Performance of the Global Diet Quality Score with Nutrition and Health Outcomes in Mexico with 24-h Recall and FFQ Data.

BACKGROUND: The Global Diet Quality Score (GDQS) is intended as a simple global diet quality metric feasible in low- and middle-income countries facing the double burden of malnutrition. OBJECTIVE: The aim of this study was to evaluate the performance of the GDQS with markers of nutrient adequacy and chronic disease in nonpregnant nonlactating (NPNL) Mexican women of reproductive age and to compare it with the Alternate Healthy Eating Index-2010 (AHEI-2010) and the Minimum Dietary Diversity for Women (MDD-W). METHODS: We included NPNL women aged 15 to 49 y from the Mexican National Health and Nutrition Surveys (2012 and 2016) with 24-h recall (n = 2542) or a FFQ (n = 4975) (separate samples). We evaluated the correlation of the GDQS with the energy-adjusted intake of several nutrients and evaluated its association with health parameters using covariate-adjusted linear regression models. RESULTS: The GDQS was positively correlated with the intake of calcium, folate, iron, vitamin A, vitamin B-12, zinc, fiber, protein, and total fat (rho = 0.09 to 0.38, P < 0.05) and was inversely correlated with the intake of added sugar (rho = -0.37 and -0.38, P < 0.05) using both instruments, and with total fat, SFA, and MUFA only with 24-h recall data (rho = -0.06 to -0.16, P < 0.05). The GDQS was inversely associated with serum ferritin, BMI, waist circumference, and serum total and LDL cholesterol using FFQ data (P < 0.05), and was positively associated with serum folate using 24-h recall data (P < 0.05). Similar correlations and associations were observed with the MDD-W (only with micronutrients) and the AHEI-2010 (only with chronic disease-related nutrients and health markers). CONCLUSIONS: In comparison to other diet metrics, the GDQS can capture both dimensions of nutrient adequacy and health markers related to the risk of chronic disease. The performance of the GDQS was satisfactory with either 24-h recall or FFQ.

Changes in the Global Diet Quality Score, Weight, and Waist Circumference in Mexican Women.

BACKGROUND: Evidence on concurrent changes in overall diet quality and weight and waist circumference in women of reproductive age from low- and middle-income countries is limited. OBJECTIVES: We examined the associations of changes in the Global Diet Quality Score (GDQS) and each GDQS food group with concurrent weight and waist circumference change in Mexican women. METHODS: We followed prospectively 8967 nonpregnant nonlactating women aged 25-49 y in the Mexican Teachers' Cohort between 2006 and 2008. We assessed diet using an FFQ of the previous year and anthropometric measures were self-reported. Regression models were used to examine 2-y changes in the GDQS and each food group (servings/d) with weight and waist circumference changes within the same period, adjusting for demographic and lifestyle factors. RESULTS: Compared with those with little change in the GDQS (-2 to 2 points), women with the largest increase in the GDQS (>5 points) had less weight (ß: -0.81 kg/2 y; 95% CI: -1.11, -0.51 kg/2 y) and waist circumference gain (ß: -1.05 cm/2 y; 95% CI: -1.62, -0.48 cm/2 y); likewise, women with the largest decrease in the GDQS (<-5 points) had more weight (ß: 0.36 kg/2 y; 95% CI: 0.06, 0.66 kg/2 y) and waist circumference gain (ß: 0.71 cm/2 y; 95% CI: 0.09, 1.32 cm/2 y). Increased intake of dark green leafy vegetables, cruciferous vegetables, deep orange vegetables, citrus fruits, and fish and shellfish was associated with less weight gain. In addition, deep orange vegetables, low fat and high fat dairy, whole grains, and fish were associated with less waist circumference gain within the 2-y period. CONCLUSIONS: Improvements in diet quality over a 2-y period reflected by an increase in the GDQS and changes in consumption of specific components of the GDQS were associated with less weight and waist circumference gain in Mexican women.

There's an App for That: Development of an Application to Operationalize the Global Diet Quality Score.

