The Validity of Urine Color as a Hydration Biomarker within the General Adult Population and Athletes: A Systematic Review.

Frequent monitoring of hydration status may help to avoid the adverse effects of dehydration. Other than urine color assessment, hydration assessment methods are largely impractical for the general population and athletes to implement on a routine basis. Despite its widespread use, the validity of urine color as an indicator of hydration status has not been systematically evaluated. The objective of this systematic review is to determine the validity of urine color evaluation as a hydration status assessment method in the general adult population, older adults, and athletes. Using the PRISMA guidelines, electronic databases were searched to identify original research articles of all study design types for inclusion. Of the 424 articles screened, 10 met inclusion criteria. Most studies compared urine color to either urinary specific gravity or urine osmolality, and reported significant associations (r) ranging from 0.40 to 0.93. Lower correlations were noted in studies of adults aged >60 years. Studies generally reported a high sensitivity of urine color as a diagnostic tool for detecting dehydration and supported the ability of this method to distinguish across categories of hydration status. Research is needed to determine if clinicians, patients, and clients can accurately utilize this method in clinical and real-world settings. Future research is also needed to extend these findings to other populations, such as children.Key teaching pointsInadequate hydration can lead to impairments in physical performance and cognitive function.Methods used to assess hydration status include plasma/serum osmolality, urinary specific gravity (USG), urine osmolality (Uosm), change in body weight, urine volume, and urine color.Urine color assessment is a practical method that is routinely used in clinical, athletic, and other settings. The validity of this method has not been systemically evaluated.Available research was limited to 10 articles.Validity of this method was generally supported; however, research has not investigated the validity of this method by clinicians, patients and clients.

Awareness and outcomes of the fruits and veggies (FNV) campaign to promote fruit and vegetable consumption among targeted audiences in California and Virginia: a cross-sectional study.

BACKGROUND: In 2015, the Partnership for a Healthier America launched the branded Fruits & Veggies (FNV) Campaign to apply a unique industry-inspired marketing approach to promote fruit and vegetable sales and intake to moms and teens in two US pilot markets: Fresno, California and Hampton Roads, Virginia. The aims of this cross-sectional study were to: 1) assess brand awareness and fruit- and vegetable-related outcomes among FNV Campaign target audiences in the California and Virginia market locations; and 2) examine whether reported awareness of the FNV Campaign was associated with differences in fruit- and vegetable-related cognitive and behavioral outcomes. METHODS: Data for this cross-sectional study were collected using an online survey administered to a non-probability convenience sample (n = 1604; February-July 2017) of youth aged 14-20 years (n = 744) and moms aged 21-36 years (n = 860) in the two pilot markets. Descriptive statistics were computed and outcomes compared between unaware and aware respondents, controlling for sociodemographic covariates. Multivariate analysis of covariance (MANCOVA) was conducted to assess whether fruit- and vegetable-related attitude, belief, and encouragement outcomes differed by FNV Campaign awareness; logistic regression was used to examine associations between FNV brand awareness and dichotomous variables (fruit- and vegetable-related behavioral intentions, trying new fruits and vegetables); and ANCOVA was used to assess associations with daily fruit and vegetable intake frequency. RESULTS: Approximately 20% (n = 315/1604) of respondents reported awareness of the FNV Campaign. Youth that reported awareness of the FNV Campaign (n = 167, 22.4%) had higher intentions to buy (p = 0.003) and eat (p = 0.009) fruits and vegetables than unaware respondents. Mothers that reported awareness of the FNV Campaign (n = 148, 17.2%) reported greater encouragement for friends and family to eat fruits and vegetables (p = 0.013) and were approximately 1.5 times more likely to report trying a new fruit or vegetable (p = 0.04) than mothers unaware of the Campaign. Daily fruit and vegetable intake frequency did not differ by Campaign awareness. CONCLUSIONS: FNV Campaign awareness was associated with limited but positive short- and intermediate-term cognitive and behavioral outcomes among target audience respondents. These findings can inform future research to enhance understanding and improve the FNV Campaign as it is expanded to new markets nationwide.

Evaluation of Pragmatic Methods to Rapidly Assess Habitual Beverage Intake and Hydration Status in U.S. Collegiate Athletes.

