Ultra-processed food and incident type 2 diabetes: studying the underlying consumption patterns to unravel the health effects of this heterogeneous food category in the prospective Lifelines cohort.

BACKGROUND: The overall consumption of ultra-processed food (UPF) has previously been associated with type 2 diabetes. However, due to the substantial heterogeneity of this food category, in terms of their nutritional composition and product type, it remains unclear whether previous results apply to all underlying consumption patterns of UPF. METHODS: Of 70,421 participants (35-70 years, 58.6% women) from the Lifelines cohort study, dietary intake was assessed with a food frequency questionnaire. UPF was identified according to the NOVA classification. Principal component analysis (PCA) was performed to derive UPF consumption patterns. The associations of UPF and adherence to UPF consumption patterns with incidence of type 2 diabetes were studied with logistic regression analyses adjusted for age, sex, diet quality, energy intake, alcohol intake, physical activity, TV watching time, smoking status, and educational level. RESULTS: During a median follow-up of 41 months, a 10% increment in UPF consumption was associated with a 25% higher risk of developing type 2 diabetes (1128 cases; OR 1.25 [95% CI 1.16, 1.34]). PCA revealed four habitual UPF consumption patterns. A pattern high in cold savory snacks (OR 1.16 [95% CI 1.09, 1.22]) and a pattern high in warm savory snacks (OR 1.15 [95% CI 1.08, 1.21]) were associated with an increased risk of incident type 2 diabetes; a pattern high in traditional Dutch cuisine was not associated with type 2 diabetes incidence (OR 1.05 [95% CI 0.97, 1.14]), while a pattern high in sweet snacks and pastries was inversely associated with type 2 diabetes incidence (OR 0.82 [95% CI 0.76, 0.89]). CONCLUSIONS: The heterogeneity of UPF as a general food category is reflected by the discrepancy in associations between four distinct UPF consumption patterns and incident type 2 diabetes. For better public health prevention, research is encouraged to further clarify how different UPF consumption patterns are related to type 2 diabetes.

Age- and Sex-Specific Analyses of Diet Quality and 4-Year Weight Change in Nonobese Adults Show Stronger Associations in Young Adulthood.

BACKGROUND: Although the general importance of diet quality in the prevention of unintentional weight gain is known, it is unknown whether its influence is age or sex dependent. OBJECTIVE: The aim of this study was to investigate whether the strength of the association between diet quality and 4-y weight change was modified by age and sex. METHODS: From the Dutch population-based Lifelines Cohort, 85,618 nonobese adult participants (age 18-93 y), recruited between 2006 and 2013, were included in the study. At baseline, diet was assessed with a 110-item food-frequency questionnaire. The Lifelines Diet Score, based on international evidence for diet-disease relations at the food group level, was calculated to assess diet quality. For analyses, the score was divided in quintiles (Qs). Body weight was objectively measured at baseline and after a median follow-up of 44 mo (25th-75th percentile: 35-51 mo). In between, body weight was self-reported twice. Linear mixed models were used to investigate the association between diet quality and weight change by sex and in 6 age categories (18-29, 30-39, 40-49, 50-59, 60-69, and ≥70 y). RESULTS: Mean 4-y weight change decreased over age categories. Confounder-adjusted linear mixed models showed that the association between diet quality and weight change was modified by sex (P-interaction = 0.001). In women, the association was also modified by age (P-interaction = 0.001). Poor diet quality was most strongly associated with weight gain in the youngest men [Q1 compared with Q5: +0.33 kg/y (95% CI: 0.10, 0.56)] and women [+0.22 kg/y (95% CI: 0.07, 0.37)]. In contrast, in women aged ≥70 y, poor diet quality was associated with greater weight loss [-0.44 kg/y (95% CI: -0.84, -0.05)]. CONCLUSIONS: Poor diet quality was related to higher weight gain, especially in young adults. Oppositely, among women aged ≥70 y, poor diet quality was related to higher weight loss. Therefore, a healthful diet is a promising target for undesirable weight changes in both directions.

An overview and online registry of microvillus inclusion disease patients and their MYO5B mutations.

