Plant-Based Dietary Patterns and Incident Diabetes in the Atherosclerosis Risk in Communities (ARIC) Study.

OBJECTIVE: Plant-based dietary patterns emphasize plant foods and minimize animal-derived foods. We investigated the association between plant-based dietary patterns and diabetes in a community-based U.S. sample of Black and White adults. RESEARCH DESIGN AND METHODS: We included middle-aged adults from the Atherosclerosis Risk in Communities (ARIC) study without diabetes at baseline who completed a food-frequency questionnaire (n = 11,965). We scored plant-based diet adherence according to three indices: overall, healthy, and unhealthy plant-based diet indices. Higher overall plant-based diet index (PDI) scores represent greater intakes of all plant foods and lower intakes of animal-derived foods. Higher healthy plant-based diet index (hPDI) scores represent greater healthy plant food intake and lower intakes of animal-derived and unhealthy plant foods. Higher unhealthy plant-based diet index (uPDI) scores represent greater unhealthy plant food intake and lower intakes of animal-derived and healthy plant foods. We used Cox regression to estimate hazard ratios (HRs) for incident diabetes (defined according to self-reported diagnosis, medication use, or elevated blood glucose) associated with each index. RESULTS: Over a median follow-up of 22 years, we identified 4,208 cases of diabetes among subjects. Higher PDI scores were associated with a lower risk of diabetes (quintile 5 vs. 1 HR 0.89 [95% CI 0.80, 0.98]; Ptrend = 0.01). hPDI scores were also inversely associated with diabetes risk (quintile 5 vs. 1 HR 0.85 [95% CI 0.77, 0.94]; Ptrend < 0.001). uPDI scores were not associated with diabetes risk. CONCLUSIONS: A dietary pattern that minimizes animal-derived foods and emphasizes plant foods may reduce diabetes risk.

Dried Fruits: Bioactives, Effects on Gut Microbiota, and Possible Health Benefits-An Update.

Dried fruits contain many bioactive compounds broadly classified as phytochemicals including phenolics, flavonoids, carotenoids, proanthocyanidins, stilbenes, chalcones/dihydrochalcones, and phytoestrogens. These compounds have antioxidant effects that may benefit health. Dried fruits are also a diverse group of foods with varying fibre contents. The evaluation of the biological activity of these bioactive compounds, including their bioaccessibility and bioavailability, may contribute to the understanding of the health effects of dried fruits. Limited evidence suggests that dried fruits (raisins, cranberries, dates, and prunes) affect human gut microbiota composition in a potentially beneficial manner (in terms of effects on Bifidobacteria, Faecalibacterium prausnitzii, Lactobacillus, Ruminococcaceae, Klebsiella spp., and Prevotella spp.). There is little epidemiological evidence about the association of dried fruit consumption with cardiovascular disease incidence and mortality, as well as the risk of type 2 diabetes or obesity. Clinical trial evidence for the effects of dried fruit consumption on cardiovascular risk factors, including glycaemic control, is mixed. Clinical trial evidence suggests prunes might preserve bone mineral density in postmenopausal women. Consumption of dried fruits is associated with higher-quality diets. Studies are needed to increase our understanding of the health effects of dried fruits and the underlying biological mechanisms.

Ultraprocessed Foods and Kidney Disease Progression, Mortality, and Cardiovascular Disease Risk in the CRIC Study.

