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.

Salmon Food-Specific Compounds and Their Metabolites Increase in Human Plasma and Are Associated with Cardiometabolic Health Indicators Following a Mediterranean-Style Diet Intervention.

BACKGROUND: Nutrimetabolomics allows for the comprehensive analysis of foods and human biospecimens to identify biomarkers of intake and begin to probe their associations with health. Salmon contains hundreds of compounds that may provide cardiometabolic benefits. OBJECTIVES: We used untargeted metabolomics to identify salmon food-specific compounds (FSCs) and their predicted metabolites that were found in plasma after a salmon-containing Mediterranean-style (MED) diet intervention. Associations between changes in salmon FSCs and changes in cardiometabolic health indicators (CHIs) were also explored. METHODS: For this secondary analysis of a randomized, crossover, controlled feeding trial, 41 participants consumed MED diets with 2 servings of salmon per week for 2 5-wk periods. CHIs were assessed, and fasting plasma was collected pre- and postintervention. Plasma, salmon, and 99 MED foods were analyzed using liquid chromatography-mass spectrometry-based metabolomics. Compounds were characterized as salmon FSCs if detected in all salmon replicates but none of the other foods. Metabolites of salmon FSCs were predicted using machine learning. For salmon FSCs and metabolites found in plasma, linear mixed-effect models were used to assess change from pre- to postintervention and associations with changes in CHIs. RESULTS: Relative to the other 99 MED foods, there were 508 salmon FSCs with 237 unique metabolites. A total of 143 salmon FSCs and 106 metabolites were detected in plasma. Forty-eight salmon FSCs and 30 metabolites increased after the intervention (false discovery rate <0.05). Increases in 2 annotated salmon FSCs and 2 metabolites were associated with improvements in CHIs, including total cholesterol, low-density lipoprotein cholesterol, triglycerides, and apolipoprotein B. CONCLUSIONS: A data-driven nutrimetabolomics strategy identified salmon FSCs and their predicted metabolites that were detectable in plasma and changed after consumption of a salmon-containing MED diet. Findings support this approach for the discovery of compounds in foods that may serve, upon further validation, as biomarkers or act as bioactive components influential to health. The trials supporting this work were registered at NCT02573129 (Mediterranean-style diet intervention) and NCT05500976 (ongoing clinical trial).

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.

Metabolomic Profiling of an Ultraprocessed Dietary Pattern in a Domiciled Randomized Controlled Crossover Feeding Trial.

BACKGROUND: Objective markers of ultraprocessed foods (UPF) may improve the assessment of UPF intake and provide insight into how UPF influences health. OBJECTIVES: To identify metabolites that differed between dietary patterns (DPs) high in or void of UPF according to Nova classification. METHODS: In a randomized, crossover, controlled-feeding trial (clinicaltrials.govNCT03407053), 20 domiciled healthy participants (mean ± standard deviation: age 31 ± 7 y, body mass index [kg/m2] 22 ± 11.6) consumed ad libitum a UPF-DP (80% UPF) and an unprocessed DP (UN-DP; 0% UPF) for 2 wk each. Metabolites were measured using liquid chromatography with tandem mass spectrometry in ethylenediaminetetraacetic acid plasma, collected at week 2 and 24-h, and spot urine, collected at weeks 1 and 2, of each DP. Linear mixed models, adjusted for energy intake, were used to identify metabolites that differed between DPs. RESULTS: After multiple comparisons correction, 257 out of 993 plasma and 606 out of 1279 24-h urine metabolites differed between UPF-DP and UN-DP. Overall, 21 known and 9 unknown metabolites differed between DPs across all time points and biospecimen types. Six metabolites were higher (4-hydroxy-L-glutamic acid, N-acetylaminooctanoic acid, 2-methoxyhydroquinone sulfate, 4-ethylphenylsulfate, 4-vinylphenol sulfate, and acesulfame) and 14 were lower following the UPF-DP; pimelic acid, was lower in plasma but higher in urine following the UPF-DP. CONCLUSIONS: Consuming a DP high in, compared with 1 void of, UPF has a measurable impact on the short-term human metabolome. Observed differential metabolites could serve as candidate biomarkers of UPF intake or metabolic response in larger samples with varying UPF-DPs. This trial was registered at clinicaltrials.gov as NCT03407053 and NCT03878108.

