A novel Nutrient Rich Food (NRFa11.3) score uses flavonoids and carotenoids to identify antioxidant-rich spices, herbs, vegetables, and fruit.

Introduction: Nutrient profiling (NP) models designed to evaluate the healthfulness of plant-based foods ought to incorporate bioactive phytochemicals. Herbs and spices are one food group of current interest. Methods: Two new versions of the well-established Nutrient Rich Food (NRF) index were applied to spices, herbs, vegetables, fruit, and other plant-based foods. Analyses used the US Department of Agriculture (USDA) SR-28 nutrient composition database merged with the USDA Expanded Flavonoid database 3.3. The NRF4.3 model was based on protein, fiber, potassium, and vitamin C. The NRFa11.3 model was based on micronutrients with reported antioxidant activity (vitamin C, vitamin E, selenium, copper, and zinc), carotenoids (alpha and beta carotene, beta-cryptoxanthin, lycopene, lutein/zeaxantin) and flavonoids. Saturated fat, added sugar, and sodium were nutrients to limit. The NRF algorithm was based on sums of percent daily values (%DVs) capped at 100%. Results: The NRF4.3 model awarded high scores to herbs and spices, cocoa powder, and nuts, but did not discriminate well among vegetables and fruit. The NRFa11.3 model performed better. Green leafy, red orange and cruciferous vegetables had the highest carotenoid content. Highest in flavonoids were cocoa powder, herbs and spices, and berries. Highest combined NRFa11.3 values were observed for herbs and spices, green leafy vegetables, cocoa, nuts, and red-orange and cruciferous vegetables. Discussion: Fresh and dry herbs and spices, often ignored by NP models, were particularly nutrient-rich and may provide non-negligible amounts of key phytonutrients to the human diet.

Pre-surgical factors related to latent trajectories of 5-year weight loss for a diverse bariatric surgery population.

BACKGROUND: Analyzing trajectories of weight loss may address how particular groups of patients respond to metabolic and bariatric surgery. OBJECTIVES: The Bariatric Experience Long Term (BELONG) study was designed to use a theoretical model to examine determinants of weight loss and recurrence. SETTING: Large integrated health system in Southern California with 11 surgical practices and 23 surgeons. METHODS: A total of n = 1338 patients who had metabolic and bariatric surgery were surveyed before surgery to measure factors related to median percent total weight loss (%TWL) over 5 years. Longitudinal weight data were available for n = 1024 (76.5% of the sample). Data were analyzed using latent growth mixture models (GMM) to estimate trajectories of weight change separately for gastric sleeve and bypass operations. These trajectories were then described using relevant variables from the baseline survey. RESULTS: For both gastric sleeve (n = 733) and bypass (n = 291) operations, 3 latent trajectories of median %TWL were found corresponding to most, moderate, and least %TWL. Sleeve trajectories were distinguished by body mass index at surgery and geocoded environmental factors. Bypass trajectories varied by self-reported and geocoded environmental factors, comorbidity burden, race, experiential avoidance, and weight control strategies. CONCLUSIONS: Future research should examine the role of the built and perceived environment in surgical weight loss. Bariatric practices should focus less on the presurgical period for predictors of long-term weight loss and begin efforts to monitor real-time patient-reported outcomes to help tailor intervention strategies for patients who either do not lose an expected amount of weight or who begin to experience weight recurrence.

Greater adherence to the Dietary Guidelines for Americans is associated with lower diet-related greenhouse gas emissions but higher costs.

Introduction: Few studies have evaluated the sustainability of popular diet patterns in the US, which limits policy action and impedes consumer efficacy to make sustainable dietary changes. This study filled this gap by evaluating the relationship between diet quality, greenhouse gas emissions (GHGE), and diet cost for plant-based, restricted carbohydrate, low grain, low fat, and time restricted diet patterns. Methods: Dietary data were retrieved from the National Health and Nutrition Examination Survey (2011-2018, n = 8,146) and linked with data on GHGE and food prices from publicly available databases. Diet quality was measured using the Healthy Eating Index-2015. The present study (1) compared the mean diet quality, GHGE, and diet cost between diet patterns, (2) evaluated the association of diet quality to GHGE and diet cost for each diet pattern, and (3) estimated the contribution of food sources to GHGE and diet cost for each diet pattern. Results: Higher diet quality was associated with lower GHGE for the general population and for most diet patterns (p < 0.01) except for the plant-based and time restricted diet patterns (p > 0.05). Higher diet quality was associated with higher cost for the general population and for all dietary patterns (p < 0.01) except the time restricted diet pattern (p > 0.05). Protein foods, mostly beef, accounted for the largest share of GHGE (29-40%) and diet cost (28-47%) for all diet patterns except plant-based. Discussion: Higher diet quality was associated with lower GHGE but was often accompanied by higher diet cost. These sustainability trade-offs can help inform major policy discussions in the US and shed light on further research needs in the area of food systems transformation.

