Valisa E. Hedrick

Dietary biomarkers: advances, limitations and future directions

The subjective nature of self-reported dietary intake assessment methods presents numerous challenges to obtaining accurate dietary intake and nutritional status. This limitation can be overcome by the use of dietary biomarkers, which are able to objectively assess dietary consumption (or exposure) without the bias of self-reported dietary intake errors. The need for dietary biomarkers was addressed by the Institute of Medicine, who recognized the lack of nutritional biomarkers as a knowledge gap requiring future research. The purpose of this article is to review existing literature on currently available dietary biomarkers, including novel biomarkers of specific foods and dietary components, and assess the validity, reliability and sensitivity of the markers. This review revealed several biomarkers in need of additional validation research; research is also needed to produce sensitive, specific, cost-effective and noninvasive dietary biomarkers. The emerging field of metabolomics may help to advance the development of food/nutrient biomarkers, yet advances in food metabolome databases are needed. The availability of biomarkers that estimate intake of specific foods and dietary components could greatly enhance nutritional research targeting compliance to national recommendations as well as direct associations with disease outcomes. More research is necessary to refine existing biomarkers by accounting for confounding factors, to establish new indicators of specific food intake, and to develop techniques that are cost-effective, noninvasive, rapid and accurate measures of nutritional status.

The beverage intake questionnaire: determining initial validity and reliability.

Consuming energy-containing beverages may lead to weight gain, yet research investigating this issue is limited. An easily administered beverage intake assessment tool could facilitate research on this topic. The purpose of this cross-sectional investigation was to determine the validity and reliability of a self-administered beverage intake questionnaire (BEVQ) that estimates mean daily intake of beverages consumed across 19 beverage categories. Participants (N=105; aged 39+/-2 years) underwent assessments of height, weight, body mass index, and dietary intake using 4-day food intake records from June 2008 to June 2009. The BEVQ was completed at two additional visits (BEVQ1, BEVQ2). Urine samples were collected to objectively determine total fluid intake and encourage accurate self-reporting. Validity was assessed by comparing BEVQ1 with food intake record results; reliability was assessed by comparing BEVQ1 and BEVQ2. Analyses included descriptive statistics, bivariate correlations, paired samples t tests, and independent samples t tests. Self-reported water and total beverage intake (in grams) were not different between the BEVQ1 and food intake records (mean difference 129+/-77 g [P=0.096] and 61+/-106 g [P=0.567], respectively). Total beverage and sugar-sweetened beverage energy intake were significantly different, although mean differences were small (63 and 44 kcal, respectively). Daily consumption (in grams) of water (r=0.53), total beverages (r=0.46), and sugar-sweetened beverages (r=0.49) determined by the BEVQ1 were correlated with reported intake determined by the food intake record, as was energy from total beverages (r=0.61) and sugar-sweetened beverages (r=0.59) (all P values <0.001). Reliability was demonstrated, with correlations (P<0.001) detected between BEVQ1 and BEVQ2 results. The BEVQ is a valid, reliable, and rapid self-administered dietary assessment tool.

Association of δ13C in Fingerstick Blood with Added-Sugar and Sugar-Sweetened Beverage Intake

A reliance on self-reported dietary intake measures is a common research limitation, thus the need for dietary biomarkers. Added-sugar intake may play a role in the development and progression of obesity and related comorbidities; common sweeteners include corn and sugar cane derivatives. These plants contain a high amount of ¹³C, a naturally occurring stable carbon isotope. Consumption of these sweeteners, of which sugar-sweetened beverages are the primary dietary source, might be reflected in the δ¹³C value of blood. Fingerstick blood represents an ideal substrate for bioassay because of its ease of acquisition. The objective of this investigation was to determine if the δ¹³C value of fingerstick blood is a potential biomarker of added-sugar and sugar-sweetened beverage intake. Individuals aged 21 years and older (n = 60) were recruited to attend three laboratory visits; assessments completed at each visit depended upon a randomly assigned sequence (sequence one or two). The initial visit included assessment of height, weight, and dietary intake (sequence one: beverage intake questionnaire, sequence two: 4-day food intake record). Sequence one participants completed a food intake record at visit two, and nonfasting blood samples were obtained via routine fingersticks at visits one and three. Sequence two participants completed a beverage intake questionnaire at visit two, and provided fingerstick blood samples at visits two and three. Samples were analyzed for δ¹³C value using natural abundance stable isotope mass spectrometry. δ¹³C value was compared to dietary outcomes in all participants, as well as among those in the highest and lowest tertile of added-sugar intake. Reported mean added-sugar consumption was 66 ± 5 g/day, and sugar-sweetened beverage consumption was 330 ± 53 g/day and 134 ± 25 kcal/day. Mean fingerstick δ¹³C value was -19.94‰ ± 0.10‰, which differed by body mass index status. δ¹³C value was associated (all P < 0.05) with intake of total added sugars (g, r = 0.37; kcal, r = 0.37), soft drinks (g, r = 0.26; kcal, r = 0.27), and total sugar-sweetened beverage (g, r = 0.28; kcal, r = 0.35). The δ¹³C value in the lowest and the highest added-sugar intake tertiles were significantly different (mean difference = -0.48‰; P = 0.028). Although there are several potential dietary sources for blood carbon, the δ¹³C value of fingerstick blood shows promise as a noninvasive biomarker of added-sugar and sugar-sweetened beverage intake based on these findings.

