Patterns of weight change and progression to overweight and obesity differ in men and women: implications for research and interventions.

OBJECTIVE: To evaluate long-term patterns of weight change and progression to overweight and obesity during adulthood. DESIGN: Prospective study. Changes in mean BMI, waist circumference (WC) and weight were assessed over a mean 26-year follow-up (1971­1975 to 1998­2001). Mean BMI (95% CI) and mean WC (95% CI) of men and women in BMI and age groups were computed. Mean weight change in BMI and age categories was compared using analysis of covariance. SETTING: Framingham Heart Study Offspring/Spouse Nutrition Study. SUBJECTS: Men and women (n 2394) aged 20­63 years. RESULTS: During follow-up, increases in BMI (men: 2?2 kg/m2; women: 3?7 kg/m2) and WC (men: 5?7 cm; women: 15?1 cm) were larger in women than men. BMI gains were greatest in younger adults (20­39 years) and smallest in obese older adults (50­69 years). The prevalence of obesity doubled in men (to 33?2%) and tripled in women (to 26?6 %). Among normal-weight individuals, abdominal obesity developed in women only. The prevalence of abdominal obesity increased 1?8-fold in men (to 53?0%) and 2?4-fold in women (to 71?2 %). Weight gain was greatest in the youngest adults (20­29 years), particularly women. Gains continued into the fifth decade among men and then declined in the sixth decade; in women gains continued into the sixth decade. CONCLUSIONS: Patterns of weight change and progression to obesity during adulthood differ in men and women. Preventive intervention strategies for overweight and obesity need to consider age- and sex-specific patterns of changes in anthropometric measures.

Dietary patterns of women are associated with incident abdominal obesity but not metabolic syndrome.

Data on the relationship between empirical dietary patterns and metabolic syndrome (MetS) and its components in prospective study designs are limited. In addition, demographic and lifestyle determinants of MetS may modify the association between dietary patterns and the syndrome. We prospectively examined the relationship between empirically derived patterns and MetS and MetS components among 1146 women in the Framingham Offspring/Spouse cohort. They were aged 25-77 y with BMI ≥18.5 kg/m(2) and free of cardiovascular disease, diabetes, cancer, and MetS at baseline, and followed for a mean of 7 y. Five dietary patterns, Heart Healthier, Lighter Eating, Wine and Moderate Eating, Higher Fat, and Empty Calorie, were previously identified using cluster analysis from food intake collected using a FFQ. After adjusting for potential confounders, we observed lower odds for abdominal obesity for Higher Fat [OR = 0.48 (95% CI: 0.25, 0.91)] and Wine and Moderate Eating clusters [OR = 0.28 (95% CI: 0.11, 0.72)] compared with the Empty Calorie cluster. Additional adjustment for BMI somewhat attenuated these OR [Higher Fat OR = 0.52 (95% CI: 0.27, 1.00); Wine and Moderate Eating OR = 0.34 (95% CI: 0.13, 0.89)]. None of the clusters was associated with MetS or other MetS components. Baseline smoking status and age did not modify the relation between dietary patterns and MetS. The Higher Fat and Wine and Moderate Eating patterns showed an inverse association with abdominal obesity; certain foods might be targeted in these habitual patterns to achieve optimal dietary patterns for MetS prevention.

Diet quality, physical activity, smoking status, and weight fluctuation are associated with weight change in women and men.

The effect of diet quality on weight change, relative to other body weight determinants, is insufficiently understood. Furthermore, research on long-term weight change in U.S. adults is limited. We evaluated prospectively patterns and predictors of weight change in Framingham Offspring/Spouse (FOS) women and men (n = 1515) aged > or =30 y with BMI > or = 18.5 kg/m2 and without cardiovascular disease, diabetes, and cancer at baseline over a 16-y period. Diet quality was assessed using the validated Framingham Nutritional Risk Score. In women, older age (P < 0.0001) and physical activity (P < 0.05) were associated with lower weight gain. Diet quality interacted with former smoking status (P-interaction = 0.02); former smokers with lower diet quality gained an additional 5.2 kg compared with those with higher diet quality (multivariable-adjusted P-trend = 0.06). Among men, older age (P < 0.0001) and current smoking (P < 0.01) were associated with lower weight gain, and weight fluctuation (P < 0.01) and former smoking status (P < 0.0001) were associated with greater weight gain. Age was the strongest predictor of weight change in both women (partial R(2) = 11%) and men (partial R(2) = 8.6%). Normal- and overweight women gained more than obese women (P < 0.05) and younger adults gained more weight than older adults (P < 0.0001). Patterns and predictors of weight change differ by sex. Age in both sexes and physical activity among women as well as weight fluctuation and smoking status in men were stronger predictors of weight change than diet quality among FOS adults. Women who stopped smoking over follow-up and had poor diet quality gained the most weight. Preventive interventions need to be sex-specific and consider lifestyle factors.

