Nutrient intakes linked to better health outcomes are associated with higher diet costs in the US

Association of MIND diet with cognitive decline among Black and White older adults

INTRODUCTION

We examined the Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) diet's association with cognitive decline by race among older adults in the Chicago Health and Aging Project.

METHODS

Five thousand two hundred fifty-nine participants (73.5 [± 6.0] years, 62% Black participants, 62% female) completed a food frequency questionnaire, and two or more cognitive assessments over 7.8 ± 4.6 years.

RESULTS

Overall, higher MIND diet was associated with slower cognitive decline (p for trend = 0.0025). The MIND score (range:0-15) was different between Black and White older adults(6.97 vs. 7.12, p = 0.010). Compared to the lowest tertile, among White participants, the two highest tertiles (MIND score -7: β = 0.0121 [95% confidence interval [CI]: 0.0006, 0.0237]; MIND score -8.5: β = 0.0146 [95% CI: 0.0003, 0.0260]) and among Black participants, only the highest tertile (MIND score -8.5: β = 0.0088 [95% CI: 0.0003, 0.0172]) had association with cognitive decline. Vascular and lifestyle factors attenuated the association only for Black older adults.

DISCUSSION

The MIND diet was associated with slower cognitive decline in Black and White older adults, but this may vary with other lifestyle and vascular factors. Further research is warranted on race-specific cultural diets considering other risk factors for cognitive decline.

HIGHLIGHTS

The intake of Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) diet components varies by race. The MIND diet may slow cognitive decline in both Black and White older adults. This association may vary with other lifestyle and vascular risk factors.

Cost-effectiveness of protein-rich meals and snacks for increasing protein intake in older adults

OBJECTIVES

To investigate the cost-effectiveness of protein-rich meals and snacks for increasing protein intake in home-dwelling older adults.

DESIGN

Cost effectiveness analysis from a randomized controlled trial, the Power Meals study.

SETTING

Participants were randomized into one of three groups for eight weeks: a protein-rich meal, snack and bread (Protein), a regular meal (Normal) and a control group without meal service (Control).

PARTICIPANTS

Home-dwelling home care clients, caregivers and care recipients aged ≥65 years (n = 65).

MEASUREMENTS

Protein intake was assessed by a three-day food diary at the end of the study. Cost for the daily diet was estimated by using Finnish grocery store databases and the prices of the food service. The cost-effectiveness was assessed by an incremental cost-effectiveness ratio (ICER).

RESULTS

Costs for the daily diet in the Protein (8.35 €/d) and the Normal (7.94 €/d) groups were significantly higher than in the control group (5.65 €/d) (p < 0.001). Incremental cost-effectiveness analysis showed that increasing protein intake was cost-effective in the Protein group as incremental cost-effectiveness ratio was 8.11 in the Protein, 8.72 in the Normal and 6.45 in the Control group.

CONCLUSIONS

Including protein rich meals and snacks in a diet increases protein intake in home-dwelling older adults cost-effectively.

Toward a science-based classification of processed foods to support meaningful research and effective health policies

Processed foods have been part of the American diet for decades, with key roles in providing a safe, available, affordable, and nutritious food supply. The USDA Food Guides beginning in 1916 and the US Dietary Guidelines for Americans (DGA) since 1980 have included various types of commonly consumed processed foods (e.g., heated, fermented, dried) as part of their recommendations. However, there are multiple classification systems based on "level" of food processing, and additional evidence is needed to establish the specific properties of foods classified as "highly" or "ultra"-processed (HPF/UPFs). Importantly, many foods are captured under HPF/UPF definitions, ranging from ready-to-eat fortified whole grain breakfast cereals to sugar-sweetened beverages and baked goods. The consequences of implementing dietary guidance to limit all intake of foods currently classified as HPF/UPF may require additional scrutiny to evaluate the impact on consumers' ability to meet daily nutrient recommendations and to access affordable food, and ultimately, on health outcomes. Based on a meeting held by the Institute for the Advancement of Food and Nutrition Sciences in May 2023, this paper provides perspectives on the broad array of foods classified as HPF/UPFs based on processing and formulation, including contributions to nutrient intake and dietary patterns, food acceptability, and cost. Characteristics of foods classified as UPF/HPFs are considered, including the roles and safety approval of food additives and the effect of food processing on the food matrix. Finally, this paper identifies information gaps and research needs to better understand how the processing of food affects nutrition and health outcomes.

Does an antihypertensive diet cost more? Analysis from the Chinese Heart-Healthy diet trial

OBJECTIVE

To determine whether the Chinese heart-healthy diet (Sichuan cuisine version) (CHH diet-SC) was more expensive than the conventional Sichuan diet and explore the food groups and nutrients that mainly affected the cost of CHH diet-SC.

DESIGN

Cost analysis of 4-week intervention diets in the Sichuan center representing southwestern China in the CHH diet study.