Chlorpyrifos fate in the Arctic: Importance of analyte structure in interactions with Arctic dissolved organic matter.

The insecticide and current use pesticide chlorpyrifos (CLP) is transported via global distillation to the Arctic where it may pose a threat to this ecosystem. CLP is readily detected in Arctic environmental compartments, but current research has not studied its partitioning between water and dissolved organic matter (DOM) nor the role of photochemistry in CLP's fate in aquatic systems. Here, the partition coefficients of CLP were quantified with various types of DOM isolated from the Arctic and an International Humic Substances Society (IHSS) reference material Suwannee River natural organic matter (SRNOM). While CLP readily partitions to DOM, CLP exhibits a significantly higher binding constant with Arctic lacustrine DOM relative to fluvial DOM or SRNOM. The experimental partitioning coefficients (KDOC) were compared to a calculated value estimated using poly parameter linear free energy relationship (pp-LFER) and was found to be in good agreement with SRNOM, but none of the Arctic DOMs. We found that Arctic KDOC values decrease with increasing SUVA254, but no correlations were observed for the other DOM compositional parameters. DOM also mediates the photodegradation of CLP, with stark differences in photo-kinetics using Arctic DOM isolated over time and space. This work highlights the chemo-diversity of Arctic DOM relative to IHSS reference materials and highlights the need for in-depth characterization of DOM that transcends the current paradigm based upon terrestrial and microbial precursors.

Food Processing, According to the Nova Classification System, and Dietary Intake of US Infants and Toddlers.

BACKGROUND: High intake of ultra-processed foods (UPFs) is associated with increased risk of chronic disease; thus, it is important to understand how UPFs influence diet quality early in life. OBJECTIVES: We describe complementary foods and beverages (CFBs) according to the Nova Classification System of Food Processing for infants and toddlers in the United States and estimate how Nova groups and subgroups contribute to energy and select nutrients and food groups. METHODS: We used day 1 24-h recall from infants and toddlers aged 6-23 mo from the cross-sectional, nationally representative 2013-18 National Health and Nutrition Examination Survey (n = 1140). We estimated contributions of Nova groups and subgroups to energy and select nutrients and food groups consumed as CFBs (excluding human milk and formula) using the population ratio with weighted survey commands in SAS. RESULTS: For infants and toddlers in the United States, 42 ± 0.9% (mean ± standard error of the mean) of energy intake from CFBs came from unprocessed/minimally processed foods (U/MPFs) and 45 ± 0.8% from UPFs. U/MPFs contributed most to nutrient intakes (except iron, zinc, and sodium); ≥20% of all selected nutrients was from UPFs. UPFs contributed most to iron (75 ± 1.0%) and zinc (48 ± 1.3%); breakfast cereals were the top source. Most fruit, vegetables, and dairy were from U/MPFs. More than 80% of total grains, whole grains, refined grains, and added sugars were UPFs. CONCLUSIONS: U/MPFs support healthy dietary intake of infants and toddlers in the United States, whereas UPFs contribute meaningfully to nutrients and food groups to be encouraged (iron, zinc, and whole grains), as well as some that should be limited (added sugars and sodium). More research is needed to better understand the utility and sensitivities of using Nova for providing dietary guidance for infants and toddlers in the United States.

Identifying and Estimating Ultraprocessed Food Intake in the US NHANES According to the Nova Classification System of Food Processing.