Diet quality and obesity in women: the Framingham Nutrition Studies.

Obesity affects one in three American adult women and is associated with overall mortality and major morbidities. A composite diet index to evaluate total diet quality may better assess the complex relationship between diet and obesity, providing insights for nutrition interventions. The purpose of the present investigation was to determine whether diet quality, defined according to the previously validated Framingham nutritional risk score (FNRS), was associated with the development of overweight or obesity in women. Over 16 years, we followed 590 normal-weight women (BMI < 25 kg/m2), aged 25 to 71 years, of the Framingham Offspring and Spouse Study who presented without CVD, cancer or diabetes at baseline. The nineteen-nutrient FNRS derived from mean ranks of nutrient intakes from 3 d dietary records was used to assess nutritional risk. The outcome was development of overweight or obesity (BMI > or = 25 kg/m2) during follow-up. In a stepwise multiple logistic regression model adjusted for age, physical activity and smoking status, the FNRS was directly related to overweight or obesity (P for trend = 0.009). Women with lower diet quality (i.e. higher nutritional risk scores) were significantly more likely to become overweight or obese (OR 1.76; 95 % CI 1.16, 2.69) compared with those with higher diet quality. Diet quality, assessed using a comprehensive composite nutritional risk score, predicted development of overweight or obesity. This finding suggests that overall diet quality be considered a key component in planning and implementing programmes for obesity risk reduction and treatment recommendations.

Performance of a method for identifying the unique dietary patterns of adult women and men: the Framingham nutrition studies.

BACKGROUND: Identification of population dietary patterns has been recommended by experts as a key to developing innovative and targeted nutrition interventions and achieving long-term dietary behavior changes for health promotion and chronic disease risk reduction. Essential in this task is the evaluation of methods to accurately identify these unique dietary patterns. OBJECTIVE: To evaluate the validity and test the performance of a method for classifying adult men and women into one of five a priori dietary patterns. DESIGN: The first examination of Framingham Nutrition Studies took place between 1984 and 1987 and included 1,828 women and 1,666 men who completed the Framingham semi-quantitative food frequency questionnaire. Five unique dietary patterns for each sex were identified. Here we used Fisher's discriminant functions to create classification algorithms for identifying the dietary patterns of new individuals. Its validity and performance was evaluated using a variety of statistical tools. RESULTS: The new Framingham Dietary Pattern algorithm classified about 80% of women or men correctly and kappa statistics exceeded 0.70. The cluster-specific sensitivities ranged from 0.70 to 1.00 and specificities were all >0.88. The pooled conditional c statistics were 0.95 and 0.96 for women and men, respectively. Overall, we can be confident that our methodology offers a valid identification of male and female dietary patterns when applied in practice. CONCLUSIONS: The Framingham Dietary Pattern technique is a valid and reliable method for identifying the unique dietary behavior of adults. Our approach can also be used to guide the development and evaluation of other composite dietary quality indices.

Nutritional risk and the metabolic syndrome in women: opportunities for preventive intervention from the Framingham Nutrition Study.

