Eligibility and Prevalence of the American Heart Association Heart Check Certification Program in the US Packaged Food and Beverage Supply: A Cross-Sectional Study.

Objective: Consumers in the US make choices within a food supply dominated by processed packaged foods and beverage products. Front-of-package nutrition labels (FOPL) equip consumers to make healthier choices, but further evaluation and regulation regarding FOPL format, scope, and display have been recommended by the World Health Organization. As a leader in consumer FOPL guidance, the American Heart Association's (AHA) Heart Check programme certifies food companies seeking to add an AHA Heart Check logo as a FOPL for qualifying heart healthy products. A cross-sectional assessment of the AHA Heart Check Standard Certification was conducted within the US packaged food and beverage supply to assess the eligibility and prevalence of the programme as a FOPL. Methods: Data were derived from Label Insight's Open Data initiative, which is the largest publicly-available US branded food composition database. The proportions of products that were certified and eligible to be certified for the Standard Certification were reported by nutrient attributes, grocery aisles and food brands. Results: Among 153,453 products examined, fewer than 1% exhibited the Heart Check certification on their label. Among products that were not Heart Check certified,13.8% were eligible for Standard Certification. The most common reason for ineligibility was the saturated fat content (52%), followed by total fat content (47%) and sodium content (47%). Heart Check certification and eligibility differed substantially across grocery aisle categories. Conclusions: The abundance of unhealthy products in the US packaged food and beverage supply and absence of harmonized FOPL policies suggest the need for FOPL like the Heart Check label to promote adherence to healthy diets. There are opportunities for food manufacturers and the AHA to certify more heart healthy foods and beverages. However, more consistent criteria and transparent labelling could enhance Heart Check certification to facilitate consumers' ability to make more informed and healthful purchases.

Dietary Patterns and Years Living in the United States by Hispanic/Latino Heritage in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

BACKGROUND: Previous diet findings in Hispanics/Latinos rarely reflect differences in commonly consumed and culturally relevant foods across heritage groups and by years lived in the United States. OBJECTIVES: We aimed to identify and compare a posteriori heritage-specific dietary patterns (DPs) and evaluate their associations with "healthfulness" [using the Alternative Healthy Eating Index-2010 (AHEI-2010)] and years living in the United States. METHODS: We used baseline data from a population-based cohort of 14,099 Hispanics/Latinos aged 18-74 y in the Hispanic Community Health Study/Study of Latinos. We performed principal factor analysis using two 24-h recalls to derive DPs, separately, in each heritage group (Cuban, Dominican, Mexican, Puerto Rican, Central American, and South American), and identified overarching DPs based on high-loading foods shared by ≥2 groups. We used multivariable linear regression to test associations of DPs with AHEI-2010 and years living in the United States. RESULTS: We identified 5 overarching DPs (Burgers, Fries, & Soft Drinks; White Rice, Beans, & Red Meats; Fish; Egg & Cheese; and Alcohol). All Burgers, Fries, & Soft Drinks DPs were inversely associated with AHEI-2010, whereas all Fish DPs (except Dominican) were positively associated with this index (all P-trend < 0.001). White Rice, Beans, & Red Meats DPs showed inverse associations in Cuban and Central American groups and positive associations in Mexican-origin individuals (all P-trend < 0.001). Fewer years living in the United States was associated with higher scores for White Rice, Beans, & Red Meats DPs in Cuban and Mexican heritage groups and lower scores on Burgers, Fries, & Soft Drinks DPs in Cuban, Mexican, and Puerto Rican groups (all P-trend < 0.01). CONCLUSIONS: Our findings show substantial variation in DPs across Hispanics/Latinos and adherence to DPs by time in the United States, which could inform dietary interventions targeting this diverse US population. This trial was registered at clinicaltrials.gov as NCT02060344.

The Carbon Isotope Ratios of Serum Amino Acids in Combination with Participant Characteristics can be Used to Estimate Added Sugar Intake in a Controlled Feeding Study of US Postmenopausal Women.