Fluid intake recommendations have been established for the athletic population in order to promote adequate hydration. The Beverage Intake Questionnaire (BEVQ-15) is a quick and reliable food frequency questionnaire that quantifies habitual beverage intake, which has been validated in children, adolescents, and adults. However, no validated beverage consumption questionnaire is available for collegiate athletes. Urine color (UC), while feasible for determining hydration status, has not been validated within a variety of collegiate athletes. The purpose of this investigation was to evaluate the comparative validity and reliability of pragmatic methods to rapidly assess BEVQ-15 and UC rating in U.S. Division I collegiate athletes. Student-athletes (n = 120; 54% females; age 19 ± 1 years) from two universities were recruited to complete three study sessions. At the first and third sessions, the participants completed the BEVQ-15 and provided a urine sample to determine UC and urinary specific gravity. All sessions included completion of a 24-hr dietary recall. Total fluid intake (fl oz) was 111 ± 107 and 108 ± 42 using the BEVQ-15 and the mean of three 24-hr dietary recalls, respectively, which was not different between methods (p > .05). There were moderate associations between the BEVQ-15 and dietary recall results for total beverage intake fl oz and kcal(r = .413 and r = 4.65; p ≤ .05, respectively). Strong associations were noted between both researcher-rated and participant-rated UC with urinary specific gravity measures (r = .675 and r = .884; p ≤ .05, respectively). Therefore, these rapid assessment methods demonstrated acceptable validity and may be used as practical methods to determine whether athletes are meeting their hydration recommendations.

The δ13C Value of Fingerstick Blood Is a Valid, Reliable, and Sensitive Biomarker of Sugar-Sweetened Beverage Intake in Children and Adolescents.

Background: Reliance on self-reported dietary intake methods is a commonly cited research limitation, and dietary misreporting is a particular problem in children and adolescents. Objective indicators of dietary intake, such as dietary biomarkers, are needed to overcome this research limitation. The added sugar (AS) biomarker δ13C, which measures the relative abundance of 13C to 12C, has demonstrated preliminary validity in adults. Objective: The purpose of this investigation was to determine the comparative validity, test-retest reliability, and sensitivity of the δ13C biomarker to detect AS and sugar-sweetened beverage (SSB) intake using fingerstick blood samples in children and adolescents. Methods: Children (aged 6-11 y, n = 126, 56% male, mean ± SD age: 9 ± 2 y) and adolescents (aged 12-18 y, n = 200, 44% male, mean ± SD age: 15 ± 2 y) completed 4 testing sessions within a 3-wk period. Participants' height, weight, demographic characteristics, and health history were determined at the first session; 24-h recalls were obtained at each visit and fingerstick blood samples were collected at visits 1 and 3. Samples were analyzed for δ13C value using natural abundance stable isotope mass spectrometry. δ13C value was compared with dietary outcomes in the full sample, and in child and adolescent subgroups. t Tests and correlational analyses were used to assess biomarker validity and reliability, whereas logistic regression and area under the receiver-operator characteristic curve (AUC) were used to evaluate sensitivity. Results: Reported mean ± SD AS consumption was 82.2 ± 35.8 g/d and 329 ± 143 kcal/d, and SSB consumption was 222 ± 243 mL/d and 98 ± 103 kcal/d. Mean δ13C value was -19.65 ± 0.69‰, and was lower in children than in adolescents (-19.80 ± 0.67‰ compared with -19.56 ± 0.67‰, P = 0.002). δ13C values were similar across sessions (visit 1: -19.66 ± 0.68‰; visit 3: -19.64 ± 0.68‰; r = 0.99, P < 0.001) and were associated (P < 0.001) with intake of total AS (grams, kilocalories: r = 0.29) and SSB (milliliters, kilocalories: r = 0.35). The biomarker was able to better discriminate between high and low SSB consumers than high and low AS consumers, as demonstrated by the AUC (0.75 and 0.62, respectively). Conclusions: The δ13C biomarker is a promising, minimally invasive, objective biomarker of SSB intake in children and adolescents. Further evaluation using controlled feeding designs is warranted. Registered at clinicaltrials.gov as NCT02455388.

Associations Between Nonnutritive Sweetener Intake and Metabolic Syndrome in Adults.

OBJECTIVE: Individuals looking to improve their health or weight status often use nonnutritive sweeteners (NNS), yet NNS consumption has been associated with increased risk factors for metabolic syndrome (MetS). Most studies examining NNS only assess total intake using diet soda as a proxy for NNS consumption, without distinguishing potential risks associated with individual sweeteners. The objective of this cross-sectional investigation was to identify whether there were associations between NNS consumption (total or individual) and risk factors for MetS in adults (n = 125) from Southwest Virginia. METHODS: Participants provided three 24-hour dietary recalls and blood pressure, waist circumference, fasting glucose, triglycerides, and high-density lipoprotein cholesterol were assessed. Linear regression models, adjusted for age, sex, caloric intake, dietary quality, and physical activity, examined associations between total and individual types of NNS with MetS and MetS risk factors. RESULTS: Sixty-three participants were classified as NNS consumers and eighteen met the criteria for MetS. While no significant associations between MetS and NNS consumption were found, waist circumference was positively associated with total NNS, saccharin, sucralose, and acesulfame potassium, and both fasting glucose and triglyceride values were positively associated with total NNS and aspartame consumption. CONCLUSION: While these cross-sectional data are consistent with previous work implicating NNS in development of MetS, additional research using randomized controlled trials is needed to clarify whether and how NNS in general or specific NNS might contribute to risk factors for MetS. This trial was registered at clinicaltrials.gov (NCT03364452).

