0.1%, and processed foods contributed 9.0% ± 0.3%. In sensitivity analyses, the dietary energy contribution of UPFs ranged from 53.4% ± 0.8% to 60.1% ± 0.8% across alternative approaches. CONCLUSIONS: We present a reference approach for applying the Nova classification system to WWEIA, NHANES 2001-2018 data to promote standardization and comparability of future research. Alternative approaches are also described, with total energy from UPFs differing by ∼6% between approaches for 2017-2018 WWEIA, NHANES.

Adherence to Federal Dietary Recommendations for Total Fruit Consumption and the Intake of Underconsumed Nutrients: Findings from the National Health and Nutrition Examination Survey, 2015 to 2018.

BACKGROUND: A persistent gap exists between U.S. consumers' actual fruit consumption and Federal dietary recommendations for fruit. Individuals who most deviate from recommendations may be at a greater risk of underconsuming some nutrients. OBJECTIVE: We investigated how widely total fruit consumption varies across adult consumers and whether those who most deviate from recommendations also consume less vitamins A and C, calcium, magnesium, and potassium. The 2020 Dietary Guidelines Advisory Committee has identified each of these nutrients as being underconsumed by the U.S. population in general. METHODS: Data used were from the NHANES, 2015 to 2016 and 2017 to 2018 cycles. For 9832 adults (age >18), we compared their total fruit consumption to recommendations for their age and sex. We also calculated 2015 Healthy Eating Index (HEI-2015) scores. Component scores for Total Fruit and Whole Fruit were subtracted from the total HEI-2015 scores to measure adherence with dietary recommendations outside the fruit group. Two-way and 3-way contingency tables were then used to measure the association between adherence to fruit recommendations and the intake of underconsumed nutrients before and after controlling for adherence to other food group recommendations, respectively. RESULTS: About two-thirds of adults eat less than half the recommended amount of fruit on any given day. Those who routinely unconsume fruit may be at a greater risk of underconsuming potassium and vitamin C. Calcium, magnesium, and vitamin A consumption do not show a consistent relationship with fruit intake relative to recommendations after controlling for diet quality outside the fruit group. CONCLUSIONS: There is much variation across the U.S. population in fruit consumption relative to recommendations. The present study suggests that individuals who deviate the most are at a particularly increased risk of underconsuming vitamin C and potassium.

Application of the Database of Flavonoid Values for USDA Food Codes 2007-2010 in Assessing Intake Differences Between the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) Study and What We Eat in America (WWEIA), NHANES.

Flavonoids are polyphenolic plant compounds whose biological activities may promote human health. It is worthwhile to examine whether flavonoid intake varies between populations with differing prevalence of diet-related diseases. This study compared flavonoid intakes in the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study with nationally representative estimates from What We Eat in America (WWEIA), NHANES stratified by sex, age (30-49, 50-64 years), and poverty status (income <125%, >125% of the 2004 HHS Poverty Guidelines). Flavonoid intakes from both surveys were estimated using the Database of Flavonoid Values for USDA Food Codes 2007-2010. Across all subpopulations analyzed, intake of anthocyanidins was lower in HANDLS (p<0.01). Intakes of total flavonoids and all or most flavonoid classes were lower in HANDLS for men overall and in both age groups and for both men and women with poverty status <125%. These findings of lower flavonoid intakes in HANDLS, particularly among men and those with the lowest incomes, suggest that flavonoid intake may be a factor in the high prevalence of diet-related disease in populations represented by HANDLS. This research illustrates how any survey using USDA's food codes can utilize the Flavonoid Database in comparing flavonoid intakes.

Dairy and Fruit Listed as Main Ingredients Improve NRF8.3 Nutrient Density Scores of Children's Snacks.

Background: The US Food and Drug Administration has modified its regulations on nutrient content claims by considering healthy dietary ingredients as well as nutrients. Objective: To assess the relation between dairy and fruit as main ingredients in children's snacks and the Nutrient Rich Food (NRF8.3) nutrient density score. Methods: Commonly consumed children's snacks in the United States, Canada, France, and the United Kingdom (n = 261) were assigned into USDA What We Eat in America (WWEI) categories. Nutrient composition data came from industry websites, open-source government databases (USDA Standard Reference SR28; CIQUAL), and back-of-pack food labels. Nutrient density was calculated using the Nutrient Rich Food Index NRF8.3. Snacks with dairy or fruit as the first listed ingredient (n = 115) were compared to those that listed neither (n = 146). Snacks that contained fruits-vegetables-nuts (FVN) (n = 88) were compared to those that did not (n = 173). Results: NRF8.3 scores were higher for snacks listing dairy or fruit as main ingredients. Dairy or fruit when listed as the first ingredient were associated with higher percent daily values of protein, fiber, calcium, vitamin A, vitamin C, and vitamin D, lower saturated fat content and a 30-point increment in NRF8.3 scores. The presence of FVN was associated with a 22-point increment in NRF8.3 scores. Conclusion: The correspondence between back-of-pack food ingredients and the nutrient based NRF8.3 scores suggests that ingredients can also be used to communicate the nutritional value of foods to the consumer. Dairy and fruit, when listed as first ingredients, were an important component of the NRF8.3 nutrient density score.

