Disparities in Health and Economic Burdens of Cancer Attributable to Suboptimal Diet in the United States, 2015‒2018.

Objectives. To quantify disparities in health and economic burdens of cancer attributable to suboptimal diet among US adults. Methods. Using a probabilistic cohort state-transition model, we estimated the number of new cancer cases and cancer deaths, and economic costs of 15 diet-related cancers attributable to suboptimal intake of 7 dietary factors (a low intake of fruits, vegetables, dairy, and whole grains and a high intake of red and processed meats and sugar-sweetened beverages) among a closed cohort of US adults starting in 2017. Results. Suboptimal diet was estimated to contribute to 3.04 (95% uncertainty interval [UI] = 2.88, 3.20) million new cancer cases, 1.74 (95% UI = 1.65, 1.84) million cancer deaths, and $254 (95% UI = $242, $267) billion economic costs among US adults aged 20 years or older over a lifetime. Diet-attributable cancer burdens were higher among younger adults, men, non-Hispanic Blacks, and individuals with lower education and income attainments than other population subgroups. The largest disparities were for cancers attributable to high consumption of sugar-sweetened beverages and low consumption of whole grains. Conclusions. Suboptimal diet contributes to substantial disparities in health and economic burdens of cancer among young adults, men, racial/ethnic minorities, and socioeconomically disadvantaged groups. (Am J Public Health. 2021;111(11):2008-2018. https://doi.org/10.2105/AJPH.2021.306475).

Plant- and animal-based diet quality and mortality among US adults: a cohort study.

Not all plant-based and animal foods exert the same health effects due to their various nutrient compositions. We aimed to assess the quality of plant-based v. animal foods in relation to mortality in a prospective cohort study. Using data collected from a nationally representative sample of 36 825 adults in the National Health and Nutrition Examination Survey 1999-2014, we developed a de novo Comprehensive Diet Quality Index (cDQI) that assesses the quality of seventeen foods based on the healthfulness and separately scored the quality of eleven plant-based foods in a plant-based Diet Quality Index (pDQI) and six animal foods in an animal-based Diet Quality Index (aDQI). Mortality from all causes, heart disease and cancer were obtained from linkage to the National Death Index up to 31 December 2015. Cox proportional hazard models were used to estimate hazard ratios (HR) and 95 % CI after multivariable adjustments. During a median follow-up of 8·3 years, 4669 all-cause deaths occurred, including 798 deaths due to heart disease and 1021 due to cancer. Compared with individuals in the lowest quartile, those in the highest quartile of cDQI had a lower risk of all-cause mortality (HR 0·75, 95 % CI 0·65, 0·86; Ptrend < 0·001), which largely reflected the inverse relationship between quality of plant-based foods (pDQI) and all-cause mortality (HR 0·66, 95 % CI 0·58, 0·74; Ptrend < 0·001). No independent association was found for the quality of animal foods (aDQI) and mortality. Our results suggest that consuming healthy plant-based foods is associated with lower all-cause mortality among US adults.

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.

Dietary Supplement Use among Adult Cancer Survivors in the United States.

BACKGROUND: Many cancer patients initiate dietary supplement use after cancer diagnosis. How dietary supplement use contributes to the total nutrient intake among cancer survivors as compared with individuals without cancer needs to be determined. OBJECTIVES: We aimed to evaluate nutrient intakes from dietary supplements among cancer survivors in relation to their total nutrient intake and compare those with individuals without cancer. METHODS: We evaluated the prevalence, dose, and reason for using dietary supplements among 2772 adult cancer survivors and 31,310 individuals without cancer who participated in the NHANES 2003-2016. RESULTS: Cancer survivors reported a higher prevalence of any (70.4% vs. 51.2%) and multivitamin/mineral (48.9% vs. 36.6%) supplement use and supplement use of 11 individual vitamins and 8 minerals than individuals without cancer. Overall, cancer survivors had significantly higher amounts of nutrient intake from supplements but lower nutrient intakes from foods for the majority of the nutrients. Compared with individuals without cancer, cancer survivors had a higher percentage of individuals with inadequate intake (total nutrient intake 

Association Among Dietary Supplement Use, Nutrient Intake, and Mortality Among U.S. Adults: A Cohort Study.