BACKGROUND: Diet is recognized as a key factor in the cause and management of the metabolic syndrome (MetS). However, policies to guide preventive clinical nutrition interventions of the condition are limited. OBJECTIVES: We examined the relation between dietary quality and incident MetS in adult women and identified foci for preventive nutrition interventions. DESIGN: This was a prospective study of 300 healthy women (aged 30-69 y) in the Framingham Offspring-Spouse study who were free of MetS risk factors at baseline. The development of individual MetS traits and overall MetS status during 12 y of follow-up were compared in women by tertile of nutritional risk, based on intake of 19 nutrients. Multivariate logistic regression models considered age, smoking, physical activity, and menopausal status. RESULTS: Baseline age-adjusted mean nutrient intake and ischemic heart disease risk profiles differed by tertile of nutritional risk. Women with higher nutritional risk profiles consumed more dietary lipids (total, saturated, and monounsaturated fats) and alcohol and less fiber and micronutrients; they had higher cigarette use and waist circumferences. Compared with women with the lowest nutritional risk, those in the highest tertile had a 2- to 3-fold risk of the development of abdominal obesity and overall MetS during 12 y of follow-up [odds ratio: 2.3 (95% CI: 1.2, 4.3) and 3.0 (95% CI: 1.2, 7.6), respectively]. CONCLUSIONS: Higher composite nutritional risk predicts the development of abdominal obesity and MetS during long-term follow-up in healthy women, independent of lifestyle and ischemic heart disease risk factors. Preventive nutrition interventions for obesity and MetS risk reduction should focus on the overall nutritional quality of women's dietary profiles.

Nutrition for the Prevention of Chronic Diseases.

Chronic non-communicable diseases (NCDs) are the leading causes of morbidity and mortality in the United States and globally, and are attributable largely to poor nutrition and suboptimal lifestyle behaviors. The 2015-2020 Dietary Guidelines for Americans promote healthy eating and lifestyle patterns across the lifespan to reduce risk of NCDs. Physicians are well positioned to provide lifestyle preventive interventions that are personalized to their patients' biological needs and cultural preferences through multidisciplinary team activities or referral to professional nutrition and physical activity experts. They can also advocate for environmental changes in healthcare and community settings that promote healthful lifestyle behaviors.

The 2015 Dietary Guidelines Advisory Committee Scientific Report: Development and Major Conclusions.

The Dietary Guidelines for Americans (DGA) is published every 5 y jointly by the Department of Health and Human Services (HHS) and the USDA and provides a framework for US-based food and nutrition programs, health promotion and disease prevention initiatives, and research priorities. Summarized in this report are the methods, major conclusions, and recommendations of the Scientific Report of the 2015 US Dietary Guidelines Advisory Committee (DGAC). Early in the process, the DGAC developed a conceptual model and formulated questions to examine nutritional risk and determinants and impact of dietary patterns in relation to numerous health outcomes among individuals aged ≥2 y. As detailed in the report, an expansive, transparent, and comprehensive process was used to address each question, with multiple opportunities for public input included. Consensus was reached on all DGAC's findings, including each conclusion and recommendation, and the entire report. When research questions were answered by original systematic literature reviews and/or with existing, high-quality expert reports, the quality and strength of the evidence was formally graded. The report was organized around the following 5 themes: 1) food and nutrient intakes and health: current status and trends; 2) dietary patterns, foods and nutrients, and health outcomes; 3) diet and physical activity behavior change; 4) food and physical activity environments; and 5) food sustainability and food safety. The following 3 cross-cutting topics were addressed: 1) sodium, 2) saturated fat, and 3) added sugars. Physical activity recommendations from recent expert reports were endorsed. The overall quality of the American diet was assessed to identify overconsumed and underconsumed nutrients of public health concern. Common food characteristics of healthy dietary patterns were determined. Features of effective interventions to change individual and population diet and physical activity behaviors in clinical, public health, and community settings were identified. The report was used by the HHS and the USDA to develop the 2015 DGA.

Compliance with expert population-based dietary guidelines and lower odds of carotid atherosclerosis in women: the Framingham Nutrition Studies.