BACKGROUND: The global diet quality score (GDQS) is a simple, standardized metric appropriate for population-based measurement of diet quality globally. OBJECTIVES: We aimed to operationalize data collection by modifying the quantity of consumption cutoffs originally developed for the GDQS food groups and to statistically evaluate the performance of the operationalized GDQS relative to the original GDQS against nutrient adequacy and noncommunicable disease (NCD)-related outcomes. METHODS: The GDQS application uses a 24-h open-recall to collect a full list of all foods consumed during the previous day or night, and automatically classifies them into corresponding GDQS food group. Respondents use a set of 10 cubes in a range of predetermined sizes to determine if the quantity consumed per GDQS food group was below, or equal to or above food group-specific cutoffs established in grams. Because there is only a total of 10 cubes but as many as 54 cutoffs for the GDQS food groups, the operationalized cutoffs differ slightly from the original GDQS cutoffs. RESULTS: A secondary analysis using 5 cross-sectional datasets comparing the GDQS with the original and operationalized cutoffs showed that the operationalized GDQS remained strongly correlated with nutrient adequacy and was equally sensitive to anthropometric and other clinical measures of NCD risk. In a secondary analysis of a longitudinal cohort study of Mexican teachers, there were no differences between the 2 modalities with the beta coefficients per 1 SD change in the original and operationalized GDQS scores being nearly identical for weight gain (-0.37 and -0.36, respectively, P < 0.001 for linear trend for both models) and of the same clinical order of magnitude for waist circumference (-0.52 and -0.44, respectively, P < 0.001 for linear trend for both models). CONCLUSION: The operationalized GDQS cutoffs did not change the performance of the GDQS and therefore are recommended for use to collect GDQS data in the future.

Development and Validation of a Novel Food-Based Global Diet Quality Score (GDQS).

BACKGROUND: Poor diet quality is a major driver of both classical malnutrition and noncommunicable disease (NCD) and was responsible for 22% of adult deaths in 2017. Most countries face dual burdens of undernutrition and NCDs, yet no simple global standard metric exists for monitoring diet quality in populations and population subgroups. OBJECTIVES: We aimed to develop an easy-to-use metric for nutrient adequacy and diet related NCD risk in diverse settings. METHODS: Using cross-sectional and cohort data from nonpregnant, nonlactating women of reproductive age in 10 African countries as well as China, India, Mexico, and the United States, we undertook secondary analyses to develop novel metrics of diet quality and to evaluate associations between metrics and nutrient intakes and adequacy, anthropometry, biomarkers, type 2 diabetes, and iteratively modified metric design to improve performance and to compare novel metric performance to that of existing metrics. RESULTS: We developed the Global Diet Quality Score (GDQS), a food-based metric incorporating a more comprehensive list of food groups than most existing diet metrics, and a simple means of scoring consumed amounts. In secondary analyses, the GDQS performed comparably with the Minimum Dietary Diversity - Women indicator in predicting an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy and with anthropometric and biochemical indicators of undernutrition (including underweight, anemia, and serum folate deficiency), and the GDQS also performed comparably or better than the Alternative Healthy Eating Index - 2010 in capturing NCD-related outcomes (including metabolic syndrome, change in weight and waist circumference, and incident type 2 diabetes). CONCLUSIONS: The simplicity of the GDQS and its ability to capture both nutrient adequacy and diet-related NCD risk render it a promising candidate for global monitoring platforms. Research is warranted to validate methods to operationalize GDQS assessment in population surveys, including a novel application-based 24-h recall system developed as part of this project.

Self-perception of dietary quality and adherence to food groups dietary recommendations among Mexican adults.

