Validation and reliability for the updated REAP-S dietary screener, (Rapid Eating Assessment of Participants, Short Version, v.2).

BACKGROUND: The American Heart Association (AHA) chose the REAP-S dietary screener in 2020 as one of three US dietary screeners recommended for integrating dietary assessment into clinical care. The REAP-S v.2 is an updated version that is aligned with the 2020-2025 US Dietary Guidelines and is easily incorporated into electronic medical records and taught to medical students. METHODS: The University of New England, Institutional Review Board, approved the study protocol. We evaluated the reliability and validity of the REAP-S v.2 scale by having first-year medical students (n = 167) complete both the REAP-S v.2 and a three-day food record and then analyzing their data with the following statistical techniques: Internal consistency was measured using Cronbach's alpha. Construct validity was assessed with exploratory factor analysis. Criterion validity was evaluated using analysis of variance (ANOVA) that explored the associations between REAP-S v.2 scale item responses and selected nutrient estimates from the food record analyses. The hierarchical cluster analysis classified healthy and unhealthy diet grouping under each subscale. Further using these groupings, cut points for "good" and "bad" diets for each of the three main REAP-S v.2 subscales (Food Sufficiency/Food Insufficiency; Healthy Eating Pattern and Low Nutrient Density Foods) were calculated using receiver operating characteristics (ROC) analysis. Students analyzed their three-day food intake records using an online USDA application called SuperTracker. RESULTS: The Cronbach's alpha measuring internal consistency was acceptable for the overall scale at 0.71. The exploratory factor analysis extracted three factors that roughly paralleled the three main subscales, suggesting construct validity. Most selected food record-derived nutrient values were significantly associated with scale items confirming criterion validity. The score cut points suggest that dietary counseling might be needed at ≤ 8, ≤ 10, and ≤ 16 for the above subscales. CONCLUSION: The REAP-S v.2 is intended for clinicians to use as a brief dietary screener with their patients. Tested in a population of first-year medical students, the REAP-S v.2 brief dietary screener showed acceptable internal consistency, criterion, and construct validity. It is easily scored and incorporated into the electronic medical record.

Triggers of Lapse and Relapse of Diet and Exercise in Behavioral Weight Loss.

OBJECTIVE: This study aimed to (1) develop instruments to evaluate situations that lead to lapse and relapse in diet and exercise and (2) prospectively investigate when and which psychosocial situations predict failure to lose weight in a clinical trial of intentional weight loss. METHODS: Participants were 469 individuals with overweight or obesity participating in a behavioral weight loss program (age: mean = 53.6 years, SD = 11.4; BMI: mean = 35.7 kg/m2 , SD = 6.5). RESULTS: The Cronbach alphas for the Diet Lapse and Relapse Triggers Scale and the Exercise Lapse and Relapse Triggers Scale were 0.93 and 0.91, respectively. Subscale alphas ranged from 0.60 to 0.96. Lapse and relapse were assessed at 3 and 9 months for associations with weight loss at 12 months. At 9 months, diet triggers were negative emotional states (beta = 0.11, P = 0.02) and urges (beta = 0.14, P = 0.01). Predicted social situations showed the opposite (beta = -0.09, P = 0.02). Exercise subscales were all nonsignificant. CONCLUSIONS: Findings suggest the ongoing importance of addressing negative emotional states and the contributing influence of urges. The novel finding that participants whose difficulties arise in social situations may do better over time requires further study.

Caloric Intake on the Sabbath: A Pilot Study of Contributing Factors to Obesity in the Orthodox Jewish Community.

The American Orthodox Jewish community has specific cultural factors that may contribute to overweight and obesity. This study aimed to look at caloric intake on the Sabbath and its contribution to overweight and obesity. Twelve married or previously married women who identify themselves as Orthodox Jews were recruited to do 24-h food recalls over the phone. The participants were divided into three weight groups (normal, overweight, and obese) based on their BMI. The overweight and obese participants' data were combined into one group for the purposes of statistical testing. Paired t tests looking at the data for all participants showed significantly great caloric intake during an average Sabbath day than an average weekday [t(4) = 7.58, p < 0.001]. A repeated-measures ANOVA showed significantly greater energy intake on the Sabbath for the overweight-obese women compared to the normal weight women [F(1) = 7.83, p = 0.02]. No statistical difference was seen between the weekday energy intake of the normal weight women as compared to the combined group of overweight-obese women [F(1) = 0.501, p = 0.499]. These results support the hypotheses that all groups eat significantly more on the Sabbath than on weekdays, and overweight and obese individuals eat significantly more on the Sabbath than normal weight individuals. This supports the theory that caloric intake on the Sabbath is a contributing factor to overweight and obesity within the American Orthodox Jewish community.