Microvillus inclusion disease (MVID) is one of the most severe congenital intestinal disorders and is characterized by neonatal secretory diarrhea and the inability to absorb nutrients from the intestinal lumen. MVID is associated with patient-, family-, and ancestry-unique mutations in the MYO5B gene, encoding the actin-based motor protein myosin Vb. Here, we review the MYO5B gene and all currently known MYO5B mutations and for the first time methodologically categorize these with regard to functional protein domains and recurrence in MYO7A associated with Usher syndrome and other myosins. We also review animal models for MVID and the latest data on functional studies related to the myosin Vb protein. To congregate existing and future information on MVID geno-/phenotypes and facilitate its quick and easy sharing among clinicians and researchers, we have constructed an online MOLGENIS-based international patient registry (www.MVID-central.org). This easily accessible database currently contains detailed information of 137 MVID patients together with reported clinical/phenotypic details and 41 unique MYO5B mutations, of which several unpublished. The future expansion and prospective nature of this registry is expected to improve disease diagnosis, prognosis, and genetic counseling.

Monitoring multidimensional aspects of quality of life after cancer immunotherapy: protocol for the international multicentre, observational QUALITOP cohort study.

INTRODUCTION: Immunotherapies, such as immune checkpoint inhibitors and chimeric antigen receptor T-cell therapy, have significantly improved the clinical outcomes of various malignancies. However, they also cause immune-related adverse events (irAEs) that can be challenging to predict, prevent and treat. Although they likely interact with health-related quality of life (HRQoL), most existing evidence on this topic has come from clinical trials with eligibility criteria that may not accurately reflect real-world settings. The QUALITOP project will study HRQoL in relation to irAEs and its determinants in a real-world study of patients treated with immunotherapy. METHODS AND ANALYSIS: This international, observational, multicentre study takes place in France, the Netherlands, Portugal and Spain. We aim to include about 1800 adult patients with cancer treated with immunotherapy in a specifically recruited prospective cohort, and to additionally obtain data from historical real-world databases (ie, databiobanks) and medical administrative registries (ie, national cancer registries) in which relevant data regarding other adult patients with cancer treated with immunotherapy has already been stored. In the prospective cohort, clinical health status, HRQoL and psychosocial well-being will be monitored until 18 months after treatment initiation through questionnaires (at baseline and 3, 6, 12 and 18 months thereafter), and by data extraction from electronic patient files. Using advanced statistical methods, including causal inference methods, artificial intelligence algorithms and simulation modelling, we will use data from the QUALITOP cohort to improve the understanding of the complex relationships among treatment regimens, patient characteristics, irAEs and HRQoL. ETHICS AND DISSEMINATION: All aspects of the QUALITOP project will be conducted in accordance with the Declaration of Helsinki and with ethical approval from a suitable local ethics committee, and all patients will provide signed informed consent. In addition to standard dissemination efforts in the scientific literature, the data and outcomes will contribute to a smart digital platform and medical data lake. These will (1) help increase knowledge about the impact of immunotherapy, (2) facilitate improved interactions between patients, clinicians and the general population and (3) contribute to personalised medicine. TRIAL REGISTRATION NUMBER: NCT05626764.

Ultra-processed foods and risk of all-cause mortality in renal transplant recipients.