BACKGROUND: The carbon isotope ratio (CIR) is a proposed biomarker for added sugar (AS) intake in the United States; however, because the CIR is also associated with meat intake in most populations the need for specificity remains. The CIR of amino acids (AAs) has the potential to differentiate sugars from meat intakes, because essential AAs must derive from dietary protein whereas certain nonessential AAs can be synthesized from sugars. OBJECTIVES: We tested whether serum CIR-AAs in combination with participant characteristics could meet a prespecified biomarker criterion for AS intake in the Nutrition and Physical Activity Assessment Study Feeding Study (NPAAS-FS) of the Women's Health Initiative, a population in which the whole-serum CIR was not associated with AS intake. METHODS: Postmenopausal women (n = 145) from Seattle, WA, were provided with individualized diets that approximated their habitual food intakes for 2 wk. Dietary intakes from consumed foods were characterized over the feeding period using the Nutrition Data System for Research. The CIR of 7 AAs-Ala, Gly, Val, Leu, Ile, Pro, and Phe-were measured in fasting serum collected at the end of the 2-wk feeding period, using gas chromatography-combustion isotope ratio mass spectrometry. Biomarker models were evaluated using regression R2 ≥ 0.36 as a major biomarker criterion, based on the benchmark R2 values of well-established recovery biomarkers in the NPAAS-FS. RESULTS: AS intake was associated with CIR-Ala (ρ = 0.32; P < 0.0001). A model of AS intake based on CIR-Ala, CIR-Gly, CIR-Ile, smoking, leisure physical activity, and body weight met the biomarker criterion (R2 = 0.37). Biomarker-estimated AS intake was not associated with meat or animal protein intake. CONCLUSIONS: Results support serum CIR-AAs in combination with participant characteristics as potential biomarkers of AS intake in US populations, including those with low AS intake.The Women's Health Initiative is registered at clinicaltrials.gov (NCT00000611).

Trends in Levels of Lipids and Apolipoprotein B in US Youths Aged 6 to 19 Years, 1999-2016.

Importance: Favorable trends occurred in the lipid levels of US youths through 2010, but these trends may be altered by ongoing changes in the food supply, obesity prevalence, and other factors. Objective: To analyze trends in levels of lipids and apolipoprotein B in US youths during 18 years from 1999 through 2016. Design, Setting, and Participants: Serial cross-sectional analysis of US population-weighted data for youths aged 6 to 19 years from the National Health and Nutrition Examination Surveys for 1999 through 2016. Linear temporal trends were analyzed using multivariable regression models with regression coefficients (ß) reported as change per 1 year. Exposures: Survey year; examined periods spanned 10 to 18 years based on data availability. Main Outcomes and Measures: Age- and race/ethnicity-adjusted mean levels of high-density lipoprotein (HDL), non-HDL, and total cholesterol. Among fasting adolescents (aged 12-19 years), mean levels of low-density lipoprotein cholesterol, geometric mean levels of triglycerides, and mean levels of apolipoprotein B. Prevalence of ideal and adverse (vs borderline) levels of lipids and apolipoprotein B per pediatric lipid guidelines. Results: In total, 26 047 youths were included (weighted mean age, 12.4 years; female, 51%). Among all youths, the adjusted mean total cholesterol level declined from 164 mg/dL (95% CI, 161 to 167 mg/dL) in 1999-2000 to 155 mg/dL (95% CI, 154 to 157 mg/dL) in 2015-2016 (ß for linear trend, -0.6 mg/dL [95% CI, -0.7 to -0.4 mg/dL] per year). Adjusted mean HDL cholesterol level increased from 52.5 mg/dL (95% CI, 51.7 to 53.3 mg/dL) in 2007-2008 to 55.0 mg/dL (95% CI, 53.8 to 56.3 mg/dL) in 2015-2016 (ß, 0.2 mg/dL [95% CI, 0.1 to 0.4 mg/dL] per year) and non-HDL cholesterol decreased from 108 mg/dL (95% CI, 106 to 110 mg/dL) to 100 mg/dL (95% CI, 99 to 102 mg/dL) during the same years (ß, -0.9 mg/dL [95% CI, -1.2 to -0.6 mg/dL] per year). Among fasting adolescents, geometric mean levels of triglycerides declined from 78 mg/dL (95% CI, 74 to 82 mg/dL) in 1999-2000 to 63 mg/dL (95% CI, 58 to 68 mg/dL) in 2013-2014 (log-transformed ß, -0.015 [95% CI, -0.020 to -0.010] per year), mean levels of low-density lipoprotein cholesterol declined from 92 mg/dL (95% CI, 89 to 95 mg/dL) to 86 mg/dL (95% CI, 83 to 90 mg/dL) during the same years (ß, -0.4 mg/dL [95% CI, -0.7 to -0.2 mg/dL] per year), and mean levels of apolipoprotein B declined from 70 mg/dL (95% CI, 68 to 72 mg/dL) in 2005-2006 to 67 mg/dL (95% CI, 65 to 70 mg/dL) in 2013-2014 (ß, -0.4 mg/dL [95% CI, -0.7 to -0.04 mg/dL] per year). Favorable trends were generally also observed in the prevalence of ideal and adverse levels. By the end of the study period, 51.4% (95% CI, 48.5% to 54.2%) of all youths had ideal levels for HDL, non-HDL, and total cholesterol; among adolescents, 46.8% (95% CI, 40.9% to 52.6%) had ideal levels for all lipids and apolipoprotein B, whereas 15.2% (95% CI, 13.1% to 17.3%) of children aged 6 to 11 years and 25.2% (95% CI, 22.2% to 28.2%) of adolescents aged 12 to 19 years had at least 1 adverse level. Conclusions and Relevance: Between 1999 and 2016, favorable trends were observed in levels of lipids and apolipoprotein B in US youths aged 6 to 19 years.