BACKGROUND: The degree of food processing may be an important dimension of diet in how it relates to health outcomes. A major challenge is standardizing food processing classification systems for commonly used datasets. OBJECTIVES: To standardize and increase transparency in its application, we describe the approach used to classify foods and beverages according to the Nova food processing classification in the 24-h dietary recalls from the 2001-2018 cycles of What We Eat in America (WWEIA), NHANES, and investigate variability and potential for Nova misclassification within WWEIA, NHANES 2017-2018 data via various sensitivity analyses. METHODS: First, we described how the Nova classification system was applied to the 2001-2018 WWEIA, NHANES data using the reference approach. Second, we calculated the percentage energy from Nova groups [1: unprocessed or minimally processed foods, 2: processed culinary ingredients, 3: processed foods, and 4: ultraprocessed foods (UPFs)] for the reference approach using day 1 dietary recall data from non-breastfed participants aged ≥1 y from the 2017-2018 WWEIA, NHANES. We then conducted 4 sensitivity analyses comparing potential alternative approaches (e.g., opting for more vs. less degree of processing for ambiguous items) to the reference approach, to assess how estimates differed. RESULTS: The energy contribution of UPFs using the reference approach was 58.2% ± 0.9% of the total energy; unprocessed or minimally processed foods contributed 27.6% ± 0.7%, processed culinary ingredients contributed 5.2% ± 0.1%, and processed foods contributed 9.0% ± 0.3%. In sensitivity analyses, the dietary energy contribution of UPFs ranged from 53.4% ± 0.8% to 60.1% ± 0.8% across alternative approaches. CONCLUSIONS: We present a reference approach for applying the Nova classification system to WWEIA, NHANES 2001-2018 data to promote standardization and comparability of future research. Alternative approaches are also described, with total energy from UPFs differing by ∼6% between approaches for 2017-2018 WWEIA, NHANES.

Understanding responses to different types of conflicting information about cancer prevention.

BACKGROUND: Individuals are regularly exposed to conflicting information about health; however, understanding of how individuals respond to different types of conflicting information is limited. METHODS: In total, 1027 US adults were randomly assigned to 1 of 8 conflicting information messages about nutrition and cancer risk, depicting 1/4 conflicting information types (conflict in evidence - sources A and B agree the evidence is mixed; conflict between two expert sources - sources A and B present conflicting evidence about nutrition and cancer risk; conflict within the same expert source - source A changes its own recommendation about the evidence; no conflict control) crossed by 1/2 baseline recommendations with which new information conflicted (limit vs. do not limit red meat intake to reduce cancer risk). RESULTS: Compared to the control, each conflicting information type led to lower perceived scientific consensus about how much red meat one should eat (p < .001); conflict in evidence (p = .004) and between sources (p = .006) led to lower trust in scientists. Intentions to consume red meat more frequently were higher in the conflicting information conditions than control in the group initially told to "limit red meat" and lower in the "do not limit red meat" group (p = .022). Conflict within the same source led to higher perceived scientific consensus compared to conflict in evidence (p = .007) and between sources (p = .013); it also lowered intentions to consume red meat more frequently compared to conflict in evidence, but only in the "do not limit red meat" condition (p = .033). Conflict in evidence (p = .007) and within the same source (p = .013) increased cancer fatalism compared to conflict between sources. CONCLUSIONS: Conflict in scientific evidence and conflict arising from the same expert source (e.g., a changing public health guideline) may have pernicious effects. Future efforts could investigate how best to publicly communicate these instances of scientific conflict to minimize negative impact.

Red and processed meat intakes and cardiovascular disease and type 2 diabetes mellitus: An umbrella systematic review and assessment of causal relations using Bradford Hill's criteria.

