Carolina Batis

Understanding the patterns and trends of sodium intake, potassium intake, and sodium to potassium ratio and their effect on hypertension in China

BACKGROUND Recent studies have shown inconsistent effects of sodium reduction, potassium intake, and the ratio of sodium to potassium (Na/K ratio) on hypertension and other cardiovascular diseases. Major gaps exist in knowledge regarding these issues in China. OBJECTIVE We analyzed the patterns and trends of dietary sodium intake, potassium intake, and the Na/K ratio and their relations with incident hypertension in China. DESIGN The China Health and Nutrition Survey cohort includes 16,869 adults aged 20-60 y from 1991 to 2009. Three consecutive 24-h dietary recalls and condiment and food weights provided detailed dietary data. Multinomial logistic regression models determined trends and patterns of sodium and potassium intake and the Na/K ratio. Models for survival-time data estimated the hazard of incident hypertension. RESULTS Sodium intake is decreasing but remains double the Institute of Medicine recommendations. Most sodium comes from added condiments. Adults in the central provinces have the highest sodium intake and the most rapid increase in hypertension. Potassium intake has increased slightly but is below half of the recommended amount. The Na/K ratio is significantly higher than the recommended amounts. Recent measurements of high sodium intake, low potassium intake, and high Na/K ratio have strong independent dose-response associations with incident hypertension. CONCLUSIONS Reducing sodium in processed foods, the major public health strategy in Western countries, may be less effective in China, where salt intake remains high. Replacing sodium with potassium in salt to control and prevent hypertension in China should be considered along with other public health and clinical prevention options.

Longitudinal Analysis of Dietary Patterns in Chinese Adults from 1991 to 2009

In the present study, we aimed to identify the changes or stability in the structure of dietary patterns and tracking, trends and factors related to the adherence to these dietary patterns in China from 1991 to 2009. We analysed dietary data collected during seven waves of the China Health and Nutrition Survey and included 9253 adults with complete dietary data for three or more waves. Dietary intake assessment was carried out over a 3 d period with 24 h recalls and a household food inventory. Using factor analysis in each wave, we found that the structure of the two dietary patterns identified remained stable over the studied period. The traditional southern dietary pattern was characterised by high intakes of rice, fresh leafy vegetables, low-fat red meat, pork, organ meats, poultry and fish/seafood and low intakes of wheat flour and maize/coarse grains and the modern high-wheat dietary pattern was characterised by high intakes of wheat buns/breads, cakes/cookies/pastries, deep-fried wheat, nuts/seeds, starchy root/tuber products, fruits, eggs/egg products, soya milk, animal-based milk and instant noodles/frozen dumplings. Temporal tracking (maintenance of a relative position over time) was higher for the traditional southern dietary pattern, whereas adherence to the modern high-wheat dietary pattern had an upward trend over time. Higher income, education and urbanicity levels were positively associated with both the dietary patterns, but the association became weaker in the later years. These results suggest that even in the context of rapid economic changes in China, the way people chose to combine their foods remained relatively stable. However, the increasing popularity of the modern high-wheat dietary pattern, a pattern associated with several energy-dense foods, is a cause of concern.

First-Year Evaluation of Mexico's Tax on Nonessential Energy-Dense Foods: An Observational Study.

