Application of a New Carbohydrate Food Quality Scoring System: An Expert Panel Report.

Carbohydrate foods (≥40% energy from carbohydrates) are the main source of energy in the US diet. In contrast to national-level dietary guidance, many regularly consumed carbohydrate foods are low in fiber and whole grains but high in added sugar, sodium, and/or saturated fat. Given the important contribution of higher-quality carbohydrate foods to affordable healthy diets, new metrics are needed to convey the concept of carbohydrate quality to policymakers, food industry stakeholders, health professionals, and consumers. The recently developed Carbohydrate Food Quality Scoring System is well aligned with multiple key healthy messages on nutrients of public health concern from the 2020-2025 Dietary Guidelines for Americans. Two models are described in a previously published paper: one for all non-grain carbohydrate-rich foods (e.g., fruits, vegetables, legumes) known as the Carbohydrate Food Quality Score-4 (CFQS-4), and one for grain foods only known as the Carbohydrate Food Quality Score-5 (CFQS-5). These CFQS models provide a new tool that can guide policy, programs, and people towards improved carbohydrate food choices. Specifically, the CFQS models represent a way to unify and reconcile diverse ways to describe different types of carbohydrate-rich foods (e.g., refined vs. whole, starchy vs. non-starchy, dark green vs. red/orange) and make for more useful and informative messaging that better aligns with a food's nutritional and/or health contributions. The present paper's aims are to show that the CFQS models can inform future dietary guidelines and help support carbohydrate food recommendations with other health messages aimed at promoting foods that are nutrient-dense, fiber-rich, and low in added sugar.

A New Carbohydrate Food Quality Scoring System to Reflect Dietary Guidelines: An Expert Panel Report.

Existing metrics of carbohydrate food quality have been based, for the most part, on favorable fiber- and free sugar-to-carbohydrate ratios. In these metrics, higher nutritional quality carbohydrate foods are defined as those with >10% fiber and <10% free sugar per 100 g carbohydrate. Although fiber- and sugar-based metrics may help to differentiate the nutritional quality of various types of grain products, they may not aptly capture the nutritional quality of other healthy carbohydrate foods, including beans, legumes, vegetables, and fruits. Carbohydrate food quality metrics need to be applicable across these diverse food groups. This report introduces a new carbohydrate food scoring system known as a Carbohydrate Food Quality Score (CFQS), which supplements the fiber and free sugar components of previous metrics with additional dietary components of public health concern (e.g., sodium, potassium, and whole grains) as identified by the Dietary Guidelines for Americans. Two CFQS models are developed and tested in this study: one that includes four dietary components (CFQS-4: fiber, free sugars, sodium, potassium) and one that considers five dietary components (CFQS-5: fiber, free sugars, sodium, potassium, and whole grains). These models are applied to 2596 carbohydrate foods in the Food and Nutrient Database for Dietary Studies (FNDDS) 2017−2018. Consistent with past studies, the new carbohydrate food scoring system places large percentages of beans, vegetables, and fruits among the top scoring carbohydrate foods. The whole grain component, which only applies to grain foods (N = 1561), identifies ready-to-eat cereals, oatmeal, other cooked cereals, and selected whole grain breads and crackers as higher-quality carbohydrate foods. The new carbohydrate food scoring system shows a high correlation with the Nutrient Rich Food (NRF9.3) index and the Nutri-Score. Metrics of carbohydrate food quality that incorporate whole grains, potassium, and sodium, in addition to sugar and fiber, are strategically aligned with multiple 2020−2025 dietary recommendations and may therefore help with the implementation of present and future dietary guidelines.

Fortification of grain foods and NOVA: the potential for altered nutrient intakes while avoiding ultra-processed foods.