Background: The health benefits and risks of dietary supplement use are controversial. Objective: To evaluate the association among dietary supplement use, levels of nutrient intake from foods and supplements, and mortality among U.S. adults. Design: Prospective cohort study. Setting: NHANES (National Health and Nutrition Examination Survey) data from 1999 to 2010, linked to National Death Index mortality data. Participants: 30 899 U.S. adults aged 20 years or older who answered questions on dietary supplement use. Measurements: Dietary supplement use in the previous 30 days and nutrient intake from foods and supplements. Outcomes included mortality from all causes, cardiovascular disease (CVD), and cancer. Results: During a median follow-up of 6.1 years, 3613 deaths occurred, including 945 CVD deaths and 805 cancer deaths. Ever-use of dietary supplements was not associated with mortality outcomes. Adequate intake (at or above the Estimated Average Requirement or the Adequate Intake level) of vitamin A, vitamin K, magnesium, zinc, and copper was associated with reduced all-cause or CVD mortality, but the associations were restricted to nutrient intake from foods. Excess intake of calcium was associated with increased risk for cancer death (above vs. at or below the Tolerable Upper Intake Level: multivariable-adjusted rate ratio, 1.62 [95% CI, 1.07 to 2.45]; multivariable-adjusted rate difference, 1.7 [CI, -0.1 to 3.5] deaths per 1000 person-years), and the association seemed to be related to calcium intake from supplements (≥1000 mg/d vs. no use: multivariable-adjusted rate ratio, 1.53 [CI, 1.04 to 2.25]; multivariable-adjusted rate difference, 1.5 [CI, -0.1 to 3.1] deaths per 1000 person-years) rather than foods. Limitations: Results from observational data may be affected by residual confounding. Reporting of dietary supplement use is subject to recall bias. Conclusion: Use of dietary supplements is not associated with mortality benefits among U.S. adults. Primary Funding Source: National Institutes of Health.

Associations between Diet Quality Scores and Risk of Postmenopausal Estrogen Receptor-Negative Breast Cancer: A Systematic Review.

Background: Estrogen receptor-negative (ER-) breast cancer tends to have poorer prognosis than estrogen receptor-positive breast cancer. A number of studies have examined the association between diet quality as measured by various diet quality scores and the risk of ER- breast cancer. Objective: This systematic review aimed to summarize existing evidence on this topic. Methods: Medline and Embase searches were conducted until 2 April 2017 for cohort and case-control studies on diet quality scores and ER- breast cancer. Results: We included 6 prospective cohort studies and 1 case-control study on postmenopausal ER- breast cancer: 4 from Europe and 3 from the United States. There were 12 different diet quality scores: 2 versions of the Dietary Inflammatory Index, 4 versions of the Mediterranean diet score, the Healthy Eating Index, the Alternate Healthy Eating Index, the Dietary Approaches to Stop Hypertension (DASH) score, and 3 versions of low-carbohydrate diet scores that differentiate between different sources of protein and fat. Of the 4 studies on Mediterranean diet scores, 3 showed a significant inverse association with postmenopausal ER- breast cancer, whereas no consistent association was observed with the other diet quality scores. Although most diet quality scores in this review share similar food components, most of the non-Mediterranean diet scores were represented by only 1 study each, and the associations with postmenopausal ER- breast cancer were mixed. All studies were adjusted for multiple covariates. Conclusion: This systematic review shows mixed results for an association between a variety of diet quality scores and postmenopausal ER- cancer. However, results from different versions of the Mediterranean diet scores are more consistent and suggest an inverse relation with ER- breast cancer.

Excluding whole grain-containing foods from the Nova ultraprocessed food category: a cross-sectional analysis of the impact on associations with cardiometabolic risk measures.

