Selecting a healthy diet score: lessons from a study of diet and health in early old age (the Boyd Orr cohort)

The association between healthy diet indicator and phytochemical index with prostate cancer odds ratio: a case-control study

BACKGROUND AND OBJECTIVE

Healthy diets and diets rich in phytochemicals can have health-promoting benefits in prostate cancer. Therefore, this study aimed to explore the possible association between Healthy Diet Indicator (HDI) and Phytochemical Index (PI) with prostate cancer odds ratio.

METHODS

This is a case-control study conducted in Shiraz, Iran, involving 62 newly diagnosed prostate cancer cases and 63 hospital-based controls. The study collected demographic and anthropometric data, as well as dietary intake information via a semi-quantitative food frequency questionnaire. Logistic regression models were employed to evaluate the association between HDI and PI with prostate cancer.

RESULTS

The study included 120 participants and found that individuals with higher HDI and PI scores had a lower odds ratio of prostate cancer (HDI: odds ratio (OR): 0.322 - confidence interval (CI) 95%: 0.14-0.700 - PI: OR: 0.426 - CI 95%: 0.204-0.888). After adjusting for potential confounders, a lower odds ratio of prostate cancer was observed specifically among those with higher HDI scores (OR: 0.376 - CI 95%: 0.163-0.868).

CONCLUSION

The findings of the present study suggest that adopting healthier dietary habits rich in dietary phytochemicals could be effective in preventing and halting the progression of prostate cancer.

The association between ultra-processed foods and conventional markers of cardiovascular risk in an adult Iranian population

BACKGROUND AND AIMS

According to the NOVA classification system, ultra-processed foods result from extensive industrial processing and use ingredients derived from food and non-food products, which can negatively impact on cardiovascular disease risk factors. Despite this, few studies have investigated UPFs in Middle Eastern populations regardless of high consumption in this region.

METHODS AND RESULTS

This cross-sectional study was conducted on data from the Prospective Epidemiological Research Studies in Iran Kharemeh cohort (n = 6611). Food frequency questionnaires were assessed and the ratio of total UPFs energy/total energy intake was calculated. Data was categorized into tertiles of UPF consumption using the NOVA classification system. Kruskal-Wallis tests were used to assess differences in nutrient and food intakes between tertiles and logistic regression analysis was applied to assess the associations between UPFs and CVD risk factors. After adjustment for potential confounders the logistic regression analysis revealed significant positive relationships between intakes of UPFs and waist circumference (WC) (T2: OR; 1.34, 95% CI; 1.13-1.60 - T3: OR; 1.41, 95% CI; 1.18-1.69, P ˂0.001), low-density lipoprotein cholesterol (LDL-C) (T2: OR; 1.20, 95% CI; 1.05-1.37 - T3: OR; 1.27, 95% CI; 1.11-1.45, P ˂0.001), non-high-density lipoprotein cholesterol (non-HDL) (T2: OR; 1.21, 95% CI; 1.07-1.37 - T3: OR; 1.24, 95% CI; 1.10-1.41, P ˂0.001) and LDL-C to HDL-C ratio (T2: OR; 1.15, 95% CI; 1.02-1.31 - T3: OR; 1.21, 95% CI; 1.07-1.38, P = 0.002).

CONCLUSION

The consumption of UPFs was positively associated with WC and atherogenic blood lipids. However, increased intakes of fiber and unsaturated fats were also found in those consuming more UPFs, which was not expected. These findings offer insights into an understudied population and warrant further research.

Pre-Diagnosis Dietary Patterns and Risk of Multiple Myeloma in the NIH-AARP Diet and Health Study

Background

Despite patient interest in knowing whether diet is linked to multiple myeloma (MM), there is limited research on dietary patterns and MM risk. Two studies have assessed this risk, albeit with a small number of MM cases. The EPIC-Oxford cohort and Oxford Vegetarian study (65 MM cases) showed that fish eaters, vegetarians and vegans had significantly reduced MM risk compared to meat eaters. The Nurses' Health Study and Health Professionals Follow-up Study (478 MM cases) showed a significantly increased MM risk in men with Empirical Dietary Inflammatory Pattern.