Dietary Fats and Cardiovascular Disease: A Presidential Advisory From the American Heart Association.

Cardiovascular disease (CVD) is the leading global cause of death, accounting for 17.3 million deaths per year. Preventive treatment that reduces CVD by even a small percentage can substantially reduce, nationally and globally, the number of people who develop CVD and the costs of caring for them. This American Heart Association presidential advisory on dietary fats and CVD reviews and discusses the scientific evidence, including the most recent studies, on the effects of dietary saturated fat intake and its replacement by other types of fats and carbohydrates on CVD. In summary, randomized controlled trials that lowered intake of dietary saturated fat and replaced it with polyunsaturated vegetable oil reduced CVD by ≈30%, similar to the reduction achieved by statin treatment. Prospective observational studies in many populations showed that lower intake of saturated fat coupled with higher intake of polyunsaturated and monounsaturated fat is associated with lower rates of CVD and of other major causes of death and all-cause mortality. In contrast, replacement of saturated fat with mostly refined carbohydrates and sugars is not associated with lower rates of CVD and did not reduce CVD in clinical trials. Replacement of saturated with unsaturated fats lowers low-density lipoprotein cholesterol, a cause of atherosclerosis, linking biological evidence with incidence of CVD in populations and in clinical trials. Taking into consideration the totality of the scientific evidence, satisfying rigorous criteria for causality, we conclude strongly that lowering intake of saturated fat and replacing it with unsaturated fats, especially polyunsaturated fats, will lower the incidence of CVD. This recommended shift from saturated to unsaturated fats should occur simultaneously in an overall healthful dietary pattern such as DASH (Dietary Approaches to Stop Hypertension) or the Mediterranean diet as emphasized by the 2013 American Heart Association/American College of Cardiology lifestyle guidelines and the 2015 to 2020 Dietary Guidelines for Americans.

Added Sugars and Cardiovascular Disease Risk in Children: A Scientific Statement From the American Heart Association.

BACKGROUND: Poor lifestyle behaviors are leading causes of preventable diseases globally. Added sugars contribute to a diet that is energy dense but nutrient poor and increase risk of developing obesity, cardiovascular disease, hypertension, obesity-related cancers, and dental caries. METHODS AND RESULTS: For this American Heart Association scientific statement, the writing group reviewed and graded the current scientific evidence for studies examining the cardiovascular health effects of added sugars on children. The available literature was subdivided into 5 broad subareas: effects on blood pressure, lipids, insulin resistance and diabetes mellitus, nonalcoholic fatty liver disease, and obesity. CONCLUSIONS: Associations between added sugars and increased cardiovascular disease risk factors among US children are present at levels far below current consumption levels. Strong evidence supports the association of added sugars with increased cardiovascular disease risk in children through increased energy intake, increased adiposity, and dyslipidemia. The committee found that it is reasonable to recommend that children consume ≤25 g (100 cal or ≈6 teaspoons) of added sugars per day and to avoid added sugars for children <2 years of age. Although added sugars most likely can be safely consumed in low amounts as part of a healthy diet, few children achieve such levels, making this an important public health target.

Cardiovascular Health Promotion in Children: Challenges and Opportunities for 2020 and Beyond: A Scientific Statement From the American Heart Association.

