Toward healthy and sustainable diets for the 21st century: Importance of sociocultural and economic considerations.

Four years after the EAT-Lancet landmark report, worldwide movements call for action to reorient food systems to healthy diets that respect planetary boundaries. Since dietary habits are inherently local and personal, any shift toward healthy and sustainable diets going against this identity will have an uphill road. Therefore, research should address the tension between the local and global nature of the biophysical (health, environment) and social dimensions (culture, economy). Advancing the food system transformation to healthy, sustainable diets transcends the personal control of engaging consumers. The challenge for science is to scale-up, to become more interdisciplinary, and to engage with policymakers and food system actors. This will provide the evidential basis to shift from the current narrative of price, convenience, and taste to one of health, sustainability, and equity. The breaches of planetary boundaries and the environmental and health costs of the food system can no longer be considered externalities. However, conflicting interests and traditions frustrate effective changes in the human-made food system. Public and private stakeholders must embrace social inclusiveness and include the role and accountability of all food system actors from the microlevel to the macrolevel. To achieve this food transformation, a new "social contract," led by governments, is needed to redefine the economic and regulatory power balance between consumers and (inter)national food system actors.

No Effect of High Eating Frequency Compared with Low Eating Frequency on Appetite and Inflammation Biomarkers: Results from a Randomized Crossover Clinical Trial.

BACKGROUND: Eating frequency (EF) focuses on the total number of eating occasions per day and may influence metabolic health. OBJECTIVES: We sought to examine the effect of high compared with low EF on appetite regulation and inflammatory biomarkers among healthy adults. METHODS: Data are from a randomized, crossover trial (the Frequency of Eating and Satiety Hormones study). Participants (n = 50) completed 2 isocaloric 21-d study periods of low EF (3 eating occasions/d) and high EF (6 eating occasions/d) in random order with a 14-d washout period in between. Participants were free-living and consumed their own food, using study-directed, structured meal plans with identical foods and total energy in both study periods. On days 1 and 21 of each EF period, fasting blood was collected during in-person clinic visits to assess plasma concentrations of ghrelin, leptin, adiponectin, and high-sensitivity C-reactive protein (hs-CRP). Linear mixed models with EF, diet sequence, and period as fixed effects and participant as random effect were used to estimate the intervention effect. Interaction effects between EF and body fat percentage were examined. RESULTS: Among the 50 participants who completed the trial, 39 (78%) were women, 30 (60%) were Non-Hispanic White, and 40 (80%) had a body mass index of <25 kg/m2, and the mean age was 32.1 y. The differences between high and low EF in fasting ghrelin (geometric mean difference: 17.76 ng/mL; P = 0.60), leptin (geometric mean difference: 2.09 ng/mL; P = 0.14), adiponectin (geometric mean difference: 381.7 ng/mL; P = 0.32), and hs-CRP (geometric mean difference: -0.018 mg/dL; P = 0.08) were not statistically significant. No significant interaction was observed between EF and body fat percentage on appetite regulation and inflammatory biomarkers. CONCLUSIONS: No differences was observed in fasting ghrelin, leptin, adiponectin, and hs-CRP comparing high and low EF. Future studies are needed to understand the physiology of EF and appetite as they relate to metabolic health. This trial was registered at clinicaltrials.gov as NCT02392897.

New metrics of dietary carbohydrate quality.

PURPOSE OF REVIEW: The aim of this study was to introduce novel metrics of dietary carbohydrates quality relevant for products and diets. RECENT FINDINGS: Carbohydrate quality has long been associated with a low glycemic index. More recently, novel metrics of carbohydrate quality featuring variations of total carbohydrates-fibers-free sugars ratios have been applied to carbohydrate-rich foods, including grains, beans, vegetables, and fruit. High scoring products had higher levels of health-promoting nutrients (protein, dietary fiber, iron, magnesium, zinc, potassium, selenium, and various B-vitamins) and lower levels of nutrients of public health concern (total sugar, added/free sugars, and fat profile). Cross-sectional studies also found variants of carbohydrate quality metrics to be associated with better markers of cardiometabolic disease, including lower levels of blood triglycerides:high-density lipoprotein cholesterol ratio, homeostatic model assessment of insulin resistance, and SBP. SUMMARY: New ratio-based carbohydrate quality metrics are built around high fiber and whole grain content, combined with a low free sugar content. Such metrics allow the identification of food products of higher overall nutritional quality, and are associated with improved diet quality and certain health outcomes.