Methods

The NIH-AARP Diet and Health study is a prospective cohort of 567,169 persons who completed a food frequency questionnaire in 1995-1996 and were followed until December 2011. Healthy Eating Index-2015 (HEI-2015), Healthy Diet Score (HDS), alternate Mediterranean Diet (aMED) and healthful Plant-based Diet Index (hPDI) scores were calculated using a priori defined methods and grouped into quartiles, with higher scores reflecting healthier eating patterns. We prospectively evaluated the association between pre-diagnosis dietary patterns and MM incidence in this cohort. Hazard ratios (HR) and 95% confidence intervals (95%CI) were estimated using multivariate Cox proportional hazards models adjusted for age at study entry, sex, race, body mass index, education, and total energy intake (by residual method). Sensitivity analysis was conducted to assess reverse causality by excluding MM cases diagnosed within one year of follow-up.

Results

Among 392,589 participants (after exclusions), a total of 1,366 MM cases (59% males; 92% non-Hispanic whites) were identified during the follow-up period. Analysis revealed a significant association between hPDI scores and reduced MM risk (highest vs lowest quartile, HR 0.85; 95%CI 0.73-1.0; p=0.043) (Table). In sensitivity analysis (1,302 MM cases), the association was no longer significant (HR 0.87; 95%CI 0.74-1.03; p 0.09) but trended in the same direction. This may be due to small sample size, given MM is a rare disease. HEI-2015, HDS and aMED scores were not associated with MM risk.

Conclusions

A healthful plant-based diet was associated with reduced MM risk in the NIH-AARP cohort. These results will help oncologists and patients make informed choices about their diet. To our knowledge, this is the largest epidemiologic study to date assessing pre-diagnosis dietary patterns and MM risk.

Associations of Diet Quality with Midlife Brain Volume: Findings from the UK Biobank Cohort Study

BACKGROUND

Higher quality diets may be related to lower dementia rates. Midlife is emerging as a critical life stage for a number of dementia risk factors.

OBJECTIVE

This study examines whether diet quality is related to brain structure during midlife, and if this differs by sex.

METHODS

This study used data from 19184 UK Biobank participants aged 40-65 years. Diet quality was assessed using three dietary indices including the Mediterranean Diet Score (MDS), Healthy Diet Score (HDS), and Recommended Food Score (RFS). MRI brain measures included total, grey, white and hippocampal volume. Linear regression examined associations between diet quality and brain volume, controlling for potential confounders.

RESULTS

Better quality diet across all indices was significantly related to larger grey matter volume: MDS β= 429.7 (95%CI: 65.2, 794.2); HDS β= 700.1 (348.0, 1052.1); and RFS β= 317.1 (106.8, 527.3). Higher diet scores were associated with greater total volume: HDS β= 879.32 (286.13, 1472.50); RFS β= 563.37 (209.10, 917.65); and white matter volume: RFS β= 246.31 (20.56, 472.05), with the exception of Mediterranean diet adherence. Healthy eating guidelines and dietary variety associations with total and grey matter volume were more prominent in men.

CONCLUSION

Findings suggest that diet quality is associated with brain structure during midlife, potentially decades prior to the onset of dementia.

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.

Whole almond consumption is associated with better diet quality and cardiovascular disease risk factors in the UK adult population: National Diet and Nutrition Survey (NDNS) 2008-2017

PURPOSE

 This work aimed to estimate whole almond consumption in a nationally representative UK survey population and examine associations with diet quality and cardiovascular disease (CVD) risk.

METHODS

 Four-day food record data from the National Diet and Nutrition Survey (NDNS) 2008-2017 (n = 6802, age ≥ 19 year) were analyzed to investigate associations between whole almond consumption and diet quality, measured by the modified Mediterranean Diet Score (MDS) and modified Healthy Diet Score (HDS), and CVD risk markers, using survey-adjusted multivariable linear regression.

RESULTS

 Whole almond consumption was reported in 7.6% of the population. Median intake in whole almond consumers was 5.0 g/day (IQR 9.3). Consumers had higher diet quality scores relative to non-consumers; higher intakes of protein, total fat, monounsaturated, n-3 and n-6 polyunsaturated fats, fiber, folate, vitamin C, vitamin E, potassium, magnesium, phosphorus, and iron; and lower intakes of trans-fatty acids, total carbohydrate, sugar, and sodium. BMI and WC were lower in whole almond consumers compared to non-consumers: 25.5 kg/m2 (95% CI 24.9, 26.2) vs 26.3 kg/m2 (25.9, 26.7), and 88.0 cm (86.2, 89.8) vs 90.1 cm (89.1, 91.2), respectively. However, there were no dose-related fully adjusted significant associations between increasing almond intake (g per 1000 kcal energy intake) and lower CVD risk markers.

CONCLUSIONS

 Almond intake is low in the UK population, but consumption was associated with better dietary quality and lower CVD risk factors. Habitual consumption of whole almonds should be encouraged as part of a healthy diet.