PURPOSE: NOVA is a food classification system describing a hierarchy from minimally processed to ultra-processed foods (UPF). Research has associated intake of UPF with chronic diseases. In Australia, the primary sources of grains, both refined and whole, are breads and breakfast cereals, which are typically fortified. Most are classified as UPF, yet are recommended core foods according to the Australian Dietary Guidelines (ADG). This research aimed to identify if avoidance of ultra-processed grain foods would alter nutrient intakes in an Australian population and whether sample diets using substitute (non-UPF) foods would be likely to meet nutrient requirements. METHODS: Quantitative analysis of usual nutrient intake from the National Nutrition and Physical Activity Survey 2011-12 (n = 12,153) for all foods including and excluding UPF. Dietary modelling examined the nutritional adequacy of sample diets aligned with the ADG and another containing replacements for UPF. We particularly focused on grain foods and meeting whole-grain intake targets. RESULTS: There was a significant decrease (all p < 0.05) in modelled intake of key nutrients when UPF were excluded, specifically, thiamin, folate and iodine, as substitutions are rarely fortified. Diets with no UPF, where substitutes are carefully chosen, have the potential to meet Nutrient Reference Values, but deviation from customary food choices may mean adoption of substitutes is unlikely. CONCLUSIONS: Exclusion of UPF may result in lowered intakes of key nutrients of particular concern for at risk groups (including women of child-bearing age), negating gains made by public health policy of fortification. Substitutions may not be realistic in these at-risk populations.

Toward an Evidence-Based Definition and Classification of Carbohydrate Food Quality: An Expert Panel Report.

Carbohydrate-containing crops provide the bulk of dietary energy worldwide. In addition to their various carbohydrate forms (sugars, starches, fibers) and ratios, these foods may also contain varying amounts and combinations of proteins, fats, vitamins, minerals, phytochemicals, prebiotics, and anti-nutritional factors that may impact diet quality and health. Currently, there is no standardized or unified way to assess the quality of carbohydrate foods for the overall purpose of improving diet quality and health outcomes, creating an urgent need for the development of metrics and tools to better define and classify high-quality carbohydrate foods. The present report is based on a series of expert panel meetings and a scoping review of the literature focused on carbohydrate quality indicators and metrics produced over the last 10 years. The report outlines various approaches to assessing food quality, and proposes next steps and principles for developing improved metrics for assessing carbohydrate food quality. The expert panel concluded that a composite metric based on nutrient profiling methods featuring inputs such as carbohydrate-fiber-sugar ratios, micronutrients, and/or food group classification could provide useful and informative measures for guiding researchers, policymakers, industry, and consumers towards a better understanding of carbohydrate food quality and overall healthier diets. The identification of higher quality carbohydrate foods could improve evidence-based public health policies and programming-such as the 2025-2030 Dietary Guidelines for Americans.

Consensus, Global Definitions of Whole Grain as a Food Ingredient and of Whole-Grain Foods Presented on Behalf of the Whole Grain Initiative.

Proposed global definitions of whole grain as an ingredient and whole grain food are presented by the authors on behalf of the Whole Grain Initiative. Whole grains are an important pillar of healthy and sustainable diets. Internationally accepted credible definitions of whole grains as food ingredients and whole-grain foods are necessary to ensure that all global stakeholders have shared standards, and that consumers find them clear, credible, and useful. Based on widely accepted, existing definitions and new developments, the Definitions Working Group of the global Whole Grain Initiative, with experts from academia, government agencies and industry, developed definitions for global application. The key statements of the definition documents are as follows: "Whole grains shall consist of the intact, ground, cracked, flaked or otherwise processed kernel after the removal of inedible parts such as the hull and husk; all anatomical components, including the endosperm, germ, and bran must be present in the same relative proportions as in the intact kernel" and "A whole-grain food shall contain at least 50% whole-grain ingredients based on dry weight. Foods containing 25-50% whole-grain ingredients based on dry weight, may make a front-of-pack claim on the presence of whole grain but cannot be designated 'whole grain' in the product name". The definition documents have been ratified by the leading international scientific associations in this area. We urge that these consensus Whole Grain Initiative definitions be adopted as the basis for definitions used by national regulatory authorities and for health promotion organisations worldwide to use in nutrition education and food labelling.

Perspective: Whole and Refined Grains and Health-Evidence Supporting "Make Half Your Grains Whole".