BACKGROUND: Carotid stenosis, an indicator of subclinical atherosclerosis, predicts future coronary artery disease (CAD) and stroke and provides a noninvasive method to identify candidates for primary prevention. The relation between diet and stenosis is relatively unexplored, particularly in women. OBJECTIVE: We evaluated in women the association between nutrient intakes that were consistent with expert population-based dietary guidelines and carotid stenosis. DESIGN: We used prospective logistic regression analyses to evaluate relations between baseline nutrient intake and the presence of carotid stenosis at 4-y follow-up in 1123 women from the Framingham Offspring-Spouse study, after control for multiple CAD risk factors. We also developed multivariate models that were stratified by compliance with expert population-based dietary guidelines and smoking status. RESULTS: Baseline nutrient and risk factor profiles differed by women's compliance and smoking status. Dietary noncompliance and smoking were each associated with odds for stenosis that were 2.5-fold those of dietary compliance and nonsmoking. Odds were highest for dietary noncompliance in combination with smoking (odds ratio: 3.49; 95% CI: 1.67, 7.27). CONCLUSIONS: Nutrient intake consistent with current expert population-based dietary guidelines and smoking abstinence are associated with lower odds of carotid atherosclerosis in women. Unique dietary and risk factor profiles of at-risk women suggest areas for targeted primary CAD prevention.

Unique dietary patterns and chronic disease risk profiles of adult men: the Framingham nutrition studies.

OBJECTIVE: To identify the dietary patterns of adult men and examine their relationships with nutrient intake and chronic disease risk over long-term follow-up. DESIGN/SUBJECTS: Baseline 145-item food frequency questionnaires from 1,666 Framingham Offspring-Spouse cohort men were used to identify comprehensive dietary patterns. Independent 3-day dietary records at baseline and 8 years later provided estimates of subjects' nutrient intake by dietary pattern. Chronic disease risk factor status was compared at baseline and 16-year follow-up across all male dietary patterns. STATISTICAL ANALYSES: Cluster analysis was applied to food frequency data to identify non-overlapping male dietary patterns. Analysis of covariance and logistic regression were used to compare nutrient intake, summary nutritional risk scores, and chronic disease risk status at baseline and follow-up by male dietary pattern. RESULTS: Five distinct and comprehensive dietary patterns of Framingham Offspring-Spouse men were identified and ordered according to overall nutritional risk: Transition to Heart Healthy, Higher Starch, Average Male, Lower Variety, and Empty Calories. Nutritional risk was high and varied by dietary pattern; key nutrient contrasts were stable over 8-year follow-up. Chronic disease risk also varied by dietary pattern and specific subgroup differences persisted over 16 years, notably rates of overweight/obesity and smoking. CONCLUSIONS: Quantitative cluster analysis applied to food frequency questionnaire data identified five distinct, comprehensive, and stable dietary patterns of adult Framingham Offspring-Spouse cohort men. The close associations between the dietary patterns, nutritional risk, and chronic disease profiles of men emphasize the importance of targeted preventive nutrition interventions to promote health in the male population.

The elderly nutrition program: an effective national framework for preventive nutrition interventions.

OBJECTIVE: To guide national policy, Congress mandated the 1992 research evaluation of the Elderly Nutrition Program (ENP), the nation's oldest framework for providing community- and home-based preventive nutrition and health-related services to older persons. This article summarizes key findings on the program's influence on nutritional health, the targeting and costs of its nutrition services, and the study's policy implications. DESIGN: The research included a nationally representative sample of ambulatory and homebound ENP participants And a matched sample of nonparticipants drawn from the US Health Care Financing Administration's Medicare beneficiary listings. Interviews conducted in respondents' homes considered demographic and health characteristics and assessed anthropometry and physical functioning, nutrient intake and socialization patterns, and utilization of ENP program services (participants only). Administrative and service delivery data were gathered from all levels of the ENP infrastructure. RESULTS: The ENP program currently provides congregate and home-delivered meals and other nutrition- and health-related services to about 7% of the older population overall, including an estimated 20% of the nation's poor elders. Compared with nonparticipants, ambulatory and homebound ENP participants are better nourished (4% to 31% higher mean daily nutrient intakes; P<.001) and achieve higher levels of socialization (17% higher average monthly social contacts; P<.001). Federal spending on ENP nutrition services is efficiently leveraged by funding from other public and private sources, allowing ENP to more than double the nutrition services it provides to program participants. CONCLUSIONS: ENP is a well-targeted, effective, and efficient federal program available to dietetics and other professionals for providing elderly persons with community-based and home-delivered nutrition and related services. The ENP infrastructure offers a potential model for preventive nutrition intervention programs in ambulatory and homebound at-risk older populations.