Differences in Weight Gain Following Residential Relocation in the Moving to Health (M2H) Study.

BACKGROUND: Neighborhoods may play an important role in shaping long-term weight trajectory and obesity risk. Studying the impact of moving to another neighborhood may be the most efficient way to determine the impact of the built environment on health. We explored whether residential moves were associated with changes in body weight. METHODS: Kaiser Permanente Washington electronic health records were used to identify 21,502 members aged 18-64 who moved within King County, WA between 2005 and 2017. We linked body weight measures to environment measures, including population, residential, and street intersection densities (800 m and 1,600 m Euclidian buffers) and access to supermarkets and fast foods (1,600 m and 5,000 m network distances). We used linear mixed models to estimate associations between postmove changes in environment and changes in body weight. RESULTS: In general, moving from high-density to moderate- or low-density neighborhoods was associated with greater weight gain postmove. For example, those moving from high to low residential density neighborhoods (within 1,600 m) gained an average of 4.5 (95% confidence interval [CI] = 3.0, 5.9) lbs 3 years after moving, whereas those moving from low to high-density neighborhoods gained an average of 1.3 (95% CI = -0.2, 2.9) lbs. Also, those moving from neighborhoods without fast-food access (within 1600m) to other neighborhoods without fast-food access gained less weight (average 1.6 lbs [95% CI = 0.9, 2.4]) than those moving from and to neighborhoods with fast-food access (average 2.8 lbs [95% CI = 2.5, 3.2]). CONCLUSIONS: Moving to higher-density neighborhoods may be associated with reductions in adult weight gain.

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.

Aligning nutrient profiling with dietary guidelines: modifying the Nutri-Score algorithm to include whole grains.

PURPOSE: Whole grains, generally recognised as healthy choices, are not included in most nutrient profiling systems. We tested modifications to the Nutri-Score algorithm to determine whether including whole grains would provide an improved measure of food, and overall diet quality. METHODS: The whole-grain content of food, with a minimum cut-point of 25%, was added to the algorithm, following similar methods used to score other health-promoting components such as fibre. We applied and compared the original and the modified Nutri-Score to food composition and dietary intake data from Australia, France, the United Kingdom, and the United States. RESULTS: At the food level, correlations between whole-grain content and food nutritional score were strengthened using the modified algorithm in Australian data, but less so for the other countries. Improvements were greater in grain-specific food groups. The largest shift in Nutri-Score class was from B to A (best score). At the dietary intake level, whole-diet nutritional scores for individuals were calculated and compared against population-specific diet-quality scores. With modifications, correlations with diet-quality scores were improved slightly, suggesting that the modified score better aligns with national dietary guidelines. An inverse linear relationship between whole-diet nutritional score and whole-grain intake was evident, particularly with modifications (lower whole-diet nutritional score indicative of better diet quality). CONCLUSION: Including a whole-grain component in the Nutri-Score algorithm is justified to align with dietary guidelines and better reflect whole grain as a contributor to improved dietary quality. Further research is required to test alternative algorithms and potentially other nutrient profiling systems.

Differential associations of the built environment on weight gain by sex and race/ethnicity but not age.