Baseline Psychosocial, Environmental, Health, and Behavioral Correlates of 1- and 3-Year Weight Loss After Bariatric Surgery.

PURPOSE: Weight loss surgery is an effective, long-term treatment for severe obesity but individual response to surgery varies widely. The purpose of this study was to test a comprehensive theoretical model of factors that may be correlated with the greatest surgical weight loss at 1-3 years following surgery. Such a model would help determine what predictive factors to measure when patients are preparing for surgery that may ensure the best weight outcomes. MATERIALS AND METHODS: The Bariatric Experience Long Term (BELONG) study collected self-reported and medical record-based baseline information as correlates of 1- and 3-year % total weight loss (TWL) in n = 1341 patients. Multiple linear regression was used to determine the associations between 120 baseline variables and %TWL. RESULTS: Participants were 43.4 ± 11.3 years old, Hispanic or Black (52%; n = 699), women (86%; n = 1149), and partnered (72%; n = 965) and had annual incomes of ≥ $51,000 (60%; n = 803). A total of 1006 (75%) had 3-year follow-up weight. Regression models accounted for 10.1% of the variance in %TWL at 1-year and 13.6% at 3 years. Only bariatric operation accounted for a clinically meaningful difference (~ 5%) in %TWL at 1-year. At 3 years after surgery, only bariatric operation, Black race, and BMI ≥ 50 kg/m2 were associated with clinically meaningful differences in %TWL. CONCLUSIONS: Our findings combined with many others support a move away from extensive screening and selection of patients at the time of surgery to a focus on improving access to this treatment.

Greenhouse gas emissions, cost, and diet quality of specific diet patterns in the United States.

BACKGROUND: Major policy agendas are calling for accelerated investment in research that addresses the impact of diet patterns on multiple domains of sustainability. OBJECTIVES: To evaluate the comparative greenhouse gas emissions, diet cost, and diet quality of plant-based, low-grain, restricted carbohydrate, low-fat, and time-restricted diet patterns on a daily per capita basis. METHODS: Dietary data from the National Health and Nutrition Examination Survey (2013-2016, n = 4025) were merged with data on greenhouse gas emissions (GHGEs) and food prices from multiple databases. The Healthy Eating Index-2015 was used to measure diet quality. RESULTS: The plant-based diet pattern had the lowest GHGEs [3.5 kg carbon dioxide equivalent (CO2eq); 95% confidence interval (CI): 3.3, 3.8 kg CO2eq] and among the lowest diet cost ($11.51; 95% CI: $10.67, $12.41), but diet quality (45.8; 95% CI: 43.3, 48.5) was similar (P > 0.005) to most other diet patterns. All of the sustainability impacts of the low-grain diet pattern were intermediate. The restricted carbohydrate diet pattern had the highest diet cost ($18.46; 95% CI: $17.80, $19.13) but intermediate diet quality (46.8; 95% CI: 45.7, 47.9) and moderate-to-high GHGEs (5.7 kg CO2eq; 95% CI: 5.4, 5.9 kg CO2eq). The low-fat diet pattern had the highest diet quality (52.0; 95% CI: 50.8, 53.1) and intermediate GHGEs (4.4 kg CO2eq; 95% CI: 4.1, 4.6 kg CO2eq) and diet cost ($14.53; 95% CI: $13.73, $15.38). The time-restricted diet pattern had among the lowest diet quality score (42.6; 95% CI: 40.8, 44.6), had GHGEs similar to most other diet patterns (4.6 kg CO2eq; 95% CI: 4.2, 5.0 kg CO2eq), and low-to-moderate diet cost ($12.34; 95% CI: $11.38, $13.40). CONCLUSIONS: Most diet patterns are associated with sustainability trade-offs. The nature of these trade-offs can help inform discussions on food and nutrition policy in the United States, including the National Strategy on Hunger, Nutrition, and Health, and future Dietary Guidelines for Americans.