Talking Health, A pragmatic randomized-controlled health literacy trial targeting sugar-sweetened beverage consumption among adults: Rationale, design & methods

High consumption of sugar-sweetened beverages (SSB) contributes to a wide range of poor health outcomes. Further, few US adults drink less than the recommended ≤8 oz per day; and individuals with low socioeconomic, low health literacy status, and in rural areas are even less likely to meet recommendations. Unfortunately, few SSB behavioral interventions exist targeting adults, and none focus on low health literacy in rural areas. Talking Health, a type 1 effectiveness-implementation hybrid trial targeting adults in rural southwest Virginia, was developed using the RE-AIM planning and evaluation framework (reach, effectiveness, adoption, implementation, maintenance). The primary aim of this pragmatic randomized-controlled trial was to determine the effectiveness of a scalable 6-month intervention aimed at decreasing SSB consumption (SIPsmartER) when compared to a matched contact physical activity promotion control group (MoveMore). SIPsmartER was developed based upon the Theory of Planned Behavior and uses health literacy strategies to improve comprehension of the intervention content among participants. MoveMore is based on a research-tested intervention that was adapted to address all theory of planned behavior constructs and health literacy principles. Secondary aims include additional health outcomes (e.g., physical activity, weight) and reach, adoption, implementation, and maintenance indicators. This paper highlights the opportunities and considerations for developing health behavior trials that aim to determine intervention effectiveness, provide all study participants an opportunity to benefit from research participation, and collect key information on reach and the potential for organizational adoption, implementation, and maintenance with the longer-term goal of speeding translation into practice settings.

A rapid beverage intake questionnaire can detect changes in beverage intake

UNLABELLED Attention on beverage intake, specifically sugar-sweetened beverages (SSB), has increased in recent years. A brief valid, reliable and sensitive assessment tool for quantifying beverage consumption and determining its influence on weight status could help to advance research on this topic. The valid and reliable 15-item beverage questionnaire (BEVQ-15) estimates mean daily intake of water, SSB and total beverages (g, kcal) across multiple beverage categories. OBJECTIVE to determine the ability of the BEVQ-15 to detect changes in beverage intake over time. Participants (n=70; age=37±2 yr; BMI=24.5±0.4 kg/m(2)) underwent two randomly assigned 30-day periods (intervention, increased water and fruit juice consumption; control, increased solid fruit consumption), with a 30-day washout phase between feeding periods. The BEVQ-15 was administered at the beginning and end of each period. Reliability was assessed by Pearsons correlations, paired sample t tests and Cronbachs alpha. Paired sample t tests and repeated measures ANOVA were used to evaluate sensitivity to change. Sixty-nine participants completed all study sessions. Reliability was acceptable for most beverages (range: R(2)=0.52-0.95, P<0.001), but not for energy drinks. Increases in water (g), juice (kcal, g) and total beverage (g) were detected during the intervention period (P<0.001); no changes in these variables were detected in the control period. The BEVQ-15 demonstrates the ability to detect changes in beverage intake over time. This brief (~2 min), self-administered, valid, reliable and sensitive beverage intake assessment tool may be used by researchers and practitioners who evaluate and intervene upon beverage intake patterns in adults.