OBJECTIVE: To explore the built environment (BE) and weight change relationship by age, sex, and racial/ethnic subgroups in adults. METHODS: Weight trajectories were estimated using electronic health records for 115,260 insured Kaiser Permanente Washington members age 18-64 years. Member home addresses were geocoded using ArcGIS. Population, residential, and road intersection densities and counts of area supermarkets and fast food restaurants were measured with SmartMaps (800 and 5000-meter buffers) and categorized into tertiles. Linear mixed-effect models tested whether associations between BE features and weight gain at 1, 3, and 5 years differed by age, sex, and race/ethnicity, adjusting for demographics, baseline weight, and residential property values. RESULTS: Denser urban form and greater availability of supermarkets and fast food restaurants were associated with differential weight change across sex and race/ethnicity. At 5 years, the mean difference in weight change comparing the 3rd versus 1st tertile of residential density was significantly different between males (-0.49 kg, 95% CI: -0.68, -0.30) and females (-0.17 kg, 95% CI: -0.33, -0.01) (P-value for interaction = 0.011). Across race/ethnicity, the mean difference in weight change at 5 years for residential density was significantly different among non-Hispanic (NH) Whites (-0.47 kg, 95% CI: -0.61, -0.32), NH Blacks (-0.86 kg, 95% CI: -1.37, -0.36), Hispanics (0.10 kg, 95% CI: -0.46, 0.65), and NH Asians (0.44 kg, 95% CI: 0.10, 0.78) (P-value for interaction <0.001). These findings were consistent for other BE measures. CONCLUSION: The relationship between the built environment and weight change differs across demographic groups. Careful consideration of demographic differences in associations of BE and weight trajectories is warranted for investigating etiological mechanisms and guiding intervention development.

Does the built environment have independent obesogenic power? Urban form and trajectories of weight gain.

OBJECTIVE: To determine whether selected features of the built environment can predict weight gain in a large longitudinal cohort of adults. METHODS: Weight trajectories over a 5-year period were obtained from electronic health records for 115,260 insured patients aged 18-64 years in the Kaiser Permanente Washington health care system. Home addresses were geocoded using ArcGIS. Built environment variables were population, residential unit, and road intersection densities captured using Euclidean-based SmartMaps at 800-m buffers. Counts of area supermarkets and fast food restaurants were obtained using network-based SmartMaps at 1600, and 5000-m buffers. Property values were a measure of socioeconomic status. Linear mixed effects models tested whether built environment variables at baseline were associated with long-term weight gain, adjusting for sex, age, race/ethnicity, Medicaid insurance, body weight, and residential property values. RESULTS: Built environment variables at baseline were associated with differences in baseline obesity prevalence and body mass index but had limited impact on weight trajectories. Mean weight gain for the full cohort was 0.06 kg at 1 year (95% CI: 0.03, 0.10); 0.64 kg at 3 years (95% CI: 0.59, 0.68), and 0.95 kg at 5 years (95% CI: 0.90, 1.00). In adjusted regression models, the top tertile of density metrics and frequency counts were associated with lower weight gain at 5-years follow-up compared to the bottom tertiles, though the mean differences in weight change for each follow-up year (1, 3, and 5) did not exceed 0.5 kg. CONCLUSIONS: Built environment variables that were associated with higher obesity prevalence at baseline had limited independent obesogenic power with respect to weight gain over time. Residential unit density had the strongest negative association with weight gain. Future work on the influence of built environment variables on health should also examine social context, including residential segregation and residential mobility.

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.

Characterising percentage energy from ultra-processed foods by participant demographics, diet quality and diet cost: findings from the Seattle Obesity Study (SOS) III.