BACKGROUND: Whole grain (WG) consumption is linked with a reduced risk of chronic disease. However, the recommendations of the Nova classification system tend to contradict this evidence as high WG-containing foods, such as bread and cereals, are considered ultraprocessed, and intake is discouraged. OBJECTIVES: This study aimed to explore associations of cardiometabolic risk measures with ultraprocessed food (UPF) intake as classified by Nova compared with when foods with ≥25% and ≥50% WG are removed from the Nova UPF category. METHODS: A cross-sectional analysis of the 2015-18 National Health and Nutrition Examination Survey. Nova was used to identify UPFs, and the WG Initiative's definition of a WG food and front-of-pack labeling requirements was used to identify high WG foods. Regression models were used to explore impacts on the association of UPF intake (quintiles) and cardiometabolic risk measures when high WG foods were excluded from the Nova UPF category. RESULTS: Participants in the highest quintile of UPF intake had significantly higher weight [83.6 kg (0.8)], BMI (in kg/m2) [30.6 (0.3)], waist circumference [103.1 cm (0.6)], and weight-to-height ratio [0.63 (0.003)] compared to those in the lowest quintile (P < 0.0001 for all). The same was found when foods with ≥25% and ≥50% WG were removed. Positive associations for C-reactive protein were found when ≥25% and ≥50% WG-containing foods were removed only [2.32 mg/L (0.1), P = 0.0209; 2.37 mg/L (0.1), P = 0.0179, respectively]. Participants in the highest quintile had significantly lower total cholesterol after adjustment when foods with ≥50% WG were removed [4.98 mmol/L (0.04), P = 0.0292]. Adjusted R2 values remained relatively unchanged across each approach for all outcomes. CONCLUSIONS: Foods high in WG may not significantly contribute to the deleterious associations previously observed between UPF intake and cardiometabolic risk factors. Consideration of their contribution to healthful dietary patterns and diet quality in the United States population should be made prior to the endorsement of Nova.

Ultra-processed food consumption and mortality among patients with stages I-III colorectal cancer: a prospective cohort study.

Background: Ultra-processed foods (UPFs) are emerging as a risk factor for colorectal cancer (CRC), yet how post-diagnostic UPF intake may impact CRC prognosis remains unexplored. Methods: Data collected from food frequency questionnaires were used to estimate intakes of total UPFs and UPF subgroups (serving/d) at least 6 months but less than 4 years post-diagnosis among 2498 patients diagnosed with stages I-III CRC within the Nurses' Health Study and Health Professionals Follow-up Study during 1980-2016. Hazard ratios (HR) and 95% confidence intervals (CIs) of all-cause, CRC- and cardiovascular disease (CVD)-specific mortality in association with UPF consumption were estimated using an inverse probability weighted multivariable Cox proportional hazards regression model, adjusted for confounders. Findings: The mean (SD) age of patients at diagnosis was 68.5 (9.4) years. A total of 1661 deaths were documented, including 321 from CRC and 335 from CVD. Compared to those in the lowest quintile (median = 3.6 servings/d), patients in the highest quintile (median = 10 servings/d) of post-diagnostic UPF intake had higher CVD mortality (HR = 1.65, 95% CI = 1.13-2.40) but not CRC or all-cause mortality. Among UPF subgroups, higher consumption of fats/condiments/sauces was associated with a higher risk of CVD-specific mortality (highest vs. lowest quintile of intake, HR = 1.96, 95% CI = 1.41-2.73), and higher intake of ice cream/sherbet was associated with an increased risk of CRC-specific mortality (highest vs. lowest quintile, HR = 1.86, 95% CI: 1.33-2.61). No statistically significant association was found between UPF subgroups and overall mortality. Interpretation: Higher post-diagnostic intake of total UPFs and fats/condiments/sauces in CRC survivors is associated with higher CVD mortality, and higher ice cream/sherbet intake is linked to higher CRC mortality. Funding: US National Institutes of Health and the American Cancer Society.

Impact of Produce Prescriptions on Diet, Food Security, and Cardiometabolic Health Outcomes: A Multisite Evaluation of 9 Produce Prescription Programs in the United States.