SETTING

A multicentre, parallel-group, single-blind, randomised feeding trial evaluating the efficacy of lowering blood pressure with the cuisine-based CHH diet.

PARTICIPANTS

Totally, fifty-three participants with hypertension aged 25-75 years in the Sichuan center were randomised into the control group (n 26) or the CHH diet-SC group (n 27).

RESULTS

The CHH diet-SC was more expensive than the control diet (¥27·87 ± 2·41 v. ¥25·18 ± 2·79 equals $3·90 ± 0·34 v. $3·52 ± 0·39, P < 0·001), and the incremental cost-effectiveness ratio for a 1-mm Hg systolic blood pressure reduction was ¥9·12 ($1·28). Intakes and the cost of seafood, dairy products, fruits, soybeans and nuts, whole grains and mixed beans were higher for the CHH diet-SC than for the control diet (P < 0·001). Intakes of vitamin B1, vitamin B6, vitamin C, Mg and phosphorus were positively correlated with the cost (P < 0·05).

CONCLUSIONS

The CHH diet-SC costs more than the conventional Sichuan diet, partly due to the high cost of specific food groups. Positive correlations between the intakes of vitamin B1, vitamin B6, vitamin C, Mg, phosphorus and the dietary cost could be a direction to adjust the composition within the food groups to reduce the cost of the CHH diet-SC.

Which Program Implementation Factors Lead to more Fruit and Vegetable Purchases? An Exploratory Analysis of Nutrition Incentive Programs across the United States

Background

Nutrition incentive (NI) programs help low-income households better afford fruits and vegetables (FVs) by providing incentives to spend on FVs (e.g., spend $10 to receive an additional $10 for FVs). NI programs are heterogeneous in programmatic implementation and operate in food retail outlets, including brick-and-mortar and farm-direct sites.

Objective

This study aimed to explore NI program implementation factors and the amount of incentives redeemed.

Methods

A total of 28 NI projects across the United States including 487 brick-and-mortar and 1078 farm-direct sites reported data between 2020 and 2021. Descriptive statistics and linear regression analyses (outcome: incentives redeemed) were applied.

Results

Traditional brick-and-mortar stores had 0.48 times the incentives redeemed compared with small brick-and-mortar stores. At brick-and-mortar sites, automatic discounts had 3.47 times the incentives redeemed compared with physical discounts; and auxiliary services and marketing led to greater redemption. Farm-direct sites using multilingual and direct promotional marketing had greater incentives redeemed.

Conclusions

To our knowledge, this is the first national study to focus on NI program implementation across sites nationwide. Factors identified can help inform future programming and research.

Diabetes risk among US adults with different socioeconomic status and behavioral lifestyles: evidence from the National Health and Nutrition Examination Survey

Background

Diabetes disproportionately affects minorities and those with low socioeconomic status (SES) in the United States, and differences in behavioral lifestyles are largely responsible for the unequal distribution of diabetes among different groups.

Methods

With data of 9,969 participants collected in the 2007-2008 and 2009-2010 cycles of the US National Health and Nutrition Examination Survey (NHANES), this study examined several mediators and their mediating effects in the connection between SES and the risk of diabetes. The SES is assessed by the income-to-poverty ratio (IPR), education level, and employment status. For the mediation analysis, we used health-related behaviors as mediators (smoking, alcohol use, consumption of green vegetables and fruits, physical activity and sedentary time, health insurance, and healthcare). In this study, the structural equation model was utilized to evaluate the mediating effects of behavioral lifestyle as a mediator in the relationship between SES and diabetes.

Results

A total of 9,969 participants were included in this study. We found a negative nonlinear association between IPR and diabetes risk (Poverall < 0.001; Pnon-linear = 0.46), which was independent of the majority of known or suspected risk factors and confounding variables (gender, age, race). Participants with lower SES had higher risk of diabetes compared with those with higher SES. In mediating analysis, we found alcohol intake (OR = 0.996), physical activity (OR = 0.993), health insurance (OR = 0.998), and healthcare (OR = 1.002) mediated the IPR-diabetes association. But in the relationship between education status and diabetes, the mediation effect of alcohol intake (OR = 0.995), physical activity (OR = 0.991), and health care (OR = 1.008) were obvious. Likewise, alcohol intake (OR = 0.996), fruit intake (OR = 0.998), and health care (OR = 0.975) were important mediators in the association between employment status and diabetes.

Conclusion

This study provides critical insights on the link between SES and diabetes. Our results highlight that poor health-related behaviors and limited access to healthcare are important pathways for increased diabetes risk related to those with low SES, particularly among Mexican Americans and males. They should be top priorities for agencies and healthcare providers to develop behavior-related interventions to reduce inequalities in diabetes risk.

The combined consumption of fresh/minimally processed food and ultra-processed food on food insecurity: COVID Inconfidentes, a population-based survey

OBJECTIVE

To investigate whether the combined consumption of fresh/minimally processed and ultra-processed food is associated with food insecurity (FI) during the COVID-19 pandemic.