Observational research suggests higher red and processed meat intakes predict greater risks of developing or dying from cardiovascular diseases (CVD) and type 2 diabetes mellitus (T2DM), but this research limits causal inference. This systematic review of reviews utilizes both observational and experimental research findings to infer causality of these relations. Reviews from four databases were screened by two researchers. Reviews included unprocessed red meat (URM), processed meat (PM), or mixed URM + PM intake, and reported CVD or T2DM outcomes. Twenty-nine reviews were included, and causality was inferred using Bradford Hill's Criteria. Observational assessments of CVD outcomes and all meat types consistently reported weak associations while, T2DM outcomes and PM and Mixed URM + PM assessments consistently reported strong associations. Experimental assessments of Mixed URM + PM on CVD and T2DM risk factors were predominately not significant which lacked coherence with observational findings. For all meat types and outcomes, temporality and plausible mechanisms were established, but specificity and analogous relationships do not support causality. Evidence was insufficient for URM and T2DM. More experimental research is needed to strengthen these inferences. These results suggest that red and processed meat intakes are not likely causally related to CVD but there is potential for a causal relationship with T2DM.

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.

Top sources and trends in consumption of total energy and energy from solid fats and added sugars among youth aged 2-18 years: United States 2009-2018.

BACKGROUND: High energy intake from non-nutrient-dense sources correlates with poorer diet quality. OBJECTIVES: The aims were to 1) estimate total energy intake and energy from solid fats and added sugars combined (SoFAS) and identify their top food category sources for ages 2-18 y in 2015-2018 and 2) describe trends over time in 2009-2018. METHODS: Data were from the NHANES. Pairwise differences were examined using univariate t statistics (2015-2018, n = 5038), and trends by age and over time (2009-2018, n = 14,038) were examined using orthogonal polynomials. RESULTS: In 2015-2018, SoFAS contributed a mean (SE) of 30.0% (0.3%) of total energy. Solid fats [16.1% (0.2%)] and added sugars [13.8% (0.2%)] each contributed >10%. The contribution of added sugars increased with age from 11.1% (2-3 y) to 14.4% (14-18 y), and was higher for all other race/Hispanic origins than non-Hispanic Asians. The top 5 sources of energy were sweet bakery products, savory snacks, pizza, other mixed dishes, and unflavored milk, and for SoFAS also included soft drinks, other desserts, candy, and snack bars. Total energy did not change between 2009 and 2018, but energy from SoFAS, and servings of solid fats, and added sugars declined. The contribution of unflavored milk to total energy declined for all ages and most race/Hispanic origins. Fruit drinks (all ages) and soft drinks (9-18 y) remained among top added sugars sources despite declines. The contribution of sweet bakery products to energy from SoFAS increased for most ages and candy and snack bars to energy from added sugars. CONCLUSIONS: In 2015-2018, SoFAS contributed >30% of total energy for ages 2-18 y, which doubled the Dietary Guidelines for Americans' recommended limit of 15%. The top 5 sources of total energy were similar to those of solid fats, and those of SoFAS similar to those of added sugars. These results may inform public health efforts for improving diet quality.

Plant- and Animal-Based Protein-Rich Foods and Cardiovascular Health.

PURPOSE OF REVIEW: To summarize recent evidence from randomized controlled feeding trials (RCTs) on the effects of consuming plant- and animal-based protein-rich foods on cardiovascular health of adults. RECENT FINDINGS: Results from meta-analyses of RCTs exemplify the importance of considering relative effects of protein-rich foods, i.e., when intake of one food increases, intake of another food likely decreases. Results from short-term RCTs showed that overall diet quality is more influential for improving cardiovascular disease (CVD) risk factors than intake of a single protein-rich food, e.g., red meat. Yet, assessing long-term CVD risk associated with intake of a single protein-rich food as part of a dietary pattern is methodologically challenging. While accumulating evidence suggests gut microbiota as a potential mediator for such effects, current knowledge is preliminary and restricts causal or functional inferences. A variety of protein-rich foods, both plant- and animal-based, should be consumed as part of nutrient-dense dietary patterns to meet nutrient needs and improve cardiovascular health for adults.

A Standardized Assessment of Processed Red Meat and Processed Poultry Intake in the US Population Aged ≥2 Years Using NHANES.

