Macronutrient composition of plant-based diets and breast cancer risk: the E3N prospective cohort study.

PURPOSE: Recent evidence suggests that plant-based diets may reduce the risk of breast cancer (BC). However, the macronutrient composition of plant-based diets and its potential impact on BC risk has not been well explored. This analysis investigated the association of macronutrient composition with BC risk across a spectrum of plant-based diet indexes using a multidimensional approach. DESIGN: This study followed 64,655 participants from the Etude Epidémiologique auprès de femmes de la Mutuelle Générale de l'Education Nationale (E3N) cohort from 1993 to 2014. Diets were evaluated using validated 208-item diet history questionnaires at baseline (1993) and follow-up (2005), to calculate adherence to the overall plant-based diet (PDI), healthful plant-based diet (hPDI), and unhealthful plant-based diet (uPDI). The association of macronutrient composition with BC risk was assessed via generalized additive time-dependent Cox models across different levels of these indexes. Response surfaces were generated to visualize compositional associations at the 25th, 50th, and 75th percentile of each index (low, moderate, and high). RESULTS: A total of 3,932 incident BC cases were identified during the 21-year follow-up. There was a significant association between macronutrient composition and BC risk for hPDI, uPDI, and PDI (all P < 0.001). Akaike information criterion favored the hPDI model for characterizing the association between macronutrients and BC. BC risk was highest for individuals with a lower hPDI score who also consumed a diet containing lower protein (10%), lower carbohydrate (35%), and higher fat (55%). The lowest risk of BC was observed in those with higher hPDI scores with the lowest intake of protein (10%). At higher PDI and uPDI, diets containing higher protein (30%) and fat (45%) had the highest BC risk. CONCLUSION: These results demonstrate a complex relationship between macronutrient composition, plant-based diet quality, and BC risk. Further research is needed to examine specific foods that may be driving these associations. REGISTRY: The protocol is registered at clinicaltrials.gov as NCT03285230.

The Relationship between Dietary Macronutrient Composition and Telomere Length Among US Adults.

The role of dietary macronutrients and energy intake in the aging process has been well-established. However, previous research has mainly focused on the association between leukocyte telomere length (LTL) and individual macronutrients, while the effects of macronutrient composition on LTL remain unclear. This cross-sectional analysis involved 4130 US adults (44.8 ± 17.0 years; 51% female) from the National Health and Nutrition Examination Survey during 1999-2002. A single 24-h dietary recall is used to collect dietary data. The relationship between dietary macronutrient composition and LTL is examined using three-dimensional generalized additive models. After adjustment for age, sex, ethnicity, education, physical activity, BMI, and dietary quality, a three-dimensional association of macronutrient composition with LTL (P = 0.02) is revealed. Diets lower in protein (5-10%), higher in carbohydrates (75%), and lower in fat (15-20%) are associated with the longest LTL corresponding to 7.7 years of slower biological aging. Diets lowest in protein (5%) and carbohydrate (40%), while highest in dietary fat (55%) are associated with the shortest LTL, corresponding to accelerated biological aging of 4.4 years. The associations appeared magnified with higher energy intake. These findings support a complex relationship between dietary macronutrients and biological aging independent of diet quality.

Diet Quality, Microbial Lignan Metabolites, and Cardiometabolic Health among US Adults.

The gut microbiome has been shown to play a role in the relationship between diet and cardiometabolic health. We sought to examine the degree to which key microbial lignan metabolites are involved in the relationship between diet quality and cardiometabolic health using a multidimensional framework. This analysis was undertaken using cross-sectional data from 4685 US adults (age 43.6 ± 16.5 years; 50.4% female) participating in the National Health and Nutrition Examination Survey for 1999-2010. Dietary data were collected from one to two separate 24-hour dietary recalls and diet quality was characterized using the 2015 Healthy Eating Index. Cardiometabolic health markers included blood lipid profile, glycemic control, adiposity, and blood pressure. Microbial lignan metabolites considered were urinary concentrations of enterolignans, including enterolactone and enterodiol, with higher levels indicating a healthier gut microbial environment. Models were visually examined using a multidimensional approach and statistically analyzed using three-dimensional generalized additive models. There was a significant interactive association between diet quality and microbial lignan metabolites for triglycerides, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, insulin, oral glucose tolerance, adiposity, systolic blood pressure, and diastolic blood pressure (all p < 0.05). Each of these cardiometabolic health markers displayed an association such that optimal cardiometabolic health was only observed in individuals with both high diet quality and elevated urinary enterolignans. When comparing effect sizes on the multidimensional response surfaces and model selection criteria, the strongest support for a potential moderating relationship of the gut microbiome was observed for fasting triglycerides and oral glucose tolerance. In this study, we revealed interactive associations of diet quality and microbial lignan metabolites with cardiometabolic health markers. These findings suggest that the overall association of diet quality on cardiometabolic health may be affected by the gut microbiome.