BACKGROUND: Produce prescriptions may improve cardiometabolic health by increasing fruit and vegetable (F&V) consumption and food insecurity yet impacts on clinical outcomes and health status have not been evaluated in large, multisite evaluations. METHODS: This multisite, pre- and post-evaluation used individual-level data from 22 produce prescription locations in 12 US states from 2014 to 2020. No programs were previously evaluated. The study included 3881 individuals (2064 adults aged 18+ years and 1817 children aged 2-17 years) with, or at risk for, poor cardiometabolic health recruited from clinics serving low-income neighborhoods. Programs provided financial incentives to purchase F&V at grocery stores or farmers markets (median, $63/months; duration, 4-10 months). Surveys assessed F&V intake, food security, and self-reported health; glycated hemoglobin, blood pressure, body mass index (BMI), and BMI z-score were measured at clinics. Adjusted, multilevel mixed models accounted for clustering by program. RESULTS: After a median participation of 6.0 months, F&V intake increased by 0.85 (95% CI, 0.68-1.02) and 0.26 (95% CI, 0.06-0.45) cups per day among adults and children, respectively. The odds of being food insecure dropped by one-third (odds ratio, 0.63 [0.52-0.76]) and odds of improving 1 level in self-reported health status increased for adults (odds ratio, 1.62 [1.30-2.02]) and children (odds ratio, 2.37 [1.70-3.31]). Among adults with glycated hemoglobin ≥6.5%, glycated hemoglobin declined by -0.29% age points (-0.42 to -0.16); among adults with hypertension, systolic and diastolic blood pressures declined by -8.38 mm Hg (-10.13 to -6.62) and -4.94 mm Hg (-5.96 to -3.92); and among adults with overweight or obesity, BMI decreased by -0.36 kg/m2 (-0.64 to -0.09). Child BMI z-score did not change -0.01 (-0.06 to 0.04). CONCLUSIONS: In this large, multisite evaluation, produce prescriptions were associated with significant improvements in F&V intake, food security, and health status for adults and children, and clinically relevant improvements in glycated hemoglobin, blood pressure, and BMI for adults with poor cardiometabolic health.

Ultra-processed food consumption and risk of colorectal cancer precursors: results from 3 prospective cohorts.

BACKGROUND: Growing evidence indicates the adverse effect of ultra-processed food (UPF) consumption. However, it remains unknown whether UPF consumption influences the risk of colorectal cancer (CRC) precursors, namely conventional adenomas and serrated lesions. METHODS: We drew data from the Nurses' Health Study, Nurses' Health Study II, and Health Professionals Follow-up Study, comprising 142 052 participants who had undergone at least 1 lower gastrointestinal endoscopy during follow-up. To handle multiple records per participants, we used multivariable logistic regression for clustered data to calculate odds ratios (OR) and 95% confidence intervals (CIs) of colorectal polyps in relation to cumulative average consumption of UPFs. All statistical tests were 2-sided. RESULTS: We documented 11 644 patients with conventional adenomas and 10 478 with serrated lesions during 18-20 years of follow-up. Compared with participants in the lowest quintile of UPF consumption, those in the highest quintile had an increased risk of conventional adenomas (OR = 1.18, 95% CI = 1.11 to 1.26) and serrated lesions (OR = 1.20, 95% CI = 1.13 to 1.28). Similar results were found for high-risk polyps (ie, advanced adenomas and ≥10 mm serrated lesions; OR = 1.17, 95% CI = 1.07 to 1.28). These associations were slightly attenuated but remained statistically significant after further adjusting for body mass index, Western dietary pattern score, or individual dietary factors (fiber, folate, calcium, and vitamin D). The results remained essentially unchanged after excluding processed meat from total UPF intake. CONCLUSIONS: Higher consumption of UPFs is associated with an increased risk of CRC precursors. UPFs might be a modifiable target for early prevention of CRC.

What is the cost-effectiveness of menu calorie labelling on reducing obesity-associated cancer burdens? An economic evaluation of a federal policy intervention among 235 million adults in the USA.

OBJECTIVE: To assess the impact of menu calorie labelling on reducing obesity-associated cancer burdens in the USA. DESIGN: Cost-effectiveness analysis using a Markov cohort state-transition model. SETTING: Policy intervention. PARTICIPANTS: A modelled population of 235 million adults aged ≥20 years in 2015-2016. INTERVENTIONS: The impact of menu calorie labelling on reducing 13 obesity-associated cancers among US adults over a lifetime was evaluated for: (1) effects on consumer behaviours; and (2) additional effects on industry reformulation. The model integrated nationally representative demographics, calorie intake from restaurants, cancer statistics and estimates on associations of policy with calorie intake, dietary change with body mass index (BMI) change, BMI with cancer rates, and policy and healthcare costs from published literature. MAIN OUTCOME MEASURES: Averted new cancer cases and cancer deaths and net costs (in 2015 US$) among the total population and demographic subgroups were determined. Incremental cost-effectiveness ratios from societal and healthcare perspectives were assessed and compared with the threshold of US$150 000 per quality-adjusted life year (QALY) gained. Probabilistic sensitivity analyses incorporated uncertainty in input parameters and generated 95% uncertainty intervals (UIs). RESULTS: Considering consumer behaviour alone, this policy was associated with 28 000 (95% UI 16 300 to 39 100) new cancer cases and 16 700 (9610 to 23 600) cancer deaths averted, 111 000 (64 800 to 158 000) QALYs gained, and US$1480 (884 to 2080) million saved in cancer-related medical costs among US adults. The policy was associated with net cost savings of US$1460 (864 to 2060) million and US$1350 (486 to 2260) million from healthcare and societal perspectives, respectively. Additional industry reformulation would substantially increase policy impact. Greater health gains and cost savings were predicted among young adults, Hispanic and non-Hispanic Black individuals. CONCLUSIONS: Study findings suggest that menu calorie labelling is associated with lower obesity-related cancer burdens and reduced healthcare costs. Policymakers may prioritise nutrition policies for cancer prevention in the USA.

