Ashima K. Kant

Indexes of Overall Diet Quality: A Review

This article reviews the published indexes of overall diet quality. Approaches used for measuring overall diet quality include those based on examination of the intake of nutrients, food groups, or a combination of both. A majority of the indexes have been examined in relation to nutrient adequacy only; few have been evaluated for assessment of quality according to current dietary guidelines, namely, a diet relatively low in fat that meets energy and nutrient needs. The indexes of overall diet quality were related to the risk of disease more strongly than individual nutrients or foods.

Dietary diversity and subsequent cause-specific mortality in the NHANES I epidemiologic follow-up study.

OBJECTIVES Human diets tend to be complex mixtures of foods and nutrients. Therefore, we examined the relation of a measure of overall diet quality (independent of intake of individual foods or nutrients) with mortality from cardiovascular disease (CVD), cancer, and non-CVD, non-cancer (other) causes. METHODS We used data from the NHANES I Epidemiologic follow-up study (n = 10,337; median follow-up time = 14 years; age 25-74 years at baseline), and included 988 CVD, 571 cancer, and 910 other cases. The 24-hour dietary recalls obtained at baseline were scored for quality using a dietary diversity score (DDS). The DDS (range 0-5) counts the number of major food groups--dairy, meat, grain, fruit, and vegetable consumed daily. RESULTS Age-adjusted risk of mortality from all three causes (except cancer in women) was inversely related with DDS in both men and women. Adjustment for multiple covariates attenuated the relative risk estimates slightly for CVD and cancer mortality, but markedly for other mortality. CONCLUSIONS The results are suggestive of an increased risk of CVD and cancer mortality associated with diets characterized by omission of several major food groups.

A Comparison of Three Dietary Pattern Indexes for Predicting Biomarkers of Diet and Disease

Objective: Examination of dietary indexes in association with objective biomarkers of dietary intake and chronic disease risk is an important step in their validation. We compared three dietary pattern indexes—Healthy Eating Index (HEI), Recommended Foods Score (RFS-24 hour recall), and Dietary Diversity Score for recommended foods (DDS-R)—for their ability to predict biomarkers of dietary intake, obesity, cardiovascular disease, and diabetes. Methods: We used dietary and laboratory data from the third National Health and Nutrition Examination Survey to study these associations in 8719 disease-free adults aged ≥20 y. The HEI, developed by the USDA, was a sum of scores on consideration of ten individual components; the RFS was a sum of all recommended foods (lean meat, poultry and fish, whole grains, fruits and juices, low-fat dairy, and vegetables) mentioned in the recall; the DDS-R examined whether or not a recommended food was mentioned from each of the five major food groups. The independent association of the dietary pattern indexes with body mass index (BMI), blood pressure, and serum concentrations of several biomarkers were examined using regression methods to adjust for multiple covariates. Results: All indexes were strong independent positive predictors of serum concentrations of vitamin C, E, folate, and all carotenoids (p ≤ 0.00001), except lycopene, and were negative predictors of BMI, serum homocysteine, C-reactive protein, plasma glucose, and hemoglobin A1C (p < 0.05). The RFS and DDS-R were inversely associated with blood pressure and serum cholesterol (p ≤ 0.03). Conclusions: The RFS and DDS-R performed as well or better than the HEI for predicting serum concentration of nutrients and biomarkers of disease risk.

Secular Trends in the Association of Socio-Economic Position with Self-Reported Dietary Attributes and Biomarkers in the US Population: National Health and Nutrition Examination Survey (NHANES) 1971–1975 to NHANES 1999–2002

OBJECTIVE Recent reports suggest persistence of health disparities related to socio-economic position (SEP). To understand if diet may be a contributor to these trends, we examined secular trends in the association of diet and indicators of SEP from 1971-1975 to 1999-2002. DESIGN We used data from the National Health and Nutrition Examination Surveys (NHANES) I (1971-1975), II (1976-1980), III (1988-1994) and 1999-2002 to examine the independent associations of poverty income ratio (PIR) and education with diet and biomarkers of diet and disease in 25-74-year-olds (n = 36,600). We used logistic and linear regression methods to adjust for multiple covariates and survey design to examine these associations. RESULTS A large PIR differential in the likelihood of reporting a fruit or all five food groups and vitamin C intake, and an education differential in likelihood of obesity and carbohydrate intake, was noted in 1971-1975 but narrowed in 1999-2002 (P < 0.007). The positive association of education with intake of a fruit, vegetable or all five food groups, vitamins A and C, calcium and potassium intake remained unchanged across surveys (P < 0.001). Similarly, the positive association of PIR with the amount of foods and intakes of energy and potassium remained unchanged over three decades (P < 0.001). The education and the PIR differential in energy density, and the PIR differential in the likelihood of obesity, persisted over the period of the four surveys (P < 0.001). CONCLUSIONS Persistence of unfavourable dietary and biomarker profiles in Americans with low income and education suggests continued need for improvement in the quality of diets of these high-risk groups.

