Sharon I. Kirkpatrick

Update of the Healthy Eating Index: HEI-2010

The Healthy Eating Index (HEI) is a measure of diet quality in terms of conformance with federal dietary guidance. Publication of the 2010 Dietary Guidelines for Americans prompted an interagency working group to update the HEI. The HEI-2010 retains several features of the 2005 version: (a) it has 12 components, many unchanged, including nine adequacy and three moderation components; (b) it uses a density approach to set standards, eg, per 1,000 calories or as a percentage of calories; and (c) it employs least-restrictive standards; ie, those that are easiest to achieve among recommendations that vary by energy level, sex, and/or age. Changes to the index include: (a) the Greens and Beans component replaces Dark Green and Orange Vegetables and Legumes; (b) Seafood and Plant Proteins has been added to capture specific choices from the protein group; (c) Fatty Acids, a ratio of polyunsaturated and monounsaturated to saturated fatty acids, replaces Oils and Saturated Fat to acknowledge the recommendation to replace saturated fat with monounsaturated and polyunsaturated fatty acids; and (d) a moderation component, Refined Grains, replaces the adequacy component, Total Grains, to assess overconsumption. The HEI-2010 captures the key recommendations of the 2010 Dietary Guidelines and, like earlier versions, will be used to assess the diet quality of the US population and subpopulations, evaluate interventions, research dietary patterns, and evaluate various aspects of the food environment.

Income and Race/Ethnicity Are Associated with Adherence to Food-Based Dietary Guidance among US Adults and Children

BACKGROUND Income and race/ethnicity are associated with differences in dietary intakes that may contribute to health disparities among members of the US population. OBJECTIVE To examine alignment of intakes of food groups and energy from solid fats, added sugars, and alcohol with the 2005 Dietary Guidelines for Americans and MyPyramid, by family income and race/ethnicity. DESIGN Data from the National Health and Nutrition Examination Survey, a cross-sectional, nationally representative survey, for 2001-2004. PARTICIPANTS/SETTING Persons aged ≥2 years for whom reliable dietary intake data were available (n=16,338) were categorized by income (lowest, middle, and highest) and race/ethnicity (non-Hispanic white, non-Hispanic black, and Mexican American). STATISTICAL ANALYSES PERFORMED The National Cancer Institute method was used to estimate the proportions of adults and children in each income and race/ethnic group whose usual intakes met the recommendations. RESULTS Higher income was associated with greater adherence to recommendations for most food groups; the proportions meeting minimum recommendations among adults in the highest income group were double that observed for the lowest income group for total vegetables, milk, and oils. Fewer differences by income were apparent among children. Among the race/ethnic groups, the proportions meeting recommendations were generally lowest among non-Hispanic blacks. Marked differences were observed for milk-15% of non-Hispanic black children met the minimum recommendations compared with 42% of non-Hispanic white children and 35% of Mexican-American children; a similar pattern was evident for adults. One in five Mexican-American adults met the dry beans and peas recommendations compared with approximately 2% of non-Hispanic whites and non-Hispanic blacks. Most adults and children consumed excess energy from solid fats and added sugars irrespective of income and race/ethnicity. CONCLUSIONS The diets of some subpopulations, particularly individuals in lower-income households and non-Hispanic blacks, are especially poor in relation to dietary recommendations, supporting the need for comprehensive strategies to enable healthier dietary intake patterns.

The Automated Self-Administered 24-Hour Dietary Recall (ASA24): A Resource for Researchers, Clinicians, and Educators from the National Cancer Institute

Extensive evidence has demonstrated that 24-hour dietary recalls (24HDRs) provide high-quality dietary intake data with minimal bias, making them the preferred tool for monitoring the diets of populations and, increasingly, for studying diet and disease associations (1-3). Traditional 24HDRs, however, are expensive and impractical for large-scale research because they rely on trained interviewers, and multiple administrations are needed to estimate usual intakes. To address these challenges, the National Cancer Institute (NCI), in collaboration with the research firm Westat (Rockville, MD), and with the support of other institutes and offices at the National Institutes of Health, developed the Automated Self-Administered 24-hour dietary recall (ASA24) (4-6). ASA24 is a public-access, freely available, web-based tool for researchers, clinicians and educators, modeled on the Automated Multiple Pass Method (AMPM) (7). Development of an automated self-administered 24HDR for adults began in 2006 and was informed by input from stakeholders participating in an External Working Group and small-scale cognitive and usability testing (4,5). A Beta version released in August 2009 has been used by over 175 researchers to collect over 40,000 recalls; Version 1, which offers improved usability and new features, was released in September 2011 (8). A modified version intended for self-administration by children is under development by researchers at the Baylor College of Medicine (Houston, TX) and is expected to be available mid-2012 (9,10). This paper describes the features of ASA24 and planned evaluations.

