Findings from What We Eat in America, National Health and Nutrition Examination Survey 2011-2014 support salad consumption as an effective strategy for improving adherence to dietary recommendations.

OBJECTIVE: To verify the previously untested assumption that eating more salad enhances vegetable intake and determine if salad consumption is in fact associated with higher vegetable intake and greater adherence to the Dietary Guidelines for Americans (DGA) recommendations. DESIGN: Individuals were classified as salad reporters or non-reporters based upon whether they consumed a salad composed primarily of raw vegetables on the intake day. Regression analyses were applied to calculate adjusted estimates of food group intakes and assess the likelihood of meeting Healthy US-Style Food Pattern recommendations by salad reporting status. SETTING: Cross-sectional analysis of data collected in 2011-2014 in What We Eat in America, the dietary intake component of the National Health and Nutrition Examination Survey.ParticipantsUS adults (n 9678) aged ≥20 years (excluding pregnant and lactating women). RESULTS: On the intake day, 23 % of adults ate salad. The proportion of individuals reporting salad varied by sex, age, race, income, education and smoking status (P<0·001). Compared with non-reporters, salad reporters consumed significantly larger quantities of vegetables (total, dark green, red/orange and other), which translated into a two- to threefold greater likelihood of meeting recommendations for these food groups. More modest associations were observed between salad consumption and differences in intake and likelihood of meeting recommendations for protein foods (total and seafood), oils and refined grains. CONCLUSIONS: Study results confirm the DGA message that incorporating more salads in the diet is one effective strategy (among others, such as eating more cooked vegetables) to augment vegetable consumption and adherence to dietary recommendations concerning vegetables.

Fruit and vegetable intake of US adults estimated by two methods: What We Eat In America, National Health and Nutrition Examination Survey 2009-2012.

OBJECTIVE: Estimates of fruit and vegetable (FV) consumption vary depending on intake definition, which may be determined by research purpose. Researchers have used two methods to evaluate intake: epidemiological and behavioural. The present study describes FV intake by adults using epidemiological v. behavioural approaches. DESIGN: One-day dietary intake data from What We Eat In America, National Health and Nutrition Examination Survey 2009-2012 were used. Sample weights were used to produce nationally representative estimates. FV intake (in cup-equivalents (CE)) was estimated using the Food Patterns Equivalents Database. The epidemiological method considered all FV after disaggregating foods and beverages. The behavioural method included foods that provided at least 0·2 CE FV per 100 g, and excluded sources high in fat, added sugar and Na. SETTING: Nationally representative survey of the US population. SUBJECTS: Adults (n 10 563) aged ≥20 years. RESULTS: For epidemiological v. behavioural, fruit intake was 1·1 v. 1·0 CE for males and 1·0 v. 0·9 CE for females. Vegetable intake was 1·8 v. 1·1 CE for males and 1·5 v. 1·0 CE for females. CONCLUSIONS: The definition of FV intake affects estimates of consumption by the population and is an important consideration when planning and comparing research studies. The method used should align with research goals to assure accurate interpretation and validity of results.

Effect of Animal Protein Intake on Meeting Recommendations for Nutrient Intake among US Adults, What We Eat in America, NHANES 2015-2018.

Background: Replacing some animal sources of protein with plant foods is encouraged. Nutrient intake may reflect changes in the protein source. The adequacy of habitual nutrient intake among US adults has not been evaluated by the level of animal protein (AP) intake. Objectives: The objective of this study was to compare food consumption and nutrient intake and adequacy among quintiles of percent AP intake. Methods: Dietary intake data of adults 19+ y (N = 9706) from What We Eat in America, National Health and Nutrition Examination Survey 2015-2018 were used. Proportions of protein from animal and plant sources were estimated from ingredients in the Food and Nutrient Database for Dietary Studies 2015-2018, and then applied to dietary intakes. Intakes were classified by Q of percent AP. Food intake was described using the United States Department of Agriculture Food Patterns components. Usual nutrient intakes were estimated using the National Cancer Institute Method and compared with age and gender-specific Dietary Reference Intakes (DRIs). Comparisons between quintiles were made using t-tests. Results were considered significant at P < 0.01. Results: Total protein intake was higher as the Q of AP intake increased. Among the higher quintiles of percent AP, <1% did not meet their DRIs for protein than 17% in Q1 and 5% in Q2 (P < 0.01). In quintiles with lower compared with higher percent AP, there were significantly higher percentages not meeting DRIs for vitamins A, B12, choline, zinc, and calcium but meeting recommendations for folate, vitamin C, saturated fat, cholesterol, and fiber (P < 0.01). Among all quintiles, over one-third did not meet DRIs for fiber, vitamins A, C, D, E, K, choline, calcium, and potassium. Conclusions: Replacing protein from animal sources with plant foods may result in lower intakes of protein and some nutrients but a better intake of dietary components associated with reducing chronic disease risk. The current intake of US adults indicates dietary improvements are needed, regardless of protein source.