Intakes of plain water, moisture in foods and beverages, and total water in the adult US population—nutritional, meal pattern, and body weight correlates: National Health and Nutrition Examination Surveys 1999–2006

BACKGROUND There is a surprising paucity of studies that have systematically examined the correlates of water intake in the US population. OBJECTIVE The objective was to examine the association of contributors of water intake with dietary characteristics, meal consumption, and body weight in the US population. DESIGN We used 24-h dietary recall data from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 (n = 12,283) and the NHANES 2005-2006 (n = 4112) to examine the independent association of intakes of plain water, beverage moisture, food moisture, and total water with sociodemographic factors, dietary characteristics (energy, nutrients, diet quality, and energy density), and meal patterns (number of eating episodes, mention of breakfast or snack) by using multiple regression methods. RESULTS In 2005-2006, American adults reported consuming 3.18 L of total water within the previous 24 h (in 1999-2004, estimated total water intake was 3.35 L), with plain water and beverages contributing 33% and 48% of the total, respectively. Plain water intake was unrelated to the intake of energy and body mass index but was positively related to dietary fiber and inversely related to beverages, sugars, and the energy density of foods; these associations were in the opposite direction for beverage moisture intake. Total water intake was inversely related to energy from fat and energy density but positively related to dietary fiber, caffeine, alcohol, and diet quality. The number of eating episodes predicted higher beverage and food moisture and total water intakes. A higher body mass index predicted higher intakes of beverage moisture and total water. CONCLUSION Various contributors of total water intake differed in their association with dietary characteristics and body weight in the adult US population.

Contributors of water intake in US children and adolescents: associations with dietary and meal characteristics: National Health and Nutrition Examination Survey 2005–2006

BACKGROUND Little is known about the association of contributors of total water intake with dietary characteristics in US children. OBJECTIVE We examined intakes of total water and its contributors and their associations with diet and meal reporting in children and adolescents. DESIGN Dietary data for children 2-19 y of age (n = 3978) from the National Health and Nutrition Examination Survey 2005-2006 were used to compute usual intake of total water. The association of total water and its contributors with sociodemographic characteristics and dietary and meal attributes was examined by using multiple regression analysis. RESULTS The adjusted mean intakes of total water in Americans aged 2-5, 6-11, and 12-19 y were 1.4, 1.6, and 2.4 L, respectively. The mean usual intake of total water was generally less than the Adequate Intake; overall, more boys reported intakes of at least the Adequate Intake. The percentage of total water intake from plain water increased with age. Plain water intake was inversely associated with the intake of beverage moisture and the energy density of foods; conversely, beverage moisture was positively associated with dietary energy, fat, and the energy density of foods. Associations of water contributors with meal patterns (number of eating occasions, reporting of breakfast or snack) were inconsistent across age groups. Nearly 80% of food moisture, >66% of beverage moisture, and ≈30% of plain water were reported with main meals. CONCLUSIONS Intake of total water over 24 h from different contributors varied by age. Qualitative differences in dietary intake in association with the amount of plain water and beverage moisture in the recalls were observed. American children and adolescents consumed more than two-thirds of their daily beverages with main meals.

Physician Advice About Being Overweight: Association With Self-Reported Weight Loss, Dietary, and Physical Activity Behaviors of US Adolescents in the National Health and Nutrition Examination Survey, 1999–2002

OBJECTIVE. The goal was to examine the association of physician counseling about being overweight with attempted weight loss, dietary, and physical activity/inactivity behaviors of US teens. METHODS. We used data from the National Health and Nutrition Examination Surveys 1999–2000 and 2001–2002 for 16- to 19-year-old subjects with BMI for age of ≥85th percentile (n = 716). Regression methods were used to examine the association of physician advice about teen weight status with covariate-adjusted differences in reported weight loss, dietary, and physical activity behaviors. RESULTS. Approximately 51% of overweight teens (BMI for age of ≥95th percentile) but only 17% of at-risk teens (BMI for age of 85th to <95th percentile) reported that they had been informed by a doctor about being overweight. More than 60% of those told by a doctor about being overweight had attempted weight loss in the past year, relative to 41% of those who did not receive this advice. Teens informed of their overweight status reported significantly smaller amounts of all foods and beverages and lower energy intake per kilogram of body weight in the 24-hour recall, relative to the comparison group. Physical activity and inactivity behaviors were unrelated to professional counseling about overweight status. CONCLUSION. Physician counseling regarding adolescent overweight status was associated with a positive impact on attempted weight loss and moderate dietary behaviors.