Supporting maintenance of sugar-sweetened beverage reduction using automated versus live telephone support: findings from a randomized control trial.

BACKGROUND: Although reducing sugar-sweetened beverage (SSB) intake is an important behavioral strategy to improve health, no known SSB-focused behavioral trial has examined maintenance of SSB behaviors after an initial reduction. Guided by the RE-AIM framework, this study examines 6-18 month and 0-18 month individual-level maintenance outcomes from an SSB reduction trial conducted in a medically-underserved, rural Appalachia region of Virginia. Reach and implementation indicators are also reported. METHODS: Following completion of a 6-month, multi-component, behavioral RCT to reduce SSB intake (SIPsmartER condition vs. comparison condition), participants were further randomized to one of three 12-month maintenance conditions. Each condition included monthly telephone calls, but varied in mode and content: 1) interactive voice response (IVR) behavior support, 2) human-delivered behavior support, or 3) IVR control condition. Assessments included the Beverage Intake Questionnaire (BEVQ-15), weight, BMI, and quality of life. Call completion rates and costs were tracked. Analysis included descriptive statistics and multilevel mixed-effects linear regression models using intent-to-treat procedures. RESULTS: Of 301 subjects enrolled in the 6-month RCT, 242 (80%) were randomized into the maintenance phase and 235 (78%) included in the analyses. SIPsmartER participants maintained significant 0-18 month decreases in SSB. For SSB, weight, BMI and quality of life, there were no significant 6-18 month changes among SIPsmartER participants, indicating post-program maintenance. The IVR-behavior participants reported greater reductions in SSB kcals/day during the 6-18 month maintenance phase, compared to the IVR control participants (- 98 SSB kcals/day, 95% CI = - 196, - 0.55, p < 0.05); yet the human-delivered behavior condition was not significantly different from either the IVR-behavior condition (27 SSB kcals/day, 95% CI = - 69, 125) or IVR control condition (- 70 SSB kcals/day, 95% CI = - 209, 64). Call completion rates were similar across maintenance conditions (4.2-4.6 out of 11 calls); however, loss to follow-up was greatest in the IVR control condition. Approximated costs of IVR and human-delivered calls were remarkably similar (i.e., $3.15/participant/month or $38/participant total for the 12-month maintenance phase), yet implications for scalability and sustainability differ. CONCLUSION: Overall, SIPsmartER participants maintained improvements in SSB behaviors. Using IVR to support SSB behaviors is effective and may offer advantages as a scalable maintenance strategy for real-world systems in rural regions to address excessive SSB consumption. TRIAL REGISTRY: Clinicaltrials.gov; NCT02193009 ; Registered 11 July 2014. Retrospectively registered.

Short-term changes in added sugar consumption by adolescents reflected in the carbon isotope ratio of fingerstick blood.

BACKGROUND: Consumption of added sugars (AS) and sugar-sweetened beverages (SSB) may adversely affect adolescents' weight and cardiovascular disease risk. Reliance on self-reported dietary assessment methods is a common research limitation, which could be overcome by dietary intake biomarkers. AIM: The investigation was a proof-of-concept study to evaluate the proposed carbon isotope ratio (δ13C) biomarker of AS intake in adolescents, using a controlled feeding design. METHODS: Participants (n = 33, age 15.3 years, 53% female) underwent two seven-day controlled feeding periods in a randomly assigned order. Diets were matched in composition except for AS content (5% or 25% of total energy). Fasting fingerstick blood samples were collected daily during each diet period. RESULTS: Fingerstick δ13C values changed from day 1 to 8 by -0.05 ± 0.071‰ on 5% AS, and +0.03 ± 0.083‰ on 25% AS (p ≤ 0.001). Reliability was demonstrated between day 7 and 8 δ13C values on the 5% (ICC = 0.996, p ≤ 0.001) and 25% (ICC = 0.997, p ≤ 0.001) AS diets. CONCLUSIONS: Larger scale investigations are warranted to determine if this technique could be applied to population-level research in order to help assess the effectiveness of interventions aimed at reducing the consumption of AS or SSB intake.

Urinary Excretion of Sodium, Nitrogen, and Sugar Amounts Are Valid Biomarkers of Dietary Sodium, Protein, and High Sugar Intake in Nonobese Adolescents.