DESIGN

Cross-sectional observational study was derived from a survey using a population-based search of a complex sample. FI was assessed using the validated Brazilian Food Insecurity Scale. Food consumption was assessed using a qualitative FFQ and the NOVA classification for fresh/minimally processed food and ultra-processed food. A scoring system was used to evaluate combined food consumption according to the extent and purpose of processing, considering the weekly consumption of the two groups (according to the NOVA classification). Higher punctuation reflects worse diet quality (higher consumption of ultra-processed foods and lower consumption of fresh/minimally processed foods). A theoretical causality model was constructed using a directed acyclic graph, and multivariate analysis was performed using Poisson regression to test the association between FI and food consumption.

SETTING

Ouro Preto and Mariana, Brazil, between October and December 2020.

PARTICIPANTS

An epidemiological household survey was conducted with 1753 individuals selected through a stratified and clustered sampling design in three stages.

RESULTS

Those with food consumption scores in the fourth quartile had a 60 % higher prevalence ratio (PR) for FI (PR: 1·60 and 95 % CI: 1·06 - 2·40). Also, the increased consumption of fresh/minimally processed foods and low consumption of ultra-processed foods presented a 45 % lower prevalence ratio of FI (PR: 0·55 and 95 % CI: 0·40 - 0·80).

CONCLUSION

These results indicate an inverse association between FI and diet quality.

Nutrient density and cost of commonly consumed foods: a South African perspective

Food-based dietary guidelines promote consumption of a variety of nutritious foods for optimal health and prevention of chronic disease. However, adherence to these guidelines is challenging because of high food costs. The present study aimed to determine the nutrient density of foods relative to cost in South Africa, with the aim to identify foods within food groups with the best nutritional value per cost. A checklist of 116 food items was developed to record the type, unit, brand and cost of foods. Food prices were obtained from the websites of three national supermarkets and the average cost per 100 g edible portion was used to calculate cost per 100 kcal (418 kJ) for each food item. Nutrient content of the food items was obtained from the South African Food Composition Tables. Nutrient density was calculated using the Nutrient Rich Food (NRF9.3) Index. Nutrient density relative to cost was calculated as NRF9.3/price per 100 kcal. Vegetables and fruits had the highest NRF9.3 score and cost per 100 kcal. Overall, pulses had the highest nutritional value per cost. Fortified maizemeal porridge and bread had the best nutritional value per cost within the starchy food group. Foods with the least nutritional value per cost were fats, oils, foods high in fat and sugar, and foods and drinks high in sugar. Analysis of nutrient density and cost of foods can be used to develop tools to guide low-income consumers to make healthier food choices by identifying foods with the best nutritional value per cost.

SNAP participation moderates the association between household food insecurity and HbA1c among Cambodian Americans with depression

OBJECTIVES

We tested whether participation in the Supplemental Nutrition Assistance Program (SNAP) moderated the relation between household food insecurity and HbA1c among Cambodian Americans with depression enrolled in a diabetes prevention trial.

METHODS

Community health workers assessed household food insecurity and SNAP participation. HbA1c was ascertained using direct enzymatic assay.

RESULTS

Among the n = 189 respondents, 19% were food insecure, 41% received SNAP benefits, and mean HbA1c = 5.5%. There was a significant interaction between SNAP and food insecurity. HbA1c was highest among participants without SNAP who were food insecure. Simple effects analysis revealed a significant difference within the no SNAP group [Mean (SD): Secure = 5.38 (0.38), Insecure = 5.78 (0.36)] and no difference within the SNAP group [Secure = 5.61(0.44), Insecure = 5.61(0.55)]. Differences remained significant after controlling for demographic, socioeconomic, and clinical indicators.

CONCLUSIONS

SNAP may protect against the deleterious association between household food insecurity and HbA1c.

Extending the Together, We Inspire Smart Eating Curriculum to Intergenerational Nutrition Education: A Pilot Study

The COVID-19 pandemic has made accessing nutritious foods difficult for older adults and children living in low-income households. The evidence-based preschool nutrition education curriculum Together, We Inspire Smart Eating (WISE) can be used to encourage children to try healthy foods. Written as a single generation curriculum, inviting older adult community members to WISE programming for an intergenerational experience may provide further supports and mutual benefits as participants cooperate towards a common goal. While creators have evaluated implementation of WISE, research has yet to explore factors that influence WISE adoption within an intergenerational setting. We conducted a pilot study using the implementation evaluation framework to explore WISE implementation within single generation and intergenerational settings by measuring five implementation outcomes (fidelity, acceptability, appropriateness, feasibility, and sustainability) through three methods: (1) direct assessment of program fidelity via video coding; (2) indirect assessment of stakeholders’ perceptions of WISE implementation, and (3) a directed qualitative content analysis on annual interview data. Fidelity scores were comparable between the two settings and stakeholder ratings of appropriateness, acceptability, and feasibility of WISE were high. Qualitative data revealed that aspects of WISE are less appropriate for older participants and reiterated known logistical barriers of intergenerational programming that may challenge program sustainability.