BACKGROUND: Mexicans' adherence to food group's dietary recommendations is low and an inaccurate self-perception of dietary quality might perpetuate this low adherence. Our aim was to compare the intake and the adherence to the dietary recommendations for several food groups, subgroups, and to an overall Mexican Diet Quality Index (MxDQI), among those that perceived their diet as healthy vs. those that did not. METHODS: We analyzed data from 989 subjects 20-59 y old from the nationally representative Mexican National Health and Nutrition Survey 2016. Dietary intake was collected with one 24-h recall and a repeated recall in 82 subjects. Self-perception of dietary quality was evaluated with the following question "Do you consider that your diet is healthy? (yes/no)". We used the National Cancer Institute method to estimate the usual intake. We compared the mean intake adjusted by sociodemographic variables and the percentage of adherence according to the self-perception of dietary quality among the whole sample and in sociodemographic subpopulations. RESULTS: Sixty percent perceived their diet as healthy, and their adherence to recommendations was low [20% for fruits and vegetables, < 8% for legumes, seafood and SSBs, and ~ 50% for processed meats and high in saturated fat and/or added sugar (HSFAS) products]. The mean number of recommendations they met was 2.8 (out of 7) vs. 2.6 among the rest of the population (p > 0.05), and the MxDQI score was 40 vs. 37 (out of 100 points). The only food groups and subgroups with a statistically significant difference between those that perceived their diet as healthy vs. unhealthy were fruits [38 g/d (95% CI 3, 73)], fruit juices [27 g/d (95% CI 2, 52)], industrialized SSBs [- 35 kcal/d (- 70, - 1)] and salty snacks [- 40 kcal/d (- 79, - 1)]. Other differences were small or inconsistent across subgroups of the population. CONCLUSIONS: Those that perceived their diet as healthy only had a slightly healthier diet than the rest of the population, moreover, their adherence to recommendations was very low. Hence, it is necessary to improve their nutrition knowledge.

Prevalence of inadequate intake of vitamins and minerals in the Mexican population correcting by nutrient retention factors, Ensanut 2016.

OBJECTIVE: To estimate the usual intake and the prevalence of inadequacy of selected nutrients in the Mexican population and the potential effect that the nutrient retention factors (NRF) could have on these estimates. Likewise, document the methodology used in the analysis of the 24 hours of the mid-way National Health and Nutrition Survey 2016 (Ensanut MC 2016). MATERIALS AND METHODS: Dietary information from the Ensanut MC 2016 was analyzed with and without the use of NRFs. RESULTS: Results. Most nutrients evaluated showed a relevant inadequacy prevalence above 10% in all age groups. Likewise, we documented that, when NRFs were not applied, estimated intakes and prevalence were significantly under-estimated in a range of 2% to 55.5%. CONCLUSIONS: We documented the relevance of the application of NRFs for adequate estimation of the prevalence of inadequate intake of selected nutrients in population studies.

OBJETIVO: Estimar la ingesta habitual y la prevalencia de inadecuación de nutrimentos selectos en la población mexicana y el efecto potencial de los factores de retención de nutrimentos (FRN). Asimismo, describir la metodología utilizada en el procesamiento del recordatorio de 24 horas de la Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 (Ensanut MC 2016). MATERIAL Y MÉTODOS: Se analizó la información dietética de Ensanut MC 2016 con y sin utilización de FRN. RESULTADOS: En los nutrimentos evaluados, las prevalencias de inadecuación fueron superiores al 10% en todos los grupos de estudio. La no consideración de los FRN causó la subestimación en las prevalencias de inadecuación en un rango de 2% a 55.5%. CONCLUSIONES: . Se documenta la relevancia de la aplicación de FRN para la adecuada estimación de las prevalencias de inadecuación en estudios poblacionales.

Higher dietary magnesium intake is associated with lower body mass index, waist circumference and serum glucose in Mexican adults.