Background: Objective indicators of dietary intake (e.g., biomarkers) are needed to overcome the limitations of self-reported dietary intake assessment methods in adolescents. To our knowledge, no controlled feeding studies to date have evaluated the validity of urinary sodium, nitrogen, or sugar excretion as dietary biomarkers in adolescents.Objective: This investigation aimed to evaluate the validity of urinary sodium, nitrogen, and total sugars (TS) excretion as biomarkers for sodium, protein, and added sugars (AS) intake in nonobese adolescents.Methods: In a crossover controlled feeding study design, 33 adolescents [12-18 y of age, 47 ± 25th percentile (mean ± SD) of body mass index (BMI; in kg/m2) for age] consumed 5% AS [low added sugars (LAS)] and 25% AS [high added sugars (HAS)] isocaloric, macronutrient-matched (55% carbohydrate, 30% fat, and 15% protein) diets for 7 d each, in a randomly assigned order, with a 4-wk washout period between diets. On the final 2 d of each diet period, 24-h urine samples were collected. Thirty-two adolescents completed all measurements (97% retention).Results: Urinary sodium was not different from the expected 90% recovery (mean ± SD: 88% ± 18%, P = 0.50). Urinary nitrogen was correlated with protein intake (r = 0.69, P < 0.001), although it was below the 80% expected recovery (62% ± 7%, P < 0.001). Urinary TS values were correlated with AS intake during the HAS diet (r = 0.77, P < 0.001) and had a higher R2 value of 0.28 than did AS intake (R2 = 0.36). TS excretion differed between LAS (0.226 ± 0.09 mg/d) and HAS (0.365 ± 0.16 mg/d) feeding periods (P < 0.001).Conclusions: Urinary sodium appears to be a valid biomarker for sodium intake in nonobese adolescents. Urinary nitrogen is associated with protein intake, but nitrogen excretion rates were less than previously reported for adults, possibly owing to adolescent growth rates. TS excretion reflects AS at 25% AS intake and was responsive to the change in AS intake. Thus, urinary biomarkers are promising objective indicators of dietary intake in adolescents, although larger-scale feeding trials are needed to confirm these findings. This trial was registered at clinicaltrials.gov as NCT02455388.

Influence of an intervention targeting a reduction in sugary beverage intake on the δ13C sugar intake biomarker in a predominantly obese, health-disparate sample.

OBJECTIVE: Controversy exists surrounding the health effects of added sugar (AS) and sugar-sweetened beverage (SSB) intakes, primarily due to a reliance on self-reported dietary intake. The purpose of the current investigation was to determine if a 6-month intervention targeting reduced SSB intake would impact δ13C AS intake biomarker values. DESIGN: A randomized controlled intervention trial. At baseline and at 6 months, participants underwent assessments of anthropometrics and dietary intake. Fasting fingerstick blood samples were obtained and analysed for δ13C value using natural abundance stable isotope MS. Statistical analysis included descriptive statistics, correlational analyses and multilevel mixed-effects linear regression analysis using an intention-to-treat approach. SETTING: Rural Southwest Virginia, USA. SUBJECTS: Adults aged ≥18 years who consumed ≥200 kcal SSB/d (≥837 kJ/d) were randomly assigned to either the intervention (n 155) or a matched-contact group (n 146). Participants (mean age 42·1 (sd 13·4) years) were primarily female and overweight (21·5 %) or obese (57·0 %). RESULTS: A significant group by time difference in δ13C value was detected (P<0·001), with mean (sd) δ13C value decreasing in the intervention group (pre: -18·92 (0·65) ‰, post: -18·97 (0·65) ‰) and no change in the comparison group (pre: -18·94 (0·72) ‰, post: -18·92 (0·73) ‰). Significant group differences in weight and BMI change were also detected. Changes in biomarker δ13C values were consistent with changes in self-reported AS and SSB intakes. CONCLUSIONS: The δ13C sugar intake biomarker assessed using fingerstick blood samples shows promise as an objective indicator of AS and SSB intakes which could be feasibly included in community-based research trials.

Effects of a behavioral and health literacy intervention to reduce sugar-sweetened beverages: a randomized-controlled trial.