DASH to Wellness: Emphasizing Self-Regulation Through E-Health in Adults With Prehypertension

OBJECTIVE High prevalence rates of prehypertension require nonpharmaceutical lifestyle interventions. The objective of this study was to assess the feasibility and initial efficacy of a primarily electronically delivered intervention for prehypertension. METHODS Twenty-three adults with prehypertension (M age of 54.3; systolic blood pressure [BP], 126.3 mmHg; weight, 87.8 kg; body mass index, 31.5; 6514 steps/day) were randomized to DASH 2 wellness only standard of care or to DASH 2 wellness plus. Both groups received instruction on the DASH eating plan, instructions to increase steps per day and use of a weight scale and pedometer, and information about social-cognitive theory-based self-regulation strategies. D2W plus also involved home blood pressure monitoring and monitoring steps per day, nutrition, and body weight. Through weekly newsletters, participants engaged in electronic reporting and goal setting and received feedback on progress. RESULTS D2W plus showed a larger increase in daily steps (M = 2,900) than D2W only (M = 636); a larger decrease in systolic BP (mmHg), M = 15.1 versus M = 4.6, and a larger decrease in weight (in kg), M = 4.8 versus M = 1.5. CONCLUSIONS Concentrating efforts not only toward adoption and initiation of innovative risk-reduction strategies but also toward the provision for long-term maintenance of a healthy lifestyle once initial changes have been accomplished is paramount. The D2W plus program could be adapted for such use in health care and other settings for treating prehypertension.

Assessing Initial Validity and Reliability of a Beverage Intake Questionnaire in Hispanic Preschool-Aged Children

BACKGROUND Understanding the relationship between high-calorie beverage consumption and weight gain requires an accurate report of dietary intake. A critical need exists to develop and test the psychometrics of brief quantitative tools for minority pediatric populations. OBJECTIVE To modify the adult beverage intake questionnaire (BEVQ-15) for Hispanic preschool-aged children (BEVQ-PS) and test its validity and test-retest reliability in children aged 3 to 5 years. DESIGN Cross-sectional. The modified quantitative 12-beverage category questionnaire assessed consumption of water, fruit juice, sweetened juice drinks, whole milk, reduced-fat milk, low-fat milk, flavored milk, carbonated sweetened drinks, diet carbonated drinks, sweet tea, tea with or without artificial sweetener, and sport drinks consumed during the past month. Hispanic mothers (n=109) recruited from day-care centers provided one 4-day food intake record (FIR) and completed two BEVQ-PS surveys during a 2-week period for their preschool-aged child. Data collection was conducted through one-on-one interviews in Spanish. Validity was assessed by comparing amounts (in grams) and energy intake (in kilocalories) for each beverage category between the first BEVQ-PS and the mean of the FIRs using paired t tests and Pearsons correlation coefficient. Criteria for validity were nonsignificant mean differences in grams and kilocalories from the first BEVQ-PS and mean of the FIRs beverage categories, and significant correlation coefficients between beverage categories. Test-retest reliability was assessed by comparing grams and kilocalories for each beverage category in the first BEVQ-PS with those from the second BEVQ-PS using Pearsons correlation coefficient. The criterion for reliability was a significant correlation coefficient between beverage categories. Significance was set at P<0.05. RESULTS Mean differences between the first BEVQ-PS and FIR for water (42.4±23.1 g), sweetened juice drinks (-1.6±11.0 g), whole milk (18.3±9.91 g), sweetened carbonated drinks (-13.0±7.9 g), and total sugar-sweetened beverages (SSB) (1.4±8.9 g) were not significantly different, but were significantly correlated (r=0.20 to 0.37; P<0.05). Thus, validity criteria were met. With the exception of flavored milk and tea with or without artificial sweeteners, the remaining beverage categories-total beverages and SSB-in the first BEVQ-PS were correlated with those from the second BEVQ-PS (r=0.20 to 0.68; P<0.05), meeting reliability criteria. CONCLUSIONS Researchers and clinicians may use the BEVQ-PS to assess SSB, water, and whole-milk intake in Hispanic children. Additional modifications should be evaluated to assess total beverage intake.