BACKGROUND: Obesity and diabetes mellitus (DM) are public health concerns in Mexico of top-level priority due to their high prevalence and their growth rate in recent decades. The accumulation of adipose tissue leads to an unbalanced release of pro-oxidant factors, which causes cellular damage and favors the development of comorbidities. Recent evidence suggests that oxidative stress also promotes the accumulation of adipose tissue and the development of insulin resistance. The objective of this study is to evaluate the association between usual intake of antioxidant nutrients, specifically vitamins A, C, E and magnesium with body mass index (BMI), waist circumference (WC) and serum glucose concentrations in a representative sample of Mexican adults. METHODOLOGY: We analyzed data on diet, BMI, WC and serum glucose from the Mexican National Health and Nutrition Survey 2012. Analysis included 20- to 65-year-old adults without a known diagnosis of DM (n = 1573). Dietary information was obtained using the five-step multiple-pass method developed by the United States Department of Agriculture and adapted to the Mexican context. Nutrient usual intake distributions were estimated using the Iowa State University method, through the "Software for Intake Distribution Estimation" (PC-Side) v.1.02. Associations were analyzed using multivariate regression models. RESULTS: Higher dietary magnesium intake was associated with lower markers of adiposity, so that an increase in 10 mg per 1000 kcal/day of magnesium was associated with an average decrease in BMI of 0.72% (95% CI: -1.36, - 0.08) and 0.49 cm (95% CI: -0.92, - 0.07) of WC. Additionally, in women with normal glucose concentrations, an increase in magnesium intake was associated with an average decrease in serum glucose by 0.59% (95% CI: -1.08, - 0.09). CONCLUSION: The results suggest that magnesium intake is associated with lower BMI, WC and serum glucose in Mexican population. However, more studies are required to elucidate the nature of this association.

Association between the nutritional quality of food purchases and household food at home expenditures in Mexico.

BACKGROUND: Poor-quality diets are a major risk factor for non-communicable diseases. Few studies in Mexico have tested whether higher expenditures are needed to purchase high quality food. OBJECTIVE: The objective of the study was to assess how dietary quality for food purchases was associated with household food at home expenditures. DESIGN: This study is a secondary analysis of cross-sectional data from the National Household Income and Expenditure Survey (ENIGH 2018). PARTICIPANTS/SETTING: The study includes 74,469 households with information on food and beverages purchases in Mexico in 2018. MAIN OUTCOME MEASURES: Quarterly household food expenditures by adult equivalent (AE) for all food groups that were scored in the Global Dietary Quality Score (GDQS) for food purchases expressed in dollars/quarterly/AE. STATISTICAL ANALYSES PERFORMED: Adjusted generalized linear models were used to evaluate the association between GDQS for food purchases (expressed in tertiles: low-, mid-, and high-), and quarterly food expenditures. The analyses were performed at the national level, by place of residence and income quintile. RESULTS: At the national level, the difference in food expenditures between the high- and the low-GDQS group was +$13.85 dollars/AE. By place of residence, the difference between the high- and the low-GDQS group was +$17.31 dollars/AE in urban and +$5.12 dollars/AE in rural areas. For income quintile 1 (lowest) there was statistical difference of -$4.79 dollars/AE and for quintile 5 (highest) +$43.25. CONCLUSIONS: Quality of food purchases can be associated with higher or lower expenditures depending on the specific food purchased. High GDQS is associated with lower expenditures among the lowest-income households as they purchase less expensive options compared to high-income households.

Comparison of Dietary Intake Before vs After Taxes on Sugar-Sweetened Beverages and Nonessential Energy-Dense Foods in Mexico, 2012 to 2018.

Importance: Tax evaluations have shown effectiveness in reducing purchases of taxed items. However, few studies have looked at changes in overall dietary intake according to national surveys. Objective: To estimate the contribution of taxed and untaxed beverages and foods to dietary intake over time, and the nutritional dietary profile in total beverages and foods consumed. Design, Setting, and Participants: This cross-sectional study used data from 3 National Health and Nutrition Surveys of a nationally representative sample of participants aged older than 1 year in Mexico from 2012 (pretax), 2016, and 2018 (posttax). Data were analyzed from September 2021 to December 2022. Exposure: Taxes on sugar-sweetened beverages and nonessential energy-dense foods implemented since 2014. Main Outcomes and Measures: The outcomes were the contribution of taxed and untaxed beverages to total beverage volume, the contribution of taxed and untaxed foods to total food energy, and the energy density and content of added sugars and saturated fats. Outcomes were assessed with 24-hour recalls (24HR) (2012 and 2016) and Food Frequency Questionnaires (FFQ) (2012, 2016, and 2018), and were adjusted by sociodemographic and macroeconomic variables. Results: A total of 17 239 participants were analyzed from 2012, 18 974 from 2016, and 30 027 from 2018; approximately 50% were men, and approximately 75% lived in urban areas. According to 24HRs, the contribution of taxed beverages to total beverage volume changed -2.3 (95% CI, -4.4 to -0.2) percentage points from 2012 to 2016, while water increased. The contribution of taxed foods to total food energy changed -3.0 (95% CI, -4.2 to -1.8) percentage points, while untaxed whole grains, processed meats, other animal sources, and sugars and desserts increased. The content in total beverages of added sugars changed -1.1 kcal/100 mL (95% CI, -2.0 to -0.2), and in total foods, the content of added sugar changed -0.6 %kcal (95% CI, -1.0 to -0.2), saturated fat changed -0.8 %kcal (95% CI, -1.1 to -0.4), and energy density changed -9.8 kcal/100 g (95% CI, -13.8 to -5.8). Main results were consistent with the FFQ (up to 2018), with some differences in subgroups and nutritional components. Conclusions and Relevance: The findings of this study on 3 cross-sectional national dietary surveys are consistent with previous evaluations; after tax implementation, there was a decrease in the contribution of taxed items. Furthermore, some unhealthy untaxed items increased, but the content of unhealthful nutritional components, particularly added sugar, in overall beverages and foods decreased.