Research-based dietary guidelines suggest that consumers "make half their grains whole." Yet some advocate ingesting only whole-grain foods (WGFs) and avoiding all refined-grain foods (RGFs). Some even recommend avoiding all grain-based foods (GBFs). This article will provide arguments to counter negative deductions about GBFs and RGFs, especially staple ones, and to support dietary guidance recommending a balance of GBFs-achieved through the right mix, type, and quantity of WGFs and RGFs. Studies looking at early mortality, body weight, and glucose tolerance and diabetes will be used as examples to characterize the literature about GBFs. The following issues are highlighted: 1) inconsistent findings between epidemiological and interventional studies and impacts of GBFs on health outcomes, and the underreporting of findings showing RGFs neither raise nor lower health risks; 2) multiple confounding and potential interactions make adequate statistical adjustment difficult; 3) nonuniform WGF definitions among studies make comparison of results challenging, especially because some WGFs may contain 49-74% refined grain (RG); 4) binary categorization of GBFs creates bias because nearly all categories of WGFs are recommended, but nearly half the RGF categories are not; 5) ingestion of >5 (30-g) servings RGFs/d and <1 serving WFGs/d creates dietary imbalance; 6) pattern names (e.g., "white bread") may impugn RGFs, when names such as "unbalanced" or "few fruits and vegetables" may more fairly characterize the dietary imbalance; 7) avoidance of all enriched RGs may not only impair status of folate and other B vitamins and certain minerals such as iron and zinc but also decrease acceptability of WGFs; 8) extrapolation beyond median documented intakes in high-WGF consumers (∼48 g whole grain/d) in most cohorts is speculative; 9) recommended dietary patterns such as the Mediterranean diet demonstrate that the right mix of WGFs and RGFs contributes to positive health outcomes.

Food processing: criteria for dietary guidance and public health?

The NOVA food categorisation recommends 'avoiding processed foods (PF), especially ultra-processed foods (UPF)' and selecting minimally PF to address obesity and chronic disease. However, NOVA categories are drawn using non-traditional views of food processing with additional criteria including a number of ingredients, added sugars, and additives. Comparison of NOVA's definition and categorisation of PF with codified and published ones shows limited congruence with respect to either definition or food placement into categories. While NOVA studies associate PF with decreased nutrient density, other classifications find nutrient-dense foods at all levels of processing. Analyses of food intake data using NOVA show UPF provide much added sugars. Since added sugars are one criterion for designation as UPF, such a proof demonstrates a tautology. Avoidance of foods deemed as UPF, such as wholegrain/enriched bread and cereals or flavoured milk, may not address obesity but could decrease intakes of folate, calcium and dietary fibre. Consumer understanding and implementation of NOVA have not been tested. Neither have outcomes been compared with vetted patterns, such as Dietary Approaches to Stop Hypertension, which base food selection on food groups and nutrient contribution. NOVA fails to demonstrate the criteria required for dietary guidance: understandability, affordability, workability and practicality. Consumers' confusion about definitions and food categorisations, inadequate cooking and meal planning skills and scarcity of resources (time, money), may impede adoption and success of NOVA. Research documenting that NOVA can be implemented by consumers and has nutrition and health outcomes equal to vetted patterns is needed.

Several grain dietary patterns are associated with better diet quality and improved shortfall nutrient intakes in US children and adolescents: a study focusing on the 2015-2020 Dietary Guidelines for Americans.