Is Beverage Consumption Related to Specific Dietary Pattern Intakes

Evaluating dietary patterns, rather than the consumption of single food items or nutrients, can provide a greater understanding of diet and health relationships. Dietary pattern research has been specifically identified as a research gap by the US Dietary Guidelines Committees. The purpose of this review was to determine if associations exist between the intake of commonly consumed beverages and specific dietary patterns. This review provides strong evidence that the consumption of water, unsweetened tea/coffee, low-fat milk, artificially sweetened beverages, and fruit/vegetable juice closely align with a Prudent dietary pattern; and conversely, the consumption of high-fat milk, alcohol, and sugar-sweetened beverages are strongly associated with a Western dietary pattern. Future directions include: 1) continuing to examine beverage intake patterns and define their relationship to dietary patterns, 2) developing a measure of overall beverage intake quality to assess beverage patterns, and 3) identifying beverage patterns that are associated with health and disease outcomes.

Dietary quality changes in response to a sugar-sweetened beverage–reduction intervention: results from the Talking Health randomized controlled clinical trial

Background: The reduction of sugar-sweetened beverage (SSB) intake may be beneficial for weight management and other related health conditions; however, to our knowledge, no data exist regarding the spontaneous changes in other dietary components or the overall dietary quality after an SSB-reduction intervention.Objectives: We explored longitudinal changes within and between an SSB-reduction intervention (SIPsmartER) and a physical activity intervention (MoveMore) with respect to spontaneous changes in 1) energy intake and macronutrients and micronutrients, 2) dietary quality [Healthy Eating Index-2010 (HEI)], and 3) beverage categories.Design: Participants were enrolled in a 6-mo, community-based behavioral trial and randomly assigned into either the SIPsmartER (n = 149) intervention group or the MoveMore (n = 143) matched-contact comparison group. Dietary intake was assessed through a mean of three 24-h dietary recalls at baseline and 6 mo. Dietary recalls were analyzed with the use of nutritional analysis software. A multilevel, mixed-effects linear regression with intention-to-treat analyses is presented.Results: SIPsmartER participants showed a significant reduction in total SSBs (mean decrease: -366 mL; P ≤ 0.001). Several spontaneous changes occurred within the SIPsmartER group and, compared with the MoveMore group, included significant HEI improvements for empty calorie, total vegetable, and total HEI scores (mean increases: 2.6, 0.3, and 2.6, respectively; all P ≤ 0.01). Additional positive changes were shown, including significant decreases in total energy intake, trans fat, added sugars, and total beverage energy (all P ≤ 0.05). Few dietary changes were noted in the MoveMore group over the 6-mo intervention.Conclusions: Intervention of the single dietary component SSB resulted in additional spontaneous and beneficial dietary changes. Interventions that target a single dietary change, such as limiting SSB intake to <240 mL/d (<8 fl oz/d), may improve the overall dietary quality health and provide motivation to make additional dietary changes. This trial was registered at clinicaltrials.gov as NCT02193009.

Characterization of Non-Nutritive Sweetener Intake in Rural Southwest Virginian Adults Living in a Health-Disparate Region

Few data assessing non-nutritive sweetener (NNS) intake are available, especially within rural, health-disparate populations, where obesity and related co-morbidities are prevalent. The objective of this study is to characterize NNS intake for this population and examine the variance in demographics, cardio-metabolic outcomes, and dietary intake between NNS consumers and non-consumers. A cross-sectional sample (n = 301) of Virginian adults from a randomized controlled trial (data collected from 2012 to 2014) targeting sugar-sweetened beverage (SSB) intake completed three 24-h dietary recalls, and demographics and cardio-metabolic measures were assessed. The frequency, types, and sources of NNS consumption were identified. Thirty-three percent of participants reported consuming NNS (n = 100). Sucralose was the largest contributor of mean daily NNS intake by weight (mg), followed by aspartame, acesulfame potassium, and saccharin. NNS in tabletop sweeteners, diet tea, and diet soda were the top contributors to absolute NNS intake. The most frequently consumed NNS sources were diet sodas, juice drinks, and tabletop sweeteners. Although mean body mass index (BMI) was greater for NNS consumers, they demonstrated significantly lower food, beverage, and SSB caloric intake and energy density, and higher overall dietary quality. It remains unclear whether NNS use plays a role in exacerbating weight gain. NNS consumers in this sample may have switched from drinking predominantly SSB to drinking some NNS beverages in an effort to cope with weight gain. Future studies should explore motivations for NNS use across a variety of weight and health categories.