Healthy U.S.-style dietary patterns can be modified to provide increased energy from protein.

BACKGROUND: Dietary patterns developed by the USDA provide modest levels of protein (14-18% energy) within the Acceptable Macronutrient Distribution Range (AMDR) of 10-35% for adults, though diets providing a higher percentage of energy may be beneficial for some individuals. The purpose of this study was to determine if it is feasible to modify the Healthy U.S.-Style Eating Pattern ("HEP") to provide a higher percentage of energy from protein. METHODS: Using the framework implemented by the USDA in developing the HEP, energy from protein was set at 20%, 25%, and 30%. Amounts of protein foods were proportionally increased while amounts of other foods were adjusted iteratively within specified parameters. The models also disaggregated total meat/poultry into fresh and processed forms to develop patterns maintaining current proportions, current levels, reduced, or no processed meat/poultry. Nutrient intakes were compared with nutrient goals for representative U.S. populations with 2,000 kcal needs (females 19-30 years, males 51-70 years), with 90% of the Recommended Dietary Allowance or Adequate Intake regarded as sufficient. RESULTS: Dietary patterns with 20% energy from protein were constructed with minor deviations from the current 2,000 kcal HEP. Dietary patterns with 25% energy from protein were constructed for all levels of processed meat/poultry excluding the current proportion model, though relative to the current HEP the constructed patterns reflect substantial reductions in amounts of refined grains and starchy vegetables, and substantial increases in protein foods consumed as beans and peas, seafood, and soy products. It was not possible to develop a pattern with 30% energy from protein without reducing the percentage of energy from carbohydrate below the AMDR or non-compliance with other modeling constraints. Stepwise reductions in processed meat/poultry reduced sodium intake. CONCLUSIONS: It is feasible to develop dietary patterns in a 2,000 kcal diet while mirroring the HEP that meet recommended intakes of nutrients with 20% or 25% energy from protein, though the pattern with 25% energy from protein may be more idealistic than realistic. Reduced levels of processed meat/poultry may translate to lower sodium intake.

Gestational Health Outcomes Among Pregnant Women in the United States by Level of Dairy Consumption and Quality of Diet, NHANES 2003-2016.

OBJECTIVES: Diet is an important factor in gestational health. Many pregnant women have suboptimal diets and dairy foods are an excellent source of key nutrients. The aim of this work was to investigate the relationships between dairy consumption (cup equivalents/day) or diet quality assessed using the Healthy Eating Index-2015 and gestational diabetes mellitus (GDM) or gestational weight gain (GWG) among pregnant women in the United States (US). METHODS: Study populations were subsets of pregnant, non-lactating women (20-44 years) in the National Health and Nutrition Examination Surveys 2003-2016, which was approved by the National Center for Health Statistics Research Ethics Review Board. GDM and GWG were classified according to national guidelines. General characteristics were compared across categories of dietary variables. Adjusted regression models estimated associations between diet and GDM and GWG. RESULTS: No statistically significant linear associations between dairy consumption or diet quality and GDM or GWG were observed. CONCLUSIONS FOR PRACTICE: Future research should aim to address the limitations of the current cross-sectional analyses and further elucidate the underlying relationships between diet and gestational health.

Adequacy of total usual micronutrient intakes among pregnant women in the United States by level of dairy consumption, NHANES 2003-2016.

Background: Dairy products are a rich source of nutrients of public health concern, though most women do not meet the recommended intake of 3 cup-eq/day. Aim: The objective of this analysis was to examine micronutrient adequacy among pregnant women in the US by level of dairy consumption. Methods: Pregnant women (n = 791) ages 20-44 years in NHANES 2003-2016 were categorized by level of dairy consumption (<1, 1 to <2, 2 to <3, and ≥3 cup-eq/day). Usual micronutrient intakes and prevalence of intakes below the Estimated Average Requirement (EAR) or above the Adequate Intake level (AI) were calculated from food alone and food plus dietary supplements using the National Cancer Institute method. Diet quality was assessed with the Healthy Eating Index 2015 (HEI-2015). Results: Pregnant women consuming ≥3 cup-eq/day of dairy were more likely to meet the potassium AI than women consuming lower levels. Compared to women consuming ≥3 cup-eq/day of dairy, women consuming <1 or 1 to <2 cup-eq/day were more likely to have inadequate intake of vitamin D, magnesium, zinc, and vitamin A from foods plus supplements. Compared to women consuming ≥3 cup-eq/day of dairy, women consuming <1 cup-eq/day were more likely to have inadequate intake of calcium and riboflavin. The median urinary iodine concentration (UIC) among pregnant women consuming ≥3 cup-eq/day of dairy was 220 ng/mL compared with median UICs of 98-135 mg/mL among women consuming the lowest levels. Pregnant women consuming ≥3 cup-eq/day of dairy had the highest intake of sodium (mg/day) and saturated fat intake evaluated as a HEI-2015 component. Conclusions: Consumption of recommended levels of dairy products may help pregnant women achieve adequate intakes of select micronutrients.