RATIONALE & OBJECTIVE: Ultraprocessed foods are widely consumed in the United States and are associated with cardiovascular disease (CVD), mortality, and kidney function decline in the general population. We investigated associations between ultraprocessed food intake and chronic kidney disease (CKD) progression, all-cause mortality, and incident CVD in adults with chronic kidney disease (CKD). STUDY DESIGN: Prospective cohort study. SETTING & PARTICIPANTS: Chronic Renal Insufficiency Cohort Study participants who completed baseline dietary questionnaires. EXPOSURE: Ultraprocessed food intake (in servings per day) classified according to the NOVA system. OUTCOMES: CKD progression (≥50% decrease in estimated glomerular filtration rate [eGFR] or initiation of kidney replacement therapy), all-cause mortality, and incident CVD (myocardial infarction, congestive heart failure, or stroke). ANALYTICAL APPROACH: Cox proportional hazards models adjusted for demographic, lifestyle, and health covariates. RESULTS: There were 1,047 CKD progression events observed during a median follow-up of 7 years. Greater ultraprocessed food intake was associated with higher risk of CKD progression (tertile 3 vs tertile 1, HR, 1.22; 95% CI, 1.04-1.42; P=0.01 for trend). The association differed by baseline kidney function, such that greater intake was associated with higher risk among people with CKD stages 1/2 (eGFR≥60mL/min/1.73m2; tertile 3 vs tertile 1, HR, 2.61; 95% CI, 1.32-5.18) but not stages 3a-5 (eGFR<60mL/min/1.73m2; P=0.003 for interaction). There were 1,104 deaths observed during a median follow-up of 14 years. Greater ultraprocessed food intake was associated with higher risk of mortality (tertile 3 vs tertile 1, HR, 1.21; 95% CI, 1.04-1.40; P=0.004 for trend). LIMITATIONS: Self-reported diet. CONCLUSIONS: Greater ultraprocessed food intake may be associated with CKD progression in earlier stages of CKD and is associated with higher risk of all-cause mortality in adults with CKD. PLAIN LANGUAGE SUMMARY: Ultraprocessed foods are industrial formulations produced using ingredients and processes that are not commonly used in culinary preparations and contain few, if any, intact unprocessed foods. Ultraprocessed foods are widely consumed in the United States, and high intakes of such foods have been linked to cardiovascular disease, kidney disease, and mortality in the general population. In this study, we found that greater intake of ultraprocessed foods was associated with higher risk of kidney disease progression and mortality in adults with chronic kidney disease. Our findings suggest that patients with kidney disease may benefit from greater consumption of fresh, whole, and homemade or hand-prepared foods and fewer highly processed foods.

Inverse Associations between Measures of Adiposity and Glycated Albumin in US Adults, NHANES 1999-2004.

BACKGROUND: Glycated albumin (GA) is a short-term measure of glycemic control. Several studies have demonstrated an inverse association between body mass index (BMI) and GA, which may affect its performance as a biomarker of hyperglycemia. We investigated cross-sectional associations between GA and multiple measures of adiposity, and compared its performance as a glycemic biomarker by obesity status, in a nationally representative sample of US adults. METHODS: We measured GA in adults from the 1999-2004 National Health and Nutrition Examination Survey. Separately in adults with and without diabetes, we assessed associations of GA with adiposity measures (BMI, waist circumference, trunk fat, total body fat, and fat mass index) in sex-stratified multivariable regression models. We compared sensitivity and specificity of GA to identify elevated hemoglobin A1c (HbA1c), by obesity status. RESULTS: In covariate-adjusted regression models, all adiposity measures were inversely associated with GA in adults without diabetes (ß=-0.48 to -0.22%-point GA per 1 SD adiposity measure; n = 9750) and with diabetes (ß=-1.73 to -0.92%-point GA per SD). Comparing adults with vs without obesity, GA exhibited lower sensitivity (43% vs 54%) with equivalent specificity (99%) to detect undiagnosed diabetes (HbA1c ≥ 6.5%). Among adults with diagnosed diabetes (n = 1085), GA performed well to identify above-target glycemia (HbA1c ≥ 7.0%), with high specificity (>80%) overall but lower sensitivity in those with vs without obesity (81% vs 93%). CONCLUSIONS: Inverse associations between GA and adiposity were present in people with and without diabetes. GA is highly specific but may not be sufficiently sensitive for diabetes screening in adults with obesity.

Nutritional Epidemiology and Dietary Assessment for Patients With Kidney Disease: A Primer.