BACKGROUND: Renal transplant recipients (RTRs) have a 6-fold higher risk of mortality than age- and sex-matched controls. Whether high consumption of ultra-processed foods is associated with survival in RTRs is unknown. OBJECTIVES: We aimed to study the association between high consumption of ultra-processed foods and all-cause mortality in stable RTRs. METHODS: We conducted a prospective cohort study in adult RTRs with a stable graft. Dietary intake was assessed using a validated 177-item FFQ. Food items were categorized according to the NOVA classification system and the proportion ultra-processed foods comprised of total food weight per day was calculated. RESULTS: We included 632 stable RTRs (mean ± SD age: 53.0 ± 12.7 y, 57% men). Mean ± SD consumption of ultra-processed foods was 721 ± 341 g/d (28% of total weight of food intake), whereas the intake of unprocessed and minimally processed foods, processed culinary ingredients, and processed foods accounted for 57%, 1%, and 14%, respectively. During median follow-up of 5.4 y [IQR: 4.9-6.0 y], 129 (20%) RTRs died. In Cox regression analyses, ultra-processed foods were associated with all-cause mortality (HR per doubling of percentage of total weight: 2.13; 95% CI: 1.46, 3.10; P < 0.001), independently of potential confounders. This association was independent from the quality of the overall dietary pattern, expressed by the Mediterranean Diet Score (MDS) or Dietary Approaches to Stop Hypertension (DASH) score. When analyzing ultra-processed foods by groups, only sugar-sweetened beverages (HR: 1.21; 95% CI: 1.05, 1.39; P = 0.007), desserts (HR: 1.24; 95% CI: 1.02, 1.49; P = 0.03), and processed meats (HR: 1.87; 95% CI: 1.22, 2.86; P = 0.004) were associated with all-cause mortality. CONCLUSIONS: Consumption of ultra-processed foods, in particular sugar-sweetened beverages, desserts, and processed meats, is associated with a higher risk of all-cause mortality after renal transplantation, independently of low adherence to high-quality dietary patterns, such as the Mediterranean diet and the DASH diet.This trial was registered at clinicaltrials.gov as NCT02811835.

Associations of Diet Quality and All-Cause Mortality Across Levels of Cardiometabolic Health and Disease: A 7.6-Year Prospective Analysis From the Dutch Lifelines Cohort.

OBJECTIVE: To simultaneously investigate the association of diet quality and all-cause mortality in groups with varying cardiometabolic diseases (CMDs) at baseline. RESEARCH DESIGN AND METHODS: From the population-based Lifelines cohort, 40,892 non-underweight participants aged ≥50 years with data on diet quality and confounding factors were included (enrollment 2006-2013). From food-frequency questionnaire data, tertiles of the Lifelines Diet Score were calculated (T1 = poorest, T3 = best diet quality). Four CMD categories were defined: 1) CMD free, 2) type 2 diabetes, 3) one cardiovascular disease (CVD), 4) two or more CMDs. Months when deaths occurred were obtained from municipal registries up until November 2019. Multivariable Cox proportional hazards models were applied for the total population and stratified by CMD categories. RESULTS: After a median follow-up of 7.6 years, 1,438 participants died. Diet quality and CMD categories were independently associated with all-cause mortality in crude and adjusted models (P < 0.001). A dose-response relationship of diet quality with all-cause mortality was observed in the total population (P trend < 0.001, T2 vs. T3 = 1.22 [1.07-1.41], T1 vs. T3 = 1.57 [1.37-1.80]). In stratified analyses, the association was significant for CMD-free individuals (T1 vs. T3 = 1.63 [1.38-1.93]) and for patients with type 2 diabetes (1.87 [1.17-3.00]) but not for patients with one CVD (1.39 [0.93-2.08]) or multiple CMDs (1.19 [0.80-1.76]). CONCLUSIONS: A high-quality diet can potentially lower all-cause mortality risk in the majority of the aging population. Its effect may be greatest for CMD-free individuals and patients with type 2 diabetes. Tailored dietary guidelines may be required for patients with extensive histories of CMDs.

Diet quality and incident chronic kidney disease in the general population: The Lifelines Cohort Study.

RATIONALE & AIMS: Healthy dietary patterns have been associated with a lower risk of chronic kidney disease (CKD). We aimed to investigate the association of a fully food-based diet quality score assessed by the Lifelines Diet Score (LLDS) with either incident CKD or eGFR decline in the general population. METHODS: For this study, data from a prospective general population-based Lifelines cohort in the Northern Netherlands was used. Diet was assessed with a 110-item food frequency questionnaire at baseline. The LLDS, based on international evidence for diet-disease relations at the food group level, was calculated to assess diet quality. For the analysis, the score was divided into tertiles. Logistic regression was performed to evaluate the association of the LLDS at baseline with either incident CKD (eGFR <60 mL/min/1.73 m2) or a ≥20% eGFR decline at the second study visit, adjusted for relevant confounders. RESULTS: A total of 78 346 participants free of CKD at baseline were included. During a mean (SD) follow-up of 3.6 ± 0.9 years, 2071 (2.6%) participants developed CKD and 7611 (9.7%) had a ≥20% eGFR decline. Participants in the highest tertile of LLDS had a lower risk of incident CKD (fully adjusted OR 0.83, [95% CI: 0.72-0.96]) and ≥20% eGFR decline (fully adjusted OR 0.80, [95% CI: 0.75-0.86]), compared with those in the lowest tertile. Similar dose-response associations were observed in continuous LLDS. CONCLUSIONS: Higher adherence to a high-quality diet was associated with a lower risk of incident CKD or ≥20% eGFR decline in the general population.