Aspartame Consumption for 12 Weeks Does Not Affect Glycemia, Appetite, or Body Weight of Healthy, Lean Adults in a Randomized Controlled Trial.

Background: Low-calorie sweeteners are often used to moderate energy intake and postprandial glycemia, but some evidence indicates that they may exacerbate these aims. Objective: The trial's primary aim was to assess the effect of daily aspartame ingestion for 12 wk on glycemia. Effects on appetite and body weight were secondary aims. Methods: One hundred lean [body mass index (kg/m2): 18-25] adults aged 18-60 y were randomly assigned to consume 0, 350, or 1050 mg aspartame/d (ASP groups) in a beverage for 12 wk in a parallel-arm design. At baseline, body weight and composition were determined, a 240-min oral-glucose-tolerance test (OGTT) was administered, and measurements were made of appetite and selected hormones. Participants also collected a 24-h urine sample. During the intervention, the 0-mg/d ASP group consumed capsules containing 680 mg dextrose and 80 mg para-amino benzoic acid. For the 350-mg/d ASP group, the beverage contained 350 mg aspartame and the 1050-mg/d ASP group consumed the same beverage plus capsules containing 680 mg dextrose and 700 mg aspartame. Body weight, blood pressure, heart rate, and waist circumference were measured weekly. At weeks 4, 8, and 12, participants collected 24-h urine samples and kept appetite logs. Baseline measurements were repeated at week 12. Results: With the exception of the baseline OGTT glucose concentration at 60 min (and resulting area under the curve value), there were no group differences for glucose, insulin, resting leptin, glucagon-like peptide 1, or gastric inhibitory peptide at baseline or week 12. There also were no effects of aspartame ingestion on appetite, body weight, or body composition. Compliance with the beverage intervention was ∼95%. Conclusions: Aspartame ingested at 2 doses for 12 wk had no effect on glycemia, appetite, or body weight among healthy, lean adults. These data do not support the view that aspartame is problematic for the management of glycemia, appetite, or body weight. This trial was registered at www.clinicaltrials.gov as NCT02999321.

The Macronutrients, Appetite, and Energy Intake.

Each of the macronutrients-carbohydrate, protein, and fat-has a unique set of properties that influences health, but all are a source of energy. The optimal balance of their contribution to the diet has been a long-standing matter of debate. Over the past half century, thinking has progressed regarding the mechanisms by which each macronutrient may contribute to energy balance. At the beginning of this period, metabolic signals that initiated eating events (i.e., determined eating frequency) were emphasized. This was followed by an orientation to gut endocrine signals that purportedly modulate the size of eating events (i.e., determined portion size). Most recently, research attention has been directed to the brain, where the reward signals elicited by the macronutrients are viewed as potentially problematic (e.g., contribute to disordered eating). At this point, the predictive power of the macronutrients for energy intake remains limited.

Conceptualization and Assessment of 24-H Timing of Eating and Energy Intake: A Methodological Systematic Review of the Chronic Disease Literature.