Neighborhood deprivation and residential property values do not affect weight loss at 1 or 3 years after bariatric surgery.

OBJECTIVE: This study examined the association between individual- and neighborhood-level sociodemographic factors and surgical weight loss at 1 year (short term) and 3 years (long term). METHODS: Data were obtained from the baseline survey of the BELONG (Bariatric Experience Long Term) prospective longitudinal cohort study. Individual-level self-reported data on sex, race and ethnicity, education, and household income were obtained by survey. Data from the 2010 US Census were used to calculate area Neighborhood Deprivation Index score and median value of owner-occupied housing units at the census tract level. RESULTS: Patients (N = 1341) had a mean age of 43.4 (SD 11.3) years, were mostly female (86%), were mostly Black or Hispanic (52%), had some college education (83%), and had annual household incomes ≥$51,000 (55%). Percentage total weight loss was 25.8% (SD 9.0%) at year 1 and 22.2% (SD 10.5%) at year 3. Race and ethnicity and age were significant predictors of weight loss at 1 and 3 years with a small effect of self-reported household income at year 1. There were no significant associations between census tract-level Neighborhood Deprivation Index score or value of owner-occupied housing units and weight loss at either time point. CONCLUSIONS: Health systems could improve the chances of weight-loss maintenance after surgery by addressing factors related to racial and ethnic disparities and to income disparities.

No Association between Low-Calorie Sweetener (LCS) Use and Overall Cancer Risk in the Nationally Representative Database in the US: Analyses of NHANES 1988-2018 Data and 2019 Public-Use Linked Mortality Files.

Low-calorie sweeteners (LCS) serve to replace added sugars in beverages and foods. The present goal was to explore any potential links between LCS use and cancer risk using the nationally representative National Health and Nutrition Examination Surveys 1988-2018 linked to 2019 Public-Use Linked Mortality Files. Analyses were based on dietary intakes from 1988-1994 NHANES (n = 15,948) and 1999-2018 NHANES (n = 48,754) linked to mortality data. The 1988-1994 NHANES separated aspartame from saccharin consumption; later data did not. LCS consumers were more likely to be older, female, non-Hispanic White, and with higher education and incomes compared to nonconsumers. LCS consumers were less likely to smoke and had higher HEI-2015 scores indicating higher-quality diets. In the cross-sectional NHANES data, LCS use was associated with higher BMI and higher prevalence of obesity and diabetes. There was no indication that aspartame, saccharin, or all LCS had any impact on overall cancer mortality. By using nonconsumers as the reference group, the hazard ratio (95th confidence interval, CI) group trend for tertiles of LCS use for 1988-1994 for aspartame was 1.00 (0.89-1.12), for saccharin 0.96 (0.79-1.10), and for 1988-2018 for all LCS was 0.92 (0.88-1.101). The null group trend effects were seen for analyses stratified by age/gender. The present analyses confirm past US-based reports that LCS use was associated with higher socioeconomic status, lower prevalence of smoking, and generally higher-quality diets. No association with cancer mortality was observed.

The association of 1-year weight loss from bariatric surgery and self-reported sleep: a prospective cohort.

OBJECTIVE: This study examined the association of weight loss following bariatric surgery with self-reported sleep quality after accounting for other sleep-related factors. METHODS: Participants were from the Bariatric Experience Long Term (BELONG) study. Participants completed a survey up to 6 months before surgery and approximately 1 year after surgery. The Pittsburgh Sleep Quality Index (PSQI) was used to measure sleep quality. One-year percentage total weight loss (%TWL) was determined from electronic medical records. Covariates included demographics, Charlson Comorbidity Index, geocoded variables to assess neighborhood quality, and physical activity. The authors assessed the association between %TWL at 1 year and PSQI component scores with separate cumulative logit models. RESULTS: There were 997 participants in the analytic cohort. Participants were 86.2% women, 37.0% Hispanic, and 13.7% Black adults. Mean one-year %TWL was 26.3 (SD 8.7). Each 1% increase in %TWL was associated with a 3% better daytime dysfunction score (odds ratio = 1.03; 95% CI: 1.02-1.05) and a 2% better sleep quality score (odds ratio = 1.02; 95% CI: 1.00-1.03). No significant differences were found for the other PSQI components. CONCLUSIONS: Weight loss from bariatric surgery was associated with better self-reported sleep at 1 year. For people undergoing bariatric surgery, there may be an added benefit of better sleep.

