Development and Evaluation of the Dietary Pattern Calculator (DiPaC) for Personalized Assessment and Feedback.

This study aimed to develop and validate a diet assessment screener - the Dietary Pattern Calculator (DiPaC). A scoping review identified currently available short diet quality assessment tools. Twenty-one articles covering 19 unique tools were included. The current tools mainly focused on individual nutrients or food groups or were developed for a specific population, and few ascertained overall dietary patterns. The 24-hour dietary recalls from the nationally representative Canadian Community Health Survey (CCHS)-Nutrition 2015 (n = 13,958) were used to derive and validate a personalized dietary pattern informed by the scoping review using weighted partial least squares. The dominant dietary pattern in CCHS-Nutrition 2015 was characterized by high consumption of fast foods, carbonated drinks, and salty snacks and low consumption of whole fruits, orange vegetables, other vegetables and juices, whole grains, dark green vegetables, legumes, and soy. The dietary pattern assessment was used to create and evaluate DiPaC following an agile and user-centred research and development approach. DiPaC, which demonstrated high validity and intermediate reliability (internal consistency = 0.47-0.51), is publicly available at https://www.projectbiglife.ca/. DiPaC can be used by the public, clinicians, and researchers for quick and robust assessment of diet quality, providing immediate feedback with the advantage of being easy to implement.

Adherence to a priori dietary patterns in relation to obesity: results from two cycles of the Canadian National Nutrition Survey.

OBJECTIVE: To test whether adherence to the Mediterranean diet, the Dietary Approaches to Stop Hypertension (DASH) or a dietary pattern in-line with the 2015-2020 Dietary Guidelines for Americans (DGA) was associated with obesity. DESIGN: 24-h dietary recall data from the Canadian Community Health Survey (CCHS)-Nutrition, 2004 and 2015 cycles, were analysed. Diet quality index scores were computed for the Mediterranean-Style Dietary Pattern Score (MSDPS), a DASH index and the 2015 Dietary Guidelines for Americans Adherence Index (DGAI). Higher scores indicated greater adherence. Association between scores and obesity was examined using logistic regression, adjusting for age, sex, physical activity, smoking status, sequence of dietary recall and alcohol and energy intake. SETTING: Canada (excluding territories and the institutionalised population). PARTICIPANTS: Canadian adults (≥ 18 years), non-pregnant and non-breast-feeding; 11 748 from CCHS 2004 and 12 110 from CCHS 2015. The percentage of females in each sample was 50 %. RESULTS: Mean MSDPS, DASH and DGAI scores were marginally but significantly higher in CCHS 2015 than in CCHS 2004. Those affected by obesity obtained lower scores for all indexes in CCHS 2004 (OR 10th v. 90th percentile for DASH: 2·23 (95 % CI 1·50, 3·32), DGAI: 3·01 (95 % CI 1·98, 4·57), MSDPS: 2·02 (95 % CI 1·14, 3·58)). Similar results were observed in CCHS 2015; however, results for MSDPS were not significant (OR 10th v. 90th percentile for DASH: 2·45 (95 % CI 1·72, 3·49), DGAI: 2·73 (95 % CI 1·85, 4·03); MSDPS: 1·30 (95 % CI 0·82, 2·06)). CONCLUSION: Following DASH or the 2015-2020 DGA was associated with a lower likelihood of obesity. Findings do not indicate causation, as the data are cross-sectional.

Correction: Nutrient intakes and top food categories contributing to intakes of energy and nutrients-of-concern consumed by Canadian adults that would require a 'high-in' front-of-pack symbol according to Canadian labelling regulations.

[This corrects the article DOI: 10.1371/journal.pone.0285095.].

Top Sodium Food Sources in the American Diet-Using National Health and Nutrition Examination Survey.