Diet Quality of Frequent Fast-Food Consumers on a Non-Fast Food Intake Day Is Similar to a Day with Fast Food, What We Eat in America, NHANES 2013-2016.

BACKGROUND: Frequent fast food (FF) consumers may make more healthful food choices at eating occasions without FF. However, it is not clear if poor diet quality of frequent FF consumers is a function of FF consumption or less healthful food choices overall. OBJECTIVE: The objective of this study was to compare diet quality, energy, and nutrient intakes of infrequent FF consumers (INFREQ) with that of frequent FF consumers on an intake day with FF (FREQ-FF) or without FF (FREQ_NO FF). DESIGN: This study is a cross-sectional analysis of 1 day dietary intake data from What We Eat in America, National Health and Nutrition Examination Survey 2013-2016, the dietary intake component of National Health and Nutrition Examination Survey. PARTICIPANTS/SETTING: Participants included adults aged 20 years and older (N = 4,012), who, during the previous 7 days, reported no consumption of FF or pizza (n = 2,142 INFREQ) or reported FF or pizza three or more times and either had FF/pizza (n = 1,455 FREQ_FF) or did not have FF/pizza (n = 415 FREQ_NO FF) on the intake day. MAIN OUTCOME MEASURES: Main outcomes were energy, nutrient density (nutrient intake per 1,000 kcal), and diet quality evaluated using Healthy Eating Index (HEI) 2015. STATISTICAL ANALYSES PERFORMED: Group comparisons were made using t tests. Differences were considered significant at P < 0.001. RESULTS: Compared with INFREQ consumers, FREQ_FF consumers had higher intakes of energy and fat per 1,000 kcal, lower scores for total HEI and most components, and lower nutrient densities of most micronutrients (P < 0.001). HEI component scores of INFREQ consumers for vegetables, fruit, whole grains, and added sugars were higher than FREQ_FF consumers (P < 0.001). Energy intake, most nutrient densities, and total HEI and component scores of FREQ_NO FF consumers were not significantly different from FREQ_FF consumers with the exception of fruit but were different from INFREQ consumers for some nutrients and HEI components. CONCLUSIONS: Results suggest diet quality and nutrient intake of frequent FF consumers on a non-FF intake day is not markedly different from a day with FF.

Diet Quality and Food Intakes samong US Adults by Level of Animal Protein Intake, What We Eat in America, NHANES 2015-2018.

Background: Dietary recommendations encourage consuming protein from a variety of plant and animal sources. Evaluating the diet of US adults by level of animal protein (AP) intake can inform dietary assessment and nutrition education. Objectives: The objective of this cross-sectional study was to estimate percentage of total protein intake from animal sources by US adults to compare diet quality, and intake from USDA Food Patterns (FP) groups by quintiles of AP. Methods: One day dietary intake data from adults 20+ y (N = 9566) in What We Eat in America (WWEIA), NHANES 2015-2018 were used. Proportions of total protein intake from animal and plant sources and the USDA FP groups were estimated from the ingredients in the Food and Nutrient Database for Dietary Studies 2015-2018, then applied to the dietary intakes. The 2015 Healthy Eating Index (HEI) was used as an indicator of diet quality. The USDA FP groups were used to describe the contribution of animal and plant foods to total protein intake. Data were analyzed by quintile (Q) of AP protein intake; comparisons were made using pairwise t-tests with adjustments for covariates using survey sample weights. Results were considered significant at P <0.001. Results: Total mean protein intakes ranged from 62 (Q1) to 104 g (Q5) (all comparisons P <0.001). Total HEI score (possible 100) of Q1 was slightly higher (54.2) (P <0.001) compared with Q1-Q4 (range: 48.0-50.3), which did not differ significantly from each other. Contributions of plant FP components to total protein intake of Q1 to Q5, respectively, were 15% to 1% from nuts/seeds, legumes, and soy products combined; 35 to 10% from grains. The contribution of animal FP components were 19-66% from meat/poultry/seafood, 14-19% dairy, and 3-5% eggs. Conclusions: The intake of foods considered to be good sources of plant protein was low. The overall diet quality of all adults was suboptimal regardless of plant protein intake.