Applying Behavioral Nudges in a Dietary Comparator for Surgical Trials: Developing the MediDiet.

INTRODUCTION: Dietary interventions are increasingly being proposed as alternatives to surgery for common gastrointestinal conditions. Integrating aspects of cognitive psychology (e.g., behavioral nudges) into dietary interventions is becoming popular, but evidence is lacking on their effectiveness and unintended effects. We assessed the effects of including nudges in the development of a dietary intervention based on the Mediterranean diet. METHODS: We conducted two-arm randomized surveys of United States adults. After a validated dietary questionnaire, participants received feedback about dietary consistency with a Mediterranean diet with (A) no nudge versus (B) one of several nudges: peer comparison, positive affect induction + peer comparison, or defaults. Participants rated their negative and positive emotions, motivation for dietary change, and interest in recipes. Responses were analyzed using baseline covariate-adjusted regression. RESULTS: Among 1709 participants, 56% were men and the median age was 36 y. Nudges as a class did not significantly affect the extent of negative or positive emotions, motivation, or interest. However, specific nudges had different effects: compared to no nudge, peer comparison blunted negative emotions and increased motivation, although decreased interest in recipes, while defaults increased interest in recipes but reduced motivation. CONCLUSIONS: In this pilot, behavioral nudges as a class of strategies did not improve participants' reactions to dietary feedback nor did they promote negative reactions. However, specific nudges may be better considered separately in their effects. Future testing should explore whether specific nudges including peer comparison and defaults improve dietary intervention effectiveness, especially in people with the specific gastrointestinal conditions of interest.

Key Considerations for Policymakers-Iodized Salt as a Vehicle for Iron Fortification: Current Evidence, Challenges, and Knowledge Gaps.

Could DFS help prevent iron deficiency and anemia? Studies in controlled settings (efficacy) demonstrate that double-fortified salt (DFS; iron added to iodized salt) reduces the prevalence of anemia and iron deficiency anemia. Studies in program settings (effectiveness) are limited and reported differing levels of DFS coverage, resulting in mixed evidence of impact on anemia. What iron formulations are available and how do they affect iodized salt? Ferrous sulfate and encapsulated ferrous fumarate (both with various enhancers and/or coating materials) are the main iron formulations currently in use for DFS. Adding iron to iodized salt may lead to adverse changes in the product, specifically discoloration and losses in iodine content. These changes are greatest when the iodized salt used in DFS production is of low quality (e.g., contain impurities, has high moisture, and is of large crystal size). DFS requires iodized salt of the highest quality and a high-quality iron formulation in order to minimize adverse sensory changes and iodine losses. Appropriate packaging of iodized salt is also important to prevent losses. What is known about the minimum requirements to manufacture DFS? DFS producers must use high-quality refined iodized salt meeting the minimum standards for DFS production (which is higher than standards for salt intended for iodization alone), and an iron formulation for which there are rigid quality-assurance measures to ensure consistent quality and blending techniques. The actual proportion of iodized salt meeting the stringent requirements necessary for DFS production is unclear, but likely to be low in many countries, especially those with fragmented salt industries and a low proportion of industrially produced salt. What are the financial implications of adding iron to iodized salt? As a result of higher input costs both for input salt and the iron compound, DFS is more expensive to produce than iodized salt and thus has a higher production cost. Various grades of iodized salt are produced and consumed in different sectors of the market. Experience in India indicates that, on average, producing DFS costs 31-40 US dollars/metric ton or 0.03-0.04 US dollars/kg more than high-quality refined iodized salt. The exact impact of this production-level cost difference on profit margins and consumer price is specific to the conditions of different salt markets. Factors such as transport costs, customary wholesale and retail mark-ups, and taxes all vary greatly and need to be assessed on a case by case basis. Is DFS in alignment with salt-reduction efforts? The WHO has long recognized that salt iodization is an important public health intervention to achieve optimal iodine nutrition and is compatible with salt-reduction goals. Fortification of salt (with any nutrient) should not be used to justify or encourage an increase in salt intake to the public. Any effort to expand salt fortification to other nutrients should be done in close consultation with WHO and those working on salt reduction. What has been the experience with DFS delivery under different platforms? To date, DFS has been introduced into the retail market and in social safety net (primarily in India) programs, but sensory changes in DFS have been raised as concerns. The higher price for DFS has limited expansion in the retail market. In social safety net programs where the cost of DFS is subsidized for beneficiaries, programs must consider long-term resourcing for sustainability. Overall: The optimal production and delivery of DFS are still under development, as many challenges need to be overcome. There is a beneficial impact on hemoglobin in efficacy trials. Thus, if those conditions can be replicated in programs or the technology can be adapted to better fit current production and delivery realities, DFS may provide an effective contribution in countries that need additional food-fortification vehicles to improve iron intake.