Reducing population-level sodium intake can reduce hypertension, an important preventative strategy to lower the risk of cardiovascular diseases, the leading cause of death in the United States. Considering that most dietary sodium is derived from prepackaged foods, this study quantitatively estimates the proportion contribution and mean sodium intake from key food category contributors to total sodium intake in the US population. Data from the 2017-2018 National Health and Nutrition Examination Survey, which collected interviewer-administered 24 h dietary recalls from Americans (n = 7081), were analyzed. Based on the average proportion contributed, the top 15 sources of sodium were identified overall and by age/sex, poverty-income and race/ethnicity. More than 50% of US population-level dietary sodium intake was contributed by: pizza (5.3%); breads, rolls and buns (4.7%); cold cuts and cured meats (4.6%); soups (4.4%); burritos and tacos (4.3%); savoury snacks (4.1%); poultry (4.0%); cheese (3.1%); pasta mixed dishes (2.9%); burgers (2.5%); meat mixed dishes (2.5%); cookies, brownies and cakes (2.4%); bacon, frankfurters and sausages (2.4%); vegetables (2.2%); and chicken nuggets (1.5%), with the results remaining consistent among population subgroups. The results identified the top sources of sodium in the American population overall, as well as in key population subgroups, which can inform policies and programs aimed at reducing sodium intake.

Nutrient intakes and top food categories contributing to intakes of energy and nutrients-of-concern consumed by Canadian adults that would require a 'high-in' front-of-pack symbol according to Canadian labelling regulations.

Canada recently mandated front-of-pack (FOP) labelling regulations, where foods meeting and/or exceeding recommended thresholds for nutrients-of-concern (i.e., saturated fat, sodium, and sugars) must display a 'high-in' FOP nutrition symbol. However, there is limited research on the amounts and sources of foods consumed by Canadians that would require a FOP symbol. The objective was to examine the intakes of nutrients-of-concern from foods that would display a FOP symbol and to identify the top food categories contributing to intakes for each nutrient-of-concern. Using the first day 24-hour dietary recall from the nationally representative 2015 Canadian Community Health Survey-Nutrition (CCHS), Canadian adults' intakes of nutrients-of-concern from foods that would display a FOP symbol was examined. Foods were assigned to 1 of 62 categories to identify the top food categories contributing to intakes of energy and nutrient-of-concern that would display a FOP symbol for each nutrient-of-concern. Canadian adults (n = 13,495) consumed approximately 24% of total calories from foods that would display a FOP symbol. Foods that would display a FOP symbol for exceeding thresholds for nutrients-of-concern accounted for 16% of saturated fat, 30% of sodium, 25% of total sugar, and 39% of free sugar intakes among Canadian adults. The top food category contributing intakes of each nutrient-of-concern that would display a FOP symbol were nutrient-specific: Processed meat and meat substitutes for saturated fat; Breads for sodium; and Fruit juices & drinks for total and free sugars. Our findings show that Canadian FOP labelling regulations have the potential to influence the intakes of nutrients-of-concern for Canadian adults. Using the findings as baseline data, future studies are warranted to evaluate the impact of FOP labelling regulations.

Examining the diet quality of Canadian adults and the alignment of Canadian front-of-pack labelling regulations with other front-of-pack labelling systems and dietary guidelines.