A healthy, sustainable and safe food system: examining the perceptions and role of the Australian policy actor using a Delphi survey.

OBJECTIVE: There is an urgent need to identify and develop cross-sectoral policies which promote and support a healthy, safe and sustainable food system. To help shape the political agenda, a critical first step is a shared definition of such a system among policy makers across relevant sectors. The aim of the present study was to determine how Australian policy actors define, and contribute to, a healthy, safe and sustainable food system. DESIGN: A Delphi survey, consisting of two rounds, was conducted. Participants were asked how they define, and contribute to, a healthy, safe and sustainable food system (Round 1) and indicate their level of agreement with summary statements (Round 2). SETTING: This was an online Delphi survey conducted in Australia. PARTICIPANTS: Twenty-nine and fourteen multisectoral and multilevel policy makers completed Round 1 and Round 2, respectively. RESULTS: The definition included food processing regulation, environmentally friendly food production and access to nutritious food. All agreed that it was important for them to improve access and supply of healthy food and ensure healthy planning principles are applied. CONCLUSIONS: There were cross-sectoral differences in definitions and contributions; however, critical consensus was achieved. The study contributes to the definition of key elements of a cross-sectoral food and nutrition policy to meet today's environmental, health, social and economic challenges; however, further research using a more representative multisectoral sample is warranted.

Body Mass Index Increases With Ageing and Risk Factors for Overweight/Obesity in a Representative Macau Population.

The aim of this study was to investigate trends of body mass index (BMI) with age in westernizing Macau and to make comparisons with Australian data. A representative random sample (n = 1406, 18-93 years, 55% female) from Macau was recruited in 2012. The Australian sample was extracted from the Australian Health Survey 2011-2012 (n = 7958, 18 to ≥85 years, 52% female). BMI in Australians was greater than Macanese, mean difference 4.4 kg/m2 ( P < .001). While BMI increases steadily with ageing in each population, the plateau for Macau subjects appears 5 to 10 years earlier than Australians. Prevalence of overweight/obesity in young Macanese adults (18-40 years) was 25% (men) and 22% (women), with the greatest increase in BMI from age 25 to 39 years and 24 to 45 years in men and women, respectively. BMI shifts in younger Macanese men and women, which may reflect emerging lifestyle and nutrition transitions, are a future population health concern in Macau.

Modelling of the impact of universal added sugar reduction through food reformulation.

Food reformulation has been suggested to be one of the strategies to reduce population added sugar (AS) intake. This study aims to investigate the untested assumption that a reduction in AS through reformulation will result in a reduction in population intakes of AS and energy. Plausible dietary data from 4,140 respondents of an Australian national nutrition survey were used. Dietary modelling was performed at AS reductions of 10%, 15%, and 25% using four strategies: simple removal of AS or replacement with non-nutritive sweeteners (NNS), and replacement of AS with NNS and either: polyols, 50% fibres or 50% maltodextrin. Paired t-tests were conducted to compare the intake of energy, fat, and AS pre- and post-reformulation. The chosen reformulation strategies resulted in a projected reduction in AS and energy, with the greatest reduction found in 25% reformulation which was the highest level modelled. The overall projected mean (SD) reduction in energy and AS after 25% reformulation was 114 (92) kJ/day and 11.73 (7.52) g/day, p < 0.001. To conclude, product reformulation may be a potentially useful strategy for reducing AS intake. Although the magnitude of projected reduction was small at the individual level, the impact may be meaningful at a population level.

Intake and sources of added sugars among Australian children and adolescents.