Bariatric Surgical Alterations in Tolerability, Enjoyment and Cravings in the Diet (BSATED) instrument: A new scale to measure food preferences following bariatric surgery.

Bariatric surgery is associated with changing food preferences, but it is not known whether these changes differ by type of operation or are associated with weight loss. The current study presents validation results for a new 27-item scale, Bariatric Surgical Alterations in Tolerability, Enjoyment and Cravings in the Diet (BSATED). This scale measured enjoyment, craving, and intolerance changes for nine food and beverage categories common to dietary habits in the Southern California region of the U.S. one year following bariatric surgery in the Bariatric Experience Long Term (BELONG) study. Validation of BSATED was done using exploratory factor analyses, construct validity with other conceptually related survey instruments, and criterion validity using hypothesized differences for operation type and percent total weight loss (%TWL) at 12-18 months after surgery. Participants (n = 999) were 86% female, 41% non-Hispanic White, with a mean age of 43.1 ± 11.3 years and a body mass index (BMI) of 43.4 ± 6.8 kg/m2 at the time of surgery. Participants reported less enjoyment and craving for high-fat meats (62%), grains (54%), candy and other desserts (e.g. candy bars, chocolate, ice cream) (52%), and sweet baked goods (48%) 12 months after surgery. These changes were more common among participants undergoing Roux-en-Y gastric bypass (RYGB) compared to those receiving sleeve gastrectomy (SG). Participants who reported decreased enjoyment and craving for foods and beverages that post-bariatric patients are counseled to reduce or avoid had greater %TWL at 12-18 months following surgery (p < .001 and p = .003 respectively). The foods and beverages in BSATED that post-bariatric patients are counseled to reduce or avoid could be used to understand how changes in enjoyment, craving and tolerability of these foods/beverages contribute to weight loss following surgery.

The Bariatric Experience Long Term (BELONG): Factors Related to Having Bariatric Surgery in a Large Integrated Healthcare System.

PURPOSE: Bariatric surgery is the most effective treatment for severe obesity, but currently, only 1-2% of all eligible patients undergo surgery each year. This study examined which factors were associated with a patient receiving bariatric surgery after referral in a real-world healthcare setting. MATERIALS AND METHODS: The current study used the baseline survey and electronic medical record (EMR) data from the Bariatric Experience Long Term (BELONG) study (n = 1975). Predictors of who did (n = 1680) and who did not (n = 295) have surgery were analyzed using multivariate logistic regression. RESULTS: Participants (n = 1975; 42.4% response rate) were primarily women (84%) and either non-Hispanic Black or Hispanic (60%). In the fully adjusted multivariate model, the strongest predictors of having surgery were being a woman (OR = 3.17; 95% CI = 2.15, 4.68; p < .001) and losing at least 5% of their body weight in the year before surgery (OR = 3.16; 95% CI = 2.28, 4.38; p < .001). The strongest predictors of not having surgery were a ≥ BMI 50 kg/m2 (OR = .39; 95% CI = .27, .56; p < .001) and having a higher physical comorbidity burden (OR = .84; 95% CI = .75, .94; p = .004). CONCLUSIONS: Practices such as 5-10% total weight loss before surgery and selection of patients with safer operative risk profiles (younger with lower comorbidity burden) may inadvertently contribute to under-utilization of bariatric surgery among some demographic subpopulations who could most benefit from this intervention.

A new category-specific nutrient rich food (NRF9f.3) score adds flavonoids to assess nutrient density of fruit.