Nutrition beyond the first 1000 days: diet quality and 7-year change in BMI and overweight in 3-year old children from the Dutch GECKO Drenthe birth cohort.

The identification of early-life determinants of overweight is crucial to start early prevention. As weight gain accelerates between 2 and 6 years, we studied the association between diet quality in children aged 3 years and the change in BMI and overweight incidence in the following 7 years. From the Dutch GECKO Drenthe birth cohort, 1001 children born in 2006 or 2007 with complete data on diet (food frequency questionnaire at the age of 3 years) and growth at the age of 3 and 10 years were included. Diet quality was estimated with the evidence-based Lifelines Diet Score (LLDS). Measured height and weight at the age of 3 and 10 years were used to calculate BMI z-scores standardized for age and sex. The associations of the LLDS (in quintiles) with BMI-z change and overweight incidence were studied with linear and logistic regression analyses. Overweight prevalence in the total study population increased from 8.3% at the age of 3 years to 16.7% at the age of 10 years. The increase in overweight prevalence ranged from 14.7% in Q1 to 3.5% in Q5. Children with a better diet quality (higher quintiles of LLDS) increased significantly less in BMI-z (confounder adjusted ßLLDS = -0.064 (-0.101; -0.026)). Children with a poor diet quality at the age of 3 years had a considerably higher risk for overweight at the age of 10 years (confounder adjusted OR for Q1 vs. Q5 was 2.86 (95% CI 1.34-6.13). These results show the importance of diet in healthy development in the early life following the first 1000 days when new habits for a mature diet composed of food groups with lifelong importance are developed, providing a relevant window for overweight prevention early in life.

Diet quality, stress and common mental health problems: A cohort study of 121,008 adults.

BACKGROUND & AIMS: Overall diet quality may partially mediate the detrimental effects of stress and neuroticism on common mental health problems: stressed and/or neurotic individuals may be more prone to unhealthy dietary habits, which in turn may contribute to depression and anxiety. Lifestyle interventions for depressed, anxious or at-risk individuals hinge on this idea, but evidence to support such pathway is missing. Here, we aim to prospectively evaluate the role of overall diet quality in common pathways to developing depression and anxiety. METHODS: At baseline, N = 121,008 individuals from the general population (age 18-93) completed an extensive food frequency questionnaire, based on which overall diet quality was estimated. Participants also reported on two established risk factors for mental health problems, i.e. past-year stress exposure (long-term difficulties, stressful life-events) and four neuroticism traits (anger-hostility, self-consciousness, impulsivity, vulnerability). Depression and anxiety were assessed at baseline and follow-up (n = 65,342, +3.6 years). Overall diet quality was modeled as a mediator in logistic regression models predicting the development of depression and anxiety from common risk factors. RESULTS: High stress and high neuroticism scores were - albeit weakly - associated with poorer diet quality. Poor diet quality, in turn, did not predict mental health problems. Overall diet quality did not mediate the relationship between stress/neuroticism and common mental health problems: effects of stress, neuroticism and stress-by-neuroticism interactions on mental health problems at follow-up consisted entirely of direct effects (98.6%-100%). CONCLUSIONS: Diet quality plays no mediating role in two established pathways to common mental health problems. As overall diet quality was reduced in stressed and neurotic individuals, these groups may benefit from dietary interventions. However, such interventions are unlikely to prevent the onset or recurrence of depression and anxiety.