Estimating national and subnational nutrient intake distributions of global diets.

BACKGROUND: Access to high-quality dietary intake data is central to many nutrition, epidemiology, economic, environmental, and policy applications. When data on individual nutrient intakes are available, they have not been consistently disaggregated by sex and age groups, and their parameters and full distributions are often not publicly available. OBJECTIVES: We sought to derive usual intake distributions for as many nutrients and population subgroups as possible, use these distributions to estimate nutrient intake inadequacy, compare these distributions and evaluate the implications of their shapes on the estimation of inadequacy, and make these distributions publicly available. METHODS: We compiled dietary data sets from 31 geographically diverse countries, modeled usual intake distributions for 32 micronutrients and 21 macronutrients, and disaggregated these distributions by sex and age groups. We compared the variability and skewness of the distributions and evaluated their similarity across countries, sex, and age groups. We estimated intake inadequacy for 16 nutrients based on a harmonized set of nutrient requirements and bioavailability estimates. Last, we created an R package-nutriR-to make these distributions freely available for users to apply in their own analyses. RESULTS: Usual intake distributions were rarely symmetric and differed widely in variability and skewness across nutrients and countries. Vitamin intake distributions were more variable and skewed and exhibited less similarity among countries than other nutrients. Inadequate intakes were high and geographically concentrated, as well as generally higher for females than males. We found that the shape of usual intake distributions strongly affects estimates of the prevalence of inadequate intakes. CONCLUSIONS: The shape of nutrient intake distributions differs based on nutrient and subgroup and strongly influences estimates of nutrient intake inadequacy. This research represents an important contribution to the availability and application of dietary intake data for diverse subpopulations around the world.

Toward a healthy and sustainable diet in Mexico: where are we and how can we move forward?

BACKGROUND: Dietary recommendations worldwide have focused on promoting healthy diets to prevent diseases. In 2019, the EAT-Lancet Commission presented global scientific targets for healthy diets and sustainable food production and proposed a healthy reference diet (EAT-HRD) that can be adapted to the culture, geography, and demography of the population and individuals in any country. OBJECTIVES: We aimed to describe the daily energy intake from food groups and subgroups in Mexican adults relative to the EAT-HRD and propose an adaptation of the EAT-HRD to the Mexican context. METHODS: We analyzed data from the Mexican National Health and Nutrition Surveys in 2012 and 2016. Diet information was obtained using the 5-step multiple-pass 24-h dietary recall method. We estimated the mean energy intake from food groups and subgroups and compared these figures with the midpoint of the EAT-HRD and with the Mexican Dietary Guidelines (MDGs). We also proposed an adaptation of the EAT-HRD to the Mexican context based on the mean energy intake and the comparison between the MDGs and the EAT-HRD. RESULTS: Mexican adults consume higher than the EAT-HRD for grains (mostly refined), dairy, added sugars, and animal-based proteins (particularly red meat, poultry, eggs, and processed meats); and lower than the EAT-HRD for vegetables, fruits, legumes, nuts, tubers and starchy vegetables, fish, and added fats. Based on these findings, we propose a healthy and sustainable reference diet adapted for the Mexican population. CONCLUSIONS: Mexican adults have a diet that is far from being healthy and is not sustainable. The adaptation of the EAT-HRD to the Mexican context is a timely input for current government efforts to move to a sustainable and healthy food system, including the update of the current MDGs.