This document provides a pediatric-focused companion to "Defining and Setting National Goals for Cardiovascular Health Promotion and Disease Reduction: The American Heart Association's Strategic Impact Goal Through 2020 and Beyond," focused on cardiovascular health promotion and disease reduction in adults and children. The principles detailed in the document reflect the American Heart Association's new dynamic and proactive goal to promote cardiovascular health throughout the life course. The primary focus is on adult cardiovascular health and disease prevention, but critical to achievement of this goal is maintenance of ideal cardiovascular health from birth through childhood to young adulthood and beyond. Emphasis is placed on the fundamental principles and metrics that define cardiovascular health in children for the clinical or research setting, and a balanced and critical appraisal of the strengths and weaknesses of the cardiovascular health construct in children and adolescents is provided. Specifically, this document discusses 2 important factors: the promotion of ideal cardiovascular health in all children and the improvement of cardiovascular health metric scores in children currently classified as having poor or intermediate cardiovascular health. Other topics include the current status of cardiovascular health in US children, opportunities for the refinement of health metrics, improvement of health metric scores, and possibilities for promoting ideal cardiovascular health. Importantly, concerns about the suitability of using single thresholds to identify elevated cardiovascular risk throughout the childhood years and the limits of our current knowledge are noted, and suggestions for future directions and research are provided.

Understanding risk and causal mechanisms for developing obesity in infants and young children: A National Institutes of Health workshop.

Obesity in children remains a major public health problem, with the current prevalence in youth ages 2-19 years estimated to be 19.7%. Despite progress in identifying risk factors, current models do not accurately predict development of obesity in early childhood. There is also substantial individual variability in response to a given intervention that is not well understood. On April 29-30, 2021, the National Institutes of Health convened a virtual workshop on "Understanding Risk and Causal Mechanisms for Developing Obesity in Infants and Young Children." The workshop brought together scientists from diverse disciplines to discuss (1) what is known regarding epidemiology and underlying biological and behavioral mechanisms for rapid weight gain and development of obesity and (2) what new approaches can improve risk prediction and gain novel insights into causes of obesity in early life. Participants identified gaps and opportunities for future research to advance understanding of risk and underlying mechanisms for development of obesity in early life. It was emphasized that future studies will require multi-disciplinary efforts across basic, behavioral, and clinical sciences. An exposome framework is needed to elucidate how behavioral, biological, and environmental risk factors interact. Use of novel statistical methods may provide greater insights into causal mechanisms.

Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations.

Recent reports of selected observational studies and a meta-analysis have stirred controversy and have become the impetus for calls to abandon recommendations for reduced sodium intake by the US general population. A detailed review of these studies documents substantial methodological concerns that limit the usefulness of these studies in setting, much less reversing, dietary recommendations. Indeed, the evidence base supporting recommendations for reduced sodium intake in the general population remains robust and persuasive. The American Heart Association is committed to improving the health of all Americans through implementation of national goals for health promotion and disease prevention, including its recommendation to reduce dietary sodium intake to <1500 mg/d.

Residence in Hispanic/Latino Immigrant Neighborhoods, Away-From-Home Food Consumption, and Diet Quality: The Hispanic Community Health Study/Study of Latinos.

BACKGROUND: Hispanics/Latinos are disproportionately burdened by nutrition-related diseases but immigrants appear healthier than their US-born counterparts. Neighborhoods characterized by high Hispanic/Latino immigrant segregation may provide environments to support healthier diets. OBJECTIVE: To examine whether or not Hispanic/Latino immigrant segregation is associated with frequency of away-from-home food consumption and diet quality in a large, diverse sample of Hispanic/Latino adults. DESIGN: Cross-sectional baseline data from the Hispanic Community Health Study/Study of Latinos were analyzed (2008-2011). Residential addresses were geocoded and linked to census tract-level 2008-2012 American Community Survey data. Hispanic/Latino immigrant segregation was characterized using the local Getis-Ord Gi∗ statistic, a spatial clustering measure that quantifies the extent to which demographically similar neighborhoods group together. PARTICIPANTS/SETTING: Participants were 15,661 adults in the Hispanic Community Health Study/Study of Latinos, a population-based study of Hispanic/Latinos aged 18 to 74 years from 4 US regions (Bronx, NY; Chicago, IL; Miami, FL; and San Diego, CA). MAIN OUTCOME MEASURES: Away-from-home food consumption was assessed using a modified dietary behavior questionnaire. Diet quality was assessed using the Alternate Healthy Eating Index 2010 (range = 0 to 110) from two 24-hour recalls. STATISTICAL ANALYSIS: Multilevel linear and logistic regression with multilevel weights were used to estimate associations between Hispanic/Latino immigrant segregation (low, medium, or high) with Alternate Healthy Eating Index 2010 score, and away-from-home food consumption (≥3 vs <3 times/week) in separate models, respectively. The mediating role of neighborhood poverty and whether or not associations differed by nativity were also assessed. RESULTS: Higher levels of segregation were associated with higher adjusted mean Alternate Healthy Eating Index 2010 scores; estimates were further magnified after accounting for neighborhood poverty (low segregation: reference category; medium segregation: ß = 2.43, 95% CI 1.10 to 3.77; and high segregation: ß = 1.63, 95% CI .43 to 2.82). Associations were strongest among the foreign-born compared with the US-born. There was no association between segregation and away-from-home food consumption. CONCLUSIONS: These results highlight the potential role of Hispanic/Latino immigrant neighborhoods in supporting healthy diets among residents, especially immigrants.