BACKGROUND: Standardized methods are needed to investigate intake patterns of processed meat subtypes, considering health concerns surrounding processed meat intake. OBJECTIVES: The objectives of this study were to create a standardized method of disaggregating processed meat into processed red meat and processed poultry and describe intake patterns of the US population aged ≥2 y. METHODS: Two researchers independently manually disaggregated processed meat from the Food Patterns Equivalents Database into processed red meat and processed poultry based on available information from the Foods and Nutrient Database for Dietary Studies. We created an SAS program (called Processed Meat Categories) to mimic the manual coding. We used the program to describe intake patterns and trends over time of processed red meat and processed poultry using 24-h recalls from 2007-2008 through 2017-2018 NHANES data with SAS survey-weighted procedures for complex surveys. RESULTS: The SAS program had high agreement with the manual code (Pearson concordance correlation ≥0.95). Of the US population aged ≥2 y, 46.8% (95% CI: 45.3, 48.2%) reported consuming any processed meat, 42.5% (95% CI: 41.0, 43.9%) reported consuming processed red meat, and 11.3% (95% CI: 10.2, 12.4%) reported consuming processed poultry. Most [74.1 ± 0.13% (SEM)] processed meat reported was red meat compared with poultry, and 32.1 ± 0.01% of total red meat and 13.7 ± 0.01% of total poultry reported were processed. Prevalence of processed poultry intake increased from 9.5% (95% CI: 8.9, 10.1%) in 2007-2010 to 11.3% (95% CI: 10.2, 12.4%) in 2015-2018 (P < 0.0001), but mean intake amount did not change. Prevalence of processed red meat intake did not change over time, but mean intake decreased from 0.8 ± 0.03 ounce-equivalents in 2007-2010 to 0.7 ± 0.02 ounce-equivalents (P = 0.0058) in 2015-2018. CONCLUSIONS: The Processed Meat Categories SAS program is a tool available for researchers to standardize estimates of processed meat subtypes for future dietary patterns research. Intake of total processed meat did not change in the United States, but intake amount of processed red meat decreased and the prevalence of processed poultry consumers increased.

Adopting a Mediterranean-style eating pattern with low, but not moderate, unprocessed, lean red meat intake reduces fasting serum trimethylamine N-oxide (TMAO) in adults who are overweight or obese.

A Mediterranean-style eating pattern (MED-EP) may include moderate red meat intake. However, it is unknown if the pro-atherogenic metabolite trimethylamine N-oxide (TMAO) is affected by the amount of red meat consumed with a MED-EP. The results presented are from a secondary, retrospective objective of an investigator-blinded, randomized, crossover, controlled feeding trial (two 5-wk interventions separated by a 4-wk washout) to determine if a MED-EP with 200g unprocessed lean red meat/wk (MED-CONTROL) reduces circulating TMAO concentrations compared to a MED-EP with 500g unprocessed lean red meat/wk (MED-RED). Participants were 27 women and 12 men (n=39 total) who were either overweight or obese (BMI: 30.5 ± 0.3 kg/m2 mean ± SEM). Serum samples were obtained following an overnight fast both before (pre) and after (post) each intervention. Fasting serum TMAO, choline, carnitine, and betaine concentrations were measured using a targeted Liquid chromatography-mass spectrometry. Data were analyzed to assess if (a) TMAO and related metabolites differed by intervention, and (b) if changes in TMAO were associated with changes in Framingham 10-year risk score. Serum TMAO was lower post-intervention following MED-CONTROL compared to MED-RED intervention (post-MED-CONTROL 3.1 ± 0.2 µM vs. post-MED-RED 5.0 ± 0.5 µM, p<0.001), and decreased following MED-CONTROL (pre- vs post-MED-CONTROL, p = 0.025). Exploratory analysis using mixed model analysis of covariance identified a positive association between changes in TMAO and changes in HOMA-IR (p = 0.036). These results suggest that lower amounts of red meat intake leads to lower TMAO concentrations in the context of a MED-EP.