Timing of eating (TOE) and energy intake (TOEI) has important implications for chronic disease risk beyond diet quality. The 2020 Dietary Guidelines Advisory Committee recommended developing consistent terminology to address the lack of TOE/TOEI standardization. The primary objective of this methodological systematic review was to characterize the conceptualization and assessment of TOE/TOEI within the chronic disease literature (International Prospective Register of Systematic Reviews registration number: CRD42021236621). Literature searches in Cumulative Index to Nursing and Allied Health Literature (CINAHL) Plus, Embase, PubMed, and Scopus were limited to English language publications from 2000 to August 2022. Eligible studies reported the association between TOE/TOEI and obesity, cardiovascular disease, type 2 diabetes mellitus, cancer, or a related clinical risk factor among adults (≥19 y) in observational and intervention studies. A qualitative synthesis described and compared TOE/TOEI conceptualization, definitions, and assessment methods across studies. Of the 7579 unique publications identified, 259 studies (observational [51.4 %], intervention [47.5 %], or both [1.2 %]) were eligible for inclusion. Key findings indicated that most studies (49.6 %) were conducted in the context of obesity and body weight. TOE/TOEI variables or assigned conditions conceptualized interrelated aspects of time and eating or energy intake in varying ways. Common TOE/TOEI conceptualizations included the following: 1) timepoint (specific time to represent when intake occurs, such as time of breakfast [74.8 %]); 2) duration (length of time or interval when intake does/does not occur, such as "eating window" [56.5 %]); 3) distribution (proportion of daily intake at a given time interval, such as "percentage of energy before noon" [29.8 %]); and 4) cluster (grouping individuals based on temporal ingestive characteristics [5.0 %]). Assessment, definition, and operationalization of 24-h TOE/TOEI variables varied widely across studies. Observational studies most often used surveys or questionnaires (28.9 %), whereas interventions used virtual or in-person meetings (23.8 %) to assess TOE/TOEI adherence. Overall, the diversity of terminology and methods solidifies the need for standardization to guide future research in chrononutrition and to facilitate inter-study comparisons.

Lower Intakes of Key Nutrients Are Associated with More School and Workplace Absenteeism in US Children and Adults: A Cross-Sectional Study of NHANES 2003-2008.

The influence of individual macro- and micronutrients on absenteeism in the United States is largely unknown. The objective of this study was to determine whether nutritional status or nutrient intake were associated with absenteeism from school and work due to illness or injury. Data from NHANES 2003-2008 were used to assess nutrient intake from food and food plus supplements, nutritional biomarker levels, and school and work absenteeism per year in children and adults. Negative binomial regression models were used to predict mean days of missed work per year and to estimate incidence rate ratios (IRRs) of absenteeism by nutrient biomarker status. Of 7429 children, 77% reported missing school days (mean 4.0 days). Of 8252 adults, 51% reported missing work days (mean 4.9 days). Children and adults who reported more absent days had a significantly lower intake of protein and several essential micronutrients from the diet. When nutrients from supplements were included, this negative association was retained for protein, selenium, choline, and DHA in children and for protein, selenium, vitamin K, choline, potassium, fiber, octadecatrienoic acid, and lycopene in adults. Future studies are needed to ascertain whether dietary interventions, such as access to healthier food options and/or dietary supplements, can reduce absenteeism.

Perspective: A Research Roadmap about Ultra-Processed Foods and Human Health for the United States Food System: Proceedings from an Interdisciplinary, Multi-Stakeholder Workshop.

Our objective was to convene interdisciplinary experts from government, academia, and industry to develop a Research Roadmap to identify research priorities about processed food intake and risk for obesity and cardiometabolic diseases (CMD) among United States populations. We convened attendees at various career stages with diverse viewpoints in the field. We held a "Food Processing Primer" to build foundational knowledge of how and why foods are processed, followed by presentations about how processed foods may affect energy intake, obesity, and CMD risk. Breakout groups discussed potential mechanistic and confounding explanations for associations between processed foods and obesity and CMD risk. Facilitators created research questions (RQs) based on key themes from discussions. Different breakout groups convened to discuss what is known and unknown for each RQ and to develop sub-RQs to address gaps. Workshop attendees focused on ultra-processed foods (UPFs; Nova Group 4) because the preponderance of evidence is based on this classification system. Yet, heterogeneity and subjectivity in UPF classification was a challenge for RQ development. The 6 RQs were: 1) What objective methods or measures could further categorize UPFs, considering food processing, formulation, and the interaction of the two? 2) How can exposure assessment of UPF intake be improved? 3) Does UPF intake influence risk for obesity or CMDs, independent of diet quality? 4) What, if any, attributes of UPFs influence ingestive behavior and contribute to excess energy intake? 5) What, if any, attributes of UPFs contribute to clinically meaningful metabolic responses? 6) What, if any, external environmental factors lead people to consume high amounts of UPFs? Uncertainty and complexity around UPF intake warrant further complementary and interdisciplinary causal, mechanistic, and methodological research related to obesity and CMD risk to understand the utility of applying classification by degree of processing to foods in the United States.