Nutritional epidemiology seeks to understand nutritional determinants of disease in human populations using experimental and observational study designs. Though randomized controlled trials provide the strongest evidence of causality, the expense and difficulty of sustaining adherence to dietary interventions are substantial barriers to investigating dietary determinants of kidney disease. Therefore, nutritional epidemiology commonly employs observational study designs, particularly prospective cohort studies, to investigate long-term associations between dietary exposures and kidney disease. Due to the covarying nature and synergistic effects of dietary components, holistic characterizations of dietary exposures that simultaneously consider patterns of foods and nutrients regularly consumed are generally more relevant to disease etiology than single nutrients or foods. Dietary intakes have traditionally been self-reported and are subject to bias. Statistical methods including energy adjustment and regression calibration can reduce random and systematic measurement errors associated with self-reported diet. Novel approaches that assess diet more objectively are gaining popularity but have not yet fully replaced self-report and require refinement and validation in populations with chronic kidney disease. More accurate and frequent diet assessment in existing and future studies will yield evidence to better personalize dietary recommendations for the prevention and treatment of kidney disease.

A Low-Sodium DASH Dietary Pattern Affects Serum Markers of Inflammation and Mineral Metabolism in Adults with Elevated Blood Pressure.

BACKGROUND: The blood pressure-lowering effects of the Dietary Approaches to Stop Hypertension (DASH) dietary pattern and reduced sodium intake are well established. The effects on other biomarkers related to vascular health are of interest and might assist in explaining the effects of the DASH diet and sodium reduction. OBJECTIVES: We hypothesized that a low-sodium DASH diet improves (lowers) biomarkers of inflammation [C-reactive protein (CRP) and soluble urokinase plasminogen activator receptor (suPAR)] and mineral metabolism [phosphorus and fibroblast growth factor-23 (FGF23)]. METHODS: We conducted a secondary analysis of the DASH-Sodium trial using frozen serum samples. This controlled feeding study randomly assigned 412 adults (≥22 y) with elevated blood pressure (120-159/80-95 mmHg) to consume either a DASH diet or control diet. Within each arm, participants received 3 sodium levels [low (1150 mg), intermediate (2300 mg), high (3450 mg)] in random sequence, each for 30 d. To maximize contrast, samples collected at the end of the low-sodium DASH (n = 198) and high-sodium control (n = 194) diets were compared. Between-diet differences in serum CRP, suPAR, phosphorus, and FGF23 concentrations were assessed using linear regression adjusted for age, sex, race, income, education, smoking status, and BMI. RESULTS: CRP concentrations did not differ between groups (P = 0.83), but suPAR was higher after the low-sodium DASH diet than the high-sodium control [geometric mean 2470 pg/mL (95% CI: 2380, 2560 pg/mL), compared with 2290 pg/mL (95% CI: 2210, 2380 pg/mL); P = 0.006]. Phosphorus was higher after the low-sodium DASH diet [geometric mean 3.50 mg/dL (95% CI: 3.43, 3.57 mg/dL)] compared with the high-sodium control diet [geometric mean 3.39 mg/dL (95% CI: 3.33, 3.46 mg/dL); P = 0.04]. FGF23 was also higher after the low-sodium DASH diet [geometric mean 35.3 pg/mL (95% CI: 33.3, 37.3 pg/mL) compared with 28.2 pg/mL (95% CI: 26.6, 29.8 pg/mL); P < 0.001]. CONCLUSIONS: Contrary to our hypothesis, biomarkers of inflammation and mineral metabolism were increased or unchanged by a low-sodium DASH diet compared with a high-sodium control diet in adults with elevated blood pressure.

Self-Rated Diet Quality and Cardiometabolic Health Among U.S. Adults, 2011-2018.

INTRODUCTION: Self-rated health has been extensively studied, but the utility of a similarly structured question to rate diet quality is not well characterized. This study aims to assess the relative validity of self-rated diet quality, compared with that of a validated diet quality measure (Healthy Eating Index-2015) and to examine the associations with cardiometabolic risk factors. METHODS: Analyses were conducted in 2020-2021 using cross-sectional data from the National Health and Nutrition Examination Survey, 2011-2018. Nonpregnant adults who responded to the question: How healthy is your overall diet? and provided 2 dietary recalls were eligible (n=16,913). Associations between self-rated diet quality (modeled as a 5-point continuous variable, poor=1 to excellent=5) and Healthy Eating Index-2015 scores and cardiometabolic risk factors were assessed by linear regression, accounting for the complex survey design and adjusting for demographic and lifestyle characteristics. RESULTS: Self-rated diet quality was positively associated with total Healthy Eating Index-2015 scores (p < 0.001) and with all components except with Dairy (p=0.94) and Sodium (p=0.66). Higher self-rated diet quality was associated with lower BMI, waist circumference, glucose, insulin, triglycerides, and HbA1c and with higher high-density lipoprotein cholesterol (all p<0.01). Positive associations with total diet quality persisted across all racial/ethnic groups, although the associations with individual dietary components varied. Higher self-ratings were most consistently associated with better-scored diet quality among individuals with BMI <30 kg/m2. CONCLUSIONS: Self-rated diet quality was associated with Healthy Eating Index-2015 scores and cardiometabolic disease risk factors. This single-item assessment may be useful in time-limited settings to quickly and easily identify patients in need of dietary counseling to improve cardiometabolic health.