Socio-economic disparities in the association of diet quality and type 2 diabetes incidence in the Dutch Lifelines cohort.

BACKGROUND: It is unknown whether a socio-economic difference exists in the association of diet quality with type 2 diabetes incidence, nor how diet influences the socioeconomic inequality in diabetes burden. METHODS: In 91,025 participants of the population-based Lifelines Cohort (aged ≥30, no diabetes or cardiovascular diseases at baseline), type 2 diabetes incidence was based on self-report, fasting glucose ≥ 7·0 mmol/l and/or HbA1c ≥ 6·5%. The evidence-based Lifelines Diet Score was calculated with data of a 110-item food frequency questionnaire. Socio-economic status (SES) was defined by educational level. Cox proportional hazards models were adjusted for age, gender, smoking, energy intake, alcohol intake and physical activity. FINDINGS: In 279,796 person-years of follow-up, 1045 diabetes cases were identified. Incidence rate was 5·7, 3·2 and 2·4 cases/1000 person-years in low, middle and high SES, respectively. Diet was associated with greater diabetes risk (HR(95%CI) in Q1 (poor diet quality) vs. Q5 (high diet quality) = 2·11 (1·70-2·62)). SES was a moderator of the association(pINTERACTION = 0·038). HRs for Q1 vs. Q5 were 1·66 (1·22-2·.27) in low, 2·76 (1·86-4·08) in middle and 2·46 (1·53-3·97) in high SES. With population attributable fractions of 14·8%, 40·1% and 37·3%, the expected number of cases/1000 person-years preventable by diet quality improvement was 0·85 in low, 1·28 in middle and 0·90 in high SES. INTERPRETATION: Diet quality improvement can potentially prevent one in three cases of type 2 diabetes, but because of a smaller impact in low SES, it will not narrow the socioeconomic health gap in diabetes burden. FUNDING: None.

Young Children's Sugar-Sweetened Beverage Consumption and 5-Year Change in BMI: Lessons Learned from the Timing of Consumption.

Sugar-sweetened beverages (SSBs) are an already known risk factor for weight gain in childhood. To identify windows of opportunity for public health interventions, insight into the consumption behavior of SSBs is needed. We investigated whether total SSB consumption was related to body mass index (BMI) change and overweight and compared whether the timing of consumption over the day differed between low and high consumers. In the Dutch GECKO Drenthe birth cohort, a cohort embedded within the Groningen Expert Center for Kids with Obesity (GECKO), height and weight were measured by trained nurses at age 5/6 years (y) and 10/11 y (N = 1257). BMI was standardized for age and sex (BMI-z). In the food pattern questionnaire completed by parents at age 5/6 y, beverages were assessed for seven time segments (breakfast, morning, lunch at school, lunch at home, afternoon, dinner, and evening). Linear and logistic regression analyses were adjusted for potential confounders (sex, baseline BMI-z, parental BMI, parental education level, maternal age at birth, maternal smoking during pregnancy). The median daily SSB consumption frequency ranged from 1.9 times per day (1.5-2.0, 25th-75th percentile) in the lowest quartile to 4.9 times per day (4.6-5.5) in the highest quartile. In the highest compared to the lowest quartile of SSB consumption frequency, the confounder-adjusted odds ratio for overweight incidence was 3.12 (95% CI, 1.60-6.07). The difference in consumption between quartile 1 and quartile 4 occurred mainly during main meals and in the evening, e.g., at breakfast (31% vs. 98%, p < 0.001), lunch at home (32% vs. 98%, p < 0.001), and dinner (17% vs. 72%, p < 0.001). These drinking occasions characterizing high SSB consumers mostly occurred in the home environment, where parental influence on dietary behaviors is profound. Therefore, these results exposed a window of opportunity, leading to the advice for parents to offer their children sugar-free drinks to quench thirst with main meals.

Offspring Birth Weight Is Associated with Specific Preconception Maternal Food Group Intake: Data from a Linked Population-Based Birth Cohort.