Introduction: Canada promulgated mandatory front-of-pack labelling (FOPL) regulations in 2022, requiring pre-packaged foods meeting and/or exceeding recommended thresholds for nutrients-of-concern (i.e., saturated fat, sodium, sugars) to display a "high-in" nutrition symbol. However, there is limited evidence on how Canadian FOPL (CAN-FOPL) regulations compare to other FOPL systems and dietary guidelines. Therefore, the objectives of the study were to examine the diet quality of Canadians using the CAN-FOPL dietary index system and its alignment with other FOPL systems and dietary guidelines. Methods: Nationally representative dietary data from the 2015 Canadian Community Health Survey-Nutrition survey (n = 13,495) was assigned dietary index scores that underpin CAN-FOPL, Diabetes Canada Clinical Practice (DCCP) Guidelines, Nutri-score, Dietary Approaches to Stop Hypertension (DASH) and Canada's Food Guide (Healthy Eating Food Index-2019 [HEFI-2019]). Diet quality was examined by assessing linear trends of nutrient intakes across quintile groups of CAN-FOPL dietary index scores. The alignment of CAN-FOPL dietary index system compared with other dietary index systems, with HEFI as the reference standard, was examined using Pearson's correlations and к statistics. Results: The mean [95% CI] dietary index scores (range: 0-100) for CAN-FOPL, DCCP, Nutri-score, DASH, and HEFI-2019 were 73.0 [72.8, 73.2], 64.2 [64.0, 64.3], 54.9 [54.7, 55.1], 51.7 [51.4, 51.9], and 54.3 [54.1, 54.6], respectively. Moving from the "least healthy" to the "most healthy" quintile in the CAN-FOPL dietary index system, intakes of protein, fiber, vitamin A, vitamin C, and potassium increased, while intakes of energy, saturated fat, total and free sugars, and sodium decreased. CAN-FOPL showed moderate association with DCCP (r = 0.545, p < 0.001), Nutri-score (r = 0.444, p < 0.001), and HEFI-2019 (r = 0.401, p < 0.001), but poor association with DASH (r = 0.242, p < 0.001). Slight to fair agreement was seen between quintile combinations of CAN-FOPL and all dietary index scores (к = 0.05-0.38). Discussion: Our findings show that CAN-FOPL rates the dietary quality of Canadian adults to be healthier than other systems. The disagreement between CAN-FOPL with other systems suggest a need to provide additional guidance to help Canadians select and consume 'healthier' options among foods that would not display a front-of-pack nutrition symbol.

How Many Diet-Related Non-Communicable Disease Deaths Could Be Averted or Delayed If Canadians Reduced Their Consumption of Calories Derived from Free Sugars Intake? A Macrosimulation Modeling Study.

Free sugars are a major source of calories in diets and contribute to the burden of many non-communicable diseases (NCDs). The World Health Organization (WHO) recommends reducing free sugars intake to less than 10% of total energy. This study aimed to estimate the number of diet-related NCD deaths which could be averted or delayed if Canadian adults were to reduce their calorie intake due to a systematic 20% reduction in the free sugars content in foods and beverages in Canada. We used the Preventable Risk Integrated ModEl (PRIME) to estimate the potential health impact. An estimated 6770 (95% UI 6184-7333) deaths due to diet-related NCDs could be averted or delayed, mostly from cardiovascular diseases (66.3%). This estimation would represent 7.5% of diet-related NCD deaths observed in 2019 in Canada. A 20% reduction in the free sugars content in foods and beverages would lead to a 3.2% reduction in calorie intake, yet an important number of diet-related NCD deaths could be averted or delayed through this strategy. Our findings can inform future policy decisions to support Canadians' free sugars intake reduction, such as proposing target levels for the free sugars content in key food categories.

Canadian Free Sugar Intake and Modelling of a Reformulation Scenario.

Recommendations suggest limiting the intake of free sugar to under 10% or 5% of calories in order to reduce the risk of negative health outcomes. This study aimed to examine Canadian free sugar intake and model how intakes change following the implementation of a systematic reformulation of foods and beverages to be 20% lower in free sugar. Additionally, this study aimed to examine how calorie intake might be impacted by this reformulation scenario. Canadians' free sugar and calorie intakes were determined using free sugar and calorie data from the Food Label Information Program (FLIP) 2017, a Canadian branded food composition database, and applied to foods reported as being consumed in Canadian Community Health Survey-Nutrition (CCHS-Nutrition) 2015. A "counterfactual" scenario was modelled to examine changes in intake following the reformulation of foods to be 20% lower in free sugar. The overall mean free sugar intake was 12.1% of calories and was reduced to align with the intake recommendations at 10% of calories in the "counterfactual" scenario (p < 0.05). Calorie intake was reduced by 3.2% (60 calories) in the "counterfactual" scenario (p < 0.05). Although the overall average intake was aligned with the recommendations, many age/sex groups exceeded the recommended intake, even in the "counterfactual" scenario. The results demonstrate a need to reduce the intake of free sugar in Canada to align with dietary recommendations, potentially through reformulation. The results can be used to inform future program and policy decisions related to achieving the recommended intake levels of free sugar in Canada.