Greater Scores for Dietary Fat and Grain Quality Components Underlie Higher Total Healthy Eating Index-2015 Scores, While Whole Fruits, Seafood, and Plant Proteins Are Most Favorably Associated with Cardiometabolic Health in US Adults.

BACKGROUND: High-quality diets reduce the risk of cardiometabolic and other chronic diseases. The dietary components that distinguish higher from lower quality diets, and their associations with health, have not been fully investigated. OBJECTIVES: This study aimed to assess the component scores that underlie differences in total Healthy Eating Index (HEI)-2015 scores, quantify fatty acid (saturated, monounsaturated, polyunsaturated) intakes that comprise Fatty Acids component scores, and assess associations between component scores and cardiometabolic risk factors. METHODS: A cross-sectional analysis of data from the NHANES (2001-2016) was conducted. Total and component HEI-2015 scores were assessed in adult (≥19 y) participants who provided one 24-h dietary recall (n = 39,799). Survey-weighted mean component scores by quartile of total HEI-2015 score were determined. Regression analyses were conducted to assess fatty acid intakes across quartiles of Fatty Acids component scores. Separate regression analyses were conducted to assess associations between component scores and cardiometabolic risk factors, after adjusting for demographic characteristics and health behaviors. RESULTS: Scores for components related to dietary fat (Fatty Acids, Saturated Fats) and grain quality (Whole Grains, Refined Grains) accounted for the greatest differences in HEI-2015 scores. Higher Fatty Acids scores were primarily composed of lower saturated and greater polyunsaturated fat intakes. Whole Fruits, and Seafood and Plant Proteins, were most favorably associated with cardiometabolic risk factors including anthropometric measures (P < 0.001), systolic blood pressure (P < 0.01), glycemic markers (Whole Fruits only, P < 0.01), and HDL cholesterol and triglycerides (Seafood and Plant Proteins only, P < 0.001). CONCLUSIONS: Average diet quality in US adults is suboptimal. Higher quality diets are primarily distinguished by the types of fats and grain-based foods that are consumed. Interventions targeting dietary components that are most favorably associated with cardiometabolic risk factors-whole fruits, seafood, and plant proteins-may have the greatest impact on disease risk.

Consumption of Dried Fruits Is Associated with Greater Intakes of Underconsumed Nutrients, Higher Total Energy Intakes, and Better Diet Quality in US Adults: A Cross-Sectional Analysis of the National Health and Nutrition Examination Survey, 2007-2016.