Whole-grain food intake among US adults, based on different definitions of whole-grain foods, NHANES 2003-2018.

BACKGROUND: Whole-grain (WG) foods are defined by the Dietary Guidelines for Americans (DGA), FDA, AHA, American Association of Cereal Chemists International (AACCI), and Whole Grains Council (WGC) in different ways with diverse focuses on grain components only, whole foods, or nutrient contents. OBJECTIVES: We aimed to compare estimated WG food intake among US adults using different definitions. METHODS: For each definition, we estimated the mean intake and trends of WG food consumption using survey-weighted 24-h dietary recalls from nationally representative samples of 39,755 US adults aged 20+ y from 8 cycles (2003-2018) of the NHANES. This is an observational study that used deidentified and publicly available datasets. RESULTS: The estimated mean consumption of WG foods (ounces equivalents/2000 kcal/d, oz. eq./d) varied by definition. In 2017-2018, the AHA (mean [SEM]: 1.05 [0.07] oz. eq./d) and WGC (0.95 [0.07]) definitions yielded the highest amounts, followed by the DGA (0.81 [0.06]), AACCI (0.73 [0.05]), and FDA (0.53 [0.04]). Using all definitions except for WGC, US adults increased WG food intake from 2003-2004 to 2017-2018 with the largest increase (61.5%) using the AHA (from 0.65 to 1.05 oz. eq./d), followed by DGA (0.50 to 0.81) and AACCI (0.51 to 0.73) definitions. For each definition, the main sources of WG foods consumed by US adults were ready-to-eat cereals, cooked grains and cereals, and breads (including rolls and tortillas). For all definitions except the AHA, non-Hispanic White adults and individuals with college degrees or above consumed higher levels of WG foods than non-Hispanic Blacks and those with lower levels of education. CONCLUSIONS: Different definitions affect the determination of WG foods, estimated intakes, and associated trends in WG food consumption among US adults. These findings call for a standardized definition of WG foods to guide consumers, industry, and policymakers in promoting WG intake in the US.Clinical Trial Registration: Not Applicable.

Association of ultra-processed food consumption with colorectal cancer risk among men and women: results from three prospective US cohort studies.

OBJECTIVE: To examine the association between consumption of ultra-processed foods and risk of colorectal cancer among men and women from three large prospective cohorts. DESIGN: Prospective cohort study with dietary intake assessed every four years using food frequency questionnaires. SETTING: Three large US cohorts. PARTICIPANTS: Men (n= 46 341) from the Health Professionals Follow-up Study (1986-2014) and women (n=159 907) from the Nurses' Health Study (1986-2014; n=67 425) and the Nurses' Health Study II (1991-2015; n=92 482) with valid dietary intake measurement and no cancer diagnosis at baseline. MAIN OUTCOME MEASURE: Association between ultra-processed food consumption and risk of colorectal cancer, estimated using time varying Cox proportional hazards regression models adjusted for potential confounding factors. RESULTS: 3216 cases of colorectal cancer (men, n=1294; women, n=1922) were documented during the 24-28 years of follow-up. Compared with those in the lowest fifth of ultra-processed food consumption, men in the highest fifth of consumption had a 29% higher risk of developing colorectal cancer (hazard ratio for highest versus lowest fifth 1.29, 95% confidence interval 1.08 to 1.53; P for trend=0.01), and the positive association was limited to distal colon cancer (72% increased risk; hazard ratio 1.72, 1.24 to 2.37; P for trend<0.001). These associations remained significant after further adjustment for body mass index or indicators of nutritional quality of the diet (that is, western dietary pattern or dietary quality score). No association was observed between overall ultra-processed food consumption and risk of colorectal cancer among women. Among subgroups of ultra-processed foods, higher consumption of meat/poultry/seafood based ready-to-eat products (hazard ratio for highest versus lowest fifth 1.44, 1.20 to 1.73; P for trend<0.001) and sugar sweetened beverages (1.21, 1.01 to 1.44; P for trend=0.013) among men and ready-to-eat/heat mixed dishes among women (1.17, 1.01 to 1.36; P for trend=0.02) was associated with increased risk of colorectal cancer; yogurt and dairy based desserts were negatively associated with the risk of colorectal cancer among women (hazard ratio 0.83, 0.71 to 0.97; P for trend=0.002). CONCLUSIONS: In the three large prospective cohorts, high consumption of total ultra-processed foods in men and certain subgroups of ultra-processed foods in men and women was associated with an increased risk of colorectal cancer. Further studies are needed to better understand the potential attributes of ultra-processed foods that contribute to colorectal carcinogenesis.