Food Insecurity and Pediatric Malnutrition Related to Under- and Overweight in the United States: An Evidence Analysis Center Systematic Review.

Both food insecurity and malnutrition are associated with adverse health outcomes in the pediatric population. However, the research on the relationship between these factors has been inconsistent, leading to uncertainty regarding whether or how evaluation of food insecurity should be incorporated into nutrition screening or the nutrition care process. The objective of this systematic review was to determine the association between food insecurity and malnutrition related to undernutrition or overnutrition (defined by anthropometrics) in the pediatric population in the United States. A literature search was conducted using Medline, Embase, and CINAHL databases for studies published from January 2002 through November 2017. A total of 23 studies (19 cross-sectional and 4 prospective cohort studies) met inclusion criteria and were included in qualitative analysis. In 6 studies, there was no overall relationship between food insecurity and underweight. All included studies examined the relationship between food insecurity status and overweight/obesity and results were mixed, with large cross-sectional studies demonstrating a positive relationship between food insecurity and overweight/obesity. There were no clear patterns according to subpopulation. Evidence quality was graded as fair due to heterogeneity in how food insecurity was measured and populations included as well as inconsistency in results. Use of a 2-item food insecurity screening tool may allow for efficient, effective screening of food insecurity in order to identify potential contributors overweight and obesity.

Fruit and Vegetable Consumption of US Adults by Level of Variety, What We Eat in America, NHANES 2013-2016.

BACKGROUND: Dietary guidance encourages consuming a variety of fruit and vegetables (FVs), which has been associated with higher FV intake and nutrient adequacy. Dietary intake of adults in the United States has not been described in the context of variety. OBJECTIVES: The objective of this study was to describe FV consumption of adults in the United States by level of FV variety. METHODS: One day of dietary intake data of adults aged ≥20 y (n = 10,064) in What We Eat in America, NHANES 2013-2016 were used. FV variety was the count of foods consumed that contributed to total FV intake. Each FV was counted only once; a mixed dish counted as 1. Variety levels were high (≥5 items, n = 2316); moderate (3-4 items, n = 3423); or low (1-2 items, n = 3746). Differences between each level of variety were compared by t test. RESULTS: Among the low, moderate, and high levels, total FV intakes were 1.4, 2.6, and 4.4 cup equivalents (CE), respectively. CE amounts of FVs consumed were 0.3, 0.6, and 1.4 of vegetables excluding potatoes; 0.2, 0.3, and 0.3 of potatoes; 0.3, 0.6, and 1.2 of fruit; and 0.4, 0.4, and 0.5 from mixed dishes, respectively; percentages of each level reporting intake were 34%, 64%, and 89% for vegetables excluding potatoes; 23%, 34%, and 32% for potatoes; 22%, 49%, and 75% for fruit; and 72%, 71%, and 72% for mixed dishes, respectively. CONCLUSIONS: Those with more variety of FV intake include whole FVs more frequently and in higher amounts. These results support suggestions for encouraging more FVs at snacks and as side dishes and salads at meals to increase total intake.

Validity and Reliability of Pediatric Nutrition Screening Tools for Hospital, Outpatient, and Community Settings: A 2018 Evidence Analysis Center Systematic Review.