Dietary patterns predict the development of overweight in women: The Framingham Nutrition Studies.

OBJECTIVE: To investigate relationships between dietary patterns and the development of overweight. DESIGN: Longitudinal analyses during 12 years of follow-up involved the identification of dietary patterns at baseline using cluster analysis applied to a 145-item semiquantitative food frequency questionnaire. SUBJECTS/SETTING: 737 non-overweight women in the Framingham Offspring/Spouse cohort (mean age, 45 years). MAIN OUTCOME MEASURE: Development of overweight (BMI> or =25) at follow-up. STATISTICAL ANALYSES: Relative risks were calculated using Proc Genmod and multivariate models comprehensively considered potential confounders. RESULTS: Five dietary patterns were identified among the cohort at baseline: Heart Healthy, Light Eating, Wine and Moderate Eating, High Fat, and Empty Calorie. Over 12 years, the crude risk of becoming overweight was 29% overall, ranging from 22% of women in the Wine and Moderate Eating cluster to 41% of women in the Empty Calorie cluster. Compared with women who ate a lower-fat, nutritionally varied Heart Healthy diet, women who ate an Empty Calorie diet that was rich in sweets and fats with fewer servings of nutrient-dense fruits, vegetables, and lean food choices were at higher risk for developing overweight [RR 1.4, 95% CI (0.9, 2.2)] after adjusting for age, smoking status, physical activity, menopausal status, energy intake, intentional dieting, and usual weight pattern. Women who ate an Empty Calorie dietary pattern were also younger and were more likely to smoke. CONCLUSIONS: Behavioral interventions for weight management and obesity prevention may be enhanced by creatively targeting differences in eating patterns, dietary quality, and other lifestyle behaviors of distinct subgroups of the population.

Dietary patterns, smoking, and subclinical heart disease in women: opportunities for primary prevention from the Framingham Nutrition Studies.

OBJECTIVES: To investigate the relationship between a heart-healthy dietary pattern and subclinical heart disease in women, and to identify potential opportunities for primary prevention. DESIGN: Prospective analysis in which dietary patterns and cardiovascular disease (CVD) risk factors were assessed at baseline. Presence of subclinical heart disease was assessed using carotid atherosclerosis (stenosis >or=25%) measured by ultrasound at 12-year follow-up. SUBJECTS/SETTING: We studied 1,423 women in the population-based Framingham Offspring/Spouse (FOS) Study cohort, Framingham, Massachusetts. Subjects did not have CVD at baseline. STATISTICAL ANALYSES: CVD risk factor differences among the dietary clusters were evaluated using analysis of covariance and logistic regression. The relationship between heart-healthy and less heart-healthy dietary patterns and the presence of subclinical heart disease at follow-up was examined using odds ratios calculated from multivariate logistic regressions; stratification by smoking status (current, former, never) was also explored. RESULTS: Women who ate a heart-healthy diet had more favorable baseline CVD risk factor profiles. The age-adjusted odds of subclinical heart disease at follow-up was 40% lower for heart-healthy women (OR 0.60, P=.02). Multivariate adjustment for BMI, blood lipid levels, and blood pressure only slightly attenuated these odds. The odds remained reduced after adding pack-years of smoking to the multivariate model, but statistical significance was attenuated (OR 0.74, P=.20). In analyses stratified by smoking status, women who consumed a heart-healthy diet and who had never smoked had more than 80% less odds for subclinical heart disease compared with smokers whose diets were less heart-healthy (adjusted OR 0.17; P=.0001). CONCLUSIONS: Women who achieve a heart-healthy eating pattern, in combination with the avoidance of smoking, have a lower odds of subclinical heart disease. Among former smokers, the avoidance of smoking seemed to have somewhat more influence than diet on stenosis risk. A public health priority for women to promote the primary prevention of heart disease is the adoption of positive lifestyle behaviors, especially healthful eating (dietary patterns rich in fruits, vegetables, low-fat dairy foods, leaner protein sources, and lower in fats) and the avoidance of smoking.

Methodology for adding glycemic index to the National Health and Nutrition Examination Survey nutrient database.