Trends in linoleic acid intake in the United States adult population: NHANES 1999-2014.

Linoleic acid (LA), the primary polyunsaturated fatty acid (PUFA) in the US diet, is an essential fatty acid. LA is available from a wide variety of foods, although it is primarily sourced from plant seed oils. Individual-level data on demography and food and nutrient intake were acquired from the NHANES waves 1999-2000, 2001-2002, 2003-2004, 2005-2006, 2007-2008, 2009-2010, 2011-2012, and 2013-2014. Mean daily intake of (LA) was estimated for each survey wave overall, and by age, gender, educational attainment, race/ethnicity, and income-to-poverty ratio. Linear temporal (1999-2014) trends in LA intake were estimated using univariate linear regression tests, with P < 0.05 and a two-tailed distribution. We found that US adults meet intake recommendation for LA and observed a trend of increasing intake of LA in the US overall and by sub-categories of age, sex, education, race/ethnicity, and income-to-poverty ratio.

Dietary Cholesterol Intake and Sources among U.S Adults: Results from National Health and Nutrition Examination Surveys (NHANES), 2001⁻2014.

The 2015 Dietary Guidelines for Americans recommends that individuals should minimize their dietary cholesterol intake. However, current dietary cholesterol intake and its food sources have not been well-characterized. We examined dietary cholesterol intake by age, sex, race, and food sources using 24-h dietary recall data from a nationally representative sample of 5047 adults aged 20 years or older who participated in NHANES (2013⁻2014 survey cycle). We also reported trends in cholesterol intake across the past seven NHANES surveys. Mean dietary cholesterol intake was 293 mg/day (348 mg/day for men and 242 mg/day for women) in the 2013⁻2014 survey cycle; 39% of adults had dietary cholesterol intake above 300 mg/day (46% for men and 28% for women). Meat, eggs, grain products, and milk were the highest four food sources of cholesterol, contributing to 96% of the total consumption. Both average cholesterol intake and food source varied by age, sex, and race (each p < 0.05). Mean cholesterol intake of the overall population had been relatively constant at ~290 mg/day from 2001⁻2002 to 2013⁻2014 (p-trend = 0.98). These results should inform public health efforts in implementing dietary guidelines and tailoring dietary recommendations.

Calculating Intake of Dietary Risk Components Used in the Global Burden of Disease Studies from the What We Eat in America/National Health and Nutrition Examination Surveys.

Disability adjusted life years (DALYs) is a health burden metric that combines years of life lost due to disease disability and premature mortality. The Global Burden of Disease (GBD) has been using DALYs to determine the health burden associated with numerous health risks, including risks associated with dietary intakes, at the global and national level. To translate such information at the food level in the U.S., variables in What We Eat in America (WWEIA) need to be aligned with those in the GBD. In this paper, we develop the necessary new variables needed to account for differences in definitions and units between WWEIA and the GBD. We use the Food Patterns Equivalents Database, Food Patterns Equivalents Ingredient Database, Food and Nutrient Database for Dietary Studies, and Standard Reference databases that provide data for WWEIA to develop food group and nutrient variables that align with definitions and units used in the GBD. Considerable effort was needed to disaggregate mixed dishes to GBD components. We also developed a new "non-starchy" vegetable variable, since the GBD vegetables do not include potatoes and corn, and we report fruits and vegetables in grams instead of household measures. New fiber variables were created to avoid double counting of fiber from legumes, whole grains, fruits, and vegetables. Regression analyses were used to predict trans-fat content for foods in WWEIA with missing or incomplete information. The majority of foods in various U.S. Department of Agriculture (USDA) categories contain multiple GBD food groups (e.g., vegetables, whole grains, and processed meat). For most nutrients considered in the GBD, composition is more evenly distributed across the main food categories; however, seafood omega-3 fats were predominantly from either protein foods or mixed dishes and sugar sweetened beverages were from a single category. Dietary intakes in the U.S. fall short of recommendations for all food groups/nutrients with established theoretical minimum-risk targets in GBD. To our knowledge, this is the first approach that aligns WWEIA intake variables with those used in the health burden-based GBD reports. These methods will facilitate researchers to begin comparing data from the U.S. with that from other countries, as well as assess food sustainability performances by concomitantly evaluating DALYs for environmental and nutritional impacts.