Intakes of nutrients and food categories in Canadian children and adolescents across levels of sugars intake: cross-sectional analyses of the Canadian Community Health Survey 2015 Public Use Microdata File.

Dietary recommendations to reduce sugars consumption may influence choices of sugars-containing foods and affect the intake of key micronutrients. We compared intakes of nutrients and food sources stratified by quintiles of total sugars in Canadian children (2-8 y) and adolescents (9-13 y, 14-18 y) using 24-hour dietary recalls from the 2015 Canadian Community Health Survey-Nutrition. Energy intakes did not differ across quintiles of sugars intake. Those with lower sugars intakes (Q1/Q3) generally had higher protein, fat, sodium, niacin, folate, and zinc and lower vitamin C compared with those with the highest sugars intakes (Q5). Q1 also had lower potassium but higher saturated fat compared with Q5. Further, Q1 generally had higher protein, fats, and niacin compared with Q3, while children in Q3 had higher potassium and riboflavin and older adolescents had higher calcium and fibre. Q5 had highest intakes of multiple sugar-containing food categories (e.g., fruit, confectionary, milks, cakes/pies/pastries), with higher sugars-sweetened beverages in adolescents. Q3 had higher fruit, milks, and fruit juice compared with Q1 and lower sugars/syrups/preserves, confectionary, and fruit juices compared with Q5. Certain nutrient-dense food sources of sugars (fruit, milks) may help increase key nutrients (potassium, calcium, fibre) in older adolescents with low sugars intakes. However, in those with the highest sugars intakes, nutrient-poor foods may displace nutrient-dense foods. Novelty: Canadian children and adolescents with lower sugars intake have better intakes of some nutrients. Energy intakes did not differ across sugars intake. Older adolescents with mean intakes of total sugars had better intakes of some key nutrients (potassium, calcium, fibre).

Using partial least squares to identify a dietary pattern associated with obesity in a nationally-representative sample of Canadian adults: Results from the Canadian Community Health Survey-Nutrition 2015.

BACKGROUND: Hybrid methods of dietary patterns analysis have emerged as a unique and informative way to study diet-disease relationships in nutritional epidemiology research. OBJECTIVE: To identify an obesogenic dietary pattern using weighted partial least squares (wPLS) in nationally representative Canadian survey data, and to identify key foods and/or beverages associated with the defined dietary pattern. DESIGN: Data from one 24-hr dietary recall data from the cross-sectional Canadian Community Health Survey-Nutrition (CCHS) 2015 (n = 12,049) were used. wPLS was used to identify an obesogenic dietary pattern from 40 standardized food and beverage categories using the variables energy density, fibre density, and total fat as outcomes. The association between the derived dietary pattern and likelihood of obesity was examined using weighted multivariate logistic regression. Key dietary components highly associated with the derived pattern were identified. RESULTS: Compared to quartile one (i.e. those least adherent to an obesogenic dietary pattern), those in quartile four had 2.40-fold increased odds of being obese (OR = 2.40, 95% CI = 1.91, 3.02, P-trend< 0.0001) with a monotonically increasing trend. Using a factor loading significance cut-off of ≥|0.17|, three food/beverage categories loaded positively for the derived obesogenic dietary pattern: fast food (+0.32), carbonated drinks (including energy drinks, sports drinks and vitamin water) (+0.30), and salty snacks (+0.19). Seven categories loaded negatively (i.e. in the protective direction): whole fruits (-0.40), orange vegetables (-0.32), "other" vegetables (-0.32), whole grains (-0.26), dark green vegetables (-0.22), legumes and soy (-0.18) and pasta and rice (-0.17). CONCLUSION: This is the first study to apply weighted partial least squares to CCHS 2015 data to derive a dietary pattern associated with obesity. The results from this study pinpoint key dietary components that are associated with obesity and consumed among a nationally representative sample of Canadians adults.