Trends in Consumption of Ultraprocessed Foods Among US Youths Aged 2-19 Years, 1999-2018.

Importance: The childhood obesity rate has been steadily rising among US youths during the past 2 decades. Increasing evidence links consumption of ultraprocessed foods to excessive calorie consumption and weight gain, but trends in the consumption of ultraprocessed foods among US youths have not been well characterized. Objective: To characterize trends in the consumption of ultraprocessed foods among US youths. Design, Setting, and Participants: Serial cross-sectional analysis using 24-hour dietary recall data from a nationally representative sample of US youths aged 2-19 years (n = 33 795) from 10 cycles of the National Health and Nutrition Examination Survey (NHANES) from 1999-2000 to 2017-2018. Exposures: Secular time. Main Outcomes and Measures: Percentage of total energy consumed from ultraprocessed foods as defined by NOVA, an established food classification system that categorizes food according to the degree of food processing. Results: Dietary intake from youths were analyzed (weighted mean age, 10.7 years; 49.1% were girls). From 1999 to 2018, the estimated percentage of total energy from consumption of ultraprocessed foods increased from 61.4% to 67.0% (difference, 5.6% [95% CI, 3.5% to 7.7%]; P < .001 for trend), whereas the percentage of total energy from consumption of unprocessed or minimally processed foods decreased from 28.8% to 23.5% (difference, -5.3% [95% CI, -7.5% to -3.2%]; P < .001 for trend). Among the subgroups of ultraprocessed foods, the estimated percentage of energy from consumption of ready-to-heat and -eat mixed dishes increased from 2.2% to 11.2% (difference, 8.9% [95% CI, 7.7% to 10.2%]) and from consumption of sweet snacks and sweets increased from 10.7% to 12.9% (difference, 2.3% [95% CI, 1.0% to 3.6%]), but the estimated percentage of energy decreased for sugar-sweetened beverages from 10.8% to 5.3% (difference, -5.5% [95% CI, -6.5% to -4.5%]) and for processed fats and oils, condiments, and sauces from 7.1% to 4.0% (difference, -3.1% [95% CI, -3.7% to -2.6%]) (all P < .05 for trend). There was a significantly larger increase in the estimated percentage of energy from consumption of ultraprocessed foods among non-Hispanic Black youths (from 62.2% to 72.5%; difference, 10.3% [95% CI, 6.8% to 13.8%]) and Mexican American youths (from 55.8% to 63.5%; difference, 7.6% [95% CI, 4.4% to 10.9%]) than the increase among non-Hispanic White youths (from 63.4% to 68.6%; difference, 5.2% [95% CI, 2.1% to 8.3%]) (P = .04 for trends). Conclusions and Relevance: Based on the NHANES cycles from 1999 to 2018, the estimated proportion of energy intake from consumption of ultraprocessed foods has increased among youths in the US and has consistently comprised the majority of their total energy intake.

Predictors of Palliative Care Knowledge: Findings from the Health Information National Trends Survey.