Sodium Content and Labelling of Packaged Foods and Beverages in Nigeria: A Cross-Sectional Study.

Increased consumption of unhealthy processed foods, particularly those high in sodium, is a major risk factor for cardiovascular diseases. The nutrition information on packaged foods can help guide consumers toward products with less sodium and support government actions to improve the healthiness of the food supply. The aims of this study were to estimate the proportion of packaged foods displaying nutrition information for sodium and other nutrients specified by Nigerian nutrition labelling regulations and to determine the amount of sodium in packaged foods sold in Nigeria using data from the nutritional information panel. Data were collected from November 2020 to March 2021 from in-store surveys conducted in supermarkets in three states. A total of 7039 products were collected. Overall, 91.5% (n = 6439) provided only partial nutrition information, 7.0% (n = 495) provided no nutritional information, and only 1.5% (n = 105) displayed a nutrient declaration that included all nutrients specified by 2019 Nigerian regulations. Some form of sodium content information was displayed for 86% of all products (n = 6032), of which around 45% (n = 2689) expressed this as 'salt' and 59% (n = 3559) expressed this as 'sodium', while a small number of food products had both 'salt' and 'sodium' content (3.6%). Provision of sodium or salt information on the label varied between food categories, ranging from 50% (vitamins and supplements, n = 2/4) to 96% (convenience foods, n = 44/46). Food categories with the highest median sodium content were 'meat and meat alternatives' (904 mg/100 g), 'sauces, dressings, spreads, and dips' (560 mg/100 g), and 'snack foods' (536 mg/100 g), although wide variation was often observed within categories. These findings highlight considerable potential to improve the availability and consistency of nutrition information on packaged products in Nigeria and to introduce further policies to reduce the amount of sodium in the Nigerian food supply.

Chocolate Candy and Incident Invasive Cancer Risk in the Women's Health Initiative: An Observational Prospective Analysis.

BACKGROUND: Laboratory and animal studies suggest an inverse association between chocolate consumption and the risk of cancer. Epidemiological studies have yielded inconsistent evidence. OBJECTIVE: To assess the association of chocolate candy consumption with incident, invasive total, breast, colorectal, and lung cancers in a large cohort of postmenopausal American women. DESIGN: Prospective cohort study with a mean 14.8-year follow-up. Chocolate candy intake was assessed by food frequency questionnaire. Invasive cancer events were assessed by physician adjudication. PARTICIPANTS/SETTING: The Women's Health Initiative Study enrolled 161,808 postmenopausal women at 40 clinical centers nationwide between 1993 and 1998. Of these women, 114,281 with plausible food frequency or biometric data and no missing data on chocolate candy exposure were selected for analysis. MAIN OUTCOME MEASURES: Cancer risk in quartiles of chocolate candy consumption with the first quartile as referent. STATISTICAL ANALYSES: Multivariable Cox regression was used to calculate hazard ratios and 95% confidence intervals. RESULTS: There were 16,164 documented incident invasive cancers, representing an incidence rate of 17.0 per 100 participants and 12.3 per 1000 person years during follow-up among participants without any preexisting cancers or missing outcome data. There were no statistically significant associations for total invasive cancer (P-linear = .47, P-curvature = .14), or invasive breast cancer (P-linear = .77, P-curvature = .26). For colorectal cancer P-linear was .02, P-curvature was .03, and compared with women eating a 1 oz (28.4 g) chocolate candy serving <1 time per month, the hazard ratio for ≥1.5 times/wk was 1.18 (95% confidence interval: 1.04-1.35). This result may be attributable to the excess adiposity associated with frequent chocolate candy consumption. CONCLUSIONS: In the Women's Health Initiative, there was no significant association between chocolate candy consumption and invasive total or breast cancer. There was a modest 18% higher risk of invasive colorectal cancer for women who ate chocolate candy at least 1.5 times/wk. These results require confirmation.