Targeting insulin inhibition as a metabolic therapy in advanced cancer: a pilot safety and feasibility dietary trial in 10 patients.

OBJECTIVE: Most aggressive cancers demonstrate a positive positron emission tomographic (PET) result using ¹8F-2-fluoro-2-deoxyglucose (FDG), reflecting a glycolytic phenotype. Inhibiting insulin secretion provides a method, consistent with published mechanisms, for limiting cancer growth. METHODS: Eligible patients with advanced incurable cancers had a positive PET result, an Eastern Cooperative Oncology Group performance status of 0 to 2, normal organ function without diabetes or recent weight loss, and a body mass index of at least 20 kg/m². Insulin inhibition, effected by a supervised carbohydrate dietary restriction (5% of total kilocalories), was monitored for macronutrient intake, body weight, serum electrolytes, ß-hydroxybutyrate, insulin, and insulin-like growth factors-1 and -2. An FDG-PET scan was obtained at study entry and exit. RESULTS: Ten subjects completed 26 to 28 d of the study diet without associated unsafe adverse effects. Mean caloric intake decreased 35 ± 6% versus baseline, and weight decreased by a median of 4% (range 0.0-6.1%). In nine patients with prior rapid disease progression, five with stable disease or partial remission on PET scan after the diet exhibited a three-fold higher dietary ketosis than those with continued progressive disease (n = 4, P = 0.018). Caloric intake (P = 0.65) and weight loss (P = 0.45) did not differ in those with stable disease or partial remission versus progressive disease. Ketosis was associated inversely with serum insulin levels (P = 0.03). CONCLUSION: Preliminary data demonstrate that an insulin-inhibiting diet is safe and feasible in selected patients with advanced cancer. The extent of ketosis, but not calorie deficit or weight loss, correlated with stable disease or partial remission. Further study is needed to assess insulin inhibition as complementary to standard cytotoxic and endocrine therapies.

Structural determinants of food insufficiency, low dietary diversity and BMI: a cross-sectional study of HIV-infected and HIV-negative Rwandan women.

OBJECTIVES: In Sub-Saharan Africa, the overlapping epidemics of undernutrition and HIV infection affect over 200 and 23 million people, respectively, and little is known about the combined prevalence and nutritional effects. The authors sought to determine which structural factors are associated with food insufficiency, low dietary diversity and low body mass index (BMI) in HIV-negative and HIV-infected Sub-Saharan women. STUDY DESIGN: Cross-sectional analysis of a longitudinal cohort. SETTING: Community-based women's organisations. PARTICIPANTS: 161 HIV-negative and 514 HIV-infected Rwandan women. PRIMARY AND SECONDARY OUTCOME MEASURES: Primary outcomes included food insufficiency (reporting 'usually not' or 'never' to 'Do you have enough food?'), low household dietary diversity (Household Dietary Diversity Score ≤3) and BMI <18.5 (kg/m(2)). The authors also measured structural and behavioural factors including: income, household size, literacy and alcohol use. RESULTS: Food insufficiency was prevalent (46%) as was low dietary diversity (43%) and low BMI (15%). Food insufficiency and dietary diversity were associated with low income (adjusted odds ratio (aOR)=2.14 (95% CI 1.30 to 3.52) p<0.01), (aOR=6.51 (95% CI 3.66 to 11.57) p<0.001), respectfully and illiteracy (aOR=2.00 (95% CI 1.31 to 3.04) p<0.01), (aOR=2.10 (95% CI 1.37 to 3.23) p<0.001), respectfully and were not associated with HIV infection. Alcohol use was strongly associated with food insufficiency (aOR=3.23 (95% CI 1.99 to 5.24) p<0.001). Low BMI was inversely associated with HIV infection (aOR≈0.5) and was not correlated with food insufficiency or dietary diversity. CONCLUSIONS: Rwandan women experienced high rates of food insufficiency and low dietary diversity. Extreme poverty, illiteracy and alcohol use, not HIV infection alone, may contribute to food insufficiency in Rwandan women. Food insufficiency, dietary diversity and low BMI do not correlate with one another; therefore, low BMI may not be an adequate screening tool for food insufficiency. Further studies are needed to understand the health effects of not having enough food, low food diversity and low weight in both HIV-negative and HIV-infected women.

Validation of a food frequency questionnaire to assess intake of n-3 polyunsaturated fatty acids in subjects with and without major depressive disorder.