How to Estimate Food Prices and Diet Costs in Population-Based Studies?

Health and nutrition surveys usually comprise detailed information on health characteristics and food consumption of certain population groups; however, the lack of data collection on the food prices may pose challenges for the estimation of the diet costs for the comprehensive analysis of food demand. The Household Budget Survey (HBS) represents an opportunity to obtain the data on the food prices for the nutrition surveys in the diverse countries worldwide. Although the HBS and the health and nutrition surveys may correspond to different periods, the application of the appropriate Consumer Price Index (CPI) allows to address the changes in the relative prices to perform the linkage between the data of food consumption with information on the food prices. Therefore, the aim of this study was to present the methods for the extraction and linkage of the food prices data from the Brazilian HBS (2002–2003 and 2008–2009) by using the pairing features related to the household characteristics to match the Health Survey of São Paulo [Inquérito de Saúde de São Paulo (ISA-Capital)] conducted in 2003, 2008, and 2015. Data referring to the household characteristics and food prices acquired by the household members living in São Paulo municipality were selected from the HBS datasets for integration with the ISA-Capital dataset. Specific deflators referring to the food items surveyed in São Paulo were obtained from the datasets of the Brazilian Broad Consumer Price Index (BCPI). Therefore, the pairing criteria referring to time, location, and household characteristics were adopted to allow linking foods consumed by the individuals in the ISA-Capital with the prices from the foods acquired by household members interviewed in the HBS. Matching data on the key pairing criteria (location/year/household income per capita/number of residents/family profile) resulted in the linkage of 94.4% (2003), 92.6% (2008), and 81.2% of the cases (2015). Following the data linkage, it was possible to estimate diet costs per gram and per calorie including application of cooking and conversion factors. Data were presented in the International Monetary Unit under the purchasing power parity (PPP) to allow the comparison at the international level. The mean diet costs identified in the population of São Paulo municipality were $8.45 (dp = 0.38) per capita per day in 2003, $8.72 (dp = 0.24) per capita per day in 2008, and $9.62 (dp = 0.23) per capita per day in 2015. Thus, it was possible to estimate the diet costs based on the prices of food items through pairing linkage of information from the household surveys, such as the Brazilian HBS, with the health and nutrition surveys lacking information on the expenditures or prices such as the ISA-Capital. Similar procedures may be used in the diverse countries with availability of the datasets of the household expenditures and health and nutrition surveys, allowing the researchers worldwide to associate the diet quality with food demand.

A Healthy Diet Is Not More Expensive than Less Healthy Options: Cost-Analysis of Different Dietary Patterns in Mexican Children and Adolescents

Unhealthy diets are recognized as a major risk factor for many diseases. The decrease in costs of industrialized products, as well as the possible misinformation about a healthy diet, has led to new behaviors in the dietary patterns of the pediatric population. The costs of dietary patterns have not been estimated in our population, so the objective of this study was to determine the cost associated with dietary patterns in Mexican children and adolescents, hypothesizing that a healthy diet is not necessarily more economically expensive. This study analyzed data from a population-based cross-sectional study of healthy children and adolescents in Mexico City. Data were collected from a food frequency questionnaire and the meal cost of habitual food shopping. Eating patterns were obtained by using principal component analysis. A micro-costing technique was performed to obtain the direct costs of each pattern. When comparing the healthy pattern with the transition and non-healthy patterns, it was observed that there were no statistically significant differences between the dietary patterns (p = 0.8293). The cost of the healthy pattern only takes up 16.6% of the total biweekly income of a salaried Mexican. In this study, no differences were observed between the costs of a healthy and a less healthy diet.

Some Ultra-Processed Foods Are Needed for Nutrient Adequate Diets: Linear Programming Analyses of the Seattle Obesity Study

Typical diets include an assortment of unprocessed, processed, and ultra-processed foods, along with culinary ingredients. Linear programming (LP) can be used to generate nutritionally adequate food patterns that meet pre-defined nutrient guidelines. The present LP models were set to satisfy 22 nutrient standards, while minimizing deviation from the mean observed diet of the Seattle Obesity Study (SOS III) sample. Component foods from the Fred Hutch food frequency questionnaire comprised the market basket. LP models generated optimized 2000 kcal food patterns by selecting from all foods, unprocessed foods only, ultra-processed foods only, or some other combination. Optimized patterns created using all foods contained less fat, sugar, and salt, and more vegetables compared to the SOS III mean. Ultra-processed foods were the main sources of added sugar, saturated fat and sodium. Ultra-processed foods also contributed most vitamin E, thiamin, niacin, folate, and calcium, and were the main sources of plant protein. LP models failed to create optimal diets using unprocessed foods only and ultra-processed foods only: no mathematical solution was obtained. Relaxing the vitamin D criterion led to optimized diets based on unprocessed or ultra-processed foods only. However, food patterns created using unprocessed foods were significantly more expensive compared to those created using foods in the ultra-processed category. This work demonstrates that foods from all NOVA categories can contribute to a nutritionally adequate diet.