Higher Neighborhood Population Density Is Associated with Lower Potassium Intake in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL).

Current U.S. dietary guidelines recommend a daily potassium intake of 3400 mg/day for men and 2600 mg/day for women. Sub-optimal access to nutrient-rich foods may limit potassium intake and increase cardiometabolic risk. We examined the association of neighborhood characteristics related to food availability with potassium intake in the Hispanic Community Health Study/Study of Latinos (HCHS/SOL). 13,835 participants completed a 24-h dietary recall assessment and had complete covariates. Self-reported potassium intake was calibrated with an objective 24-h urinary potassium biomarker, using equations developed in the SOL Nutrition & Physical Activity Assessment Study (SOLNAS, N = 440). Neighborhood population density, median household income, Hispanic/Latino diversity, and a retail food environment index by census tract were obtained. Linear regression assessed associations with 24-h potassium intake, adjusting for individual-level and neighborhood confounders. Mean 24-h potassium was 2629 mg/day based on the SOLNAS biomarker and 2702 mg/day using multiple imputation and HCHS/SOL biomarker calibration. Compared with the lowest quartile of neighborhood population density, living in the highest quartile was associated with a 26% lower potassium intake in SOLNAS (adjusted fold-change 0.74, 95% CI 0.59-0.94) and a 39% lower intake in HCHS/SOL (adjusted fold-change 0.61 95% CI 0.45-0.84). Results were only partially explained by the retail food environment. The mechanisms by which population density affects potassium intake should be further studied.

DNA Methylation GrimAge and Incident Diabetes: The Coronary Artery Risk Development in Young Adults (CARDIA) Study.

DNA methylation (DNAm)-based biological age (epigenetic age) has been suggested as a useful biomarker of age-related conditions including type 2 diabetes (T2D), and its newest iterations (GrimAge measurements) have shown early promise. In this study, we explored the association between epigenetic age and incident T2D in the context of their relationships with obesity. A total of 1,057 participants in the Coronary Artery Risk Development in Young Adults (CARDIA) study were included in the current analyses. We stratified the participants into three groups: normal weight, overweight, and obese. A 1-year increase of GrimAge was associated with higher 10-year (study years 15-25) incidence of T2D (odds ratio [OR] 1.06, 95% CI 1.01-1.11). GrimAge acceleration, which represents the deviation of GrimAge from chronological age, was derived from the residuals of a model of GrimAge and chronological age, and any GrimAge acceleration (positive GrimAA: having GrimAge older than chronological age) was associated with significantly higher odds of 10-year incidence of T2D in obese participants (OR 2.57, 95% CI 1.61-4.11). Cumulative obesity was estimated by years since obesity onset, and GrimAge partially mediated the statistical association between cumulative obesity and incident diabetes or prediabetes (proportion mediated = 8.0%). In conclusion, both older and accelerated GrimAge were associated with higher risk of T2D, particularly among obese participants. GrimAge also statistically mediated the associations between cumulative obesity and T2D. Our findings suggest that epigenetic age measurements with DNAm can potentially be used as a risk factor or biomarker associated with T2D development.

Evaluation of Dietary Patterns and All-Cause Mortality: A Systematic Review.

Importance: The 2020 Dietary Guidelines Advisory Committee conducted a systematic review of existing research on diet and health to inform the current Dietary Guidelines for Americans. The committee answered this public health question: what is the association between dietary patterns consumed and all-cause mortality (ACM)? Objective: To ascertain the association between dietary patterns consumed and ACM. Evidence Review: Guided by an analytical framework and predefined inclusion and exclusion criteria developed by the committee, the US Department of Agriculture's Nutrition Evidence Systematic Review (NESR) team searched PubMed, the Cochrane Central Register of Controlled Trials, and Embase and dual-screened the results to identify articles that were published between January 1, 2000, and October 4, 2019. These studies evaluated dietary patterns and ACM in participants aged 2 years and older. The NESR team extracted data from and assessed risk of bias in included studies. Committee members synthesized the evidence, developed conclusion statements, and graded the strength of the evidence supporting the conclusion statements. Findings: A total of 1 randomized clinical trial and 152 observational studies were included in the review. Studies enrolled adults and older adults (aged 17-84 years at baseline) from 28 countries with high or very high Human Development Index; 53 studies originated from the US. Most studies were well designed, used rigorous methods, and had low or moderate risks of bias. Precision, directness, and generalizability were demonstrated across the body of evidence. Results across studies were highly consistent. Evidence suggested that dietary patterns in adults and older adults that involved higher consumption of vegetables, fruits, legumes, nuts, whole grains, unsaturated vegetable oils, fish, and lean meat or poultry (when meat was included) were associated with a decreased risk of ACM. These healthy patterns were also relatively low in red and processed meat, high-fat dairy, and refined carbohydrates or sweets. Some of these dietary patterns also included intake of alcoholic beverages in moderation. Results based on additional analyses with confounding factors generally confirmed the robustness of main findings. Conclusions and Relevance: In this systematic review, consuming a nutrient-dense dietary pattern was associated with reduced risk of death from all causes.