Addressing Current Criticism Regarding the Value of Self-Report Dietary Data

Recent reports have asserted that, because of energy underreporting, dietary self-report data suffer from measurement error so great that findings that rely on them are of no value. This commentary considers the amassed evidence that shows that self-report dietary intake data can successfully be used to inform dietary guidance and public health policy. Topics discussed include what is known and what can be done about the measurement error inherent in data collected by using self-report dietary assessment instruments and the extent and magnitude of underreporting energy compared with other nutrients and food groups. Also discussed is the overall impact of energy underreporting on dietary surveillance and nutritional epidemiology. In conclusion, 7 specific recommendations for collecting, analyzing, and interpreting self-report dietary data are provided: (1) continue to collect self-report dietary intake data because they contain valuable, rich, and critical information about foods and beverages consumed by populations that can be used to inform nutrition policy and assess diet-disease associations; (2) do not use self-reported energy intake as a measure of true energy intake; (3) do use self-reported energy intake for energy adjustment of other self-reported dietary constituents to improve risk estimation in studies of diet-health associations; (4) acknowledge the limitations of self-report dietary data and analyze and interpret them appropriately; (5) design studies and conduct analyses that allow adjustment for measurement error; (6) design new epidemiologic studies to collect dietary data from both short-term (recalls or food records) and long-term (food-frequency questionnaires) instruments on the entire study population to allow for maximizing the strengths of each instrument; and (7) continue to develop, evaluate, and further expand methods of dietary assessment, including dietary biomarkers and methods using new technologies.

Rose's population strategy of prevention need not increase social inequalities in health

Geoffrey Roses 1985 paper, Sick individuals and sick populations, continues to spark debate and discussion. Since this original publication, there have been two notable challenges to Roses population strategy of prevention. First, identification of high-risk individuals has improved considerably in accuracy, which some believe obviates the need for population-wide prevention strategies. Secondly, and more recently, it has been suggested that population strategies of prevention may inadvertently worsen social inequalities in health. We argue that population prevention will not necessarily worsen social inequalities in health, and the likelihood of it doing so will depend on whether the prevention strategy is more structural (targets conditions in which behaviours occur) or agentic (targets behaviour change among individuals) in nature. Also, there are potential drawbacks of approaches that focus on discrete populations (i.e. high risk or vulnerable) that need to be considered when selecting a strategy. Although Roses ideas need to be continually scrutinized, his population strategy of prevention still holds considerable merit for improving population health and narrowing social inequalities in health.

The relationship between low income and household food expenditure patterns in Canada

OBJECTIVES To compare food expenditure patterns between low-income households and higher- income households in the Canadian population, and to examine the relationship between food expenditure patterns and the presence or absence of housing payments among low-income households. DESIGN Secondary data analysis of the 1996 Family Food Expenditure Survey conducted by Statistics Canada. SETTING Sociodemographic data and 1-week food expenditure data for 9793 households were analysed. SUBJECTS Data were collected from a nationally representative sample drawn through stratified multistage sampling. Low-income households were identified using Statistics Canadas Low Income Measures. RESULTS Total food expenditures, expenditures at stores and expenditures in restaurants were lower among low-income households compared with other households. Despite allocating a slightly greater proportion of their food dollars to milk products, low-income households purchased significantly fewer servings of these foods. They also purchased fewer servings of fruits and vegetables than did higher-income households. The effect of low income on milk product purchases persisted when the sample was stratified by education and expenditure patterns were examined in relation to income within strata. Among low-income households, the purchase of milk products and meat and alternatives was significantly lower for households that had to pay rents or mortgages than for those without housing payments. CONCLUSIONS Our findings indicate that, among Canadian households, access to milk products and fruits and vegetables may be constrained in the context of low incomes. This study highlights the need for greater attention to the affordability of nutritious foods for low-income groups.

Performance of the Automated Self-Administered 24-hour Recall relative to a measure of true intakes and to an interviewer-administered 24-h recall

BACKGROUND The Automated Self-Administered 24-hour Recall (ASA24), a freely available Web-based tool, was developed to enhance the feasibility of collecting high-quality dietary intake data from large samples. OBJECTIVE The purpose of this study was to assess the criterion validity of ASA24 through a feeding study in which the true intake for 3 meals was known. DESIGN True intake and plate waste from 3 meals were ascertained for 81 adults by inconspicuously weighing foods and beverages offered at a buffet before and after each participant served him- or herself. Participants were randomly assigned to complete an ASA24 or an interviewer-administered Automated Multiple-Pass Method (AMPM) recall the following day. With the use of linear and Poisson regression analysis, we examined the associations between recall mode and 1) the proportions of items consumed for which a match was reported and that were excluded, 2) the number of intrusions (items reported but not consumed), and 3) differences between energy, nutrient, food group, and portion size estimates based on true and reported intakes. RESULTS Respondents completing ASA24 reported 80% of items truly consumed compared with 83% in AMPM (P = 0.07). For both ASA24 and AMPM, additions to or ingredients in multicomponent foods and drinks were more frequently omitted than were main foods or drinks. The number of intrusions was higher in ASA24 (P < 0.01). Little evidence of differences by recall mode was found in the gap between true and reported energy, nutrient, and food group intakes or portion sizes. CONCLUSIONS Although the interviewer-administered AMPM performed somewhat better relative to true intakes for matches, exclusions, and intrusions, ASA24 performed well. Given the substantial cost savings that ASA24 offers, it has the potential to make important contributions to research aimed at describing the diets of populations, assessing the effect of interventions on diet, and elucidating diet and health relations. This trial was registered at clinicaltrials.gov as NCT00978406.