Relationship Between Dietary Knowledge, Socioeconomic Status, and Stroke Among Adults Involved in the 2015 China Health and Nutrition Survey

Stroke is a public health threat that requires urgent attention in China. Nutrients have individual significant impacts on the prevalence of stroke. However, little research has been conducted on the impact of dietary knowledge on stroke and whether the impact is potentially heterogeneous under the effect of socioeconomic status. This study used the 2015 Chinese Health and Nutrition Survey to explore the impact of dietary knowledge and socioeconomic factors on populations suffering from stroke. Results indicated that risk of stroke decreased significantly with increasing dietary knowledge score. Additionally, the impact of dietary knowledge scores on the prevalence of stroke has obvious heterogeneity. First, dietary knowledge scores significantly influenced low-income groups and individuals with low educational levels. Second, the risk of stroke in females is more affected by dietary knowledge. Third, for people living in different areas, dietary knowledge determines whether rural populations suffer from stroke.

Dietary health in the context of poverty and uncertainty around the social determinants of health

Lower household income has been consistently associated with poorer diet quality and poorer dietary health outcomes. Households experiencing poverty find themselves unable to afford enough food, and the food that they can afford is often poor quality, energy dense and low in nutrients. However, the relationship between diet, poverty and health is complex. Not everyone on a low income has a poor diet. Poverty is about more than low incomes and it is not a uniform experience. Particular aspects of the experience of poverty have implications for diet and dietary health. It is increasingly apparent that uncertainty is one of those aspects. Recession, welfare policy, employment trends and widening inequality have created more uncertainty for those on low incomes. In the context of heightened uncertainty, all aspects of household food provisioning - including budgeting, shopping, storage, meal planning and cooking - are more difficult and sometimes impossible. This review will draw on research about food practices and dietary health in low-income neighbourhoods to explore the ways in which experiences of prolonged uncertainty shape dietary practices and impact health and well-being.

Nutrient density, but not cost of diet, is associated with anemia and iron deficiency in school-age children in South Africa

OBJECTIVES

This study aimed to investigate the relationship of nutrient density and diet cost with anemia and iron deficiency (ID) in children.

METHODS

Dietary intake data of 5- to 12-y-old children (n = 578) from three independent studies in low-income communities were pooled. Nutrient densities were calculated using the Nutrient Rich Foods index and Nutrient Rich Diet index, with higher scores indicating more nutrient-dense foods and diets. Food prices and food intake data were used to calculate ratios of nutrient density to price for foods and diets. Descriptive and correlation analyses examined associations of nutrient density and diet cost with anemia and ID.

RESULTS

Most children (>50%) consumed starchy staples (100%), vegetables that are not vitamin A rich (63.9%), and legumes (58.1%), with mean NRF9.3 scores ranging from 31.9 to 56.3. Cheese, eggs, organ meat, fish, dark-green leafy vegetables, and vitamin A-rich vegetables and fruits had mean NRF9.3 scores ranging from 112.6 to 184.7, but each was consumed by less than a third of the children. Children with anemia or ID had lower NRD9.3 scores than children without (P < 0.001 and P = 0.039, respectively). Diet cost did not differ according to anemia and iron status, but nutrient-density-to-price ratio was lower in children with anemia than without (P = 0.001).

CONCLUSIONS

Careful selection of nutrient-dense foods as substitutes for foods with lower nutrient density could make it possible for children to consume a diet richer in specific nutrients and help prevent anemia and ID without affecting diet cost.

Racial Differences in Dietary Relations to Cognitive Decline and Alzheimer's Disease Risk: Do We Know Enough?

The elderly population in the US is increasing and projected to be 44% minority by 2060. African Americans and Hispanics are at increased risk of cognitive impairment and Alzheimer’s disease compared to non-Hispanic whites. These conditions are associated with many other adverse health outcomes, lower quality of life, and substantial economic burden. In the past few decades, diet has been identified as an important modifiable risk factor for cognitive decline and Alzheimer’s disease. Some studies report poor diet quality among African American and Hispanic older adult populations compared to their white counterparts. We have a limited understanding of how diet affects brain health in different racial-ethnic groups. One primary reason for our lack of knowledge is that most cohort studies are of majority non-Hispanic white participants. Moreover, those that do include minority participants do not publish their findings stratified by racial-ethnic groups, and likely have a less accurate measurement of dietary intake among minority groups. In this review, we summarize the current, albeit limited, literature on racial/ethnic differences in dietary relations to dementia outcomes. We will also discuss methodological issues in conducting nutrition studies in diverse cultures, and suggestions for future research directions. Overcoming the gaps will make it possible to make dietary recommendations for Alzheimer’s prevention that are more relevant for different racial/ethnic groups and set us on a faster track to reduce health disparities.