Cardiovascular Health Among Pregnant Women, Aged 20 to 44 Years, in the United States.

Background Pregnancy is a cardiometabolic stressor and thus a critical period to address women's lifetime cardiovascular health (CVH). However, CVH among US pregnant women has not been characterized. Methods and Results We analyzed cross-sectional data from National Health and Nutrition Examination Surveys 1999 to 2014 for 1117 pregnant and 8200 nonpregnant women, aged 20 to 44 years. We assessed 7 CVH metrics using American Heart Association definitions modified for pregnancy; categorized metrics as ideal, intermediate, or poor; assigned these categories 2, 1, or 0 points, respectively; and summed across the 7 metrics for a total score of 0 to 14 points. Total scores 12 to 14 indicated high CVH; 8 to 11, moderate CVH; and 0 to 7, low CVH. We applied survey weights to generate US population-level estimates of CVH levels and compared pregnant and nonpregnant women using demographic-adjusted polytomous logistic and linear regression. Among pregnant women, the prevalences (95% CIs) of ideal levels of CVH metrics were 0.1% (0%-0.3%) for diet, 27.3% (22.2%-32.3%) for physical activity, 38.9% (33.7%-44.0%) for total cholesterol, 51.1% (46.0%-56.2%) for body mass index, 77.7% (73.3%-82.2%) for smoking, 90.4% (87.5%-93.3%) for blood pressure, and 91.6% (88.3%-94.9%) for fasting glucose. The mean total CVH score was 8.3 (95% CI, 8.0-8.7) of 14, with high CVH in 4.6% (95% CI, 0.5%-8.8%), moderate CVH in 60.6% (95% CI, 52.3%-68.9%), and low CVH in 34.8% (95% CI, 26.4%-43.2%). CVH levels were significantly lower among pregnant versus nonpregnant women; for example, 13.0% (95% CI, 11.0%-15.0%) of nonpregnant women had high CVH (adjusted, comparison P=0.01). Conclusions From 1999 to 2014, <1 in 10 US pregnant women, aged 20 to 44 years, had high CVH.

Relative validity and reliability of a diet risk score (DRS) for clinical practice.

INTRODUCTION: Adherence to cardioprotective dietary patterns can reduce risk for developing cardiometabolic disease. Rates of diet assessment and counselling by physicians are low. Use of a diet screener that rapidly identifies individuals at higher risk due to suboptimal dietary choices could increase diet assessment and brief counselling in clinical care. METHODS: We evaluated the relative validity and reliability of a 9-item diet risk score (DRS) based on the Healthy Eating Index (HEI)-2015, a comprehensive measure of diet quality calculated from a 160-item, validated food frequency questionnaire (FFQ). We hypothesised that DRS (0 (low risk) to 27 (high risk)) would inversely correlate with HEI-2015 score. Adults aged 35 to 75 years were recruited from a national research volunteer registry (ResearchMatch.org) and completed the DRS and FFQ in random order on one occasion. To measure reliability, participants repeated the DRS within 3 months. RESULTS: In total, 126 adults (87% female) completed the study. Mean HEI-2015 score was 63.3 (95% CI: 61.1 to 65.4); mean DRS was 11.8 (95% CI: 10.8 to 12.8). DRS and HEI-2015 scores were inversely correlated (r=-0.6, p<0.001; R2=0.36). The DRS ranked 37% (n=47) of subjects in the same quintile, 41% (n=52) within ±1 quintile of the HEI-2015 (weighted κ: 0.28). The DRS had high reliability (n=102, ICC: 0.83). DRS mean completion time was 2 min. CONCLUSIONS: The DRS is a brief diet assessment tool, validated against a FFQ, that can reliably identify patients with reported suboptimal intake. Future studies should evaluate the effectiveness of DRS-guided diet assessment in clinical care. Trial registration details ClinicalTrials.gov (NCT03805373).