Background In an effort to prevent continued increases in obesity and diabetes, in January 2014, the Mexican government implemented an 8% tax on nonessential foods with energy density ≥275 kcal/100 g and a peso-per-liter tax on sugar-sweetened beverages (SSBs). Limited rigorous evaluations of food taxes exist worldwide. The objective of this study was to examine changes in volume of taxed and untaxed packaged food purchases in response to these taxes in the entire sample and stratified by socioeconomic status (SES). Methods and Findings This study uses data on household packaged food purchases representative of the Mexican urban population from The Nielsen Company’s Mexico Consumer Panel Services (CPS). We included 6,248 households that participated in the Nielsen CPS in at least 2 mo during 2012–2014; average household follow-up was 32.7 mo. We analyzed the volume of purchases of taxed and untaxed foods from January 2012 to December 2014, using a longitudinal, fixed-effects model that adjusted for preexisting trends to test whether the observed post-tax trend was significantly different from the one expected based on the pre-tax trend. We controlled for household characteristics and contextual factors like minimum salary and unemployment rate. The mean volume of purchases of taxed foods in 2014 changed by -25 g (95% confidence interval = -46, -11) per capita per month, or a 5.1% change beyond what would have been expected based on pre-tax (2012–2013) trends, with no corresponding change in purchases of untaxed foods. Low SES households purchased on average 10.2% less taxed foods than expected (-44 [–72, –16] g per capita per month); medium SES households purchased 5.8% less taxed foods than expected (-28 [–46, –11] g per capita per month), whereas high SES households’ purchases did not change. The main limitations of our findings are the inability to infer causality because the taxes were implemented at the national level (lack of control group), our sample is only representative of urban areas, we only have 2 y of data prior to the tax, and, as with any consumer panel survey, we did not capture all foods purchased by the household. Conclusions Household purchases of nonessential energy-dense foods declined in the first year after the implementation of Mexico’s SSB and nonessential foods taxes. Future studies should evaluate the impact of the taxes on overall energy intake, dietary quality, and food purchase patterns (see S1 Abstract in Spanish).

Sugar-Sweetened Beverages Are the Main Sources of Added Sugar Intake in the Mexican Population

BACKGROUND Sugar intake has been associated with an increased prevalence of obesity, other noncommunicable diseases, and dental caries. The WHO recommends that free sugars should be <10% of total energy intake (TEI) and that additional health benefits could be obtained with a reduction below 5% of TEI. OBJECTIVE The objective of this study was to estimate the total, intrinsic, and added sugar intake in the Mexican diet and to identify the food groups that are the main sources of these sugars. METHODS We used data from a national probabilistic survey [ENSANUT (National Health and Nutrition Survey) 2012], which represents 3 geographic regions and urban and rural areas. Dietary information was obtained by administering a 24-h recall questionnaire to 10,096 participants. Total sugar intake was estimated by using the National Institute of Public Health (INSP) food-composition table and an established method to estimate added sugars. RESULTS The mean intakes of total, intrinsic, and added sugars were 365, 127, and 238 kcal/d, respectively. Added sugars contributed 13% of TEI. Sugar-sweetened beverages (SSBs) were the main source of sugars, contributing 69% of added sugars. Food products high in saturated fat and/or added sugar (HSFAS) were the second main sources of added sugars, contributing 25% of added sugars. CONCLUSIONS The average intake of added sugars in the Mexican diet is higher than WHO recommendations, which may partly explain the high prevalence of obesity and diabetes in Mexico. Because SSBs and HSFAS contribute >94% of total added sugars, strategies to reduce their intake should be strengthened. This includes stronger food labels to warn the consumer about the content of added sugars in foods and beverages.

Dietary pattern trajectories during 15 years of follow-up and HbA1c, insulin resistance and diabetes prevalence among Chinese adults

Background Most research on dietary patterns and health outcomes does not include longitudinal exposure data. We used an innovative technique to capture dietary pattern trajectories and their association with haemoglobin A1c (HbA1c), homeostasis model of insulin resistance (HOMA-IR) and prevalence of newly diagnosed diabetes. Methods We included 4096 adults with 3–6 waves of diet data (1991–2006) and biomarkers measured in 2009 from the China Health and Nutrition Survey. Diet was assessed with three 24-h recalls and a household food inventory. We used a dietary pattern previously identified with reduced rank regression that positively predicted diabetes in 2006 (high in wheat products and soy milk and low in rice, legumes, poultry, eggs and fish). We estimated a score for this dietary pattern for each subject at each wave. Using latent class trajectory analysis, we grouped subjects with similar dietary pattern score trajectories over time into five classes. Results Three trajectory classes were stable over time, and in two classes the diet became unhealthier over time (upward trend in dietary pattern score). Among two classes with similar scores in 2006, the one with the lower (healthier) initial score had an HbA1c 1.64% lower (−1.64 (95% CI −3.17 to −0.11)) and non-significantly a HOMA-IR 6.47% lower (−6.47 (−17.37 to 4.42)) and lower odds of diabetes (0.86 (0.44 to 1.67)). Conclusions Our findings suggest that dietary pattern trajectories with healthier scores longitudinally had a lower HbA1c compared with those with unhealthier scores, even when the trajectories had similar scores in the end point.