BACKGROUND: The present study identified the most commonly consumed grain food patterns in US children and adolescents (2-18 years-old; N = 8,367) relative to those not consuming grains and compared diet quality and nutrient intakes, with focus on 2015-2020 Dietary Guidelines for Americans (2015-2020 DGA) shortfall nutrients. METHODS: Cluster analysis using data from the National Health and Nutrition Examination Survey 2005-2010, identified 8 unique grain food patterns: a) no consumption of main grain groups, b) cakes, cookies and pies, c) yeast bread and rolls, d) cereals, e) pasta, cooked cereals and rice, f) crackers and salty snacks, g) pancakes, waffles and French toast and other grains, and h) quick breads. RESULTS: Energy intake was higher for all grain cluster patterns examined, except 'cereals', compared to no grains. Children and adolescents in the 'yeast bread and rolls', 'cereals', 'pasta, cooked cereals and rice', and 'crackers and salty snacks' patterns had a higher diet quality relative to no grains (all p < 0.01). Energy adjusted (EA) dietary fiber intake was greater in five of the seven grain patterns, ranging from 1.8 - 2.8 g more per day (all p < 0.01), as compared to those consuming no grains. All grain patterns, except cakes, cookies and pies had higher EA daily folate relative to children in the no grains pattern (all p < 0.0001). EA total fat was lower in 'cereals', 'pasta, cooked cereals and rice', and 'pancakes, waffles, French toast and other grains' in comparison to the no grains food pattern (all p < 0.01). EA magnesium intakes were greater in children and adolescents consuming 'yeast bread and rolls', 'pasta, cooked cereals and rice', and 'quick breads', while EA iron was higher in all grain patterns relative to no grains (all p < 0.01). EA vitamin D intake was higher only in children consuming 'cereals' vs. no grain group (p < 0.0001). There were no significant differences in total or added sugar intake across all grain clusters as compared to no grains. CONCLUSIONS: Consumption of several, but not all, grain food patterns in children and adolescents were associated with improved 2015-2020 DGA shortfall nutrient intakes and diet quality as compared to those consuming no grains.

Identifying practical solutions to meet America's fiber needs: proceedings from the Food & Fiber Summit.

Fiber continues to be singled out as a nutrient of public health concern. Adequate intakes of fiber are associated with reduced risk for cardiovascular disease, cancer, diabetes, certain gastrointestinal disorders and obesity. Despite ongoing efforts to promote adequate fiber through increased vegetable, fruit and whole-grain intakes, average fiber consumption has remained flat at approximately half of the recommended daily amounts. Research indicates that consumers report increasingly attempting to add fiber-containing foods, but there is confusion around fiber in whole grains. The persistent and alarmingly low intakes of fiber prompted the "Food & Fiber Summit," which assembled nutrition researchers, educators and communicators to explore fiber's role in public health, current fiber consumption trends and consumer awareness data with the objective of generating opportunities and solutions to help close the fiber gap. The summit outcomes highlight the need to address consumer confusion and improve the understanding of sources of fiber, to recognize the benefits of various types of fibers and to influence future dietary guidance to provide prominence and clarity around meeting daily fiber recommendations through a variety of foods and fiber types. Potential opportunities to increase fiber intake were identified, with emphasis on meal occasions and food categories that offer practical solutions for closing the fiber gap.

CODEX-aligned dietary fiber definitions help to bridge the 'fiber gap'.

A comprehensive dietary fiber (DF) definition was adopted by the CODEX Alimentarius Commission (CAC) (1) to reflect the current state of knowledge about DF, (2) to recognize that all substances that behave like fiber regardless of how they are produced can be named as DF if they show physiological benefits, and (3) to promote international harmonization for food labeling and food composition tables. This review gives the history and evolution of the state of DF knowledge as looked at by refinements in DF methods and definitions subsequent to the launch of the DF hypothesis. The refinements parallel both interventional and epidemiological research leading to better understanding of the role of DF in contributing to the numerous physiological benefits imparted by all the various digestion resistant carbohydrates. A comparison of the CODEX definition (including its footnote that authorizes the inclusion of polymers with DP 3-9) and approved CODEX Type 1 methods with other existing definitions and methods will point out differences and emphasize the importance of adoption of CODEX-aligned definitions by all jurisdictions. Such harmonization enables comparison of nutrition research, recommendations, food composition tables and nutrition labels the world over. A case will be made that fibers are analogous to vitamins, in that they vary in structure, function and amount needed, but each when present in the right amount contributes to optimal health. Since the intake of DF is significantly below recommended levels throughout the world, the recognition that 'all fibers fit' is an important strategy in bridging the 'fiber gap' by enfranchising and encouraging greater intake of foods with inherent and added DF. Fortifying foods with added DF makes it easier to increase intakes while maintaining calories at recommended levels.

ILSI Brazil International Workshop on Functional Foods: a narrative review of the scientific evidence in the area of carbohydrates, microbiome, and health.