Adapting the Healthy Eating Index 2010 for the Canadian Population: Evidence from the Canadian National Nutrition Survey.

The Healthy Eating Index (HEI) is a diet quality index shown to be associated with reduced chronic disease risk. Older versions of the HEI have been adapted for Canadian populations; however, no Canadian modification of the Healthy Eating Index-2010 (HEI-2010) has been made. The aims of this study were: (a) to develop a Canadian adaptation of the HEI-2010 (i.e., Healthy Eating Index-Canada 2010 (HEI-C 2010)) by adapting the recommendations of the HEI-2010 to Canada's Food Guide (CFG) 2007; (b) to evaluate the validity and reliability of the HEI-C 2010; and (c) to examine relationships between HEI-C 2010 scores with diet quality and the likelihood of being obese. Data from 12,805 participants (≥18 years) were obtained from the Canadian Community Health Survey Cycle 2.2. Weighted multivariate logistic regression was used to test the association between compliance to the HEI-C 2010 recommendations and the likelihood of being obese, adjusting for errors in self-reported dietary data. The total mean error-corrected HEI-C 2010 score was 50.85 ± 0.35 out of 100. Principal component analysis confirmed multidimensionality of the HEI-C 2010, while Cronbach's α = 0.78 demonstrated internal reliability. Participants in the fourth quartile of the HEI-C 2010 with the healthiest diets were less likely to consume refined grains and empty calories and more likely to consume beneficial nutrients and foods (p-trend < 0.0001). Lower adherence to the index recommendations was inversely associated with the likelihood of being obese; this association strengthened after correction for measurement error (Odds Ratio: 1.41; 95% Confidence Interval: 1.17-1.71). Closer adherence to Canada's Food Guide 2007 assessed through the HEI-C 2010 was associated with improved diet quality and reductions in the likelihood of obesity when energy intake and measurement errors were taken into account. Consideration of energy requirements and energy density in future updates of Canada's Food Guide are important and necessary to ensure broader application and usability of dietary quality indexes developed based on this national nutrition guideline.

Effect of Replacing Animal Protein with Plant Protein on Glycemic Control in Diabetes: A Systematic Review and Meta-Analysis of Randomized Controlled Trials.

UNLABELLED: Previous research on the effect of replacing sources of animal protein with plant protein on glycemic control has been inconsistent. We therefore conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess the effect of this replacement on glycemic control in individuals with diabetes. We searched MEDLINE, EMBASE, and Cochrane databases through 26 August 2015. We included RCTs ≥ 3-weeks comparing the effect of replacing animal with plant protein on HbA1c, fasting glucose (FG), and fasting insulin (FI). Two independent reviewers extracted relevant data, assessed study quality and risk of bias. Data were pooled by the generic inverse variance method and expressed as mean differences (MD) with 95% confidence intervals (CIs). Heterogeneity was assessed (Cochran Q-statistic) and quantified (I²-statistic). Thirteen RCTs (n = 280) met the eligibility criteria. Diets emphasizing a replacement of animal with plant protein at a median level of ~35% of total protein per day significantly lowered HbA1c (MD = -0.15%; 95%-CI: -0.26, -0.05%), FG (MD = -0.53 mmol/L; 95%-CI: -0.92, -0.13 mmol/L) and FI (MD = -10.09 pmol/L; 95%-CI: -17.31, -2.86 pmol/L) compared with control arms. Overall, the results indicate that replacing sources of animal with plant protein leads to modest improvements in glycemic control in individuals with diabetes. Owing to uncertainties in our analyses there is a need for larger, longer, higher quality trials. TRIAL REGISTRATION: ClinicalTrials.gov registration number: NCT02037321.