Associations of Late Adolescent or Young Adult Cardiovascular Health With Premature Cardiovascular Disease and Mortality.

BACKGROUND: When measured in adolescence or young adulthood, cardiovascular health (CVH) is associated with future subclinical cardiovascular disease (CVD), but data are lacking regarding CVD events or mortality. OBJECTIVES: This study examined associations of CVH at ages 18 to 30 years with premature CVD and mortality. METHODS: This study analyzed data from the CARDIA (Coronary Artery Risk Development in Young Adults Study). CVH was scored at baseline (1985 to 1986) using Life's Simple 7 metrics and categorized as high (12 to 14 points), moderate (8 to 11), or low (0 to 7). CVD events and cause-specific mortality were adjudicated over 32 years of follow-up. Adjusted associations were estimated using Cox models and event rates and population attributable fractions were calculated by CVH category. RESULTS: Among 4,836 participants (mean age: 24.9 years, 54.8% female, 50.5% Black, mean education: 15.2 years), baseline CVH was high (favorable) in 28.8%, moderate in 65.0%, and low in 6.3%. During follow-up, 306 CVD events and 431 deaths occurred. The adjusted hazard ratios for high (vs. low) CVH were 0.14 (95% confidence interval [CI]: 0.09 to 0.22) for CVD and 0.07 (95% CI: 0.03 to 0.19) for CVD mortality, and the population attributable fractions for combined moderate or low (vs. high) CVH were 0.63 (95% CI: 0.47 to 0.74) for CVD and 0.81 (95% CI: 0.55 to 0.92) for CVD mortality. Among individuals with high CVH, event rates were low across sociodemographic subgroups (e.g., CVD rates per 1,000 person-years: age 18 to 24 years, 0.64; age 25 to 30 years, 0.65; men, 1.04; women, 0.36; Blacks, 0.90; Whites, 0.50; up to/through high-school education, 1.00; beyond high-school education, 0.61). CONCLUSIONS: High CVH in late adolescence or young adulthood was associated with very low rates of premature CVD and mortality over 32 years, indicating the critical importance of maintaining high CVH.

Cardiovascular Health Trajectories From Childhood Through Middle Age and Their Association With Subclinical Atherosclerosis.

Importance: Cross-sectional measures of cardiovascular health (CVH) have been associated with cardiovascular disease in older age, but little is known about longitudinal trajectories in CVH and their association with subclinical atherosclerosis in middle age. Objectives: To model long-term patterns in CVH starting in childhood and to assess their association with subclinical atherosclerosis in middle age. Design, Setting, and Participants: This cohort study used data from 5 prospective cardiovascular cohort studies from the United States and Finland from 1973 to 2015. A total of 9388 participants aged 8 to 55 years had at least 3 examinations and were eligible for this study. Statistical analysis was performed from December 1, 2015, to June 1, 2019. Exposures: Clinical CVH factors (body mass index, total cholesterol level, blood pressure, and glucose level) were classified as ideal, intermediate, or poor, and were summed as a clinical CVH score. Group-based latent class modeling identified trajectories in this score over time. Main Outcomes and Measures: Carotid intima-media thickness (cIMT) was measured for participants in 3 cohorts, and high cIMT was defined as a value at or above the 90th percentile. The association between CVH trajectory and cIMT was modeled using both linear and logistic regression adjusted for demographics, baseline health behaviors, and baseline (or proximal) CVH score. Results: Among 9388 participants (5146 [55%] female; 6228 [66%] white; baseline mean [SD] age, 17.5 [7.5] years), 5 distinct trajectory groups were identified: high-late decline (1518 participants [16%]), high-moderate decline (2403 [26%]), high-early decline (3066 [32%]), intermediate-late decline (1475 [16%]), and intermediate-early decline (926 [10%]). The high-late decline group had significantly lower adjusted cIMT vs other trajectory groups (high-late decline: 0.64 mm [95% CI, 0.63-0.65 mm] vs intermediate-early decline: 0.72 mm [95% CI, 0.69-0.75 mm] when adjusted for demographics and baseline smoking, diet, and physical activity; P < .01). The intermediate-early declining group had higher odds of high cIMT (odds ratio, 2.4; 95% CI, 1.3-4.5) compared with the high-late decline group, even after adjustment for baseline or proximal CVH score. Conclusions and Relevance: In this study, CVH declined from childhood into adulthood. Promoting and preserving ideal CVH from early life onward may be associated with reduced CVD risk later in life.