Higher consumption of 'ultra-processed' (UP) foods has been linked to adverse health outcomes. The present paper aims to characterise percentage energy from UP foods by participant socio-economic status (SES), diet quality, self-reported food expenditure and energy-adjusted diet cost. Participants in the population-based Seattle Obesity Study III (n 755) conducted in WA in 2016-2017 completed socio-demographic and food expenditure surveys and the FFQ. Education and residential property values were measures of SES. Retail prices of FFQ component foods (n 378) were used to estimate individual-level diet cost. Healthy Eating Index (HEI-2015) and Nutrient Rich Food Index 9.3 (NRF9.3) were measures of diet quality. UP foods were identified following NOVA classification. Multivariable linear regressions were used to test associations between UP foods energy, socio-demographics, two estimates of food spending and diet quality measures. Higher percentage energy from UP foods was associated with higher energy density, lower HEI-2015 and NRF9.3 scores. The bottom decile of diet cost ($216·4/month) was associated with 67·5 % energy from UP foods; the top decile ($369·9/month) was associated with only 48·7 % energy from UP foods. Percentage energy from UP foods was inversely linked to lower food expenditures and diet cost. In multivariate analysis, percentage energy from UP foods was predicted by lower food expenditures, diet cost and education, adjusting for covariates. Percentage energy from UP foods was linked to lower food spending and lower SES. Efforts to reduce UP foods consumption, an increasingly common policy measure, need to take affordability, food expenditures and diet costs into account.

Nutrient density and affordability of foods in Brazil by food group and degree of processing.

OBJECTIVE: Affordable nutrition refers to the relation between nutrient density of foods and their monetary cost. There are limited data on affordable nutrition in low- and middle-income countries. The present study aimed to develop a nutrient density score and nutrient affordability metrics for 377 most consumed foods in Brazil. DESIGN: The foods were aggregated into seven major food groups and four NOVA food categories. Nutrient composition data were obtained from the Brazilian Institute of Geography and Statistics. Food prices were obtained from retailer websites and were converted to prices per 100 g and 418 kJ. The Nutrient Rich Food (NRF8.2) score was based on protein, fiber, vitamins A, C and E, Ca, Fe and K. Nutrients to limit were sugar and Na. Affordability was measured as kcal/R$ and nutrients/R$. RESULTS: Grains, fats and sweets were more energy dense and had lower NRF8.2 scores than dairy, vegetables and fruits. Grains, fats and sweets were the lowest cost sources of energy. Vegetables and fruits, beans, nuts and seeds and eggs and dairy were the lowest cost sources of multiple nutrients. Ultra-processed foods (48 % of total) had higher energy density and lower NRF8.2 scores than did unprocessed foods. In Brazil, fruits, vegetables and dairy products offered the most nutrients per real. CONCLUSIONS: Analysis of the relationship between nutrient density of foods and their cost can help identify locally available foods that are nutrient rich, affordable and culturally acceptable. Achieving high nutrient density at an affordable cost should be the goal of Brazil's food systems.

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.

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.

Flavonoid Intakes in the US Diet Are Linked to Higher Socioeconomic Status and to Tea Consumption: Analyses of NHANES 2011-16 Data.

BACKGROUND: Many of the health benefits of tea have been attributed to its flavonoid content. Tea consumption in US adults varies by socioeconomic status (SES). OBJECTIVES: The present objective was to explore intakes of total flavonoids and flavonoid subclasses by participant sociodemographics and by patterns of tea consumption. METHODS: The present analyses were based on 2 d of dietary recalls for 17,506 persons aged >9 y in the 2011-2016 NHANES. The What We Eat in America nutrient composition database was merged with the USDA Expanded Flavonoid database, which included total flavonoids and flavan-3-ols (including catechins), flavanones, flavonols, anthocyanidins, flavones, and isoflavones. Flavonoid intakes were compared by sex, age, race/ethnicity, education, and income-to-poverty ratio (IPR) in univariate analyses. Flavonoid intakes of children and adults were also compared by tea consumption status. Time trends in flavonoid intakes were also examined. RESULTS: Mean total flavonoid intake was 219 mg/d, of which flavan-3-ols provided 174 mg/d, or 79%. The highest total flavonoid intakes were found in adults aged 51-70 y (293 mg/d), non-Hispanic whites (251 mg/d) and in groups with college education (251 mg/d) and higher income (IPR >3.5: 249 mg/d) (P < 0.001 for all). The socioeconomic gradient was significant for anthocyanidins, flavonols, and flavones (P < 0.001 for all) but not for flavan-3-ols, and persisted across 3 cycles of NHANES. Adult tea consumers had higher intakes of total flavonoids (610 mg/d compared with 141 mg/d) and flavan-3-ols (542 mg/d compared with 97.8 mg/d) than did nonconsumers (P < 0.001). Time trend analyses showed that both tea consumption and flavonoid intakes were unchanged from 2011 to 2016. CONCLUSIONS: Flavonoid intakes in children and adults in the NHANES 2011-16 sample were associated with higher SES and were largely determined by tea consumption. Studies of diet and disease risk need to take sociodemographic gradients and eating and drinking habits into account.