BACKGROUND: Nutrition screening tools are used to identify risk of malnutrition or change in risk of malnutrition. However, it is unclear which tools have demonstrated high validity, reliability, and agreement. OBJECTIVE: Our aim was to conduct a systematic review of valid and reliable pediatric nutrition screening tools for identifying malnutrition risk (under- or overnutrition), and to determine whether there are differences in validity and reliability according to users of the tools. METHODS: A literature search using Medline, Embase, and CINAHL databases was conducted to identify relevant research published between 1995 and May 2017 examining validity and reliability of nutrition screening tools in the pediatric population. A multidisciplinary workgroup developed eligibility criteria, data were extracted and summarized, risk of bias was assessed, and evidence strength was graded, according to a standard process. RESULTS: Twenty-nine studies met inclusion criteria. Thirteen pediatric nutrition screening tools designed for various settings were included in the review (seven inpatient/hospital, three outpatient or specialty setting, and three community). The most frequently examined tools were the Screening Tool for the Assessment of Malnutrition in Pediatrics, Screening Tool for Risk on Nutritional Status and Growth (13 studies each), and Paediatric Yorkhill Malnutrition Score (nine studies). No tools demonstrated high validity. Reliability and agreement were reported infrequently. CONCLUSIONS: Nutrition screening tools with good/strong or fair evidence and moderate validity included the Screening Tool for the Assessment of Malnutrition in Pediatrics, Screening Tool for Risk on Nutritional Status and Growth, and Paediatric Yorkhill Malnutrition Score in the inpatient setting and Nutrition Risk Screening Tool for Children and Adolescents with Cystic Fibrosis in the specialty setting. No tools in the community setting met these criteria. While differences in validity and reliability measures among tool users were found, the significance of these findings is unclear. Limitations included few studies examining each tool, heterogeneity between studies examining a common tool, and lack of tools that included currently recommended indicators to identify pediatric malnutrition.

Consuming Vegetable-Based Salad Is Associated with Higher Nutrient Intakes and Diet Quality among US Adults, What We Eat in America, National Health and Nutrition Examination Survey 2011-2014.

BACKGROUND: Consuming salad is one strategy with the potential to harmonize diets more closely with national dietary guidance. However, it is not known whether nutrient intake and diet quality differ between people who consume vegetable-based salad and those who do not. OBJECTIVE: The objective of this study was to compare nutrient intake and diet quality between salad reporters and nonreporters. DESIGN: This study is a cross-sectional analysis of 1 day of dietary intake data collected via 24-hour recall. PARTICIPANTS/SETTING: Adults 20 years and older (n=9,678) in What We Eat in America, National Health and Nutrition Examination Survey 2011-2014 were included. Respondents who ate salad on the intake day were considered salad reporters. MAIN OUTCOME MEASURES: This study estimated nutrient intake from all foods and beverages (excluding supplements) and evaluated diet quality using the Healthy Eating Index (HEI) 2015. STATISTICAL ANALYSES: Nutrient intake and HEI scores were compared between salad reporters and nonreporters using paired t tests with regression adjustment for confounding variables. Results were considered significant at P<0.001. RESULTS: On the intake day, 23% of adults consumed salad. Energy, protein, and carbohydrate intakes did not differ between salad reporters and nonreporters. Salad reporters had higher intakes than nonreporters of dietary fiber, total fat, unsaturated fatty acids, vitamins A, B-6, C, E, K, folate, choline, magnesium, potassium, and sodium (P<0.001). Total HEI 2015 scores were significantly higher for reporters (56 of a possible 100 points) than nonreporters (50 points) P<0.001. Reporters also had significantly higher scores for eight of 13 HEI components: total vegetables, greens and beans, whole fruits, total protein foods, seafood and plant proteins, fatty acids, refined grains, and added sugars (P<0.001). CONCLUSIONS: Incorporating vegetable-based salad into one's diet may be one effective way to increase nutrient intake and improve overall diet quality. Regardless of salad reporting status, HEI scores show that diets of US adults need improvement.