Maternal consumption of ultra-processed foods and subsequent risk of offspring overweight or obesity: results from three prospective cohort studies.

OBJECTIVE: To assess whether maternal ultra-processed food intake during peripregnancy and during the child rearing period is associated with offspring risk of overweight or obesity during childhood and adolescence. DESIGN: Population based prospective cohort study. SETTING: The Nurses' Health Study II (NHSII) and the Growing Up Today Study (GUTS I and II) in the United States. PARTICIPANTS: 19 958 mother-child (45% boys, aged 7-17 years at study enrollment) pairs with a median follow-up of 4 years (interquartile range 2-5 years) until age 18 or the onset of overweight or obesity, including a subsample of 2925 mother-child pairs with information on peripregnancy diet. MAIN OUTCOME MEASURES: Multivariable adjusted, log binomial models with generalized estimating equations and an exchangeable correlation structure were used to account for correlations between siblings and to estimate the relative risk of offspring overweight or obesity defined by the International Obesity Task Force. RESULTS: 2471 (12.4%) offspring developed overweight or obesity in the full analytic cohort. After adjusting for established maternal risk factors and offspring's ultra-processed food intake, physical activity, and sedentary time, maternal consumption of ultra-processed foods during the child rearing period was associated with overweight or obesity in offspring, with a 26% higher risk in the group with the highest maternal ultra-processed food consumption (group 5) versus the lowest consumption group (group 1; relative risk 1.26, 95% confidence interval 1.08 to 1.47, P for trend<0.001). In the subsample with information on peripregnancy diet, while rates were higher, peripregnancy ultra-processed food intake was not significantly associated with an increased risk of offspring overweight or obesity (n=845 (28.9%); group 5 v group 1: relative risk 1.17, 95% confidence interval 0.89 to 1.53, P fortrend=0.07). These associations were not modified by age, sex, birth weight, and gestational age of offspring or maternal body weight. CONCLUSIONS: Maternal consumption of ultra-processed food during the child rearing period was associated with an increased risk of overweight or obesity in offspring, independent of maternal and offspring lifestyle risk factors. Further study is needed to confirm these findings and to understand the underlying biological mechanisms and environmental determinants. These data support the importance of refining dietary recommendations and the development of programs to improve nutrition for women of reproductive age to promote offspring health.

Effect of reducing ultraprocessed food consumption on obesity among US children and adolescents aged 7-18 years: evidence from a simulation model.