Study design for a clinical trial to examine food price elasticity among participants in federal food assistance programs: A laboratory-based grocery store study.

We present a protocol for a study investigating the effect of food price changes on purchasing decisions among individuals participating in federal food assistance programs and among those not participating in these programs. We use a laboratory-based grocery store design, which provides greater control over factors influencing food purchasing than in situ experiments in actual grocery stores. We focus primarily, but not exclusively, on eggs because they are highly nutritious, easy to prepare, can be included in many different dishes, and are a part of a wide range of cultural food menus. The primary aim of this study is to compare the own-and cross-price elasticity of eggs between individuals participating in federal food assistance programs and those not participating in these programs. Our secondary aims are to 1) compare the own- and cross-price elasticity of eggs between overweight/obese individuals and non-overweight/obese individuals, 2) examine whether delay discounting moderates the effect of income on own- and cross-price elasticity, 3) examine whether subjective social status moderates the effect of participation in federal food assistance programs on the purchase of high nutrient-dense foods, and 4) examine whether usual psychological stress level moderates the effect of subjective social status on the purchase of high-nutrient dense foods. The results of this study will provide information about the drivers of food demand among low-income adults. A better understanding of these drivers is needed to develop effective nutrition interventions for this large population.

Dietary Sources of Phosphorus among Adults in the United States: Results from NHANES 2001-2014.

Interest in the health effects of dietary phosphorus is burgeoning, yet sources and trends in phosphorus consumption have not been well characterized. We describe trends in and primary sources of dietary phosphorus in a nationally representative sample of 34,741 US adults, 20+ years old (NHANES 2001-2014). Dietary sources of phosphorus were estimated in nine food groups and 26 food categories. Phosphorus consumption was expressed in absolute intake, phosphorus density, and proportion contributed by dietary sources. Between 2001 and 2014, dietary phosphorus intake increased from 1345 to 1399 mg/day (p-trend = 0.02), while calorie intake slightly declined (p-trend = 0.1). Grains were the largest dietary phosphorus source, followed by meats, and milk products. Soft drinks accounted for just 3.3% of total dietary phosphorus. Phosphorus intake from grains increased 68 mg/day (p < 0.001), 25 mg/day from meats (p = 0.02), and decreased 75 mg/day (p < 0.001) from milk products. Dietary phosphorus intake and the phosphorus density of the diet are increasing. Grains are an important dietary phosphorus source that has increased in total consumption and phosphorus density. Further research is needed to determine if this is due to individuals' selection of grains or the composition of those available.

Relationship of the Reported Intakes of Fat and Fatty Acids to Body Weight in US Adults.

Dietary fat composition may modulate energy expenditure and body weight. Little is known about the relationship between fatty acid intake and body weight at a population level. The purposes of this study were to compare intakes of energy, macronutrients, and individual fatty acids across BMI categories (1) for the US adult population and, (2) by sociodemographic groups. Reported dietary intake data from the National Health and Nutrition Examination Survey (NHANES) and What We Eat in America (WWEIA) surveys in the years 2005-2012 were analyzed. Overall, we found that the reported intake of carbohydrate, protein, total fat, total saturated fat (as well as long-chain saturated fatty acids 14:0-18:0), and monounsaturated fatty acids (MUFAs) were positively associated with BMI; while lauric acid (a medium-chain saturated fatty acid, 12:0) and total polyunsaturated fatty acids (PUFAs) (as well as all individual PUFAs) were not associated with BMI. Non-Hispanic black individuals demonstrated a negative association between BMI and energy intake and a positive association between total PUFAs, linoleic acid (LA), α-linolenic acid (ALA) and BMI. Individuals with less than a high school education showed a negative association between BMI and DHA. Mexican-Americans reported intakes with no association between BMI and energy, any macronutrient, or individual fatty acids. These findings support those of experimental studies demonstrating fatty acid-dependent associations between dietary fatty acid composition and body weight. Notably, we observed divergent results for some sociodemographic groups which warrant further investigation.

Nutritional adequacy of dietary intake in women with anorexia nervosa.