BACKGROUND: Palliative care plays an important role in improving the quality of life for patients with cancer and their caregivers and has been associated with increased patient satisfaction. However, palliative care knowledge in the general population is limited, and often physician referral occurs late in prognosis. The objective of this analysis was to examine factors associated with palliative care knowledge. METHOD: Using data from the 2018 NCI's Health Information National Trends Survey (HINTS) 5 Cycle 2, descriptive statistics, bivariate analyses, and multivariable logistic regressions were used to assess factors associated with respondents' palliative care knowledge using ORs and 95% confidence intervals as measures of association. The outcome of interest was measured with the item "How would you describe your level of knowledge about palliative care?" Possible response selections were "I've never heard of it," "I know a little bit about palliative care," and "I know what palliative care is and could explain it to someone else." To reduce the risk of type 1 error, jackknife variance estimations with repeated replications were used. All analyses were conducted with the SURVEYLOGISTIC command using SAS 9.4 (SAS Institute Inc.), and the statistical significance level was set at P < 0.05. RESULTS: A total of 3,450 respondents (weighted sample size: 249,489,772) met the inclusion criteria. About 89% (n = 3,000) of all respondents had inadequate knowledge of palliative care. Multivariable analyses indicated that frequent health care utilization as defined as ≥ 2 times per year [OR, 3.01; 95% confidence interval (CI), 2.65-3.58], female gender (OR, 2.15; 95% CI, 1.31-3.59), being married (OR, 2.02; 95% CI, 1.14-3.59), having a college degree or higher (OR, 13.83; 95% CI, 1.71-12.04), and having a regular source of care (OR, 2.67; 95% CI, 1.37-1.90) had greater odds of adequate palliative care knowledge. Those without a cancer diagnosis were less likely to have adequate knowledge of palliative care (OR, 0.49; 95% CI, 0.41-0.89). CONCLUSIONS: Knowledge of palliative care in the United States is low, particularly for those not already actively using their available healthcare system. Public health education efforts are needed to target subgroups of the U.S. population identified by this analysis to increase palliative care knowledge. IMPACT: Healthcare providers have a major role to play in improving palliative care knowledge.

Nonfood Prebiotic, Probiotic, and Synbiotic Use Has Increased in US Adults and Children From 1999 to 2018.

BACKGROUND & AIMS: Public interest in pre-, pro-, and synbiotic products is increasing because of interactions between gut microbiota and human health. Our aim was to describe nonfood (from dietary supplements or medication) pre-, pro-, and synbiotic use by US adults and children and reported reasons. METHODS: Using data from the National Health and Nutrition Examination Survey (NHANES), we text-mined dietary supplement and prescription medication labels and ingredients to identify pre-, pro-, and synbiotic products used in the past 30 days. We describe trends in use from 1999 to 2018 (n = 101,199) and prevalence in 2015-2016 and 2017-2018 (n = 19,215) by age groups, sex, ethnicity/race, education, income, self-reported diet and health quality, and prescription gastrointestinal medication use stratified by children (<19 years) and adults (19+ years). RESULTS: Nonfood pre-, pro-, and synbiotic use increased up to 3-fold in recent cycles. Prevalence of use for all ages for prebiotics was 2.4% (95% confidence interval [CI], 2.0-2.9), for probiotics was 4.5% (95% CI, 3.5-5.6), and for synbiotics was 1.1% (95% CI, 0.8-1.5). Use was highest among older adults (8.8% [95% CI, 5.4-13.3] among those aged 60-69 years for probiotics), non-Hispanic Whites, those with higher educational attainment and income, those with more favorable self-reported diet or health quality, and those with concurrent prescription gastrointestinal medication use. The top reasons for use were for digestive health and to promote/maintain general health. Less than 30% reported using these products based on a health care provider's recommendation. CONCLUSIONS: One in 20 US adults or children use nonfood pre-, pro-, or synbiotic products, and use has sharply increased in recent years. Most individuals voluntarily take these products for general digestive or overall health reasons.

Heterogeneity in Meat Food Groups Can Meaningfully Alter Population-Level Intake Estimates of Red Meat and Poultry.