Flavonoid Intakes in the US Diet Are Linked to Higher Socioeconomic Status and to Tea Consumption: Analyses of NHANES 2011-16 Data

BACKGROUND

Many of the health benefits of tea have been attributed to its flavonoid content. Tea consumption in US adults varies by socioeconomic status (SES).

OBJECTIVES

The present objective was to explore intakes of total flavonoids and flavonoid subclasses by participant sociodemographics and by patterns of tea consumption.

METHODS

The present analyses were based on 2 d of dietary recalls for 17,506 persons aged >9 y in the 2011-2016 NHANES. The What We Eat in America nutrient composition database was merged with the USDA Expanded Flavonoid database, which included total flavonoids and flavan-3-ols (including catechins), flavanones, flavonols, anthocyanidins, flavones, and isoflavones. Flavonoid intakes were compared by sex, age, race/ethnicity, education, and income-to-poverty ratio (IPR) in univariate analyses. Flavonoid intakes of children and adults were also compared by tea consumption status. Time trends in flavonoid intakes were also examined.

RESULTS

Mean total flavonoid intake was 219 mg/d, of which flavan-3-ols provided 174 mg/d, or 79%. The highest total flavonoid intakes were found in adults aged 51-70 y (293 mg/d), non-Hispanic whites (251 mg/d) and in groups with college education (251 mg/d) and higher income (IPR >3.5: 249 mg/d) (P < 0.001 for all). The socioeconomic gradient was significant for anthocyanidins, flavonols, and flavones (P < 0.001 for all) but not for flavan-3-ols, and persisted across 3 cycles of NHANES. Adult tea consumers had higher intakes of total flavonoids (610 mg/d compared with 141 mg/d) and flavan-3-ols (542 mg/d compared with 97.8 mg/d) than did nonconsumers (P < 0.001). Time trend analyses showed that both tea consumption and flavonoid intakes were unchanged from 2011 to 2016.

CONCLUSIONS

Flavonoid intakes in children and adults in the NHANES 2011-16 sample were associated with higher SES and were largely determined by tea consumption. Studies of diet and disease risk need to take sociodemographic gradients and eating and drinking habits into account.

Neighborhood Poverty and Control of HIV, Hypertension, and Diabetes in the Women's Interagency HIV Study

Neighborhoods with high poverty rates have limited resources to support residents' health. Using census data, we calculated the proportion of each Women's Interagency HIV Study participant's census tract (neighborhood) living below the poverty line. We assessed associations between neighborhood poverty and (1) unsuppressed viral load [VL] in HIV-seropositive women, (2) uncontrolled blood pressure among HIV-seropositive and HIV-seronegative hypertensive women, and (3) uncontrolled diabetes among HIV-seropositive and HIV-seronegative diabetic women using modified Poisson regression models. Neighborhood poverty was associated with unsuppressed VL in HIV-seropositive women (> 40% versus ≤ 20% poverty adjusted prevalence ratio (PR), 1.42; 95% confidence interval (CI) 1.04-1.92). In HIV-seronegative diabetic women, moderate neighborhood poverty was associated with uncontrolled diabetes (20-40% versus ≤ 20% poverty adjusted PR, 1.75; 95% CI 1.02-2.98). Neighborhood poverty was associated with neither uncontrolled diabetes among HIV-seropositive diabetic women, nor uncontrolled hypertension in hypertensive women, regardless of HIV status. Women living in areas with concentrated poverty may need additional resources to control health conditions effectively.

Monetary diet cost is positively associated with diet quality and obesity: an analysis of school-aged children in Southwest China

BACKGROUND

Little is known about the relationships between diet cost, dietary intake and obesity in Chinese populations. This study explored how diet cost was related to diet quality and obesity among school-aged children in Southwest China.

METHODS

Data from a cross-sectional study was analysed. Diet cost was estimated based on dietary intake assessed with 24-h dietary recalls and retail food prices. Diet quality was measured using the Chinese Children Dietary Index. Body height, weight, waist circumference and skinfold thicknesses were measured, and their body mass index standard deviation score (BMISDS), waist-to-height ratio (WHtR), fat mass index (FMI) and fat-free mass index (FFMI) were calculated. Multivariate regression models were used to explore the relevance of diet cost to diet quality and obesity.

RESULTS

After adjustment for potential confounders, a positive association was observed between diet quality and energy-adjusted diet cost (β = 0.143, 95% confidence interval, CI: 0.014-0.285, Pfor-trend = 0.0006). Energy-adjusted diet cost also showed a positive association with FMI (β = 0.0354, 95% CI: 0.0001-0.0709, Pfor-trend = 0.01), BMISDS (β = 0.0200, 95% CI: 0.0006-0.0394, Pfor-trend = 0.002) and WHtR (β = 0.0010, 95% CI: 0.0003-0.0017, Pfor-trend = 0.02).