Understanding nutrient intake of anorexia nervosa (AN) patients is essential for the treatment. Therefore, estimates of total energy and nutrient consumption were made in a group of young women (19 to 30 years) with restricting and binge purge subtypes of AN participating in an ecological momentary assessment study. Participants completed three nonconsecutive 24-hour diet recalls. Mean nutrient intakes were stratified by subtype and by quartiles of energy intake and compared to the age specific Dietary Reference Intake (DRI) levels, as well as to the reported intakes from the What We Eat In America (WWEIA) dietary survey 2011-2012. Reported intake was determined for energy, macronutrients, and micronutrients. The mean body mass index (BMI) for all participants was 17.2 ± 0.1 kg/m2. Reported nutrient intake was insufficient for participants in quartiles 1-3 of both AN subtypes when compared to the DRIs. Intake reported by participants in quartile 4 of both subgroups met requirements for most nutrients and even met or exceeded estimated energy needs. Counseling of AN patients should be directed to total food consumption to improve energy intake and to reduce individual nutritional gaps.

Towards Measuring the Food Quality of Grocery Purchases: an Estimation Model of the Healthy Eating Index-2010 Using only Food Item Counts.

Measuring the quality of food consumed by individuals or groups in the U.S. is essential to informed public health surveillance efforts and sound nutrition policymaking. For example, the Healthy Eating Index-2010 (HEI) is an ideal metric to assess the food quality of households, but the traditional methods of collecting the data required to calculate the HEI are expensive and burdensome. We evaluated an alternative source: rather than measuring the quality of the foods consumers eat, we want to estimate the quality of the foods consumers buy. To accomplish that we need a way of estimating the HEI based solely on the count of food items. We developed an estimation model of the HEI, using an augmented set of the What We Eat In America (WWEIA) food categories. Then we mapped ~92,000 grocery food items to it. The model uses an inverse Cumulative Distribution Function sampling technique. Here we describe the model and report reliability metrics based on NHANES data from 2003-2010.

Dietary intakes of pesticides based on community duplicate diet samples.

The calculation of dietary intake of selected pesticides was accomplished using food samples collected from individual representatives of a defined demographic community using a community duplicate diet approach. A community of nine participants was identified in Apopka, FL from which intake assessments of organophosphate (OP) and pyrethroid pesticides were made. From these nine participants, sixty-seven individual samples were collected and subsequently analyzed by gas chromatography/mass spectrometry. Measured concentrations were used to estimate dietary intakes for individuals and for the community. Individual intakes of total OP and pyrethroid pesticides ranged from 6.7 to 996 ng and 1.2 to 16,000 ng, respectively. The community intake was 256 ng for OPs and 3430 ng for pyrethroid pesticides. The most commonly detected pesticide was permethrin, but the highest overall intake was of bifenthrin followed by esfenvalerate. These data indicate that the community in Apopka, FL, as represented by the nine individuals, was potentially exposed to both OP and pyrethroid pesticides at levels consistent with a dietary model and other field studies in which standard duplicate diet samples were collected. Higher levels of pyrethroid pesticides were measured than OPs, which is consistent with decreased usage of OPs. The diversity of pyrethroid pesticides detected in food samples was greater than expected. Continually changing pesticide usage patterns need to be considered when determining analytes of interest for large scale epidemiology studies. The Community Duplicate Diet Methodology is a tool for researchers to meet emerging exposure measurement needs that will lead to more accurate assessments of intake which may enhance decisions for chemical regulation. Successfully determining the intake of pesticides through the dietary route will allow for accurate assessments of pesticide exposures to a community of individuals, thereby significantly enhancing the research benefit realized from epidemiological exposure studies.

Methods for calculating dietary energy density in a nationally representative sample.

There has been a growing interest in examining dietary energy density (ED, kcal/g) as it relates to various health outcomes. Consuming a diet low in ED has been recommended in the 2010 Dietary Guidelines, as well as by other agencies, as a dietary approach for disease prevention. Translating this recommendation into practice; however, is difficult. Currently there is no standardized method for calculating dietary ED; as dietary ED can be calculated with foods alone, or with a combination of foods and beverages. Certain items may be defined as either a food or a beverage (e.g., meal replacement shakes) and require special attention. National survey data are an excellent resource for evaluating factors that are important to dietary ED calculation. The National Health and Nutrition Examination Survey (NHANES) nutrient and food database does not include an ED variable, thus researchers must independently calculate ED. The objective of this study was to provide information that will inform the selection of a standardized ED calculation method by comparing and contrasting methods for ED calculation. The present study evaluates all consumed items and defines foods and beverages based on both USDA food codes and how the item was consumed. Results are presented as mean EDs for the different calculation methods stratified by population demographics (e.g. age, sex). Using United State Department of Agriculture (USDA) food codes in the 2005-2008 NHANES, a standardized method for calculating dietary ED can be derived. This method can then be adapted by other researchers for consistency across studies.