Scoping Review and Evidence Map of the Relation between Exposure to Dietary Sweetness and Body Weight-Related Outcomes in Adults.

Numerous governmental and health organizations recommend reduced intake of added sugars due to the health risks associated with excess intake, including the risk of obesity. Some organizations further recommend avoiding dietary sweetness, regardless of the source. A scoping review and evidence map were completed to characterize the research that investigated associations between dietary sweetness and body weight. The aim was to identify and map published studies that have investigated total dietary sweetness, sweet food/beverages, sugar, or sweetener intake, and body weight-related outcomes and/or energy intake. Using preregistered search terms (osf.io/my7pb), 36,779 publications (duplicates removed) were identified from PubMed, Cochrane Library, and Scopus and screened for inclusion. Eligible studies were clinical trials, longitudinal cohorts, case-control studies, cross-sectional studies, and systematic reviews conducted among adults (age ≥18 y), which were performed to investigate associations between dietary sweetness, sweet foods/beverages, sugar, or sweetener (energetic or nonenergetic) intake and body weight, BMI, adiposity, and/or energy intake. A total of 833 eligible publications were identified, detailing 804 studies. Only 7 studies (0.9% of included studies; 2 clinical trials, 4 cross-sectional studies, and 1 with another design type) investigated associations between total dietary sweetness and body weight-related outcome and/or energy intake. An additional 608 (75.6%) studies investigated intakes of sweet foods/beverages, sugar, or sweetener, and body weight-related outcomes and/or energy intake, including 225 clinical trials, 81 longitudinal cohorts, 4 case-control studies, and 280 cross-sectional studies. Most studies (90.6%) did not measure the sweetness of the diet or individual foods consumed. Ninety-two (11.4%) publications reported data from studies on dietary patterns that included sweet foods/beverages alongside other dietary components and 97 (12.1%) systematic reviews addressed different but related research questions. Although there is a breadth of evidence from studies that have investigated associations between intakes of sweet foods and beverages, sugars, and sweeteners and body weight, there is a limited depth of evidence on the association between total dietary sweetness and body weight.

Systematic Review and Meta-Analysis on the Effect of Portion Size and Ingestive Frequency on Energy Intake and Body Weight among Adults in Randomized Controlled Feeding Trials.

Energy intake is the product of portion size (PS)-the energy content of an ingestive event-and ingestive frequency (IF)-the number of ingestive events per unit time. An uncompensated alteration in either PS or IF would result in a change in energy intake and body weight if maintained over time. The objective of this meta-analysis was to assess the independent effects of PS and IF on energy intake and body weight among healthy adults in randomized controlled trials (RCTs). A total of 9708 articles were identified in PubMed, Web of Science, Cochrane, and CINAHL databases. The articles were divided among 10 researchers; each article was screened for eligibility by 2-3 independent reviewers. Exclusion criteria included: populations <19 y and >65 y, unhealthy populations (i.e. participants with an acute or chronic disease), assessments <24 h and <4 wk in duration for trials investigating energy intake or body weight, respectively. Controlled feeding trials (i.e. fixed energy intake) that manipulated IF and PS in the same study intervention (IF/PS) were evaluated separately and for the body weight outcome only. Twenty-two studies (IF = 4, PS = 14, IF/PS = 4) met the inclusion criteria. There was an insufficient number of studies to assess the effect of IF, PS, or IF/PS on body weight. There was heterogeneity in the effect sizes among all comparisons (I2 ≥75%). Consuming larger portion sizes was associated with higher daily energy intake [295 kcal (202, 388), n = 24; weighted mean differences (WMD) (95% CI), n = comparisons], and increased frequency of ingestive events was associated with higher energy intake [203 kcal (76, 330), n = 10]. Results from RCTs support that larger PS and greater IF are both associated with higher energy consumption. However, there is insufficient information to determine chronic effects on body weight. This protocol was registered at the International Prospective Register of Systematic Reviews (PROSPERO) as CRD42018104757.