CONCLUSIONS

Energy-adjusted diet cost was independently and positively associated with diet quality and obesity among Chinese school-aged children.

Dietary Patterns and Associated Factors Among Adolescents in Malaysia: Findings from Adolescent Nutrition Survey 2017

Balanced diet in the early stages of life plays a role in optimum growth and maintains good health status of adolescents. Dietary habits that are established during adolescence will sustain till adulthood. Therefore, this present study aims to identify the dietary patterns and to determine factors associated with dietary patterns in terms of socio-demographic characteristics, locality of schools, ethnicity, eating habits, self-perceived weight status, and food label reading habit among adolescents in Malaysia. Data from the Adolescent Nutrition Survey (ANS) 2017 was used for the present study. ANS is a population representative school-based cross-sectional study among school-going adolescents from primary four to secondary five from schools in 13 states and three federal territories registered under the Ministry of Education Malaysia. A self-administrated questionnaire was used to collect information on socio-demographic characteristics, locality of schools, ethnicity, eating habits, self-perceived weight status, and food label reading habit. A pre-tested face-to-face food frequency questionnaire (FFQ) was used to collect information on food group intake frequency. Dietary patterns were identified by using exploratory factor analysis and associated factors, using complex sample general linear model (GLM) analysis. All statistical analyses were carried out at 95% confidence interval or p-value < 0.05. The dietary patterns identified are healthy, unhealthy, and alternative proteins. The healthy dietary pattern was significantly associated with the types of school and ethnicity. The unhealthy dietary pattern was significantly associated with the locality of schools, ethnicity, frequency of snacks intake per week, frequency of eating out per week, self-perceived weight status, and food label reading habit. Significant associations were found between alternative proteins dietary pattern and locality of schools, ethnicity, and types of school. This study found that there is a disparity of dietary patterns between different ethnicity, locality of schools, and types of school. We recommend strategies of specifying ethnicity and geographical area to improve dietary patterns of adolescents in Malaysia.

The Influence of Socioeconomic Status on Snacking and Weight among Adolescents: A Scoping Review

Eating behaviors, including unhealthy snacking or excessive snacking leading to excess calorie consumption, may contribute to obesity among adolescents. Socioeconomic status (SES) also significantly influences eating behaviors, and low SES is associated with increased risk for obesity. However, little is known regarding the relationship between snacking behavior and SES among adolescents and how this may contribute to obesity-related outcomes. The primary objective of this scoping review was to review the literature to assess and characterize the relationship between SES and snacking in adolescents. The secondary objective was to assess weight-related outcomes and their relation to snacking habits. Included articles were published between January 2000 and May 2019; written in English, Portuguese, or Spanish; and focused on adolescents (13-17 years). In total, 14 bibliographic databases were searched, and seven studies met the inclusion criteria. Preliminary evidence from the seven included studies suggests a weak but potential link between SES and snacking. Additionally, these dietary patterns seemed to differ by sex and income type of country. Finally, only three of the included studies addressed weight-related outcomes, but the overall available evidence suggests that snacking does not significantly affect weight-related outcomes. Due to the small number of included studies, results should be interpreted with caution.

Social, demographic, and economic correlates of food and chemical consumption measured by wastewater-based epidemiology

Wastewater is a potential treasure trove of chemicals that reflects population behavior and health status. Wastewater-based epidemiology has been employed to determine population-scale consumption of chemicals, particularly illicit drugs, across different communities and over time. However, the sociodemographic or socioeconomic correlates of chemical consumption and exposure are unclear. This study explores the relationships between catchment specific sociodemographic parameters and biomarkers in wastewater generated by the respective catchments. Domestic wastewater influent samples taken during the 2016 Australian census week were analyzed for a range of diet, drug, pharmaceutical, and lifestyle biomarkers. We present both linear and rank-order (i.e., Pearson and Spearman) correlations between loads of 42 biomarkers and census-derived metrics, index of relative socioeconomic advantage and disadvantage (IRSAD), median age, and 40 socioeconomic index for area (SEIFA) descriptors. Biomarkers of caffeine, citrus, and dietary fiber consumption had strong positive correlations with IRSAD, while tramadol, atenolol, and pregabalin had strong negative correlation with IRSAD. As expected, atenolol and hydrochlorothiazide correlated positively with median age. We also found specific SEIFA descriptors such as occupation and educational attainment correlating with each biomarker. Our study demonstrates that wastewater-based epidemiology can be used to study sociodemographic influences and disparities in chemical consumption.