To stimulate discussion around the topic of 'carbohydrates' and health, the Brazilian branch of the International Life Sciences Institute held the 11th International Functional Foods Workshop (1-2 December 2011) in which consolidated knowledge and recent scientific advances specific to the relationship between carbohydrates and health were presented. As part of this meeting, several key points related to dietary fiber, glycemic response, fructose, and impacts on satiety, cognition, mood, and gut microbiota were realized: 1) there is a need for global harmonization of a science-based fiber definition; 2) low-glycemic index foods can be used to modulate the postprandial glycemic response and may affect diabetes and cardiovascular outcomes; 3) carbohydrate type may influence satiety and satiation; glycemic load and glycemic index show links to memory, mood, and concentration; 4) validated biomarkers are needed to demonstrate the known prebiotic effect of carbohydrates; 5) negative effects of fructose are not evident when human data are systematically reviewed; 6) new research indicates that diet strongly influences the microbiome; and 7) there is mounting evidence that the intestinal microbiota has the ability to impact the gut-brain axis. Overall, there is much promise for development of functional foods that impact the microbiome and other factors relevant to health, including glycemic response (glycemic index/glycemic load), satiety, mood, cognition, and weight management.

Dietary fiber future directions: integrating new definitions and findings to inform nutrition research and communication.

The CODEX Alimentarius definition of dietary fiber includes all nondigestible carbohydrate polymers with a degree of polymerization of 3 or more as dietary fiber with the proviso that they show health benefits. The global definition, if accepted by all authoritative bodies, offers a chance for international harmonization in research, food composition tables, and food labeling. Its nonacceptance highlights problems that may develop when definitions vary by region. The definition requires that the research community agrees upon physiological effects for which there is substantial scientific agreement, e.g., fibers' effects on laxation and gut health, on attenuating blood lipids and blood glucose and insulin, and in promoting fermentation in the large bowel. The definition also necessitates the delineation of research protocols to prove the benefits of various isolated and synthesized fibers. These should emanate from evidence-based reviews that fairly weigh epidemiological data while considering that added fibers are not reflected in many food composition databases. They then should include well-controlled, randomized, control trials and utilize animal studies to determine mechanisms. Agreement on many study variables such as the type of subject and the type of baseline diet that best fits the question under investigation will also be needed. Finally, the definition establishes that all types of fiber can address the severe fiber consumption gap that exists throughout the world by recognizing that the combination of fiber-rich and -fortified foods increases fiber intake while allowing consumers to stay within allowed energy levels.

Functional replacements for gluten.

Celiac disease (CD) is an immune-mediated disease triggered in genetically susceptible individuals by ingested gluten from wheat, rye, barley, and other closely related cereal grains. Currently, the only therapy able to normalize the clinical and histological manifestation of the disease is a strict and life-long gluten-free (GF) diet. The replacement of gluten presents a significant technological challenge, as it is an essential structure-building protein, which is necessary for formulating high-quality baked goods. The objective of this paper is to review some basics about CD, its current prevalence, and the recent advances in the preparation of high-quality GF breads using GF flours, starches, hydrocolloids, gums, and novel functional ingredients and technologies.

The definition of dietary fiber - discussions at the Ninth Vahouny Fiber Symposium: building scientific agreement.

A definition for dietary fiber was adopted in June 2009 by the Codex Alimentarius Commission based on the recommendation for endorsement of the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU) in November 2008. The definition listed three categories of carbohydrate polymers that are not hydrolyzed by the endogenous enzymes in the small intestine of humans. However, the definition left the inclusion of carbohydrates with degrees of polymerization (DP) in the range of 3 and 9 to the discretion of national authorities and left the 'physiological effect(s) of benefit to health' as undefined. The ILSI Europe and ILSI North America's committees on dietary carbohydrates organized a forum at the Ninth Vahouny Fiber Symposium in 2010 to discuss these implementation issues with the objective of building scientific consensus on how to resolve them. The results of this session are encouraging and indicated that the scientific community agrees on maintaining a worldwide consensus regarding the inclusion of non-digestible carbohydrates with ≥DP3 as dietary fiber and on a core, non-exhaustive list of beneficial physiological effects that dietary fibers have. These results are consistent with previous worldwide agreements.

Whole grains: benefits and challenges.