Housing Circumstances are Associated with Household Food Access among Low-Income Urban Families

Household food insecurity is a pervasive problem in North America with serious health consequences. While affordable housing has been cited as a potential policy approach to improve food insecurity, the relationship between conventional notions of housing affordability and household food security is not well understood. Furthermore, the influence of housing subsidies, a key policy intervention aimed at improving housing affordability in Western countries, on food insecurity is unclear. We undertook a cross-sectional survey of 473 families in market rental (n = 222) and subsidized (n = 251) housing in high-poverty urban neighborhoods to examine the influence of housing circumstances on household food security. Food insecurity, evident among two thirds of families, was inversely associated with income and after-shelter income. Food insecurity prevalence did not differ between families in market and subsidized housing, but families in subsidized housing had lower odds of food insecurity than those on a waiting list for such housing. Market families with housing costs that consumed more than 30% of their income had increased odds of food insecurity. Rent arrears were also positively associated with food insecurity. Compromises in housing quality were evident, perhaps reflecting the impact of financial constraints on multiple basic needs as well as conscious efforts to contain housing costs to free up resources for food and other needs. Our findings raise questions about current housing affordability norms and highlight the need for a review of housing interventions to ensure that they enable families to maintain adequate housing and obtain their other basic needs.

Assessing the relevance of neighbourhood characteristics to the household food security of low-income Toronto families

OBJECTIVE Although the sociodemographic characteristics of food-insecure households have been well documented, there has been little examination of neighbourhood characteristics in relation to this problem. In the present study we examined the association between household food security and neighbourhood features including geographic food access and perceived neighbourhood social capital. DESIGN Cross-sectional survey and mapping of discount supermarkets and community food programmes. SETTING Twelve high-poverty neighbourhoods in Toronto, Ontario, Canada. SUBJECTS Respondents from 484 low-income families who had children and who lived in rental accommodations. RESULTS Food insecurity was pervasive, affecting two-thirds of families with about a quarter categorized as severely food insecure, indicative of food deprivation. Food insecurity was associated with household factors including income and income source. However, food security did not appear to be mitigated by proximity to food retail or community food programmes, and high rates of food insecurity were observed in neighbourhoods with good geographic food access. While low perceived neighbourhood social capital was associated with higher odds of food insecurity, this effect did not persist once we accounted for household sociodemographic factors. CONCLUSIONS Our findings raise questions about the extent to which neighbourhood-level interventions to improve factors such as food access or social cohesion can mitigate problems of food insecurity that are rooted in resource constraints. In contrast, the results reinforce the importance of household-level characteristics and highlight the need for interventions to address the financial constraints that underlie problems of food insecurity.

Index-based Dietary Patterns and the Risk of Prostate Cancer in the NIH-AARP Diet and Health Study

Few studies have investigated the relationship between overall diet and the risk of prostate cancer. We examined the association between 3 diet quality indices-the Healthy Eating Index-2005 (HEI-2005), Alternate Healthy Eating Index-2010 (AHEI-2010), and alternate Mediterranean diet score (aMED)-and prostate cancer risk. At baseline, dietary intake was assessed in a cohort of 293,464 US men in the National Institutes of Health (NIH)-AARP Diet and Health Study. Cox proportional hazards regression was used to estimate hazard ratios. Between 1995 and 2006, we ascertained 23,453 incident cases of prostate cancer, including 2,251 advanced cases and 428 fatal cases. Among men who reported a history of prostate-specific antigen testing, high HEI-2005 and AHEI-2010 scores were associated with lower risk of total prostate cancer (for the highest quintile compared with the lowest, hazard ratio (HR) = 0.92, 95% confidence interval (CI): 0.86, 0.98, P for trend = 0.01; and HR = 0.93, 95% CI: 0.88, 0.99, P for trend = 0.05, respectively). No significant association was observed between aMED score and total prostate cancer or between any of the indices and advanced or fatal prostate cancer, regardless of prostate-specific antigen testing status. In individual component analyses, the fish component of aMED and ω-3 fatty acids component of AHEI-2010 were inversely associated with fatal prostate cancer (HR = 0.79, 95% CI: 0.65, 0.96, and HR = 0.94, 95% CI: 0.90, 0.98, respectively).