Using both Principal Component Analysis and Reduced Rank Regression to Study Dietary Patterns and Diabetes in Chinese Adults

OBJECTIVE We examined the association between dietary patterns and diabetes using the strengths of two methods: principal component analysis (PCA) to identify the eating patterns of the population and reduced rank regression (RRR) to derive a pattern that explains the variation in glycated Hb (HbA1c), homeostasis model assessment of insulin resistance (HOMA-IR) and fasting glucose. DESIGN We measured diet over a 3 d period with 24 h recalls and a household food inventory in 2006 and used it to derive PCA and RRR dietary patterns. The outcomes were measured in 2009. SETTING Adults (n 4316) from the China Health and Nutrition Survey. RESULTS The adjusted odds ratio for diabetes prevalence (HbA1c≥6·5 %), comparing the highest dietary pattern score quartile with the lowest, was 1·26 (95 % CI 0·76, 2·08) for a modern high-wheat pattern (PCA; wheat products, fruits, eggs, milk, instant noodles and frozen dumplings), 0·76 (95 % CI 0·49, 1·17) for a traditional southern pattern (PCA; rice, meat, poultry and fish) and 2·37 (95 % CI 1·56, 3·60) for the pattern derived with RRR. By comparing the dietary pattern structures of RRR and PCA, we found that the RRR pattern was also behaviourally meaningful. It combined the deleterious effects of the modern high-wheat pattern (high intakes of wheat buns and breads, deep-fried wheat and soya milk) with the deleterious effects of consuming the opposite of the traditional southern pattern (low intakes of rice, poultry and game, fish and seafood). CONCLUSIONS Our findings suggest that using both PCA and RRR provided useful insights when studying the association of dietary patterns with diabetes.

Sodium intake from various time frames and incident hypertension among Chinese adults.

Background: Although it is clear that there are short-term effects of sodium intake on blood pressure, little is known about the most relevant timing of sodium exposure for the onset of hypertension. This question can be addressed only in cohorts with repeated measures of sodium intake. Methods: Using up to seven measures of dietary sodium intake and blood pressure between 1991 and 2009, we compared the association of baseline, mean, and most recent sodium intake with incident hypertension, in 6578 adults enrolled in the China Health and Nutrition Survey (age 18 to 65 years and free of hypertension at baseline). We used survival methods that account for the interval-censored nature of this study and inverse-probability weights to generate adjusted survival curves and time-specific cumulative risk differences; hazard ratios were also estimated. Results: Baseline sodium intake was not associated with incident hypertension. For the mean and most recent measures, the probability of hypertension-free survival was the lowest among those with the highest sodium intake compared with all other intake groups across the entire follow-up. In addition, the most recent sodium intake had a positive dose-response association with incident hypertension (risk difference at 11 years of follow-up = 0.04 [95% confidence interval = 0.00 to 0.08], 0.06 [0.02 to 0.11], 0.18 [0.12 to 0.24], and 0.20 [0.12 to 0.27] for the second to fifth sodium-intake groups compared with the lowest group, respectively). Conclusion: We found that, among the various time frames, the most recent exposure to sodium was most strongly associated with incident hypertension.

Dietary Patterns and Cognitive Decline among Chinese Older Adults

Background: Prospective evidence of associations of dietary patterns with cognitive decline is limited and inconsistent. We examined how cognitive changes among Chinese older adults relate to either an adapted Mediterranean diet score or factor analysis-derived dietary patterns. Methods: This prospective cohort study comprised 1,650 adults ≥55 years of age, who completed a cognitive screening test at two or more waves of the China Health and Nutrition Survey in 1997, 2000, or 2004. Outcomes were repeated measures of global cognitive scores, composite cognitive z scores (standardized units [SU]), and standardized verbal memory scores (SU). Baseline diet was measured by 24-hour recalls over 3 days. We used linear mixed effects models to evaluate how changes in cognitive scores were associated with adapted Mediterranean diet score and two dietary pattern scores derived from factor analysis. Results: Among adults ≥65 years of age, compared with participants in the lowest tertile of adapted Mediterranean diet, those in the highest tertile had a slower rate of cognitive decline (difference in mean SU change/year &bgr; = 0.042; 95% confidence interval [CI]: 0.002, 0.081). A wheat-based diverse diet derived by factor analysis shared features of the adapted Mediterranean diet, with the top tertile associated with slower annual decline in global cognitive function (&bgr; = 0.069 SU/year; 95% CI: 0.023, 0.114). We observed no associations among adults <65 years of age. Conclusions: Our findings suggest that an adapted Mediterranean diet or a wheat-based, diverse diet with similar components may reduce the rate of cognitive decline in later life in the Chinese population.