BACKGROUND: Children and adolescents in the USA consume large amounts of daily calories from ultraprocessed foods (UPFs). Recent evidence links UPF consumption to increased body fat in youth. We aimed to estimate the potential impact of reducing UPF consumption on childhood obesity rate in the USA. METHODS: We developed a microsimulation model to project the effect of reducing UPF consumption in children's diet on reducing the prevalence of overweight or obesity among US youth. The model incorporated nationally representative data on body mass index (BMI) percentile and dietary intake of 5804 children and adolescents aged 7-18 years from the National Health and Nutrition Examination Survey 2011-2016, and the effect of reducing UPF consumption on calorie intake from a recent randomised controlled trial. Uncertainties of model inputs were incorporated using probabilistic sensitivity analysis with 1000 simulations. RESULTS: Reducing UPFs in children's diet was estimated to result in a median of -2.09 kg/m2 (95% uncertainty interval -3.21 to -0.80) reduction in BMI among children and adolescents aged 7-18 years. The median prevalence of overweight (BMI percentile ≥85th) and obesity (BMI percentile ≥95th percentile) was reduced from 37.0% (35.9%, 38.1%) to 20.9% (15.1%, 29.9%) and from 20.1% (19.2%, 21.0%) to 11.0% (7.86%, 15.8%), respectively. Larger BMI and weight reductions were seen among boys than girls, adolescents than children, non-Hispanic black and Hispanic youth than non-Hispanic white youth, and those with lower levels of parental education and family income. CONCLUSIONS: Reducing UPF consumption in children's diet has the potential to substantially reduce childhood obesity rate among children and adolescents in the USA.

Self-Reported Changes and Perceived Barriers to Healthy Eating and Physical Activity among Global Breast Cancer Survivors: Results from an Exploratory Online Novel Survey.

BACKGROUND: Despite being motivated to improve nutrition and physical activity behaviors, cancer survivors are still burdened by suboptimal dietary intake and low levels of physical activity. OBJECTIVE: The aim of this study was to assess changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, barriers to eating a healthy diet and staying physically active, and sources for seeking nutrition advice reported by breast cancer survivors. DESIGN: This was a cross-sectional study. PARTICIPANTS/SETTING: The study included 315 survivors of breast cancer who were recruited through social media and provided completed responses to an online exploratory survey. MAIN OUTCOME MEASURES: Self-reported changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, perceived barriers to healthy eating and physical activity, and sources of nutrition advice were measured. STATISTICAL ANALYSIS: Frequency distribution of nutrition and physical activity behaviors and changes, barriers to healthy eating and physical activity, and sources of nutrition advice were estimated. RESULTS: About 84.4% of the breast cancer survivors reported at least 1 positive behavior for improving nutrition and physical activity after cancer diagnosis or treatment. Fatigue was the top barrier to both making healthy food choices (72.1%) and staying physically active (65.7%), followed by stress (69.5%) and treatment-related changes in eating habits (eg, change in tastes, loss of appetite, and craving unhealthy food) (31.4% to 48.6%) as barriers to healthy eating, and pain or discomfort (53.7%) as barriers to being physically active. Internet search (74.9%) was the primary source for seeking nutrition advice. Fewer than half reported seeking nutrition advice from health care providers. CONCLUSIONS: Despite making positive changes in nutrition and physical activity behaviors after cancer diagnosis or treatment, breast cancer survivors experience treatment-related barriers to eating a healthy diet and staying physically active. Our results reinforce the need for developing tailored intervention programs and integrating nutrition into oncology care.

Categorising ultra-processed foods in large-scale cohort studies: evidence from the Nurses' Health Studies, the Health Professionals Follow-up Study, and the Growing Up Today Study.

This manuscript details the strategy employed for categorising food items based on their processing levels into the four NOVA groups. Semi-quantitative food frequency questionnaires (FFQs) from the Nurses' Health Studies (NHS) I and II, the Health Professionals Follow-up Study (HPFS) and the Growing Up Today Studies (GUTS) I and II cohorts were used. The four-stage approach included: (i) the creation of a complete food list from the FFQs; (ii) assignment of food items to a NOVA group by three researchers; (iii) checking for consensus in categorisation and shortlisting discordant food items; (iv) discussions with experts and use of additional resources (research dieticians, cohort-specific documents, online grocery store scans) to guide the final categorisation of the short-listed items. At stage 1, 205 and 315 food items were compiled from the NHS and HPFS, and the GUTS FFQs, respectively. Over 70 % of food items from all cohorts were assigned to a NOVA group after stage 2. The remainder were shortlisted for further discussion (stage 3). After two rounds of reviews at stage 4, 95⋅6 % of food items (NHS + HPFS) and 90⋅7 % items (GUTS) were categorised. The remaining products were assigned to a non-ultra-processed food group (primary categorisation) and flagged for sensitivity analyses at which point they would be categorised as ultra-processed. Of all items in the food lists, 36⋅1 % in the NHS and HPFS cohorts and 43⋅5 % in the GUTS cohorts were identified as ultra-processed. Future work is needed to validate this approach. Documentation and discussions of alternative approaches for categorisation are encouraged.