Association of self-reported sleep duration with eating behaviors of American adults: NHANES 2005–2010

BACKGROUND Published evidence suggests an inverse association between sleep duration and body weight status. OBJECTIVE We examined the association of sleep duration with eating behaviors reported by adult Americans to understand the relation between sleep duration and body weight status. DESIGN This cross-sectional study used sleep duration and dietary data from the continuous NHANES conducted from 2005 to 2010 (n = 15,199, age ≥20 y). Eating behaviors examined included the following: reporting of and energy from main meals (breakfast, lunch, and dinner) and snacks (before breakfast, after dinner, and after 2000 h), intermeal intervals, time of day of main meal reporting, and intakes of macronutrients and beverages. Multiple regression methods were used to examine the independent association of hours of sleep duration grouped as short (≤6 h), average (7-8 h), and long (≥9 h) with eating behavior outcomes. RESULTS Relative to average-duration sleepers, a smaller percentage of short-duration sleepers mentioned breakfast, lunch (women only), and dinner in the recall (P ≤ 0.04). They also reported a lower mean percentage of energy from main meals but higher energy from all snacks (P ≤ 0.0004) and after 2000 h (P = 0.03). Short-duration sleepers reported the earliest eating time of the first episode and the latest time of the last eating episode. Absolute amounts of sugar and caffeine and percentage of energy from beverages (women only) were higher in short-duration sleepers. However, the total number of eating episodes and energy intake were not related with sleep duration. CONCLUSIONS Short-duration sleepers began eating earlier and ended their eating later in the day, but despite the longer eating period, they did not report more eating events. Profiles of the relative contribution of main meals and snacks, at or after 2000 h eating, and beverages in short-duration sleepers were suggestive of eating behaviors that may increase energy intake, but 24-h energy intake did not differ among categories of sleep duration.

Patterns of Recommended Dietary Behaviors Predict Subsequent Risk of Mortality in a Large Cohort of Men and Women in the United States

Recommendations for intake of fruits and vegetables, whole grains, lean meats, and low-fat dairy form the underpinning of dietary guidance for health promotion. We examined the association of a summary index of food consumption behaviors compatible with the spirit of prevailing dietary guidance and mortality. We used data from the NIH-American Association of Retired Persons cohort (n = 350,886), aged 50-71 y and disease free at baseline in 1995-1996, to examine the association of a dietary behavior score (DBS) with mortality after 10.5 y of follow-up (deaths, n = 29,838). The DBS included 6 equally weighted components derived from responses to questions on usual dietary behaviors related to consumption of fruits, vegetables, low-fat dairy, whole grains, lean meat and poultry, and discretionary fat. The covariate-adjusted association of DBS and mortality from all causes, cancer, and coronary heart disease was examined using Cox proportional hazards regression methods. Compared with those in the lowest one-fifth of DBS, the multivariate-adjusted relative risk of mortality in the highest one-fifth of the DBS was 0.75 (95% CI, 0.70-0.80) in women and 0.79 (95% CI, 0.75-0.83) in men (P-trend < 0.0001). The inverse association of DBS and mortality was significant in both genders in nearly all categories of covariates. Similar trends were observed for DBS associations with mortality from cancer and heart disease. Nearly 12% of the covariate-adjusted population risk of mortality was attributable to nonconformity with dietary recommendations. Adoption of recommended dietary behaviors was associated with lower mortality in both men and women independent of other lifestyle risk factors.

Nature of dietary reporting by adults in the third National Health and Nutrition Examination Survey, 1988-1994

Objective: Low reporting of food intake is an acknowledged problem in dietary assessments; however, differences in food intake relative to reporting status are poorly understood. This study examined the relation of a measure of dietary reporting status with the nature of food intake reported by adults in the third National Health and Nutrition Examination Survey. Methods: Subjects were 6948 women and 6452 men, 20 years of age or older, with a complete and reliable 24-hour dietary recall. The ratio of reported energy intake to estimated basal energy expenditure (EI/BEE) was computed as a measure of dietary reporting status. The independent relation of EI/BEE ratio with 1) the amount, number, and energy density of nutrient-dense and low-nutrient-dense foods, 2) the number of reported eating occasions, 3) macro- and micronutrient intake and 4) serum concentrations of folate, ascorbate and carotenoids were examined using gender-specific multiple regression models. Results: The EI/BEE ratio related positively with the amount, number and energy density of both nutrient-dense and low-nutrient-dense foods, and grams of alcoholic beverages. The EI/BEE ratio was an independent negative predictor of serum folate, ascorbate and alpha-carotene concentrations confirming the underreporting of food sources of these nutrients. The relative odds of reporting ≤ 30% of energy as fat or < 10% of energy as saturated fat decreased with ratio of EI/BEE; however, the odds of reporting all five food groups or meeting the recommended intake of selected micronutrients increased with EI/BEE. Conclusions: The quantity and the quality of food intake reported in the 24-hour recall in NHANES III differed in relation to the ratio of EI/BEE.