Overview of the Dietary Intakes of the Mexican Population: Results from the National Health and Nutrition Survey 2012

BACKGROUND Mexico is facing the double burden of malnutrition: stunting and micronutrient deficiencies in young children, iron deficiency in pregnant women, and widespread obesity across age groups. OBJECTIVE The aim was to summarize and discuss findings published in this supplement on dietary intakes and the eating habits of the Mexican population. METHODS A 24-h recall questionnaire that used the multiple-pass method with a repeated measure in a fraction of the sample was applied in a nationally representative sample. We estimated mean intakes and percentages of inadequacy for macronutrients and micronutrients; mean intakes and percentages of the population who adhere to dietary recommendations for food groups; sources of added sugars; intakes of discretionary foods by mealtime, place, and activity; and mean dietary intakes in children <2 y old. RESULTS Infant formula was consumed by almost half of infants aged <6 mo and sugar-sweetened beverages were consumed by two-thirds of children aged 12-23 mo. In the different age groups, a high proportion of the population had excessive intakes of added sugars (58-85%) and saturated fats (54-92%), whereas a high prevalence of insufficient intakes was found for fiber (65-87%), vitamin A (8-70%), folates (13-69%), calcium (26-88%), and iron (46-89%). Discretionary foods (nonbasic foods high in saturated fats and/or added sugars) contributed 26% of the populations total energy intake, whereas only 1-23% met recommendations for legumes, seafood, fruit, vegetables, and dairy foods. CONCLUSIONS High proportions of Mexicans consume diets that do not meet recommendations. Breastfeeding and complementary feeding diverged from recommendations, intakes of discretionary foods were high, and the prevalence of nutrient inadequacies and age groups not meeting intake recommendations of basic food groups were also high. The results are consistent with the high prevalence of the double burden of malnutrition and are useful to design food and nutrition policies.

Intakes of Energy and Discretionary Food in Mexico Are Associated with the Context of Eating: Mealtime, Activity, and Place

BACKGROUND The prevalence of obesity and the intake of discretionary foods [high saturated fat and/or added sugar (HSFAS) products and sugar-sweetened beverages (SSBs)] are high in Mexico. It is important to understand whether the intakes of HSFAS products and SSBs are associated with the context in which they are consumed. OBJECTIVE Our aim was to estimate the associations between total energy and discretionary food (HSFAS products and SSBs) intakes and the context of eating (mealtime, activity, and place). METHODS We used data from 10,087 participants aged ≥1 y from the Mexican National Health and Nutrition Survey 2012. Dietary intake was estimated through a 24-h dietary recall that included questions on mealtime, activity, and place in which each food item was consumed. The associations between energy and discretionary food intakes and the context of eating were estimated by using multiple linear regression stratified by age group and adjusted for sociodemographic variables. RESULTS Compared with breakfast, the percentage of energy that HSFAS products contributed was 16-29 (range in all age groups) percentage points higher during midafternoon snacks and 16-23 percentage points lower at lunch and almuerzo (Mexican brunch); the percentage of energy from SSBs was 3.4-7.6 percentage points higher during midmorning snacks (P < 0.05). In many age groups and mealtimes, we found that compared with eating only while seated, the percentage of energy as HSFAS was 5.3-14 percentage points higher when watching television (P < 0.05). Compared with eating at home, the percentage of energy from HSFAS was 12-26 percentage points higher on the street and the percentage of energy from SSBs was 3.4-6.0 percentage points higher at school and 2.9-15 percentage points higher at work (P < 0.05). CONCLUSIONS These results highlight the need to promote healthier food selection among the Mexican population when snacking and watching television and healthier food environments at work, school, and on the street.