BACKGROUND: Despite excessive consumption of sugar-sweetened beverages (SSB), little is known about behavioral interventions to reduce SSB intake among adults, particularly in medically-underserved rural communities. This type 1 effectiveness-implementation hybrid RCT, conducted in 2012-2014, applied the RE-AIM framework and was designed to assess the effectiveness of a behavioral intervention targeting SSB consumption (SIPsmartER) when compared to an intervention targeting physical activity (MoveMore) and to determine if health literacy influenced retention, engagement or outcomes. METHODS: Guided by the Theory of Planned Behavior and health literacy strategies, the 6 month multi-component intervention for both conditions included three small-group classes, one live teach-back call, and 11 interactive voice response calls. Validated measures were used to assess SSB consumption (primary outcome) and all secondary outcomes including physical activity behaviors, theory-based constructs, quality of life, media literacy, anthropometric, and biological outcomes. RESULTS: Targeting a medically-underserved rural region in southwest Virginia, 1056 adult participants were screened, 620 (59%) eligible, 301 (49%) enrolled and randomized, and 296 included in these 2015 analyses. Participants were 93% Caucasian, 81% female, 31 % ≤ high-school educated, 43% < $14,999 household income, and 33% low health literate. Retention rates (74%) and program engagement was not statistically different between conditions. Compared to MoveMore, SIPsmartER participants significantly decreased SSB kcals and BMI at 6 months. SIPsmartER participants significantly decreased SSB intake by 227 (95% CI = -326,-127, p < 0.001) kcals/day from baseline to 6 months when compared to the decrease of 53 (95% CI = -88,-17, p < 0.01) kcals/day among MoveMore participants (p < 0.001). SIPsmartER participants decreased BMI by 0.21 (95% CI = -0.35,-0.06; p < 0.01) kg/m(2) from baseline to 6 months when compared to the non-significant 0.10 (95 % CI = -0.23, 0.43; NS) kg/m(2) gain among MoveMore participants (p < 0.05). Significant 0-6 month effects were observed for about half of the theory-based constructs, but for no biological outcomes. Health literacy status did not influence retention rates, engagement or outcomes. CONCLUSIONS: SIPsmartER is an effective intervention to decrease SSB consumption among adults and is promising for translation into practice settings. SIPsmartER also yielded small, yet significant, improvements in BMI. By using health literacy-focused strategies, the intervention was robust in achieving reductions for participants of varying health literacy status. TRIAL REGISTRATION: Clinicaltrials.gov; ID: NCT02193009 .

Evaluation of a novel biomarker of added sugar intake (δ 13C) compared with self-reported added sugar intake and the Healthy Eating Index-2010 in a community-based, rural U.S. sample.

OBJECTIVE: The δ 13C value of human blood is an emerging novel biomarker of added sugar (AS) intake for adults. However, no free-living, community-based assessments of comparative validity of this biomarker have been conducted. The purpose of the present investigation was to determine if Healthy Eating Index-2010 (HEI-2010) score, SoFAAS score (HEI-2010 sub-component for solid fat, alcohol and AS), AS and sugar-sweetened beverage (SSB) intakes were associated with δ 13C value of fingerstick blood in a community-based sample of adults, while controlling for relevant demographics. DESIGN: A cross-sectional analysis of data obtained from assessments of BMI, dietary intake using 24 h recalls and a fingerstick blood sample was completed. Statistical analyses included descriptive statistics, multiple linear regression and one-way ANOVA. SETTING: Rural Southwest Virginia, U.S.A. SUBJECTS: Adults (n 216) aged >18 years who consumed at least 837 kJ/d (200 kcal/d) from SSB. RESULTS: This sample of adult participants with low socio-economic status demonstrated a mean HEI-2010 score of 43.4 (sd 12.2), mean SoFAAS score of 10.2 (sd 5.7), mean AS intake of 93 (sd 65) g/d and mean blood δ 13C value of -18.88 (sd 0.7) ‰. In four separate regression models, HEI-2010 (R 2=0.16), SoFAAS (R 2=0.19), AS (R 2=0.15) and SSB (R 2=0.14) predicted δ 13C value (all P≤0.001). Age was also predictive of δ 13C value, but not sex or race. CONCLUSIONS: These findings suggest that fingerstick δ 13C value has the potential to be a minimally invasive method for assessing AS and SSB intake and overall dietary quality in community-based settings. Strengths, limitations and future areas of research for using an objective δ 13C biomarker in diet-related public health studies are discussed.

A Dual-Carbon-and-Nitrogen Stable Isotope Ratio Model Is Not Superior to a Single-Carbon Stable Isotope Ratio Model for Predicting Added Sugar Intake in Southwest Virginian Adults.