Adequacy and Sources of Protein Intake among Pregnant Women in the United States, NHANES 2003-2012.

Limited information is available on protein intake and adequacy of protein intake among pregnant women. Using data from a sample of 528 pregnant women in the National Health and Nutrition Examination Surveys (NHANES) 2003-2012, usual intake of protein (g/day and g/kg body weight (bw)/day) and prevalence of intake below the Estimated Average Requirement (EAR) by trimester of pregnancy were calculated using the National Cancer Institute method. Percent contributions to protein intake by source (i.e., plant and animal, including type of animal source) were also calculated. Mean usual intake of protein was 88 ± 4.3, 82 ± 3.1, and 82 ± 2.9 g/day among women in trimester 1, 2, and 3 of pregnancy, respectively, or 1.30 ± 0.10, 1.35 ± 0.06, and 1.35 ± 0.05 g/kg bw/day, respectively. An estimated 4.5% of women in the first trimester of pregnancy consumed less protein than the EAR of 0.66 g/kg bw/day; among women in the second and third trimesters of pregnancy, 12.1% and 12.8% of women, respectively, consumed less protein than the EAR of 0.88 g/kg bw/day. Animal sources of protein accounted for approximately 66% of total protein. Findings from this study show that one in eight women in the second and third trimesters of pregnancy have inadequate intake of protein. Pregnant women should be encouraged to consume sufficient levels of protein from a variety of sources.

Potassium chloride-based replacers: modeling effects on sodium and potassium intakes of the US population with cross-sectional data from NHANES 2015-2016 and 2009-2010.

BACKGROUND: Sodium intake in the USA exceeds recommendations. The replacement of added sodium chloride (NaCl) with potassium chloride (KCl) provides a potential strategy to reduce sodium intake. OBJECTIVE: The purpose of this study was to quantitatively estimate changes in intakes of sodium and potassium by the US population assuming use of potassium-based NaCl replacers in top dietary sodium sources. METHODS: Data collected in the What We Eat in America (WWEIA) component of the 2015-2016 and 2009-2010 NHANES were used to identify top-ranking sources of dietary sodium among the population aged 2 y and older based on contributions from food categories aligning with the FDA draft guidance for voluntary sodium reduction. Predicted nutrient intakes were estimated in models assuming total and feasible and practical (F&P) replacement of added NaCl with KCl in foods and ingredients within the top food sources of sodium. An expert elicitation was conducted to collect information on the F&P KCl replacement of added NaCl. RESULTS: Using 2015-2016 consumption data, the total replacement of added NaCl with KCl in the 18 top-ranking sources of dietary sodium results in a predicted sodium intake of 2004 mg/d from the replacement of 1406 mg/d sodium with 1870 mg/d potassium as KCl. Modeled F&P replacement predicted sodium intakes of 3117 mg/d (range of 2953 to 3255 mg/d) from the replacement of 294 mg/d sodium (155 to 457 mg/d) with 390 mg/d potassium (206 to 608 mg/d). Similar results are seen with 2009-2010 data. CONCLUSIONS: The F&P replacement of NaCl with KCl in top-ranking sources of dietary sodium modeled in this study can result in decreased sodium to a level consistent with the short-term intake goal targeted by the FDA of 3000 mg/d, with the mean potassium intake remaining in the range recommended for the apparently healthy population.

Examination of different definitions of snacking frequency and associations with weight status among U.S. adults.

Snacks, while widely consumed in the United States (U.S.), do not have a standard definition, complicating research to understand associations, if any, with weight status. Therefore, the purpose of this study was to examine the association between snacking frequency and weight status using various snacking definitions that exist in the scientific literature among U.S. adults (NHANES 2013-2016; ≥20y n = 9,711). Four event-based snacking definitions were operationalized including participant-defined snacks, eating events outside of meals, and operationally defined snacks based on absolute thresholds of energy consumed (>50 kcal). Weight status was examined using body mass index (BMI), waist circumference, and sagittal abdominal diameter risk. Logistic regression models examined snacking frequency and associations with weight status. Outcomes varied by the definition of a snack employed, but the majority of findings were null. Mean energy from snacks was significantly higher among women with obesity compared to women with normal weight when a snack was defined as any event outside of a typical mealtime (i.e. other than breakfast, lunch, dinner, super, brunch), regardless of whether or not it contributed ≥50 kcal. Further investigation into ingestive behaviors that may influence the relationship between snacking frequency and weight status is needed.