The preconception period has been recognized as one of the earliest sensitive windows for human development. Maternal dietary intake during this period may influence the oocyte quality, as well as placenta and early embryonic development during the first trimester of pregnancy. Previous studies have found associations between macronutrient intake during preconception and pregnancy outcomes. However, as food products consist of multiple macro- and micronutrients, it is difficult to relate this to dietary intake behavior. Therefore, the aim of this study was to investigate the association between intake of specific food groups during the preconception period with birth weight, using data from the Perined-Lifelines linked birth cohort. The Perined-Lifelines birth cohort consists of women who delivered a live-born infant at term after being enrolled in a large population-based cohort study (The Lifelines Cohort). Information on birth outcome was obtained by linkage to the Dutch perinatal registry (Perined). In total, we included 1698 women with data available on birth weight of the offspring and reliable detailed information on dietary intake using a semi-quantitative food frequency questionnaire obtained before pregnancy. Based on the 2015 Dutch Dietary Guidelines and recent literature 22 food groups were formulated. Birth weight was converted into gestational age-adjusted z-scores. Multivariable linear regression was performed, adjusted for intake of other food groups and covariates (maternal BMI, maternal age, smoking, alcohol, education level, urbanization level, parity, sex of newborn, ethnicity). Linear regression analysis, adjusted for covariates and intake of energy (in kcal) (adjusted z score [95% CI], P) showed that intake of food groups "artificially sweetened products" and "vegetables" was associated with increased birth weight (resp. (ß = 0.001 [95% CI 0.000 to 0.001, p = 0.002]), (ß = 0.002 [95% CI 0.000 to 0.003, p = 0.03])). Intake of food group "eggs" was associated with decreased birth weight (ß = -0.093 [95% CI -0.174 to -0.013, p = 0.02]). Intake in food groups was expressed in 10 g per 1000 kcal to be able to draw conclusions on clinical relevance given the bigger portion size of the food groups. In particular, preconception intake of "artificially sweetened products" was shown to be associated with increased birth weight. Artificial sweeteners were introduced into our diets with the intention to reduce caloric intake and normalize blood glucose levels, without compromising on the preference for sweet food products. Our findings highlight the need to better understand how artificial sweeteners may affect the metabolism of the mother and her offspring already from preconception onwards.

Associations between preconception macronutrient intake and birth weight across strata of maternal BMI.

INTRODUCTION: Maternal nutrition during pregnancy is linked with birth outcomes including fetal growth, birth weight, congenital anomalies and long-term health through intra-uterine programming. However, a woman's nutritional status before pregnancy is a strong determinant in early embryo-placental development, and subsequently outcomes for both mother and child. Therefore, the aim of this study was to investigate the association between dietary macronutrient intake in the preconception period with birth weight. METHODS: We studied a group of 1698 women from the Dutch Perined-Lifelines linked birth cohort with reliable detailed information on preconception dietary macronutrient intake (using a semi quantitative food frequency questionnaire) and data available on birth weight of the offspring. Birth weight was converted into gestational age adjusted z-scores, and macronutrient intake was adjusted for total energy intake using the nutrient residual method. Preconception BMI was converted into cohort-based quintiles. Multivariable linear regression was performed, adjusted for other macronutrients and covariates. RESULTS: Mean maternal age was 29.5 years (SD 3.9), preconception BMI: 24.7 kg/m2 (SD 4.2) and median daily energy intake was 1812 kcal (IQR 1544-2140). Mean birth weight was 3578 grams (SD 472). When adjusted for covariates, a significant association (adjusted z score [95% CI], P) between polysaccharides and birth weight was shown (0.08 [0.01-0.15], 0.03). When linear regression analyses were performed within cohort-based quintiles of maternal BMI, positive significant associations between total protein, animal protein, fat, total carbohydrates, mono-disaccharides and polysaccharides with birth weight were shown in the lowest quintile of BMI independent of energy intake, intake of other macronutrients and covariates. CONCLUSION: Out of all macronutrients studied, polysaccharides showed the strongest association with birth weight, independent of energy intake and other covariates. Our study might suggest that specifically in women with low preconception BMI a larger amount of macronutrient intake was associated with increased birth weight. We recommend that any dietary assessment and advise during preconception should be customized to preconception weight status of the women.