Heterogeneity in meat food groups hinders interpretation of research regarding meat intake and chronic disease risk. Our objective was to investigate how heterogeneity in red meat (RM) and poultry food groups influences US population intake estimates. Based on a prior systematic review, we created an ontology of methods used to estimate RM [1= unprocessed RM; 2 (reference)= unprocessed RM + processed RM; 3= unprocessed RM + processed RM + processed poultry; and 4=unprocessed RM + processed RM + processed poultry + chicken patties/nuggets/tenders (PNT)] and three for poultry [A=unprocessed poultry; B= unprocessed poultry + PNT; C (reference)= unprocessed poultry + processed poultry + PNT). We applied methods to 2015-18 National Health and Nutrition Examination Survey data to estimate RM and poultry intake prevalence and amount. We estimated and compared intakes within RM and within poultry methods via the NCI Method for individuals ≥2 years old (n = 15,038), adjusted for age, sex, and race/Hispanic origin. We compared the population percentage that exceeded age- and sex-specific RM and poultry allotments from the Dietary Guidelines for Americans recommended eating patterns. The percent that consumed RM ranged from 47 ± 1.2% to 75 ± 0.8% across methods and mean amount ranged from 10.5 ± 0.28 to 18.2 ± 0.35 lean oz-equivalents/week; 38 ± 1.2% to 71 ± 0.7% and 9.8 ± 0.35 to 13.3 ± 0.35 lean oz-equivalents/week across poultry methods. Estimates for higher, but not lower, intake percentiles differed across RM methods. Compared to the reference, Method 1 was ≥3.0 oz-equivalents/week lower from 20th-70th percentiles, ≥6.0 oz-equivalents/week lower from 75th-90th percentiles, and ≥9.0 oz-equivalents/week lower for the 95th percentile. Method 4, but not Method 3, was ≥3.0 oz-equivalents/week higher than the reference from 50 to 95th percentiles. The population percentage that exceeded allotments was 27 ± 1.8% lower for Method 1, 9 ± 0.8% higher for Method 3, and 14 ± 0.9% higher for Method 4 compared to the reference. Differences were less pronounced for poultry. Our analysis quantifies the magnitude of bias introduced by heterogeneous meat food group methodology. Explicit descriptions of meat food groups are important for development of dietary recommendations to ensure that research studies are compared appropriately.

Effects of Total Red Meat Intake on Glycemic Control and Inflammatory Biomarkers: A Meta-Analysis of Randomized Controlled Trials.

Our objective was to conduct a systematic review and meta-analysis to assess the effects of total red meat (TRM) intake on glycemic control and inflammatory biomarkers using randomized controlled trials of individuals free from cardiometabolic disease. We hypothesized that higher TRM intake would negatively influence glycemic control and inflammation based on positive correlations between TRM and diabetes. We found 24 eligible articles (median duration, 8 weeks) from 1172 articles searched in PubMed, Cochrane, and CINAHL up to August 2019 that included 1) diet periods differing in TRM; 2) participants aged ≥19 years; 3) included either men or women who were not pregnant/lactating; 4) no diagnosed cardiometabolic disease; and 5) data on fasting glucose, insulin, HOMA-IR, glycated hemoglobin (HbA1c), C-reactive protein (CRP), or cytokines. We used 1) a repeated-measures ANOVA to assess pre to post diet period changes; 2) random-effects meta-analyses to compare pre to post changes between diet periods with ≥ vs. <0.5 servings (35g)/day of TRM; and 3) meta-regressions for dose-response relationships. We grouped diet periods to explore heterogeneity sources, including risk of bias, using the National Heart, Lung, and Blood Institute's Quality Assessment of Controlled Interventions Studies. Glucose, insulin, and HOMA-IR values decreased, while HbA1c and CRP values did not change during TRM or alternative diet periods. There was no difference in change values between diet periods with ≥ vs. <0.5 servings/day of TRM [weighted mean differences (95% CIs): glucose, 0.040 mmol/L (-0.049, 0.129); insulin, -0.710 pmol/L (-6.582, 5.162); HOMA-IR, 0.110 (-0.072, 0.293); CRP, 2.424 nmol/L (-1.460, 6.309)] and no dose response relationships (P > 0.2). Risk of bias (85% of studies were fair to good) did not influence results. Total red meat consumption, for up to 16 weeks, does not affect changes in biomarkers of glycemic control or inflammation for adults free of, but at risk for, cardiometabolic disease. This trial was registered at PROSPERO as 2018 CRD42018096031.