BACKGROUND: An objective measure of added sugar (AS) and sugar-sweetened beverage (SSB) intake is needed. The δ(13)C value of finger-stick blood is a novel validated biomarker of AS/SSB intake; however, nonsweetener corn products and animal protein also carry a δ(13)C value similar to AS sources, which may affect blood δ(13)C values. The δ(15)N value of blood has been proposed as a "correction factor" for animal protein intake. OBJECTIVES: The objectives were to 1) identify foods associated with δ(13)C and δ(15)N blood values, 2) determine the contribution of nonsweetener corn to the diet relative to AS intake, and 3) determine if the dual-isotope model (δ(13)C and δ(15)N) is a better predictor of AS/SSB intake than δ(13)C alone. METHODS: A cross-sectional sample of southwest Virginian adults (n = 257; aged 42 ± 15 y; 74% overweight/obese) underwent dietary intake assessments and provided finger-stick blood samples, which were analyzed for δ(13)C and δ(15)N values by using natural abundance stable isotope mass spectrometry. Statistical analyses included ANOVAs, paired-samples t tests, and multiple linear regressions. RESULTS: The mean ± SD daily AS intake was 88 ± 59 g and nonsweetener corn intake was 13 ± 13 g. The mean δ(13)C value was -19.1 ± 0.9‰, which was significantly correlated with AS and SSB intakes (r = 0.32 and 0.39, respectively; P ≤ 0.01). The δ(13)C value and nonsweetener corn intake and the δ(15)N value and animal protein intake were not correlated. AS intake was significantly greater than nonsweetener corn intake (mean difference = 76.2 ± 57.2 g; P ≤ 0.001). The δ(13)C value was predictive of AS/SSB intake (ß range: 0.28-0.35; P ≤ 0.01); however, δ(15)N was not predictive and minimal increases in R(2) values were observed when the δ(15)N value was added to the model. CONCLUSIONS: The data do not provide evidence that the dual-isotope method is superior for predicting AS/SSB intakes within a southwest Virginian population. Our results support the potential of the δ(13)C value of finger-stick blood to serve as an objective measure of AS/SSB intake. This trial was registered at clinicaltrials.gov as NCT02193009.

Representation of adults with class III obesity in studies assessing validity of self-reported energy intake using doubly labeled water: A systematic review.

The measurement of habitual energy intake remains a challenge in nutrition research. High levels of misreporting, particularly among adults with obesity, have been observed when comparing self-reported energy intake to energy expenditure assessed via the doubly labeled water technique. Little is known about misreporting in adults with class III obesity (body mass index ≥40 kg/m2). This systematic review assessed the representation of adults with class III obesity in dietary validation studies and the validity of self-reported dietary energy intake for this group. Studies were included in this review if they: compared self-reported energy intake assessment method(s) to doubly labeled water, had participants ≥18 years old, and included participants with class III obesity. Fifteen studies met these criteria. Of those, eight included information about the number of participants with class III obesity. Out of 1784 participants across eight studies, 63 (3.5%) participants had class III obesity, compared to 9.2% of US adults with class III obesity. Six studies provided data on validity of energy intake assessment for class III obesity, with five of these showing underreporting. Participants with class III obesity are underrepresented in dietary validation studies. Future research should explore the role of weight status on dietary reporting accuracy.

The Impact of Weight Bias and Stigma on the 24 h Dietary Recall Process in Adults with Overweight and Obesity: A Pilot Study.

People with overweight and obesity tend to both underreport dietary energy intake and experience weight stigma. This exploratory pilot study aimed to determine the relationship between weight bias and weight stigma and energy intake reporting accuracy. Thirty-nine weight-stable adults with BMI ≥ 25 completed three 24 h dietary recalls; indirect calorimetry to measure resting metabolic rate; a survey measuring weight stigma, psychosocial constructs, and physical activity; and a semi-structured qualitative interview. Multiple linear regression was used to determine if weight bias internalization, weight bias toward others, and experiences of weight stigma were predictive of the accuracy of energy reporting. A thematic analysis was conducted for the qualitative interviews. Weight stigma was reported by 64.1% of the sample. Weight stigma constructs did not predict the accuracy of energy intake reporting. People with obesity underreported by a mean of 477 kcals (p = 0.02). People classified as overweight overreported by a mean of 144 kcals, but this was not significant (p = 0.18). Participants reported a desire to report accurate data despite concerns about reporting socially undesirable foods. Future research should quantify the impact of weight stigma on energy reporting in 24 h recalls using a larger, more diverse sample size and objective measures like doubly labeled water for validation.

"I'm Doing the Best that I Can": Mothers Lived Experience with Food Insecurity, Coping Strategies, and Mental Health Implications.