Tree nut snack consumption is associated with better diet quality and CVD risk in the UK adult population: National Diet and Nutrition Survey (NDNS) 2008–2014

Objectives:

To examine associations of tree nut snack (TNS) consumption with diet quality and cardiovascular disease (CVD) risk in UK adults from National Diet and Nutrition Survey (NDNS) 2008–2014.

Design:

Cross-sectional analysis using data from 4-d food diaries, blood samples and physical measurements for CVD risk markers. To estimate diet quality, modified Mediterranean Diet Score (MDS) and modified Healthy Diet Score (HDS) were applied. Associations of TNS consumption with diet quality and markers of CVD risk were investigated using survey-adjusted multivariable linear regression adjusted for sex, age, ethnicity, socio-economic and smoking status, region of residency and total energy and alcohol intake.

Setting:

UK free-living population.

Subjects:

4738 adults (≥19 years).

Results:

TNS consumers had higher modified MDS and HDS relative to non-consumers. TNS consumers also had lower BMI, WC, SBP and DBP and higher HDL compared to non-consumers, although a dose-related fully adjusted significant association between increasing nut intake (g per 4184 kJ/1000 kcal energy intake) and lower marker of CVD risk was only observed for SBP. TNS consumption was also associated with higher intake of total fat, mono-, n-3 and n-6 polyunsaturated fatty acids, fibre, vitamin A, thiamin, folate, vitamin C, vitamin E, potassium, magnesium, phosphorus, selenium and iron; and lower intake of saturated fatty acids, trans fatty acids, total carbohydrate, starch, free sugar, sodium and chloride.

Conclusions:

TNS consumers report better dietary quality and consumption was associated with lower CVD risk factors. Encouraging replacement of less healthy snacks with TNS should be encouraged as part of general dietary guidelines.

Review of a priori dietary quality indices in relation to their construction criteria

A multitude of indices measure the healthiness of dietary patterns. Because validation results with respect to health outcomes do not sufficiently facilitate the choice of a specific dietary quality index, the decision of which index to use for a particular research objective should be based on other criteria. This review aims to provide guidance on which criteria to focus upon when choosing a dietary index for a specific research question. A review of 57 existing specifications of dietary quality indices was conducted, taking explicitly into account relevant construction criteria explicated in the Organisation for Economic Co-operation and Development handbook on constructing composite indicators. Index construction choices regarding the following criteria were extracted: theoretical framework, indicator selection, normalization and valuation functions, and aggregation methods. Preferable features of dietary indices are discussed, and a summarizing toolbox is provided to help identify indices with the most appropriate construction features for the respective study aim and target region and with regard to the available database. Directions for future efforts in the specification of new diet quality indices are given.

Development of the Eating Choices Index (ECI): a four-item index to measure healthiness of diet

OBJECTIVE

Current indices of diet quality generally include intakes of specific foods or nutrients. We sought to develop an index that discriminates healthy and unhealthy eating choices for use in large surveys as a short questionnaire and as a measure in existing studies with adequate dietary data.

DESIGN

The Eating Choices Index (ECI) score included four components: (i) consumption of breakfast, (ii) consumption of two portions of fruit per day, (iii) type of milk consumed and (iv) type of bread consumed, each providing a score from 1 to 5. In analysis of 5 d food records, the ECI score was examined in relation to macronutrients, fibre, vitamin C, Fe, Ca and folate using Pearson correlations. Variation with sex, BMI, socio-economic status, marital status, smoking status and physical activity were also investigated.

SETTING

Medical Research Council National Survey of Health and Development.

SUBJECTS

Individuals (n 2256) aged 43 years.

RESULTS

The ECI score (mean 12·3 (sd 3·5)) was significantly positively associated with protein, carbohydrate, fibre, vitamin C, Fe, Ca and folate (r = 0·2-0·5; P < 0·001) and significantly negatively associated with fat intake (r = -0·2; P < 0·001); ECI scores were not correlated with total energy intake. Individuals with a lower ECI score were more likely to be men (P < 0·001), overweight or obese (P < 0·001), have lower socio-economic status (P < 0·001), smoke more (P < 0·001) and be less physically active (P < 0·001).

CONCLUSIONS

ECI scores correlated with nutrient profiles consistent with a healthy diet. It provides a simple method to rank diet healthiness in large observational studies.