Short-Term Consumption of Sucralose with, but Not without, Carbohydrate Impairs Neural and Metabolic Sensitivity to Sugar in Humans.

There is a general consensus that overconsumption of sugar-sweetened beverages contributes to the prevalence of obesity and related comorbidities such as type 2 diabetes (T2D). Whether a similar relationship exists for no- or low-calorie "diet" drinks is a subject of intensive debate and controversy. Here, we demonstrate that consuming seven sucralose-sweetened beverages with, but not without, a carbohydrate over 10 days decreases insulin sensitivity in healthy human participants, an effect that correlates with reductions in midbrain, insular, and cingulate responses to sweet, but not sour, salty, or savory, taste as assessed with fMRI. Taste perception was unaltered and consuming the carbohydrate alone had no effect. These findings indicate that consumption of sucralose in the presence of a carbohydrate rapidly impairs glucose metabolism and results in longer-term decreases in brain, but not perceptual sensitivity to sweet taste, suggesting dysregulation of gut-brain control of glucose metabolism.

Comparison of health behaviours between cancer survivors and the general population: a cross-sectional analysis of the Lifelines cohort.

PURPOSE: To compare the differences in lifestyle behaviours between cancer survivors (CSs) and cancer-free participants in a large and representative population-based cohort. METHODS: We included 115,257 adults from the Lifelines cohort. Cancer status was self-reported, and health behaviours were measured (e.g. body mass index [BMI]) or assessed by questionnaire (e.g. physical activity, smoking, alcohol consumption, sedentary behaviour and diet). The data were then categorised for logistic regression analysis, stratified and adjusted by sex and age (< 55 vs ≥ 55 years). RESULTS: CSs (5473; 4.7%) were diagnosed 9 ± 8.5 years before data collection, were older (mean age 55.4 vs 44.4 years) and more often female (66.6% vs 33.4%) than the cancer-free participants. They were also more likely to be physically active and to have a better diet, and also less likely to be alcohol drinkers; but, were more likely to have a higher BMI, be former smokers and to be sedentary. After adjustment for sex and age, however, BMI was more likely to be normal, physical activity was more likely to be higher and smoking to be prevalent in CSs. Current smoking was also significantly higher among females and those aged < 55 years who were CSs than for those with no history of cancer. CONCLUSIONS: In this population-based cohort, CSs have health behaviour comparable to those without a cancer diagnosis. IMPLICATIONS FOR CANCER SURVIVORS: Smoking cessation strategies should target all CSs, but efforts could yield greatest benefit if they target females and those younger than 55 years.

Correction: Development of the food-based Lifelines Diet Score (LLDS) and its application in 129,369 Lifelines participants.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Cheese and Healthy Diet: Associations With Incident Cardio-Metabolic Diseases and All-Cause Mortality in the General Population.

Background: Many countries have established Food-Based Dietary Guidelines (FBDG). For some foods, such as cheese, there is no consensus on whether or not to include them in these guidelines. Cheese may, however, be an excellent source of vitamin K2, which is a macronutrient with demonstrated positive results on cardiovascular-related outcomes. Aim: First, we assessed the role of cheese within the recently developed Lifelines Diet Score (LLDS), a score based on the Dutch FBDG 2015 in relation to incident cardio-metabolic diseases and all-cause mortality. Secondly, we assessed the association of cheese intake with desphospho-uncarboxylated matrix Gla protein (dp-ucMGP), a marker for functional vitamin K2 status, in a subset of the population. Methods: From the Lifelines cohort study, 122,653 adult participants were included to test the association between de LLDS and health outcomes. In a subset of 1,059 participants aged 60-75 years, dp-ucMGP levels were measured. Dietary intake was assessed using a 110-item Food Frequency Questionnaire. Logistic regression were applied, adjusted for relevant confounders. Results: Median cheese intake was 23.5 [12.6-40.6] g/day. We found a positive correlation between cheese intake and the LLDS (Spearman's rho = 0.024, p < 0.001). The LLDS in quintiles was associated with T2DM [OR (95% CI) Q5 (healthy diet) vs. Q1 (poor diet) = 0.54 (0.43-0.67)] and all-cause mortality [Q5 vs. Q1 = 0.62 (0.50-0.76)]. Inclusion of cheese did not alter these associations. Additionally, we found no significant association of total cheese intake with plasma dp-ucMGP levels. Conclusion: In this population-based cohort study, the inclusion of cheese in the LLDS did not change the inverse associations with incident cardio-metabolic diseases and all-cause mortality. Furthermore, we found no significant association of total cheese intake with plasma dp-ucMGP. The results suggest that cheese is a neutral food group that fits a healthy diet.