2015 Evidence Analysis Library Evidence-Based Nutrition Practice Guideline for the Management of Hypertension in Adults.

Hypertension (HTN) or high blood pressure (BP) is among the most prevalent forms of cardiovascular disease and occurs in approximately one of every three adults in the United States. The purpose of this Evidence Analysis Library (EAL) guideline is to provide an evidence-based summary of nutrition therapy for the management of HTN in adults aged 18 years or older. Implementation of this guideline aims to promote evidence-based practice decisions by registered dietitian nutritionists (RDNs), and other collaborating health professionals to decrease or manage HTN in adults while enhancing patient quality of life and taking into account individual preferences. The systematic review and guideline development methodology of the Academy of Nutrition and Dietetics were applied. A total of 70 research studies were included, analyzed, and rated for quality by trained evidence analysts (literature review dates ranged between 2004 and 2015). Evaluation and synthesis of related evidence resulted in the development of nine recommendations. To reduce BP in adults with HTN, there is strong evidence to recommend provision of medical nutrition therapy by an RDN, adoption of the Dietary Approaches to Stop Hypertension dietary pattern, calcium supplementation, physical activity as a component of a healthy lifestyle, reduction in dietary sodium intake, and reduction of alcohol consumption in heavy drinkers. Increased intake of dietary potassium and calcium as well as supplementation with potassium and magnesium for lowering BP are also recommended (fair evidence). Finally, recommendations related to lowering BP were formulated on vitamin D, magnesium, and the putative role of alcohol consumption in moderate drinkers (weak evidence). In conclusion, the present evidence-based nutrition practice guideline describes the most current recommendations on the dietary management of HTN in adults intended to support the practice of RDNs and other health professionals.

Evidence-based care for breast cancer survivors: communicating the Institute of Medicine Guidelines in medical practice.

OBJECTIVE: To investigate patient reports of physician communication about the 2006 Institute of Medicine (IOM) Guidelines for Survivorship Care, and patient follow-up care behaviors in a sample of African American and Caucasian breast cancer survivors. METHODS: Fifteen-minute telephone interviews were conducted in a cross-sectional study with a sample of African American (n=30) and Caucasian (n=69) breast cancer patients, who were within 5 years of their diagnosis and primary treatment for breast cancer at two Baltimore, Maryland medical centers, during the summer of 2006. Multiple items assessed patient reports of physician discussions about IOM Guidelines, their recurrence concerns, and their follow-up treatment, screening, diet and exercise practices. RESULTS: Patients with higher incomes, more education, female physicians, and of younger ages reported more complete physician discussions of the IOM Guidelines. No significant differences were noted between African American and Caucasian patients. CONCLUSION: Patients at greatest risk for breast cancer recurrence - those with less education, income, and resources - report limited guidance from their physicians about evidence-based, follow-up care guidelines, designed to minimize their risk. PRACTICE IMPLICATIONS: Physicians need strategies for effectively delivering the IOM Guidelines for Survivorship Care to disadvantaged breast cancer patients, to promote enhanced quality of life and reduced risk of recurrence.

Implementing a low-fat eating plan in the Women's Intervention Nutrition Study.

The Women's Intervention Nutrition Study is a randomized clinical trial designed to evaluate if a lifestyle intervention targeting fat intake reduction influences breast cancer recurrence in women with early stage, resected disease receiving conventional cancer management. This report details the concept, content, and implementation of the low-fat eating plan used in the dietary intervention group of this trial. Intervention group participants were given a daily fat gram goal. The intervention was delivered by centrally trained, registered dietitians who applied behavioral, cognitive, and motivational counseling techniques. The low-fat eating plan was implemented in an intensive phase with eight biweekly (up to Month 4), individual counseling sessions followed by a maintenance phase (Month 5 up to and including Year 5) with registered dietitian visits every 3 months and optional monthly group sessions. Self-monitoring (daily fat gram counting and recording), goal setting, and motivational interviewing strategies were key components. Dietary fat intake was equivalent at baseline and consistently lower in the intervention compared with the control group at all time points (percent energy from fat at 60 months 23.2%+/-8.4% vs 31.2%+/-8.9%, respectively, P<0.0001) and was associated with mean 6.1 lb mean weight difference between groups (P=0.005) at 5 years (baseline and 5 years, respectively: control 160.0+/-35.0 and 161.7+/-32.8 lb; intervention 160.2+/-35.1 and 155.6+/-32.1 lb). Together with previously reported efficacy results, this information suggests that a lifestyle intervention that reduces dietary fat intake and is associated with modest weight loss may favorably influence breast cancer recurrence. The Women's Intervention Nutrition Study low-fat eating plan can serve as a model for implementing such a long-term dietary intervention in clinical practice.

Exploring patient-physician communication in breast cancer care for African American women following primary treatment.