Fruits, vegetables, and health: A comprehensive narrative, umbrella review of the science and recommendations for enhanced public policy to improve intake.

Fruit and vegetables (F&V) have been a cornerstone of healthy dietary recommendations; the 2015-2020 U.S. Dietary Guidelines for Americans recommend that F&V constitute one-half of the plate at each meal. F&V include a diverse collection of plant foods that vary in their energy, nutrient, and dietary bioactive contents. F&V have potential health-promoting effects beyond providing basic nutrition needs in humans, including their role in reducing inflammation and their potential preventive effects on various chronic disease states leading to decreases in years lost due to premature mortality and years lived with disability/morbidity. Current global intakes of F&V are well below recommendations. Given the importance of F&V for health, public policies that promote dietary interventions to help increase F&V intake are warranted. This externally commissioned expert comprehensive narrative, umbrella review summarizes up-to-date clinical and observational evidence on current intakes of F&V, discusses the available evidence on the potential health benefits of F&V, and offers implementation strategies to help ensure that public health messaging is reflective of current science. This review demonstrates that F&V provide benefits beyond helping to achieve basic nutrient requirements in humans. The scientific evidence for providing public health recommendations to increase F&V consumption for prevention of disease is strong. Current evidence suggests that F&V have the strongest effects in relation to prevention of CVDs, noting a nonlinear threshold effect of 800 g per day (i.e., about 5 servings a day). A growing body of clinical evidence (mostly small RCTs) demonstrates effects of specific F&V on certain chronic disease states; however, more research on the role of individual F&V for specific disease prevention strategies is still needed in many areas. Data from the systematic reviews and mostly observational studies cited in this report also support intake of certain types of F&V, particularly cruciferous vegetables, dark-green leafy vegetables, citrus fruits, and dark-colored berries, which have superior effects on biomarkers, surrogate endpoints, and outcomes of chronic disease.

Trends in tap and bottled water consumption among children and adults in the United States: analyses of NHANES 2011-16 data.

BACKGROUND: Dietary Guidelines for Americans 2015-20 recommend choosing water in place of sugar-sweetened beverages (SSB). This study examined water consumption patterns and trends among children and adults in the US. METHODS: Dietary intake data for 7453 children (4-18y) and 15,263 adults (>19y) came from two 24 h dietary recalls in three cycles of the National Health and Nutrition Examination Survey (NHANES 2011-2016). Water was categorized as tap or bottled (plain). Other beverages were assigned to 15 categories. Water and other beverage intakes (in mL/d) were analyzed by sociodemographic variables and sourcing location. Consumption time trends from 2011 to 2016 were also examined. Total water intakes from water, other beverages and moisture from foods (mL/d) were compared to Dietary Reference Intakes (DRI) for water. RESULTS: Total dietary water (2718 mL/d) came from water (1066 mL/d), other beverages (1036 mL/d) and from food moisture (618 mL/d). Whereas total water intakes remained stable, a significant decline in SSB from 2011 to 2016 was fully offset by an increase in the consumption of plain water. The main sources of water were tap at home (288 mL/d), tap away from home (301 mL/d), and bottled water from stores (339 mL/d). Water and other beverage consumption patterns varied with age, incomes and race/ethnicity. Higher tap water consumption was associated with higher incomes, but bottled water was not. Non-Hispanic whites consumed most tap water (781 mL/d) whereas Mexican Americans consumed most bottled water (605 mL/d). Only about 40% of the NHANES sample on average followed US recommendations for adequate water intakes. CONCLUSION: The present results suggest that while total water intakes among children and adults have stayed constant, drinking water, tap and bottled, has been replacing SSB in the US diet.