Cost-effectiveness Analysis of Nutrition Facts Added-Sugar Labeling and Obesity-Associated Cancer Rates in the US.

Importance: Obesity-associated cancer burdens are increasing in the US. Nutrition policies, such as the Nutrition Facts added-sugar labeling, may reduce obesity-associated cancer rates. Objective: To evaluate the cost-effectiveness of Nutrition Facts added-sugar labeling and obesity-associated cancer rates in the US. Design, Setting, and Participants: A probabilistic cohort state-transition model was used to conduct an economic evaluation of added-sugar labeling and 13 obesity-associated cancers among 235 million adults aged 20 years or older by age, sex, and race/ethnicity over a median follow-up of 34.4 years. Policy associations were considered in 2 scenarios: with consumer behaviors and with additional industry reformulation. The model integrated nationally representative population demographics, diet, and cancer statistics; associations of policy intervention with diet, diet change and body mass index, and body mass index with cancer risk; and policy and health-related costs from established sources. Data were analyzed from January 8, 2019, to May 6, 2020. Main Outcomes and Measures: Net costs and incremental cost-effectiveness ratio were estimated from societal and health care perspectives. Probabilistic sensitivity analyses incorporated uncertainty in input parameters and generated 95% uncertainty intervals (UIs). Results: Based on consumer behaviors, the policy was associated with a reduction of 30 000 (95% UI, 21 600-39 300) new cancer cases and 17 100 (95% UI, 12 400-22 700) cancer deaths, a gain of 116 000 (95% UI, 83 800-153 000) quality-adjusted life-years, and a saving of $1600 million (95% UI, $1190 million-$2030 million) in medical costs associated with cancer care among US adults over a lifetime. The policy was associated with a savings of $704 million (95% UI, $44.5 million-$1450 million) from the societal perspective and $1590 million (95% UI, $1180 million-$2020 million) from the health care perspective. Additional industry reformulation to reduce added-sugar amounts in packaged foods and beverages would double the impact. Greater health gains and cost savings were expected among young adults, women, and non-Hispanic Black individuals than other population subgroups. Conclusions and Relevance: These findings suggest that the added-sugar labeling is associated with reduced costs and lower rates of obesity-associated cancers. Policymakers may consider and prioritize nutrition policies for cancer prevention in the US.

Cost-Effectiveness of a National Sugar-Sweetened Beverage Tax to Reduce Cancer Burdens and Disparities in the United States.

BACKGROUND: Sugar-sweetened beverage (SSB) consumption contributes to obesity, a risk factor for 13 cancers. Although SSB taxes can reduce intake, the health and economic impact on reducing cancer burdens in the United States are unknown, especially among low-income Americans with higher SSB intake and obesity-related cancer burdens. METHODS: We used the Diet and Cancer Outcome Model, a probabilistic cohort state-transition model, to project health gains and economic benefits of a penny-per-ounce national SSB tax on reducing obesity-associated cancers among US adults aged 20 years and older by income. RESULTS: A national SSB tax was estimated to prevent 22 075 (95% uncertainty interval [UI] = 16 040-28 577) new cancer cases and 13 524 (95% UI = 9841-17 681) cancer deaths among US adults over a lifetime. The policy was estimated to cost $1.70 (95% UI = $1.50-$1.95) billion for government implementation and $1.70 (95% UI = $1.48-$1.96) billion for industry compliance, while saving $2.28 (95% UI = $1.67-$2.98) billion cancer-related healthcare costs. The SSB tax was highly cost-effective from both a government affordability perspective (incremental cost-effectiveness ratio [ICER] = $1486, 95% UI = -$3516-$9265 per quality-adjusted life year [QALY]) and a societal perspective (ICER = $13 220, 95% UI = $3453-$28 120 per QALY). Approximately 4800 more cancer cases and 3100 more cancer deaths would be prevented, and $0.34 billion more healthcare cost savings would be generated among low-income (federal poverty-to-income ratio [FPIR] ≤ 1.85) than higher-income individuals (FPIR > 1.85). CONCLUSIONS: A penny-per-ounce national SSB tax is cost-effective for cancer prevention in the United States, with the largest health gains and economic benefits among low-income Americans.