PURPOSE: To examine the intake and sources of added sugars (AS) of Australian children and adolescents, and compare their intake of free sugars (FS) to the recommended limit set by the World Health Organization (<10 % energy from FS). METHOD: Data of 4140 children and adolescents aged 2-16 years with plausible intakes based on 2 × 24 h recalls from the 2007 Australian National Children Nutrition and Physical Activity Survey were used. AS content of foods was estimated based on a published method. Intakes of AS and FS, as well as food sources of AS, were calculated. One-way ANOVA was used for comparisons between age groups and gender. RESULTS: The mean (SD) AS intake was 58.9 (35.1) g/day, representing 11.9 (5.6) % of daily energy intake and 46.9 (17.5) % of daily total sugars intake. More than 80 % of the subjects had % energy from FS > 10 %. Significant increasing trends for AS intake, % energy from AS, % energy from FS across age groups were observed. Sugar-sweetened beverages (19.6 %), cakes, biscuits, pastries and batter-based products (14.3 %), and sugar and sweet spreads (10.5 %) were the top three contributors of AS intake in the whole sample. Higher contribution of AS from sugar-sweetened beverages was observed in adolescents (p trend < 0.001). CONCLUSIONS: A large proportion of Australian youths are consuming excessive amounts of energy from AS. Since the main sources of AS were energy-dense, nutrient-poor foods, interventions which target the reduction in these foods would reduce energy and AS intake with minimal impact to core nutrient intake.

Associations between adolescent and adult socioeconomic status and risk of obesity and overweight in Danish adults.

BACKGROUND: It has been suggested that socioeconomic status (SES) may influence the risk of obesity; however it is important to consider individual changes in SES over the life-course in addition to SES at specific time-points to better understand the complex associations with obesity. We explored the relationship between lifetime-specific and life-course SES and risk of obesity and overweight in Danish adults. METHODS: Data were used from the Danish Youth and Sports Study (DYSS) ­ a 20­22 year follow-up study of Danish teenagers born between 1964 and 1969. Baseline data gathered in 1983 and 1985 included self-reported BMI, SES and physical activity. The follow-up survey (2005) repeated these assessments in addition to an assessment of diet. Complete data on adolescent and adult SES and BMI were available for 623 participants. RESULTS: Following adjustments, adolescent SES had no significant association with overweight/obesity in this sample, however females of low or medium adult SES were significantly more likely to be overweight/obese compared to those of high SES (low SES: OR: 2.7; 95% CI: (1.3­5.8); p = 0.008; medium SES: OR: 4.0, 95% CI (1.6­10.2); p = 0.003). Females who decreased in SES during adulthood were significantly more likely to be overweight/obese compared to those who remained of high SES (OR: 3.1; 95% CI (1.1­9.2); p = 0.04). CONCLUSION: Effects of early life-factors may be conditional upon the environment in adulthood, particularly for the women. Further research should consider the timing of SES exposure and the mechanisms which may be responsible for the socioeconomic gradients in prevalence of obesity and overweight.

Dairy consumption and the risk of 15-year cardiovascular disease mortality in a cohort of older Australians.

The effects of habitual dairy consumption and the risk of 15-year cardiovascular disease (CVD) mortality in a cohort of older Australians were investigated. Participants (n = 2900) completed a validated 145-item semi-quantitative food frequency questionnaire. Cox proportional hazards regression models were used to investigate associations between tertiles of the dairy consumption, including low/reduced fat dairy, whole fat dairy and their ratio (ratio(LF/WF)), and risk of mortality from coronary heart disease (CHD), stroke or combined CVD. There were 548 recorded cases of CVD mortality in this cohort. For total dairy intake, a reduction in risk of CVD was only seen in tertile 2 (adjusted hazard ratio, AHR: 0.71; 95% CI: 0.55-0.93), and for CHD both tertile 2 and tertile 3 were associated with a reduced risk (both with AHR: 0.71). However there were no linear trends between total dairy consumption and any of the three outcomes. There were no associations or trends between low/reduced fat dairy or whole fat dairy consumption, or ratio(LF/WF) and any of the three outcomes in the fully adjusted model (all p > 0.05). This study found no consistent association between baseline consumption of dairy foods and the risk of CHD, stroke and combined CVD mortality.

How well do Australian shoppers understand energy terms on food labels?