Expert consensus on low-calorie sweeteners: facts, research gaps and suggested actions.

A consensus workshop on low-calorie sweeteners (LCS) was held in November 2018 where seventeen experts (the panel) discussed three themes identified as key to the science and policy of LCS: (1) weight management and glucose control; (2) consumption, safety and perception; (3) nutrition policy. The aims were to identify the reliable facts on LCS, suggest research gaps and propose future actions. The panel agreed that the safety of LCS is demonstrated by a substantial body of evidence reviewed by regulatory experts and current levels of consumption, even for high users, are within agreed safety margins. However, better risk communication is needed. More emphasis is required on the role of LCS in helping individuals reduce their sugar and energy intake, which is a public health priority. Based on reviews of clinical evidence to date, the panel concluded that LCS can be beneficial for weight management when they are used to replace sugar in products consumed in the diet (without energy substitution). The available evidence suggests no grounds for concerns about adverse effects of LCS on sweet preference, appetite or glucose control; indeed, LCS may improve diabetic control and dietary compliance. Regarding effects on the human gut microbiota, data are limited and do not provide adequate evidence that LCS affect gut health at doses relevant to human use. The panel identified research priorities, including collation of the totality of evidence on LCS and body weight control, monitoring and modelling of LCS intakes, impacts on sugar reduction and diet quality and developing effective communication strategies to foster informed choice. There is also a need to reconcile policy discrepancies between organisations and reduce regulatory hurdles that impede low-energy product development and reformulation.

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.

Sugars and sweeteners: science, innovations, and consumer guidance for Asia.

BACKGROUND AND OBJECTIVES: Rising obesity in Southeast Asia, one consequence of economic growth, has been linked to a rising consumption of energy from added sugars. This symposium, organized by ILSI Southeast Asia, explored regional issues related to dietary sugars and health and identified ways in which these issues could be addressed by regional regulatory agencies, food producers, and the consumer. METHODS AND STUDY DESIGN: Papers on the following topics were presented: 1) current scientific evidence on the effects of sugars and non-caloric sweeteners on body weight, health, and eating behaviors; 2) innovations by food producers to reduce sugar consumption in the region; 3) regional dietary surveillance of sugar consumption and suggestions for consumer guidance. A panel discussion explored effective approaches to promote healthy eating in the region. RESULTS: Excessive consumption of energy in the form of added sugars can have adverse consequences on diet quality, lipid profiles, and health. There is a need for better surveillance of total and added sugars intakes in selected Southeast Asian countries. Among feasible alternatives to corn sweeteners (high fructose corn syrup) and cane sugar are indigenous sweeteners with low glycemic index (e.g., coconut sap sugar). Their health benefits should be examined and regional sugar consumption tracked in detail. Product reformulation to develop palatable lower calorie alternatives that are accepted by consumers continues to be a challenge for industry and regulatory agencies. CONCLUSIONS: Public-private collaborations to develop healthy products and effective communication strategies can facilitate consumer acceptance and adoption of healthier foods.

A neural basis for food foraging in obesity.

Poverty-related food insecurity can be viewed as a form of economic and nutritional uncertainty that can lead, in some situations, to a desire for more filling and satisfying food. Given the current obesogenic food environment and the nature of the food supply, those food choices could engage a combination of sensory, neurophysiological, and genetic factors as potential determinants of obesity.