Nutrient profiling (NP) models, intended to capture the full nutritional value of plant-based foods, ought to incorporate bioactive phytochemicals, including flavonoids, in addition to standard nutrients. The well-established Nutrient Rich Food (NRF9.3) score is based on 9 nutrients to encourage (protein, fiber, vitamins A, C, D and calcium, iron, potassium, magnesium) and 3 nutrients to limit (saturated fat, added sugar, sodium). The new category-specific NRF9f.3 score kept the same algorithm based on sums of percent daily values (%DVs) but swapped vitamin D for total flavonoids from the USDA database. NRF9f.3 was applied to the USDA fruit group categories, comparing nutrient density of citrus fruit, citrus juice, dried fruit, raw and cooked fruit, berries, fruit mixtures, fruit salads, non-citrus fruit juice, and fruit nectars. Adding total flavonoids to NRF9f.3 allowed for a recalibration of fruit total nutritional value. Citrus fruits and juices had significantly higher flavanones, berries had significantly higher anthocyanidins, and dried fruit and berries had significantly higher flavan-3-ols, than other fruits (all p < 0.05). Citrus fruit, citrus juice and berries had significantly higher NRFf9.3 scores than all other fruit subcategories (p < 0,05), but were not different from each other. The more innovative NP models are both category specific and make effective use of new nutrient composition databases. NRF9.3 when applied to the fruit group discriminates primarily on fiber, vitamin C, and added sugar content. Incorporating flavonoid and polyphenol data modernizes NP models to better capture nutrient density of plant foods that can aid in dietary guidance and policy development to improve diversity and nutritional value of the diet.

Impact of nutrition interventions and dietary nutrient density on productivity in the workplace.

The global spread of diet-related noncommunicable diseases represents a threat to public health and national economies alike. The elimination of poverty and the eradication of hunger, two key United Nations Sustainable Development Goals, cannot be accomplished without a well-nourished labor force. Easy access to low-cost diets that are energy dense but nutrient poor has resulted in hidden hunger, in which micronutrient deficiencies coexist with obesity or overweight. Workplace interventions in low- and middle-income countries have addressed nutrient adequacy and micronutrient deficiencies, often using fortified foods. Workplace interventions in high-income countries have largely focused on weight loss, smoking cessation, stress reduction, and physical activity. Even though improvement of productivity may have been the ultimate goal, relatively few interventions in high-income countries have explored the likely impact of improved dietary nutrient density on workplace performance. Given that optimal nutrition benefits both physical and mental health, interventions to improve diet quality ought to have a measurable impact on the productivity of the labor force. The present review examines the evidence linking workplace dietary interventions with workplace productivity measures.

Evidence from big data in obesity research: international case studies.

BACKGROUND/OBJECTIVE: Obesity is thought to be the product of over 100 different factors, interacting as a complex system over multiple levels. Understanding the drivers of obesity requires considerable data, which are challenging, costly and time-consuming to collect through traditional means. Use of 'big data' presents a potential solution to this challenge. Big data is defined by Delphi consensus as: always digital, has a large sample size, and a large volume or variety or velocity of variables that require additional computing power (Vogel et al. Int J Obes. 2019). 'Additional computing power' introduces the concept of big data analytics. The aim of this paper is to showcase international research case studies presented during a seminar series held by the Economic and Social Research Council (ESRC) Strategic Network for Obesity in the UK. These are intended to provide an in-depth view of how big data can be used in obesity research, and the specific benefits, limitations and challenges encountered. METHODS AND RESULTS: Three case studies are presented. The first investigated the influence of the built environment on physical activity. It used spatial data on green spaces and exercise facilities alongside individual-level data on physical activity and swipe card entry to leisure centres, collected as part of a local authority exercise class initiative. The second used a variety of linked electronic health datasets to investigate associations between obesity surgery and the risk of developing cancer. The third used data on tax parcel values alongside data from the Seattle Obesity Study to investigate sociodemographic determinants of obesity in Seattle. CONCLUSIONS: The case studies demonstrated how big data could be used to augment traditional data to capture a broader range of variables in the obesity system. They also showed that big data can present improvements over traditional data in relation to size, coverage, temporality, and objectivity of measures. However, the case studies also encountered challenges or limitations; particularly in relation to hidden/unforeseen biases and lack of contextual information. Overall, despite challenges, big data presents a relatively untapped resource that shows promise in helping to understand drivers of obesity.

An Overlap Between "Ultraprocessed" Foods and the Preexisting Nutrient Rich Foods Index?