Factors Associated With Dietary Quality During Initial and Later Stages of the COVID-19 Pandemic in Mexico.

Background: The COVID-19 pandemic disrupted the global economy and modified lifestyles. The aim of our study was to identify factors associated with dietary quality, and their frequency, in Mexican adults at the initial and later stages of the pandemic. Methods: Two online surveys were conducted between June and July 2020 (n = 3,131) and between November and December 2020 (n = 1,703 including non-participants from 1st round). A diet quality score was estimated using a short instrument to measure the consumption of several healthy/unhealthy food items. Linear regression models were used to identify the association between pandemic related factors and the diet quality score, adjusted by sociodemographic characteristics. The 2nd round was weighted to represent the 1st round. Results: During the 1st and 2nd rounds only ~12% of the sample perceived that their intake of healthy food decreased, relative to before the pandemic; ~20% perceived that their intake of unhealthy foods increased. Diet quality remained similar between the 1st and 2nd round. The following factors were negatively associated with diet quality: Eating food prepared away-from-home; going out to work ≥4 times/week; decreased time for food preparation; decreased interest in eating healthy; eating more due to anxiety, depression, or boredom; food insecurity; and stockpiling junk food. Purchasing food using a mixed modality of both in-store and home delivery was positively associated with diet quality. With the exception of eating more due to anxiety (reported by 47% of participants), all these factors were reported by a minority of participants during the first round (≤15%). During the 2nd round, there was an increase in the frequency of participants who reported eating food prepared away-from-home, going out to work ≥4 times/week, having less time to prepare food, being more interested in eating healthfully, and a decrease in participants eating more due to anxiety, depression or boredom, or stockpiling junk food. Conclusions: Most participants perceived that their dietary intake improved during both initial and later stages of the pandemic. This might be related to factors associated with higher dietary quality, such as not going out to work, eating homemade food, and online grocery shopping.

Prevalence of inadequate intake of vitamins and minerals in the Mexican population correcting by nutrient retention factors, Ensanut 2016 / Prevalencia de consumo inadecuado de vitaminas y minerales en población mexicana, corrigiendo por factores de retención de nutrimentos, Ensanut 2016

Abstract Objective: To estimate the usual intake and the prevalence of inadequacy of selected nutrients in the Mexican population and the potential effect that the nutrient retention factors (NRF) could have on these estimates. Likewise, document the methodology used in the analysis of the 24 hours of the mid-way National Health and Nutrition Survey 2016 (Ensanut MC 2016). Materials and methods: Dietary information from the Ensanut MC 2016 was analyzed with and without the use of NRFs. Results: Most nutrients evaluated showed a relevant inadequacy prevalence above 10% in all age groups. Likewise, we documented that, when NRFs were not applied, estimated intakes and prevalence were significantly underestimated in a range of 2% to 55.5%. Conclusions: We documented the relevance of the application of NRFs for adequate estimation of the prevalence of inadequate intake of selected nutrients in population studies.

Resumen Objetivo: Estimar la ingesta habitual y la prevalencia de inadecuación de nutrimentos selectos en la población mexicana y el efecto potencial de los factores de retención de nutrimentos (FRN). Asimismo, describir la metodología utilizada en el procesamiento del recordatorio de 24 horas de la Encuesta Nacional de Salud y Nutrición de Medio Camino 2016 (Ensanut MC 2016). Material y métodos: Se analizó la información dietética de Ensanut MC 2016 con y sin utilización de FRN. Resultados: En los nutrimentos evaluados, las prevalencias de inadecuación fueron superiores al 10% en todos los grupos de estudio. La no consideración de los FRN causó la subestimación en las prevalencias de inadecuación en un rango de 2% a 55.5%. Conclusión: Se documenta la relevancia de la aplicación de FRN para la adecuada estimación de las prevalencias de inadecuación en estudios poblacionales.