The role of n-3 polyunsaturated fatty acids (PUFAs) in psychiatric illness is a topic of public health importance. This report describes development and biomarker validation of a 21-item, self-report food frequency questionnaire (FFQ) intended for use in psychiatric research to assess intake of α-linolenic acid (18:3n-3 [ALA]), docosahexaenoic acid (22:6n-3 [DHA]), and eicosapentaenoic acid (20:5n-3 [EPA]). In a cross-sectional study conducted from September 2006 to September 2008, sixty-one ethnically diverse adult participants with (n=34) and without (n=27) major depressive disorder completed this n-3 PUFA FFQ and provided a plasma sample. Plasma levels of n-3 PUFAs EPA and DHA, and n-6 PUFA arachidonic acid (20:4n-6 [AA]) were quantified by gas chromatography. Using Spearman's ρ, FFQ-estimated intake correlated with plasma levels of DHA (r=0.50; P<0.0001) and EPA (r=0.38; P=0.002), but not with ALA levels (r=0.22; P=0.086). Participants were classified into quartiles by FFQ-estimated intake and plasma PUFA concentrations. Efficacy of the FFQ to rank individuals into same or adjacent plasma quartiles was 83% for DHA, 78.1% for EPA, and 70.6% for ALA; misclassification into extreme quartiles was 4.9% for DHA, 6.5% for EPA, and 8.2% for ALA. FFQ-estimated EPA intake and plasma EPA were superior to plasma AA levels as predictors of the plasma AA to EPA ratio. This brief FFQ can provide researchers and clinicians with valuable information concerning dietary intake of DHA and EPA.

Comparative study of the effects of a 1-year dietary intervention of a low-carbohydrate diet versus a low-fat diet on weight and glycemic control in type 2 diabetes.

OBJECTIVE: To compare the effects of a 1-year intervention with a low-carbohydrate and a low-fat diet on weight loss and glycemic control in patients with type 2 diabetes. RESEARCH DESIGN AND METHODS: This study is a randomized clinical trial of 105 overweight adults with type 2 diabetes. Primary outcomes were weight and A1C. Secondary outcomes included blood pressure and lipids. Outcome measures were obtained at 3, 6, and 12 months. RESULTS: The greatest reduction in weight and A1C occurred within the first 3 months. Weight loss occurred faster in the low-carbohydrate group than in the low-fat group (P = 0.005), but at 1 year a similar 3.4% weight reduction was seen in both dietary groups. There was no significant change in A1C in either group at 1 year. There was no change in blood pressure, but a greater increase in HDL was observed in the low-carbohydrate group (P = 0.002). CONCLUSIONS: Among patients with type 2 diabetes, after 1 year a low-carbohydrate diet had effects on weight and A1C similar to those seen with a low-fat diet. There was no significant effect on blood pressure, but the low-carbohydrate diet produced a greater increase in HDL cholesterol.

Improving dietary habits in disadvantaged women with HIV/AIDS: the SMART/EST women's project.

There is a lack of information on whether brief nutrition education can succeed in improving longer-term dietary patterns in disadvantaged populations with HIV/AIDS. In the SMART/EST II Women's Project 466 disadvantaged women with HIV/AIDS were randomized to one of four groups and received a two-phase training consisting of a coping skills/stress management and nutrition education provided either in a group or individually. At baseline the majority of participants had excessive fat and sugar consumption and suboptimal intakes of vegetables, fruits, calcium-rich foods and whole grains. Dietary patterns for all participants improved after the nutrition intervention primarily due to decreases in high fat and high sugar foods such as soda and fried foods and were still significantly better 18 months later. There were only short-term differences in improvements between the four groups. These findings support the value of even brief nutrition education for disadvantaged women living with HIV/AIDS.

Carbohydrates and increases in obesity: does the type of carbohydrate make a difference?

With the prevalence of obesity increasing in the U.S. and elsewhere, the place of carbohydrates in the diet has recently been under closer examination. This has led to the development of methods for analyzing the effects of dietary carbohydrate. Primary among these methods is the glycemic index, a measure of a food's effect on blood glucose levels, which was initially designed as a method for determining suitable carbohydrates for people with diabetes. However, the glycemic index does not address other metabolic issues related to excess sugar consumption. Prominent among these issues is the use of low glycemic index sweeteners, particularly fructose, which is increasingly present in processed food. Fructose is associated with increased adiposity, which may result from its effects on hormones associated with satiety. Other methods of determining "good" carbohydrates have also been developed. The common theme among them is increased nonstarchy vegetables and higher-fiber legumes.

A randomized trial comparing low-fat and low-carbohydrate diets matched for energy and protein.