The category of "ultra-processed" foods in the NOVA food classification scheme is ostensibly based on industrial processing. We compared NOVA category assignments with the pre-existing family of Nutrient Rich Food (NRF) indices, first developed in 2005. NRF n.3 indices are composed of two subscores; the positive NRn based on protein, fiber, and n vitamins and minerals, and the negative LIM subscore based on saturated fat, added sugar, and sodium. The 378 foods that were components of the widely used Fred Hutchinson Cancer Center food frequency questionnaire were assigned to NOVA categories and scored using multiple NRF indices. Contrary to published claims, NOVA was largely based on the foods' content of saturated fat, added sugars, and sodium. There were strong similarities between NOVA categories and NRF scores that were largely driven by the foods' content of fat, sugar, and salt. Nutrient density increased NRF scores but had less impact on NOVA categories. As a result, the NOVA scheme misclassified some nutrient-rich foods. Both NOVA categories and NRF9.3 scores were strongly affected by the amounts of saturated fat, added sugars, and sodium. Ultra-processed foods and culinary ingredients received lower NRFn.3 scores. We conclude that the arbitrary NOVA classification scheme adds little to the pre-existing nutrient profiling models. The purported links between NOVA categories and health outcomes could have been obtained using pre-existing NRFn.3 nutrient density metrics.

Plant- and animal-protein diets in relation to sociodemographic drivers, quality, and cost: findings from the Seattle Obesity Study.

BACKGROUND: Promoting plant-based proteins is at the forefront of many initiatives in public health nutrition. OBJECTIVES: The aim of this study was to characterize the sociodemographic drivers of plant-based protein diet consumption, and to study these in relation to diet quality and cost. METHODS: The Seattle Obesity Study series (SOS I and II) yielded the study sample (n = 1636). Sociodemographic data were obtained by survey self-report. Diet quality and cost came from the Fred Hutchinson Cancer Research Center Food-Frequency Questionnaire linked to retail food prices. The Healthy Eating Index 2010 (HEI-2010) and mean adequacy ratio (MAR) served as measures of diet quality. Linear regressions with robust standard errors examined associations. RESULTS: Total proteins contributed 16.8% of daily dietary energy. The breakdown by animal and plant proteins was 10.9% and 5.9%, respectively. The sociodemographic factors associated with plant-protein consumption were a positive attitude towards healthy eating and higher education but not income. Plant-protein diets were characterized by severalfold increases in nuts and seeds, soy and legumes, but much less meat, poultry, dairy, solid fats, and added sugars. Higher quartiles of plant-based diets were associated with significantly higher HEI-2010 (ß: 13.0 from quartile 1 to quartile 4; 95% CI: 11.8, 14.3) and higher MAR (ß: 6.0; 95% CI: 3.5, 8.5) with minimal impact on diet costs (ß: 0.35; 95% CI: 0.04, 0.67). In contrast, higher quartiles of animal-protein diets were associated with higher diet costs (ß: 1.07; 95% CI: 0.77, 1.36) but lower HEI-2010 (ß: -3.2; 95% CI: -4.5, -1.9). Each additional 3% of energy from plant proteins was associated with an 8.4-unit increase in HEI-2010 (95% CI: 7.6, 9.1) and with a 4.1-unit increase in MAR (95% CI: 2.7, 5.5) with a minimal increase in diet cost (ß: 0.28; 95% CI: 0.06, 0.50). CONCLUSION: Plant-based protein diets may be a cost-effective way to improve diet quality at all levels of income. Future research needs to evaluate the quality of plant-based protein in relation to amino acids and health.

Spot Urine Sodium-to-Potassium Ratio Is a Predictor of Stroke.

Background and Purpose- Dietary sodium reduction with concurrent increase in potassium intake is a current public health priority to reduce risk of cardiovascular events. This study explored associations between the spot urine sodium-to-potassium ratio and cardiovascular events in the MESA (Multi-Ethnic Study of Atherosclerosis) longitudinal cohort. Methods- The MESA is a prospective cohort study of 6814 adults from 4 ethnic groups (European-, Asian-, African- and Hispanic-American) with a mean age of 62 (±10.2) years and an average of 11.7 (±2.2) years of follow-up. Participants were free of clinical cardiovascular disease at baseline. Spot urine sodium and potassium excretion, as a marker of dietary intake, was collected at baseline. The impact of urinary sodium-to-potassium ratio on adjudicated cardiovascular events was assessed using Cox proportional hazards models. Results- Only 39% of MESA participants had a urinary sodium-to-potassium ratio ≤1, and these participants experienced only 74 of the 236 strokes. A sodium-to-potassium ratio >1 was associated with a hazard ratio of 1.47 (95% CI,1.07-2.00) for risk of stroke, adjusting for age, sex, race, cardiovascular risk factors, socio-demographic characteristics, body size, and kidney function. Conclusions- The spot urine sodium-to-potassium ratio (measurable in routine care) is associated with stroke. A urine sodium-to-potassium ratio of ≤1, may be related to a clinically relevant reduction in stroke risk and is a feasible target for health interventions.