Generating valid estimates of dietary glycemic index (GI) and glycemic load (GL) has been a challenge in nutritional epidemiology. The methodologic issues may have contributed to the wide variation of GI/GL associations with health outcomes observed in existing literature. We describe a standardized methodology for assigning GI values to items in the National Health and Nutrition Examination Survey (NHANES) nutrient database using the new International Tables to develop research-driven, systematic procedures and strategies to estimate dietary GI/GL exposures of a nationally representative population sample. Nutrient databases for NHANES 2003-2006 contain information on 3,155 unique foods derived from the US Department of Agriculture National Nutrient Database for Standard Reference versions 18 and 20. Assignment of GI values were made to a subset of 2,078 carbohydrate-containing foods using systematic food item matching procedures applied to 2008 international GI tables and online data sources. Matching protocols indicated that 45.4% of foods had identical matches with existing data sources, 31.9% had similar matches, 2.5% derived GI values calculated with the formula for combination foods, 13.6% were assigned a default GI value based on low carbohydrate content, and 6.7% of GI values were based on data extrapolation. Most GI values were derived from international sources; 36.1% were from North American product information. To confirm data assignments, dietary GI and GL intakes of the NHANES 2003-2006 adult participants were estimated from two 24-hour recalls and compared with published studies. Among the 3,689 men and 4,112 women studied, mean dietary GI was 56.2 (men 56.9, women 55.5), mean dietary GL was 138.1 (men 162.1, women 116.4); the distribution of dietary GI was approximately normal. Estimates of population GI and GL compare favorably with other published literature. This methodology of adding GI values to an existing population nutrient database utilized systematic matching protocols and the latest comprehensive data sources on food composition. The database can be applied in clinical and survey research settings where there is interest in estimating individual and population dietary exposures and relating them to health outcomes.

Nutrient database development: a historical perspective from the Framingham Nutrition Studies.

Food frequency questionnaires (FFQs) are commonly used in nutritional epidemiology to assess habitual eating habits. Development of an appropriate food and nutrient database is required for translating information derived from FFQs into estimates of nutrient intake, dietary quality, or for absolute or rank-ordered nutritional risk assessment. We discuss the procedures used recently in designing a historical nutrient database to analyze an FFQ administered in 1984-1988 to Framingham Offspring-Spouse Study members. This systematic approach should inform other research in the field. The self-administered 145-item Framingham FFQ is semi-quantitative with seven nonoverlapping response categories to determine annual consumption frequency. The database development process included selection of the US Department of Agriculture's Nutrient Database for Standard Reference as the primary raw data source, expansion of the 145 FFQ line items to code individual foods to assign nutrient values, a selection process to match foods to appropriate nutrition codes for nutrient information, and a statistical model to calculate nutrient intakes. The historical database contains 449 foods and nutrient data for all 29 nutrients available in 1985. The adequacy with which an FFQ can provide reliable diet assessment data depends on the integrity of the underlying database. We outlined a systematic protocol to derive usual dietary intake from an FFQ using a robust nutrient database that is appropriate for the Framingham Offspring-Spouse Study FFQ and its assessment time-frame. The database can be updated to accommodate changes in the food supply and eating behaviors and creates a foundation for future nutrition research.

An obesity dietary quality index predicts abdominal obesity in women: potential opportunity for new prevention and treatment paradigms.

Background. Links between dietary quality and abdominal obesity are poorly understood. Objective. To examine the association between an obesity-specific dietary quality index and abdominal obesity risk in women. Methods. Over 12 years, we followed 288 Framingham Offspring/Spouse Study women, aged 30-69 years, without metabolic syndrome risk factors, cardiovascular disease, cancer, or diabetes at baseline. An 11-nutrient obesity-specific dietary quality index was derived using mean ranks of nutrient intakes from 3-day dietary records. Abdominal obesity (waist circumference >88 cm) was assessed during follow-up. Results. Using multiple logistic regression, women with poorer dietary quality were more likely to develop abdominal obesity compared to those with higher dietary quality (OR 1.87; 95% CI, 1.01, 3.47; P for trend = .048) independent of age, physical activity, smoking, and menopausal status. Conclusions. An obesity-specific dietary quality index predicted abdominal obesity in women, suggesting targets for dietary quality assessment, intervention, and treatment to address abdominal adiposity.