Development of the food-based Lifelines Diet Score (LLDS) and its application in 129,369 Lifelines participants.

BACKGROUND/OBJECTIVES: Many diet quality scores exist, but fully food-based scores based on contemporary evidence are scarce. Our aim was to develop a food-based diet score based on international literature and examine its discriminative capacity and socio-demographic determinants. SUBJECTS/METHODS: Between 2006 and 2013, dietary intake of 129,369 participants of the Lifelines Cohort (42% male, 45 ± 13 years (range 18-93)) was assessed with a 110-item food frequency questionnaire. Based on the 2015 Dutch Dietary Guidelines and underlying literature, nine food groups with positive (vegetables, fruit, whole grain products, legumes&nuts, fish, oils&soft margarines, unsweetened dairy, coffee and tea) and three food groups with negative health effects (red&processed meat, butter&hard margarines and sugar-sweetened beverages) were identified. Per food group, the intake in grams per 1000 kcal was categorized into quintiles, awarded 0 to 4 points (negative groups scored inversely) and summed. Food groups with neutral, unknown or inconclusive evidence are described but not included. RESULTS: The Lifelines Diet Score (LLDS) discriminated well between high and low consumers of included food groups. This is illustrated by e.g. a 2-fold higher vegetable intake in the highest, compared to the lowest LLDS quintile. Differences were 5.5-fold for fruit, 3.5-fold for fish, 3-fold for dairy and 8-fold for sugar-sweetened beverages. The LLDS was higher in females and positively associated with age and educational level. CONCLUSIONS: The LLDS is based on the latest international evidence for diet-disease relations at the food group level and has high capacity to discriminate people with widely different intakes. Together with the population-based quintile approach, this makes the LLDS a flexible, widely applicable tool for diet quality assessment.

The Role of Supplemental Complex Dietary Carbohydrates and Gut Microbiota in Promoting Cardiometabolic and Immunological Health in Obesity: Lessons from Healthy Non-Obese Individuals.

Dietary supplementation with complex carbohydrates is known to alter the composition of gut microbiota, and optimal implementation of the use of these so called "prebiotics" could be of great potential in prevention and possibly treatment of obesity and associated cardiometabolic and inflammatory diseases via changes in the gut microbiota. An alternative to this "microbiocentric view" is the idea that health-promoting effects of certain complex carbohydrates reside in the host, and could secondarily affect the diversity and abundance of gut microbiota. To circumvent this potential interpretational problem, we aimed at providing an overview about whether and how dietary supplementation of different complex carbohydrates changes the gut microbiome in healthy non-obese individuals. We then reviewed whether the reported changes in gut bacterial members found to be established by complex carbohydrates would benefit or harm the cardiometabolic and immunological health of the host taking into account the alterations in the microbiome composition and abundance known to be associated with obesity and its associated disorders. By combining these research areas, we aimed to give a better insight into the potential of (foods containing) complex carbohydrates in the treatment and prevention of above-mentioned diseases. We conclude that supplemental complex carbohydrates that increase Bifidobacteria and Lactobacilli, without increasing the deleterious Bacteroides, are most likely promoting cardiometabolic and immunological health in obese subjects. Because certain complex carbohydrates also affect the host's immunity directly, it is likely that host-microbiome interactions in determination of health and disease characteristics are indeed bidirectional. Overall, this review article shows that whereas it is relatively clear in which direction supplemental fermentable carbohydrates can alter the gut microbiome, the relevance of these changes regarding health remains controversial. Future research should take into account the different causes of obesity and its adverse health conditions, which in turn have drastic effects on the microbiome balance.