PURPOSE/OBJECTIVES: To investigate patient-physician communication from the patient's perspective about guidelines and sources of information used in developing survivorship care and preferred avenues for information delivery to African American breast cancer survivors. DESIGN: Qualitative. SETTING: Medical centers in the eastern United States. SAMPLE: 39 African American breast cancer survivors with a mean age of 55. METHODS: Each participant contributed to one of four two-hour focus group discussions and completed brief questionnaires regarding sociodemographic characteristics and cancer-specific data. Focus group topics included involvement in discussions and decision making about survivorship care, specific instructions and information that physicians provided regarding follow-up medical care and preventive health actions, concerns about recurrence and ways to prevent it, and sources of information used to develop survivorship care plans. MAIN RESEARCH VARIABLES: Survivorship care, patient-provider communication, information delivery methods, and African American breast cancer survivors. FINDINGS: Participants reported gaps in the information given to them by physicians about their diagnosis, treatments, side effects, and guidelines for follow-up care. Participants expressed strong interest in self-care practices aimed at reducing their risk of recurrence and receiving evidence-based information and guidelines from healthcare providers. The majority (about 90%) reported physician checkups and mammography screening during the prior year, whereas only 54% reported making daily efforts to improve their health and reduce their risk of recurrence. Although evidence-based guidelines are available to healthcare providers delivering follow-up care to breast cancer survivors, more than 90% of participants in the present study reported a lack of specific recommendations regarding diet or physical activity as ways to improve quality of life and health as a cancer survivor. CONCLUSIONS: The present study underscores 2006 findings from the Institute of Medicine that strategies for delivering information and guidance to cancer survivors and coordinating their care remain important issues for patients and their healthcare providers. IMPLICATIONS FOR NURSING: The present study's findings highlight the need expressed by breast cancer survivors for comprehensive guidance from healthcare providers in developing plans of care that improve patients' quality of life and target recurrence risk. Guidelines are available for dissemination and use in medical settings; however, the guidelines have not been incorporated into standard medical practice for patients with cancer. Information about long-term follow-up care after primary treatment should target the specific needs of survivors from diverse ethnic, socioeconomic, and educational backgrounds to promote understanding of surveillance to detect recurrence, long-term effects of cancer treatments, and general health maintenance.

Dietary fat reduction and breast cancer outcome: interim efficacy results from the Women's Intervention Nutrition Study.

BACKGROUND: Preclinical and observational studies suggest a relationship between dietary fat intake and breast cancer, but the association remains controversial. We carried out a randomized, prospective, multicenter clinical trial to test the effect of a dietary intervention designed to reduce fat intake in women with resected, early-stage breast cancer receiving conventional cancer management. METHODS: A total of 2437 women were randomly assigned between February 1994 and January 2001 in a ratio of 40:60 to dietary intervention (n = 975) or control (n = 1462) groups. An interim analysis was performed after a median follow-up of 60 months when funding for the intervention ceased. Mean differences between dietary intervention and control groups in nutrient intakes and anthropometric variables were compared with t tests. Relapse-free survival was examined using Kaplan-Meier analysis, stratified log-rank tests, and Cox proportional hazards models. Statistical tests were two-sided. RESULTS: Dietary fat intake was lower in the intervention than in the control group (fat grams/day at 12 months, 33.3 [95% confidence interval {CI} = 32.2 to 34.5] versus 51.3 [95% CI = 50.0 to 52.7], respectively; P<.001), corresponding to a statistically significant (P = .005), 6-pound lower mean body weight in the intervention group. A total of 277 relapse events (local, regional, distant, or ipsilateral breast cancer recurrence or new contralateral breast cancer) have been reported in 96 of 975 (9.8%) women in the dietary group and 181 of 1462 (12.4%) women in the control group. The hazard ratio of relapse events in the intervention group compared with the control group was 0.76 (95% CI = 0.60 to 0.98, P = .077 for stratified log rank and P = .034 for adjusted Cox model analysis). Exploratory analyses suggested a differential effect of the dietary intervention based on hormonal receptor status. CONCLUSIONS: A lifestyle intervention reducing dietary fat intake, with modest influence on body weight, may improve relapse-free survival of breast cancer patients receiving conventional cancer management. Longer, ongoing nonintervention follow-up will address original protocol design plans, which called for 3 years of follow-up after completion of recruitment.