Inclusion of whole grains (WG) in the diet is recommended in dietary guidance around the world because of their associations with increased health and reduced risk of chronic disease. WGs are linked to reduced risk of obesity or weight gain; reduced risk of cardiovascular disease (CVD), including coronary heart disease (CHD), hypertension, and stroke; improved gut health and decreased risk of cancers of the upper gut; perhaps reduced risk of colorectal cancer; and lower mortality rate. The 2005 United States Dietary Guidelines Advisory Committee has recommended that consumers make "half their grains whole." Yet, whole grains are puzzling both consumers and scientists. Scientists are trying to determine whether their health benefits are due to the synergy of WG components, individual WG components, or the fact that WG eaters make many of the recommended diet and lifestyle choices. Consumers need to understand the WG benefits and how to identify WG foods to have incentive to purchase and use such foods. Industry needs to develop great-tasting, clearly-labeled products. With both these factors working together, it will be possible to change WG consumption habits among consumers.

Grain foods and health: a primer for clinicians.

UNLABELLED: Preventing many chronic diseases in North America requires substantial changes in dietary habits. Achieving a better balance of grain-based foods through the inclusion of whole grains is one scientifically supported dietary recommendation. Epidemiological and other types of research continue to document health benefits for diverse populations who have adequate intakes of both folic acid-fortified grain foods and whole grains. Folic acid fortification of grains is associated with reduced incidence of neural tube and other birth defects and may be related to decreased risk of other chronic disease. Whole grain intake is associated with reduced risk of chronic disease. Specifically, there is a decreased risk of obesity, coronary heart disease, hypertension, stroke, metabolic syndrome, type 2 diabetes, and some cancers observed among the highest whole grain eaters compared with those eating little or no whole grains. Nationally promulgated dietary recommendations such as those in the US Dietary Guidelines or by health promotion organizations such as the American Heart Association have incorporated the science on whole grains, recommending that consumers increase their whole grain intake. The US Dietary Guidelines state that consumers select half of the recommended bread and cereal servings as whole grain. Thus, the recommendations recognize the importance of adequate folic acid intake from refined, fortified grains to reduce the risk of birth defects and other disorders and to reflect the existing science on whole grains. The association between whole grains and decreased chronic disease is not surprising because whole grains are a source of vitamins, minerals, fatty acids, anti oxidants, and other phytochemicals and dietary fiber. Each of these components can act singly or in tandem to contribute to specific health-maintaining and disease-preventing mechanisms. Health professionals should be aware of these benefits and advocate these dietary strategies to help prevent chronic disease and to improve overall health. KEYWORDS: nutrition; whole grain; folic acid; disease prevention; diet; mortality; diabetes; cereal; pseudocereal; phytochemicals; anti-oxidants.

Becoming Proactive With the Whole-Grains Message.

Whole-grain foods have always been considered a healthy part of the diet. Only recently have epidemiologic and other data shown that whole grains have a role in preventing cardiovascular disease, diabetes, some types of cancer, and even obesity. What nearly all consumers and most health professionals fail to realize is that whole grains deliver as many if not more phytochemicals and antioxidants than do fruits and vegetables. Healthy People 2010 (DHHS) recommends 3 servings of whole grains per day. Because the average intake in the United States is less than 1 serving per day, health professionals must mount an active campaign to help consumers better understand the important health benefits of whole grains and work to increase their intake in the diet.

Applying the theory of planned behavior to promotion of whole-grain foods by dietitians.

The objective of this preliminary study was to apply the theory of planned behavior to explain dietitians' intentions to promote whole-grain foods. Surveys were mailed to a random national sample of registered dietitians to assess knowledge and attitudinal, normative, and control beliefs regarding intention to promote whole-grain foods, with a 39% return rate (n=776, with 628 usable surveys from those working in direct patient care). About half of the respondents had a master's degree, and 58% had substantial experience in the dietetics field. The theory of planned behavior explained intention to promote whole grains to a moderate extent (df=3, F=74.5, R(2)=0.278, P<.001). Most were positive about the health benefits, and few perceived barriers to promotion. However, many had low levels of knowledge and self-efficacy regarding ability to help clients consume more whole-grain foods. Continuing education for dietitians should use strategies that enhance self-efficacy regarding ability to promote whole-grain foods.