BACKGROUND: Dried fruits are shelf-stable alternatives to fresh fruit that avert common barriers to consuming fruit. Consumption of dried fruits may facilitate greater fruit consumption and contribute to better diet quality and nutrient intakes. OBJECTIVE: Our aims were to assess differences in diet quality and cardiometabolic health between dried fruit consumers and nonconsumers, and evaluate differences in nutrient intakes on days when dried fruits were consumed vs not consumed. DESIGN: This is a cross-sectional analysis of data from the National Health and Nutrition Examination Survey 2007-2016. PARTICIPANTS/SETTING: Mean dried fruit intakes were estimated in adults 20 years and older (n = 25,590) who completed a dietary recall. Dried fruit consumers (one-quarter cup-equivalent/day or more) were defined in respondents with 2 complete dietary recalls (n = 22,311). Within-person differences in nutrient intakes were assessed in respondents who consumed dried fruit on 1 of 2 dietary recalls (n = 1,233). MAIN OUTCOME MEASURES: Cardiometabolic risk factors, diet quality scored using the Healthy Eating Index 2015, and nutrient intakes were assessed. STATISTICAL ANALYSES: Diet quality and cardiometabolic health were compared in consumers vs nonconsumers using multivariate linear regression, adjusted for demographic and lifestyle factors. Within-person differences in nutrient intakes on days when dried fruits were consumed vs not were assessed using multivariate linear regression. RESULTS: Mean ± standard error dried fruit intake was 0.04 ± 0.001 cup-equivalents and represented 3.7% of total fruit consumed. Consumers (7.2% of adults) had higher quality diets than nonconsumers (mean ± standard error Healthy Eating Index 2015 score = 60.6 ± 0.5 vs 52.6 ± 0.3; P < 0.001) and lower mean body mass index, waist circumference, and systolic blood pressure (P < 0.01). Total carbohydrate, dietary fiber, potassium, and polyunsaturated fat intakes were greater on days when dried fruits were consumed vs not consumed (P < 0.001). Total calorie intakes were also greater (208-215 kcal; P ≤ 0.002) when dried fruits were consumed. CONCLUSIONS: Dried fruit consumption is associated with higher diet quality and greater intakes of underconsumed nutrients. However, dried fruits do not appear to displace other calorie sources on days when consumed.

Circulating Concentrations of Essential Fatty Acids, Linoleic and α-Linolenic Acid, in US Adults in 2003-2004 and 2011-2012 and the Relation with Risk Factors for Cardiometabolic Disease: An NHANES Analysis.

BACKGROUND: The increased use of high-oleic oils to replace trans fat has led to concern about declining intake of PUFA and the potential for essential fatty acid insufficiency or even deficiency. OBJECTIVES: The aim of this study was to examine circulating concentrations of essential and poorly biosynthesized fatty acids, as biomarkers of dietary intake, in the NHANES data sets prior to (2003-2004 cycle) and following (2011-2012 cycle) legislation to reduce trans fat in the food supply and also to explore the associations between these fatty acids and markers of cardiometabolic health. METHODS: Fasting circulating concentrations of fatty acids from adults (aged ≥20 y) in the 2003-2004 and 2011-2012 NHANES cycles were used for analysis. Dietary data from one day of both the 2003-2004 and 2011-2012 cycles were used to examine differences in dietary fatty acid intake between these cycles. Regression analyses were used to assess relations between circulating concentrations of fatty acids and cardiometabolic health. RESULTS: Between 2003-2004 and 2011-2012, circulating concentrations of linoleic acid (LA) increased (1.38%, P = 0.002); no difference in dietary intake was observed. α-Linolenic acid (ALA), measured by dietary intake (0.14 g, P < 0.001) and circulating concentrations (0.23%, P < 0.01), increased from 2003-2004 to 2011-2012. Circulating LA was inversely associated with BMI (in kg/m2; regression coefficient per percentage point change in LA ± SE: -0.22 ± 0.04), waist circumference (-0.62 ± 0.09 cm), systolic blood pressure (-0.38 ± 0.09 mm Hg), triglycerides (-9.92 ± 0.63 mg/dL), glucose (-3.34 ± 0.13 mg/dL), insulin (-0.18 ± 0.05 µU/mL), and HOMA-IR (-0.29 ± 0.05). CONCLUSIONS: In a nationally representative sample of US adults, no declines in circulating concentrations of essential fatty acids, LA and ALA, were observed between 2003-2004 and 2011-2012, a time when high-oleic oils were increasingly used in the food supply. Higher amounts of circulating LA were correlated with lower risk of cardiometabolic dysfunction, which underscores the importance of monitoring consumption in the United States.

Dried fruit consumption and cardiometabolic health: a randomised crossover trial.