High diet quality is associated with a lower risk of cardiovascular disease and all-cause mortality in older men

Although diet quality is implicated in cardiovascular disease (CVD) risk, few studies have investigated the relation between diet quality and the risks of CVD and mortality in older adults. This study examined the prospective associations between dietary scores and risk of CVD and all-cause mortality in older British men. A total of 3328 men (aged 60-79 y) from the British Regional Heart Study, free from CVD at baseline, were followed up for 11.3 y for CVD and mortality. Baseline food-frequency questionnaire data were used to generate 2 dietary scores: the Healthy Diet Indicator (HDI), based on WHO dietary guidelines, and the Elderly Dietary Index (EDI), based on a Mediterranean-style dietary intake, with higher scores indicating greater compliance with dietary recommendations. Cox proportional hazards regression analyses assessed associations between quartiles of HDI and EDI and risk of all-cause mortality, CVD mortality, CVD events, and coronary heart disease (CHD) events. During follow-up, 933 deaths, 327 CVD deaths, 582 CVD events, and 307 CHD events occurred. Men in the highest compared with the lowest EDI quartile had significantly lower risks of all-cause mortality (HR: 0.75; 95% CI: 0.60, 0.94; P-trend = 0.03), CVD mortality (HR: 0.63; 95% CI: 0.42, 0.94; P-trend = 0.03), and CHD events (HR: 0.66; 95% CI: 0.45, 0.97; P-trend = 0.05) but not CVD events (HR: 0.79; 95% CI: 0.60, 1.05; P-trend = 0.16) after adjustment for sociodemographic, behavioral, and cardiovascular risk factors. The HDI was not significantly associated with any of the outcomes. The EDI appears to be more useful than the HDI for assessing diet quality in relation to CVD and morality risk in older men. Encouraging older adults to adhere to the guidelines inherent in the EDI criteria may have public health benefits.

Nutrition and healthy ageing: the key ingredients

Healthy longevity is a tangible possibility for many individuals and populations, with nutritional and other lifestyle factors playing a key role in modulating the likelihood of healthy ageing. Nevertheless, studies of effects of nutrients or single foods on ageing often show inconsistent results and ignore the overall framework of dietary habits. Therefore, the use of dietary patterns (e.g. a Mediterranean dietary pattern) and the specific dietary recommendations (e.g. dietary approaches to stop hypertension, Polymeal and the American Healthy Eating Index) are becoming more widespread in promoting lifelong health. A posteriori defined dietary patterns are described frequently in relation to age-related diseases but their generalisability is often a challenge since these are developed specifically for the population under study. Conversely, the dietary guidelines are often developed based on prevention of disease or nutrient deficiency, but often less attention is paid to how well these dietary guidelines promote health outcomes. In the present paper, we provide an overview of the state of the art of dietary patterns and dietary recommendations in relation to life expectancy and the risk of age-related disorders (with emphasis on cardiometabolic diseases and cognitive outcomes). According to both a posteriori and a priori dietary patterns, some key 'ingredients' can be identified that are associated consistently with longevity and better cardiometabolic and cognitive health. These include high intake of fruit, vegetables, fish, (whole) grains and legumes/pulses and potatoes, whereas dietary patterns rich in red meat and sugar-rich foods have been associated with an increased risk of mortality and cardiometabolic outcomes.

Age, marital status and changes in dietary habits in later life: a 21-year follow-up among Finnish women

OBJECTIVE

To examine 21-year longitudinal changes in dietary habits and their associations with age and marital status among women aged 50-60 years at baseline.

DESIGN

Prospective, longitudinal study of a cohort in the FINMONICA population-based risk factor survey with clinical assessments in 1982, 1992 and 2003. Dietary habits were assessed via self-reported consumption of foods typically contributing to SFA, cholesterol and sugar intakes in the Finnish diet. A dietary risk score based upon five items was used.

SETTING

Kuopio region, Finland.

SUBJECTS

Complete data from all three assessments for 103 women of the original cohort of 299 were included for two age groups: 50-54 and 55-60 years at baseline.

RESULTS

Dietary habits improved between 1982 and 1992 and showed continued but less pronounced improvement between 1992 and 2003: within the younger age group, 78 % of the women reduced the number of dietary risk points from the 1982 to 2003 scores, whereas 3 % increased them and 19 % reported no change. In the older age group these percentages were 61 %, 23 % and 16 %, respectively. Women who remained married showed a steadier decline in dietary risk points than single women or women who were widows at the beginning of the follow-up.

CONCLUSIONS

Older women make positive changes to their dietary habits but the consistency of these changes may be affected by the ageing process, marital status and changes in the latter.