OBJECTIVE: To investigate nutrition literacy among adult grocery buyers regarding energy-related labelling terms on food packaging. DESIGN: Qualitative interviews and quantitative surveys to determine shoppers' understanding of energy terms ('energy', 'calories' and 'kilojoules') and how energy terms affect perceptions of healthiness and intentions to purchase breakfast cereals, muesli bars and frozen meals. SETTING: Individual in-depth interviews and surveys in two metropolitan supermarkets, Sydney, Australia. SUBJECTS: Australian adults (interview n 40, survey n 405) aged 18-79 years. RESULTS: The relationship between energy and perceived healthiness of food varied by product type: higher energy breakfast cereals were perceived to be healthier, while lower energy frozen meals were seen as healthier choices. Likewise, intentions to purchase the higher energy product varied according to product type. The primary reason stated for purchasing higher energy products was for sustained energy. Participants from households of lower socio-economic status were significantly more likely to perceive higher energy products as healthier. From the qualitative interviews, participants expressed uncertainty about their understanding of kilojoules, while only 40 % of participants in intercept surveys correctly answered that kilojoules and calories measured the same thing. CONCLUSIONS: Australian consumers have a poor understanding of energy and kilojoules and tend to perceive higher energy products as healthier and providing sustained energy. This has implications regarding the usefulness of industry front-of-pack labelling initiatives and quick service restaurant menu labelling that provides information on energy content only. Comprehensive and widely communicated education campaigns will be essential to guide consumers towards healthier choices.

Dairy consumption and diet quality in a sample of Australian children.

OBJECTIVE: To examine the association between intake of dairy products and indicators of diet quality among a sample of Australian children. METHODS: Three 24-hour recalls were collected from 222 children aged 8-10 years living in western Sydney. Analysis of covariance was used to examine differences in mean intakes of foods and nutrients among 3 dairy consumption groups (<1 serve, 1-2 serves, ≥2 serves per day). The percentage of children meeting healthy eating guidelines for foods and estimated average requirements (EAR) for nutrients was also assessed. RESULTS: Higher dairy consumption was associated with higher intakes of energy, protein, calcium, phosphorus, magnesium, potassium, zinc, vitamin A, riboflavin, and niacin as well as foods from the bread and cereal group but lower intakes of mono- and polyunsaturated fats, foods from the meat and alternatives group, and energy-dense, nutrient-poor foods. Children who consumed ≥2 serves of dairy products per day (38%) were more likely to meet food and nutrient recommendations. Body mass index z-score and waist circumference were not associated with dairy consumption. Milk intake was inversely associated with the intake of sugar-sweetened beverages, and children who did not meet their minimum dairy serve recommendations consumed higher quantities of sugar-sweetened beverages than milk. CONCLUSIONS: Adequate dairy consumption was associated with diets of higher nutritional quality but also higher intakes of energy, suggesting a potential benefit from shifting consumption from regular-fat to reduced-fat dairy products in line with current national recommendations.

Nutritional quality of Australian breakfast cereals. Are they improving?

The nutritional quality of Australian breakfast cereals is not systematically monitored despite the importance of breakfast for general health. We examined whether the nutritional quality of Australian breakfast cereals has improved between 2004 and 2010, and whether any change could be detected after the introduction of Daily Intake Guide (DIG) front-of-pack labelling. Supermarket surveys were conducted in 2004 and 2010 using the same methodology to collect information from the nutrition information panels of Australian breakfast cereals and the nutrient content of cereals was compared by year. Breakfast cereals with and without DIG labelling in 2010 were also compared. Nutritional quality was assessed using UK Traffic Light criteria. No significant difference was detected in nutritional composition of breakfast cereals between 2004 and 2010. There was no notable improvement in nutritional composition of breakfast cereals marketed as the same product in both years. Overall there has been little improvement in the nutritional quality of Australian breakfast cereals in the 6 year period. A large proportion of Australian breakfast cereals were considered high sugar. In conclusion, the introduction of DIG labelling does not appear to have promoted product reformulation, and breakfast cereals carrying DIG labels were not consistently healthier.

Do we provide meaningful guidance for healthful eating? An investigation into consumers' interpretation of frequency consumption terms.

OBJECTIVE: To investigate consumers' understanding of terms commonly used to provide guidance about frequency and quantity of food consumption. METHODS: A survey of 405 shoppers explored how frequently consumers thought food labeled with the terms "eat often," "eat moderately," "eat occasionally," "a sometimes food," and "an extra food" should be eaten. In a separate phase, 30 grocery buyers responded to open-ended questions about their interpretation of these terms. RESULTS: Responses indicated significant differences in meaning between the terms. However, the specific interpretation of each term varied considerably across respondents. The qualitative research found the terms to be highly subjective, and there was a high degree of uncertainty about the meaning of the term "an extra food" in particular. CONCLUSIONS AND IMPLICATIONS: Food frequency and descriptive terms currently used do not provide meaningful or consistent nutritional guidance. There is a need for simple, unambiguous terminology.

Changes in 'extra' food intake among Australian children between 1995 and 2007.