Several recent studies have found greater weight loss at 6 months among participants on a very-low-carbohydrate (VLC) weight-loss diet compared with a low-fat (LF) weight-loss diet. Because most of these studies were not matched for calories, it is not clear whether these results are caused by decreased energy intake or increased energy expenditure. It is hypothesized that several energy-consuming metabolic pathways are up-regulated during a VLC diet, leading to increased energy expenditure. The focus of this study was to investigate whether, when protein and energy are held constant, there is a significant difference in fat and weight loss when fat and carbohydrate are dramatically varied in the diet. The preliminary results presented in this paper are for the first four of six postmenopausal overweight or obese participants who followed, in random order, both a VLC and an LF diet for 6 weeks. Other outcome measures were serum lipids, glucose, and insulin, as well as dietary compliance and side effects. Our results showed no significant weight loss, lipid, serum insulin, or glucose differences between the two diets. Lipids were dramatically reduced on both diets, with a trend for greater triglyceride reduction on the VLC diet. Glucose levels were also reduced on both diets, with a trend for insulin reduction on the VLC diet. Compliance was excellent with both diets, and side effects were mild, although participants reported more food cravings and bad breath on the VLC diet and more burping and flatulence on the LF diet.

Computerized weight loss intervention optimizes staff time: the clinical and cost results of a controlled clinical trial conducted in a managed care setting.

OBJECTIVE: To evaluate the costs and effects of incremental components of a weight-loss program. DESIGN: A 3-arm, 12-month randomized controlled clinical trial to evaluate 3 incremental levels of intervention intensity. SUBJECTS/SETTING: The study included 588 individuals (BMI > 25 kg/m2) in a freestanding health maintenance organizalion and achieved an 81% completion rate. INTERVENTION: Using a cognitive behavioral approach for tailoring lifestyle modification goals, the incremental levels of intervention included a) a workbook alone, b) the addition of computerized tailoring using onsite computer kiosks with touch screen monitors, and c) the addition of both computers and staff consultation. MAIN OUTCOME MEASURES: Endpoints included weight parameters, lipid profile, plasma glucose, blood pressure, intervention costs, dietary intake, and physical activity. STATISTICAL ANALYSIS PERFORMED: Study endpoints were analyzed using analysis of variance for normally distributed variables and analysis of covariance to control for any baseline differences. Regression and correlation analysis assessed the relationship between weight loss and other variables. RESULTS: For the increasing levels of intervention intensity, the mean 12-month weight losses were 2.2, 4.7, and 7.4 pounds, with the respective cost per participant being $12.33, $41.99, and $133.74. The decreases in mean BMIs for these respective intervelation levels were 0.4, 0.9 and 1.2. All groups reported a decrease in energy and fat intake and an increase in blocks walked (P<.01). Intervention variables that correlated with weight loss included more computer log-ons, achieving computer-selected goals, more self-monitoring, increased walking, and decreased energy and fat intake, as well as higher attendance in staff consultation group sessions for that treatment condition. Weight loss correlated with decreases in fasting glucose and blood pressure. APPLICATIONS/CONCLUSIONS: In a weight-loss program, computers can facilitate selecting behavioral change goals. More frequent usage resulted in greater weight loss. Staff counseling to augment the computer intervention achieved the most weight loss.

Dietary fats and diabetes mellitus: is there a good fat?

As knowledge of the fatty acid functions has increased, so has the complexity of making dietary fat recommendations to people with type 2 diabetes. Oleic acid seems to offer a slight advantage over linoleic acid in reducing plasma glucose, insulin levels, total cholesterol, low-density lipoproteins (LDLs), and triglycerides, but may also have atherogenic properties through another mechanism. A diet containing a higher proportion of polyunsaturated fatty acids (PUFAs) may require a concomitant increase in antioxidant intake because PUFAs oxidize easily and are then converted to oxidized LDL, which is more atherogenic. In addition to raising total and LDL cholesterol, long chain saturated free fatty acids may interact with plasma glucose to increase insulin secretion. Omega-3 fatty acids decrease triglycerides and reduce the risk of fatal cardiac arrhythmias. Glycemic control does not appear to be adversely affected by omega-3 fatty acids at amounts of up to 3 g/d.

The cardiovascular effects of fish oils and omega-3 fatty acids.

Evidence first reported 20 years ago from the Greenland Inuit population suggested that fatty fish and fish oils contained substances that reduced the incidence of ischemic heart disease. These substances, later determined to be omega-3 fatty acids, were found in early clinical trials to reduce platelet aggregation and to reduce hypertriglyceridemia by as much as 35%. More recent trials have found that omega-3 fatty acids also appear to reduce the risk of cardiac arrhythmia and sudden cardiac death and modestly reduce atherosclerotic plaque formation and hypertension. Clinical trials have not demonstrated adverse effects at moderate daily doses. These findings have implications for clinicians who may want to suggest that patients increase their intake of fatty fish or supplement their diet with more concentrated sources of omega-3 fatty acids.