Ibero⁻American Consensus on Low- and No-Calorie Sweeteners: Safety, Nutritional Aspects and Benefits in Food and Beverages.

International scientific experts in food, nutrition, dietetics, endocrinology, physical activity, paediatrics, nursing, toxicology and public health met in Lisbon on 2⁻4 July 2017 to develop a Consensus on the use of low- and no-calorie sweeteners (LNCS) as substitutes for sugars and other caloric sweeteners. LNCS are food additives that are broadly used as sugar substitutes to sweeten foods and beverages with the addition of fewer or no calories. They are also used in medicines, health-care products, such as toothpaste, and food supplements. The goal of this Consensus was to provide a useful, evidence-based, point of reference to assist in efforts to reduce free sugars consumption in line with current international public health recommendations. Participating experts in the Lisbon Consensus analysed and evaluated the evidence in relation to the role of LNCS in food safety, their regulation and the nutritional and dietary aspects of their use in foods and beverages. The conclusions of this Consensus were: (1) LNCS are some of the most extensively evaluated dietary constituents, and their safety has been reviewed and confirmed by regulatory bodies globally including the World Health Organisation, the US Food and Drug Administration and the European Food Safety Authority; (2) Consumer education, which is based on the most robust scientific evidence and regulatory processes, on the use of products containing LNCS should be strengthened in a comprehensive and objective way; (3) The use of LNCS in weight reduction programmes that involve replacing caloric sweeteners with LNCS in the context of structured diet plans may favour sustainable weight reduction. Furthermore, their use in diabetes management programmes may contribute to a better glycaemic control in patients, albeit with modest results. LNCS also provide dental health benefits when used in place of free sugars; (4) It is proposed that foods and beverages with LNCS could be included in dietary guidelines as alternative options to products sweetened with free sugars; (5) Continued education of health professionals is required, since they are a key source of information on issues related to food and health for both the general population and patients. With this in mind, the publication of position statements and consensus documents in the academic literature are extremely desirable.

Water and beverage consumption patterns among 4 to 13-year-old children in the United Kingdom.

BACKGROUND: The UK government has announced a tax on sugar-sweetened beverages. The aim of this study was to assess consumption patterns for plain drinking water relative to sugary beverages among UK children. METHODS: Dietary intake data for 845 children aged 4-13 years came from the nationally representative cross-sectional National Diet and Nutrition Survey, 2008-2011. Beverage categories were drinking water (tap or bottled), milk, 100% fruit juices, soda, fruit drinks, tea, coffee, sports drinks, flavored waters, and liquid supplements. Consumption patterns were examined by age group, gender, household incomes, time and location of consumption, region and seasonality. Total water consumption from drinking water, beverages, and foods, and the water-to-calorie ratios (L/kcal) were compared to the EFSA (European Food Safety Authority) adequate intake standards. RESULTS: Total water intake (1338 ml/d) came from plain water (19%), beverages (48%), and food moisture (33%). Plain drinking water provided 258 g/d (241 g/d for children aged 4-8 years; 274 g/d for 9-13 years), mostly (83.8%) from tap. Water and beverages supplied 901 g /d of water. Tap water consumption increased with income and was highest in the South of England. The consumption of bottled water, soda, tea and coffee increased with age, whereas milk consumption declined. About 88.7% of children did not meet EFSA adequate intake standards. The daily water shortfall ranged from 322 ml/d to 659 ml/d. Water-to-calorie ratio was 0.845 L/1000 kcal short of desirable levels of 1.0-1.5 L/1000 kcal. CONCLUSION: Total water intake were at 74.8% of EFSA reference values. Drinking water consumption among children in the UK was well below US and French estimates.