Diet quality is associated with all-cause mortality in adults aged 65 years and older

Diet quality indices assess compliance with dietary guidelines and represent a measure of healthy dietary patterns. Few studies have compared different approaches to assessing diet quality in the same cohort. Our analysis was based on 972 participants of the British Diet and Nutrition Survey of people aged 65 y and older in 1994/1995 and who were followed-up for mortality status until 2008. Dietary intake was measured via a 4-d weighed food record. Three measures of diet quality were used: the Healthy Diet Score (HDS), the Recommended Food Score (RFS), and the Mediterranean Diet Score (MDS). HR for all-cause mortality were obtained using Cox regression adjusted for age, sex, energy intake, social class, region, smoking, physical activity, and BMI. After adjustment for confounders, the MDS was significantly associated with mortality [highest vs. lowest quartile; HR = 0.78 (95% CI = 0.62-0.98)]. Similarly, the RFS was also associated with mortality [HR = 0.67 (95 % CI = 0.52-0.86)]; however, there were no significant associations for the HDS [HR = 0.99 (95% CI = 0.79-1.24)]. The HDS was not a predictor of mortality is this population, whereas the RFS and the MDS were both associated with all-cause mortality. Simple measures of diet quality using food-based indicators can be useful predictors of longevity.

Dietary assessment in early old age: experience from the Boyd Orr cohort

BACKGROUND

The assessment of the impact of data quality issues, such as omitting to answer questions on a food frequency questionnaire (FFQ), is important in all study populations, including those in early old age. Assumptions about the limited nature of diets of older participants may influence the treatment and interpretation of their dietary data.

SUBJECTS/METHODS

The Boyd Orr cohort is a long-term study based on 4999 UK men and women whose families took part in a survey of diet and health during 1937-1939. In 1997-1998, all 3182 traced, surviving study members, then aged 60 years and over, were sent a health and lifestyle questionnaire, including a 113-item FFQ, primarily to examine relationships between childhood and adult fruit, vegetable and antioxidant intakes. In-depth interviews were conducted with a purposively sampled subset of 31 respondents.

RESULTS

Of the 1475 subjects who returned the questionnaire, 11% (n=161) had missing data on their FFQ. Those who omitted answers to more than 10 questions (n=127; 8.6%) were more likely to be aged over 70, to be female, but no more likely to report being overweight than those with 10 or fewer missing answers. Follow-up by telephone or post to reassess missing FFQ data was successful for 102 of the subjects with more than 10 omitted answers. Mean intakes of energy, fruit and vegetables, and selected nutrients were significantly increased after reassessment. The use of 'cross-check' questions to weigh fruit and vegetable intake (n=1383) showed potentially systematic errors in the reporting of these foods, vitamin C and carotene. Analysis of interview data among a subset of participants partially challenged stereotypical views of the diets of older people with, for example, increased freedom in food choice associated with life transitions.

CONCLUSIONS

Food frequency questionnaires for those in early old age, as for others, need to meet competing demands of being comprehensive for those with varied diets, while not being so onerous that they deter completion. Reviewing questionnaires with participants remains important in this group, as omitting to answer questions on the FFQ does not necessarily equate to non-consumption. Qualitative interviews may aid in the interpretation of the quantitative data obtained.

What influences diet in early old age? Prospective and cross-sectional analyses of the Boyd Orr cohort

BACKGROUND

The aim of this study is to identify the socio-economic and health-related factors in childhood and later life associated with healthy eating in early old age.

METHODS

The study is based on surviving members of the Boyd Orr cohort aged 61-80 years. Data are available on household diet and socio-economic position in childhood and on health and social circumstances in later life. A 12-item Healthy Diet Score (HDS) for each subject was constructed from food frequency questionnaire responses. Complete data on all exposures examined were available for 1234 cohort members.

RESULTS

Over 50% of study members had inadequacies in at least half of the 12 markers of diet quality. In multivariable models having a childhood diet which was rich in vegetables was associated with a healthy diet in early old age. The HDS for those in the upper quartile of childhood vegetable intake was 0.30 (95% confidence interval -0.01 to 0.61) higher than those with the lowest intake levels (P-trend across quartiles = 0.04). The adult factors that were most strongly associated with a healthy diet were not smoking, being an owner-occupier, and taking anti-hypertensive medication.

CONCLUSION

Our analysis indicates that diet in early old age is influenced by childhood vegetable consumption, current socio-economic position, and smoking. Interventions for improving the diet of older people could usefully focus on both encouragement of healthy diet choices from an early age and higher levels of income or nutritional support for older people.