Background: Food insecurity can have lasting physical and mental health consequences. The experience of food insecurity within a household may disproportionately impact mothers because they tend to manage the household food environment. Objective: This study sought to understand the stresses faced by United States mothers experiencing food insecurity, related coping mechanisms, and the impacts of these stressors on their mental health. Methods: Semistructured interviews were conducted in May and June 2022 with a purposive sample of Virginia mothers who reported experiences of food insecurity. Participants were recruited from a related survey and university and community LISTSERVs. Interviews were transcribed and analyzed by trained coders. A thematic analysis was conducted to describe themes that emerged from the data. Virtual interviews were 20-60 min in duration. Mothers with children living in their household, having experienced food insecurity, and living in Virginia were eligible. Results: The following 3 themes emerged from the interviews with the mothers (n = 15): 1) food insecurity added stress to mothers' lives in multiple ways (e.g. worry about obtaining the "right" foods and internalized or experienced stigma), 2) mothers used positive and negative coping strategies to address the impacts of these stressors (e.g. use of community resources and reduced personal food intake), and 3) the stressors and coping strategies had varying impacts on mothers' mental health (e.g. added to existing mental health challenges or reduced their mental capacity to make changes). Conclusions: Study findings suggest that a multilevel and tailored approach to address diverse stressors is warranted. Future research should explore emotional coping strategies that comprehensively empower mothers to manage stressors, leverage resources, and reduce social stigma associated with food insecurity and accessing nutrition and mental health assistance. This may improve their household food security and mitigate the burden of stressors on their mental health because system-level solutions to food insecurity are pursued.

Ultra-processed food intake, gut microbiome, and glucose homeostasis in mid-life adults: Background, design, and methods of a controlled feeding trial.

BACKGROUND: Aging is associated with gut dysbiosis, low-grade inflammation, and increased risk of type 2 diabetes (T2D). Prediabetes, which increases T2D and cardiovascular disease risk, is present in 45-50% of mid-life adults. The gut microbiota may link ultra-processed food (UPF) with inflammation and T2D risk. METHODS: Following a 2-week standardized lead-in diet (59% UPF), adults aged 40-65 years will be randomly assigned to a 6-week diet emphasizing either UPF (81% total energy) or non-UPF (0% total energy). Measurements of insulin sensitivity, 24-h and postprandial glycemic control, gut microbiota composition/function, fecal short chain fatty acids, intestinal inflammation, inflammatory cytokines, and vascular function will be made before and following the 6-week intervention period. Prior to recruitment, menus were developed in order to match UPF and non-UPF conditions based upon relevant dietary factors. Menus were evaluated for palatability and costs, and the commercial additive content of study diets was quantified to explore potential links with outcomes. RESULTS: Overall diet palatability ratings were similar (UPF = 7.6 ± 1.0; Non-UPF = 6.8 ± 1.5; Like Moderately = 7, Like Very Much = 8). Cost analysis (food + labor) of the 2000 kcal menu (7-d average) revealed lower costs for UPF compared to non-UPF diets ($20.97/d and $40.23/d, respectively). Additive exposure assessment of the 2000 kcal UPF diet indicated that soy lecithin (16×/week), citric acid (13×/week), sorbic acid (13×/week), and sodium citrate (12×/week) were the most frequently consumed additives. CONCLUSIONS: Whether UPF consumption impairs glucose homeostasis in mid-life adults is unknown. Findings will address this research gap and contribute information on how UPF consumption may influence T2D development.

Cross-sectional measurement of adherence to a proposed sustainable and healthy dietary pattern among United States adults using the newly developed Planetary Health Diet Index for the United States.

BACKGROUND: Dietary choices are an important avenue for improving food system sustainability. The Planetary Health Diet was proposed by the EAT-Lancet Commission as a reference healthy and sustainable dietary pattern. OBJECTIVES: To assess adherence to the Planetary Health Diet among United States adults, this study developed and evaluated the Planetary Health Diet Index for the United States (PHDI-US), adapted from the original PHDI validated in the Brazilian population. METHODS: The PHDI-US has 16 components with scores ranging between 0 and 150, and higher scores indicate better adherence to the Planetary Health Diet. Cross-sectional dietary data from 4741 participants of the National Health and Nutrition Examination Survey 2017-2018 were used to assess the validity and reliability of the PHDI-US. RESULTS: Validity and reliability tests were acceptable overall: principal component analysis identified 6 components; total PHDI-US and Healthy Eating Index-2015 scores were positively associated (ß = 0.67, standard error = 0.03, P <0.0001; R2 = 0.39); concurrent-criterion validity analyses identified significantly lower scores among males, everyday smokers, and younger adults; and the Cronbach's α value was 0.54. The average PHDI-US score was 46.7 out of 150, indicating that the diets of United States adults were far from meeting Planetary Health Diet recommendations. Based on component PHDI-US scores, many United States adults may be able to enhance the quality and sustainability of their diets by increasing intake of plant-based foods, including whole grains, nuts and peanuts, legumes, fruits, and vegetables, and reducing intake of animal-based foods, including red and processed meats. CONCLUSIONS: The PHDI-US is a new tool that can assess adherence to the Planetary Health Diet and identify key aspects of United States adults' diets that could be altered to potentially improve dietary sustainability and quality.