A randomized controlled trial contrasting the effects of 4 low-calorie sweeteners and sucrose on body weight in adults with overweight or obesity.

BACKGROUND: Low-calorie sweeteners (LCSs) provide sweetness with little or no energy. However, each LCS's unique chemical structure has potential to elicit different sensory, physiological, and behavioral responses that affect body weight. OBJECTIVE: The purpose of this trial was to compare the effects of consumption of 4 LCSs and sucrose on body weight, ingestive behaviors, and glucose tolerance over a 12-wk intervention in adults (18-60 y old) with overweight or obesity (body mass index 25-40 kg/m2). METHODS: In a parallel-arm design, 154 participants were randomly assigned to consume 1.25-1.75 L of beverage sweetened with sucrose (n = 39), aspartame (n = 30), saccharin (n = 29), sucralose (n = 28), or rebaudioside A (rebA) (n = 28) daily for 12 wk. The beverages contained 400-560 kcal/d (sucrose treatments) or <5 kcal/d (LCS treatments). Anthropometric indexes, energy intake, energy expenditure, appetite, and glucose tolerance were measured at baseline. Body weight was measured every 2 wk with energy intake, expenditure, and appetite assessed every 4 wk. Twenty-four-hour urine collections were completed every 4 wk to determine study compliance via para-aminobenzoic acid excretion. RESULTS: Of the participants enrolled in the trial, 123 completed the 12-wk intervention. Sucrose and saccharin consumption led to increased body weight across the 12-wk intervention (Δweight = +1.85 ± 0.36 kg and +1.18 ± 0.36 kg, respectively; P ≤ 0.02) and did not differ from each other. There was no significant change in body weight with consumption of the other LCS treatments compared with baseline, but change in body weight for sucralose was negative and significantly lower compared with all other LCSs at week 12 (weight difference ≥ 1.37 ± 0.52 kg, P ≤ 0.008). Energy intake decreased with sucralose consumption (P = 0.02) and ingestive frequency was lower for sucralose than for saccharin (P = 0.045). Glucose tolerance was not significantly affected by any of the sweetener treatments. CONCLUSIONS: Sucrose and saccharin consumption significantly increase body weight compared with aspartame, rebA, and sucralose, whereas weight change was directionally negative and lower for sucralose compared with saccharin, aspartame, and rebA consumption. LCSs should be categorized as distinct entities because of their differing effects on body weight. This trial was registered at clinicaltrials.gov as NCT02928653.

A high-protein breakfast prevents body fat gain, through reductions in daily intake and hunger, in "Breakfast skipping" adolescents.

OBJECTIVE: The purpose of this study was to examine whether the daily consumption of normal-protein (NP) vs. high-protein (HP) breakfast meals improves appetite control, food intake, and body composition in "breakfast skipping" young people with overweight/obesity. METHODS: Fifty-seven adolescents (age: 19 ± 1 years; BMI: 29.7 ± 4.6 kg m(-2)) completed a 12-week randomized controlled trial in which the adolescents consumed either a 1,464 kJ NP breakfast (13 g protein) or a HP breakfast (35 g protein) or continued to skip breakfast (CON). Pre- and post-study appetite, food intake, body weight, and body composition were assessed. RESULTS: Time-by-group interactions (P < 0.05) were detected for body fat mass, daily intake, and perceived hunger. Specifically, HP prevented fat mass gains over the 12 weeks (-0.4 ± 0.5 kg) vs. CON (+1.6 ± 0.9 kg; P = 0.02), whereas NP did not (+0.3 ± 0.5 kg). HP led to reductions in daily intake (-1,724 ± 954 kJ) vs. CON (+1,556 ± 745 kJ; P = 0.03), whereas NP did not (+494 ± 213 kJ). Lastly, only the HP group experienced reductions in daily hunger vs. CON (P < 0.05). However, when directly comparing the HP vs. NP groups, no differences were detected in any outcomes. CONCLUSIONS: The daily addition of a HP breakfast improved indices of weight management as illustrated by the prevention of body fat gain, voluntary reductions in daily intake, and reductions in daily hunger in breakfast skipping adolescents with overweight/obesity.