OBJECTIVE: To examine the consumption patterns of energy-dense, nutrient-poor 'extra' foods among Australian children and to determine any changes in consumption since the 1995 National Nutrition Survey (1995 NNS). METHODS: 'Extra' food consumption was analysed by age group and gender using 24-h recall data from the 2007 Australian National Children's Nutrition and Physical Activity Survey (2007 Survey; n = 4380) and the 1995 NNS (n = 2435). Differences in percent consuming, amounts consumed and percent energy contribution were assessed. RESULTS: 'Extra' foods contributed 35% to daily energy intake in the 2007 survey, ranging from 24% in the 2-3 year olds to 38% in the 9-13 and 14-16 year olds. The foods contributing most to energy intake included 'fried potatoes' (2.9%), 'cakes, muffins, slices' (2.9%) and 'potato crisps and similar snacks' (2.6%). Compared to the 1995 NNS, total energy intake was significantly lower in the 2007 Survey (8621 kJ in 1995 versus 8330 kJ in 2007), as was the consumption of 'extra' foods (both in terms of weight and energy) (3645 kJ in 1995 versus 3049 kJ in 2007). All age groups reported a decline in energy intake from 'extra' foods of approximately 600 kJ. CONCLUSION: The overall consumption of 'extra' foods seems to have decreased from 1995 to 2007. However, 'extra' foods continue to be over-consumed by Australian children and continuous monitoring of 'extra' foods consumption is highly warranted.

Misreporting of energy intake in the 2007 Australian Children's Survey: identification, characteristics and impact of misreporters.

Misreporting of energy intake (EI) is a common problem in national surveys. The aim of this study was to identify misreporters using a variety of criteria, examine the impact of misreporting on the association between EI and weight status, and to define the characteristics of misreporters in the 2007 Australian Children's Survey. Data from the 2007 Australian Children's Survey which included 4800 children aged 2-16 years were used to examine the extent of misreporting based on EI, physical activity level (PAL), age, gender, height and weight status. Three options for identifying misreporters using the Goldberg cut-offs were explored as was direct comparison of EI to energy expenditure (TEE) in a subset of children. Linear regression was used to determine the impact of misreporting on the association between EI and weight status. The prevalence of under-reporting among all children varied from 5.0% to 6.7%, and over-reporting from 1.6% to 3.0% depending on the option used. Direct comparison of EI to TEE revealed similar results. Regression analysis showed that excluding misreporters provided the best model to examine cross-sectional associations between EI and BMI. Characteristics associated with under-reporting included older age, female, higher BMI, higher PAL, living in an urban location, lower parental education level and feeling unwell on the survey day. Over-reporting was more common among children with a lower BMI and lower PAL. In conclusion, misreporting of EI is present among various subgroups of the 2007 Australian Children's Survey. The impact of misreporting on the association between EI and body weight should be recognised by users of this survey.

Childhood obesity in Australia remains a widespread health concern that warrants population-wide prevention programs.

Recent reports have suggested that the problem of childhood and adolescent obesity has been exaggerated in Australia, and that community-wide obesity prevention initiatives are not warranted; we argue that this is not an accurate reflection of the situation. Available data indicate that obesity affects 6%-8% of Australian schoolchildren, and that the proportion has continued to increase in recent years. Childhood and adolescent obesity is associated with a wide range of immediate health concerns, as well as increasing the risk of disease in adulthood. Some weight-related health problems are also found in overweight children. A range of strategies, including whole-of-community obesity prevention programs, will be required to tackle this problem. Concerns about disordered eating in children and adolescents should not preclude appropriate action on childhood obesity.

The weight of evidence suggests that soft drinks are a major issue in childhood and adolescent obesity.

There is much to be gained by reducing children's intake of soft drinks and little - except excess weight - to be lost.

Obesity: epidemiology and possible prevention.

Obesity can be defined as the excessive accumulation of fat in adipose tissue, to the extent that health may be impaired. The most widely used measures of total and abdominal adiposity are the body mass index and waist circumference. Obesity is now a global public health problem, with about 315 million people world-wide estimated to fall into the WHO-defined obesity categories with a body mass index (BMI) of 30 or above. The primary causes of the rapid global rise in obesity rates lie in the profound environmental and societal changes now affecting large parts of the world and creating societies in which physical activity is low and the availability of high-fat, energy-dense foods has increased. Strategies aimed at preventing weight gain and obesity have not been successful to date but are likely to be more cost effective, and to have a greater positive impact on long-term control of body weight than treating obesity once it has developed.