US Adults' Perceptions, Beliefs, and Behaviors towards Plant-Rich Dietary Patterns and Practices: International Food Information Council Food and Health Survey Insights, 2012-2022.

Expert groups recommend that populations adopt dietary patterns higher in whole, plant-based foods and lower in red and processed meat as a high-impact climate action. Yet, there is limited understanding of populations' willingness to adopt plant-rich dietary patterns. This study examined United States (US) adults' perceptions, beliefs, and behaviors towards plant-rich dietary patterns and practices over a decade. Fifteen questions from the International Food Information Council's Food and Health Surveys (2012-2022) were analyzed across four sustainability domains (i.e., human health, environmental, social, and economic domains). Most respondents had favorable perceptions of environmentally sustainable food and beverages, but sustainability influenced less than half of consumers' purchase decisions. Plant-rich dietary pattern adherence increased across survey years (12.1% [2019] to 25.8% [2022], p < 0.001). One-quarter (28.1%) of Americans reported reducing their red meat intake over 12 months (2020-2022). Yet, another 15.5% reported greater red meat intake, and 18.8% reported greater plant-based meat alternative (PBMA) intake over 12 months. The percentage of respondents who reported greater red meat and PBMA consumption in the previous 12 months significantly increased across the years surveyed (2020-2022, p < 0.05). IFIC Survey findings highlight growing US consumer awareness of health, environmental, and social sustainability but low adoption of plant-rich dietary patterns and practices. Government leadership and coordinated actions by health professionals, civil society, and businesses are needed to educate and incentivize Americans to adopt plant-rich dietary behaviors, and greater industry transparency is needed to show how food and beverage products support human and planetary health.

The influence of ultra-processed food consumption on reward processing and energy intake: Background, design, and methods of a controlled feeding trial in adolescents and young adults.

BACKGROUND: The greatest age-related weight gain occurs in the early/mid-20s. Overall dietary quality among adolescents and emerging adults (age 18-25) is poor, with ultra-processed foods (UPF) representing more than two-thirds of adolescents' total energy intake (i.e., 68%). UPF consumption may impact cognitive and neurobiological factors that influence dietary decision-making and energy intake (EI). To date, no research has addressed this in this population. METHODS: Participants aged 18-25 will undergo two 14-day controlled feeding periods (81% UPF, 0% UPF) using a randomly assigned crossover design, with a 4-week washout between conditions. Brain response to a UPF-rich milkshake, as well as behavioral measures of executive function, will be evaluated before and after each diet. Following each diet, measurements include ad libitum buffet meal EI, food selection, eating rate, and eating in the absence of hunger (EAH). Prior to initiating recruitment, controlled diet menus, buffet, and EAH snacks were developed and evaluated for palatability. Sensory and texture attributes of buffet and EAH snack foods were also evaluated. RESULTS: Overall diet palatability was rated "like very much" (8)/"like moderately"(7) (UPF: 7.6 ± 1.0; Non-UPF: 6.8 ± 1.5). Subjective hardness rating (range = 1-9 [1 = soft, 9 = hard] was similar between UPF and Non-UPF buffet and snack items (UPF:4.22 ± 2.19, Non-UPF: 4.70 ± 2.03), as was the objective measure of hardness (UPF: 2874.33 ± 2497.06 g, Non-UPF: 2243.32 ± 1700.51 g). CONCLUSIONS: Findings could contribute to an emerging neurobiological understanding of the effects of UPF consumption including energy overconsumption and weight gain among individuals at a critical developmental stage.

Dietary biomarkers: advances, limitations and future directions.

The subjective nature of self-reported dietary intake assessment methods presents numerous challenges to obtaining accurate dietary intake and nutritional status. This limitation can be overcome by the use of dietary biomarkers, which are able to objectively assess dietary consumption (or exposure) without the bias of self-reported dietary intake errors. The need for dietary biomarkers was addressed by the Institute of Medicine, who recognized the lack of nutritional biomarkers as a knowledge gap requiring future research. The purpose of this article is to review existing literature on currently available dietary biomarkers, including novel biomarkers of specific foods and dietary components, and assess the validity, reliability and sensitivity of the markers. This review revealed several biomarkers in need of additional validation research; research is also needed to produce sensitive, specific, cost-effective and noninvasive dietary biomarkers. The emerging field of metabolomics may help to advance the development of food/nutrient biomarkers, yet advances in food metabolome databases are needed. The availability of biomarkers that estimate intake of specific foods and dietary components could greatly enhance nutritional research targeting compliance to national recommendations as well as direct associations with disease outcomes. More research is necessary to refine existing biomarkers by accounting for confounding factors, to establish new indicators of specific food intake, and to develop techniques that are cost-effective, noninvasive, rapid and accurate measures of nutritional status.