Fruit intake is associated with lower risk of cardiometabolic diseases. However, effects of dried fruits on cardiometabolic health are not well researched. We investigated the effect of daily dried fruit consumption compared with a carbohydrate-rich snack on cardiometabolic disease risk factors in adults with increased cardiometabolic risk. A two-period randomised crossover trial was conducted in adults (n 55) with elevated BMI and at least one additional risk factor for cardiometabolic disease to compare the effects of consuming 3/4 cup/d mixed dried fruits (plums, figs, dates and raisins) or an energy- and carbohydrate-matched control snack for 4 weeks. The primary outcome was LDL-cholesterol; secondary outcomes included other lipids and lipoproteins, glucose and insulin, C-reactive protein, blood pressure and vascular stiffness. Linear mixed models were used for data analysis. Lipid and lipoprotein concentrations did not differ between conditions; however, dried fruit increased LDL-cholesterol (0·10 mmol/l, 95 % CI 0·01, 0·20) compared with baseline. Compared with the control, dried fruit increased mean fasting glucose (0·08 mmol/l, 95 % CI 0·005, 0·16; P = 0·038). Vascular outcomes, fasting insulin and C-reactive protein did not differ between conditions. Mean weight changes did not differ (P = 0·55) but tended to increase after both conditions (dried fruit 0·3 kg, 95 % CI -0·09, 0·65; control 0·4 kg, 95 % CI 0·01, 0·75). Thus, short-term daily consumption of a large portion of mixed dried plums, figs, dates and raisins, without structured dietary guidance, did not improve cardiometabolic risk factors, compared with carbohydrate-rich snacks, in adults with increased baseline cardiometabolic risk.

The Effect of Inflammation and Insulin Resistance on Lipid and Lipoprotein Responsiveness to Dietary Intervention.

Lipids and lipoproteins are major targets for cardiovascular disease (CVD) prevention. Findings from a limited number of clinical trials suggest diet-induced atherogenic lipoprotein lowering can be altered in the presence of chronic low-grade inflammation or insulin resistance. This review summarizes results from randomized controlled trials that have examined diet-induced changes in lipids/lipoproteins by inflammatory or insulin sensitivity status. In addition, mechanisms to explain these clinical observations are explored. Post hoc analyses of data from a limited number of randomized controlled trials suggest attenuation of diet-induced lipid/lipoprotein lowering in individuals with inflammation and/or insulin resistance. These findings are supported by experimental studies showing that inflammatory stimuli and hyperinsulinemia alter genes involved in endogenous cholesterol synthesis and cholesterol uptake, reduce cholesterol efflux, and increase fatty acid biosynthesis. Further a priori defined research is required to better characterize how chronic low-grade inflammation and insulin resistance modulate lipid and lipoprotein responsiveness to guide CVD risk reduction in individuals presenting with these phenotypes.

Nutrition and Cardiovascular Disease-an Update.

PURPOSE OF REVIEW: This review summarizes recent developments in nutrition and cardiovascular disease (CVD) prevention. RECENT FINDINGS: Contemporary dietary guidance recommends healthy dietary patterns with emphasis on food-based recommendations because the totality of the diet (i.e., the combinations and quantities of foods and nutrients consumed) is an important determinant of health. In many guidelines, recommendations are still made for saturated fat, added sugar, sodium, and dietary cholesterol because these are over-consumed by many people and are related to chronic disease development. Epidemiological research illustrates the importance of considering the total diet and the interrelatedness of nutrients in a dietary pattern. Traditionally, epidemiological research focused on individual nutrients in isolation, which can result in erroneous conclusions. An example of this, which has led to substantial controversy, is the evidence from studies evaluating the association between saturated fat and CVD without considering the replacement nutrient. Another controversial topic is the relationship between dietary cholesterol and CVD, which is confounded by saturated fat intake. Finally, the totality of evidence shows that high sodium intake is associated with greater CVD risk; however, some epidemiological research has suggested that a low-sodium intake is detrimental, which has caused some controversy. Overall, this reductionist approach has led to a debate about recommendations for saturated fat, cholesterol, and sodium. However, if approaches that accounted for the interrelatedness of nutrients had been taken, it is likely that there would be less controversy about these nutrients. To encourage dietary pattern-based approaches and consideration of total intake, dietary guidelines should emphasize food-based recommendations that meet nutrient targets. Thus, nutrient targets should underpin food-based dietary guidelines, and recommended dietary patterns should comply with nutrient-based targets. The evidence reviewed shows that it is imperative to consider total dietary patterns for CVD prevention. Dietary guidance should be aligned with nutrient targets and recommendations should be food and dietary pattern based.