Longitudinal Associations between Monetary Value of the Diet, DASH Diet Score and the Allostatic Load among Middle-Aged Urban Adults

Lower cost can lead to poorer-quality diets, potentially worsening metabolic profiles. We explored these pathways among urban adults. Longitudinal data were extracted from 1224-1479 participants in the Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study. DASH(mean) (Dietary Approaches to Stop Hypertension) score was computed using four 24 h recalls (v1/v2: 2004-2013) linked with a national food price database to estimate monetary value of the diet [MVD(mean)]. Allostatic load (AL) was measured at visits 2 (v2) and 3 (v3) in 2009-2018. Mixed-effects regression and structural equation modeling (SEM) were conducted, linking MVD(mean)/DASH(mean) to AL [v2 and annual change(v3-v2)] and exploring mediating pathways between MVD(mean) and AL(v3) through DASH(mean), stratifying by sex, race and poverty status. MVD(mean) tertiles were linearly associated with contemporaneous DASH(mean), after energy adjustment. In mixed-effects regression models, DASH(mean) was consistently linked to lower AL(v2). DASH(mean) and MVD(mean) were positively associated with higher serum albumin(v2). In SEM, MVD(mean) was linked to AL(v3) through DASH(mean), mainly among Whites and specifically for the cholesterol and Waist-Hip-Ratio AL components. In summary, energy and other covariate-adjusted increase in MVD may have a sizeable impact on DASH which can reduce follow-up AL among urban White middle-aged adults. More studies are needed to replicate findings in comparable samples of urban adults.

Together, We Inspire Smart Eating (WISE): An Examination of Implementation of a WISE Curriculum for Obesity Prevention in Children 3 to 7 Years

This study examined the implementation of a school-based, obesity prevention curriculum, Together, We Inspire Smart Eating (WISE), targeting 3- to 7-year-old low-income children. Survey data from a convenience sample were collected from educators and parents (N = 73, N = 188, respectively) at the beginning and end of a school year in which WISE was implemented. Educators also reported on lessons weekly. Measures to evaluate the success of the implementation were conceptually distinct implementation outcomes (Educators: Perceived Barriers, Appropriateness, Acceptability, Feasibility, Fidelity; Parents: Adoption, Appropriateness). WISE was successfully implemented in 33 target classrooms representing 7 preschool centers and 2 elementary schools. Based on educator report, perceived barriers were reduced. Educators rated Appropriateness, Acceptability, and Feasibility high. Evidence of Fidelity was mixed. Parents reported indicators of Adoption and Appropriateness high. The study provided support for WISE in preschools and elementary schools serving young children from low-resource homes.

Plant- and animal-protein diets in relation to sociodemographic drivers, quality, and cost: findings from the Seattle Obesity Study

BACKGROUND

Promoting plant-based proteins is at the forefront of many initiatives in public health nutrition.

OBJECTIVES

The aim of this study was to characterize the sociodemographic drivers of plant-based protein diet consumption, and to study these in relation to diet quality and cost.

METHODS

The Seattle Obesity Study series (SOS I and II) yielded the study sample (n = 1636). Sociodemographic data were obtained by survey self-report. Diet quality and cost came from the Fred Hutchinson Cancer Research Center Food-Frequency Questionnaire linked to retail food prices. The Healthy Eating Index 2010 (HEI-2010) and mean adequacy ratio (MAR) served as measures of diet quality. Linear regressions with robust standard errors examined associations.

RESULTS

Total proteins contributed 16.8% of daily dietary energy. The breakdown by animal and plant proteins was 10.9% and 5.9%, respectively. The sociodemographic factors associated with plant-protein consumption were a positive attitude towards healthy eating and higher education but not income. Plant-protein diets were characterized by severalfold increases in nuts and seeds, soy and legumes, but much less meat, poultry, dairy, solid fats, and added sugars. Higher quartiles of plant-based diets were associated with significantly higher HEI-2010 (β: 13.0 from quartile 1 to quartile 4; 95% CI: 11.8, 14.3) and higher MAR (β: 6.0; 95% CI: 3.5, 8.5) with minimal impact on diet costs (β: 0.35; 95% CI: 0.04, 0.67). In contrast, higher quartiles of animal-protein diets were associated with higher diet costs (β: 1.07; 95% CI: 0.77, 1.36) but lower HEI-2010 (β: -3.2; 95% CI: -4.5, -1.9). Each additional 3% of energy from plant proteins was associated with an 8.4-unit increase in HEI-2010 (95% CI: 7.6, 9.1) and with a 4.1-unit increase in MAR (95% CI: 2.7, 5.5) with a minimal increase in diet cost (β: 0.28; 95% CI: 0.06, 0.50).

CONCLUSION

Plant-based protein diets may be a cost-effective way to improve diet quality at all levels of income. Future research needs to evaluate the quality of plant-based protein in relation to amino acids and health.

Predictors of Supplemental Nutrition Assistance Program Use at Farmers' Markets With Monetary Incentive Programming

PURPOSE

Healthy food incentive program implementation targeting people receiving Supplemental Nutrition Assistance Program (SNAP) benefits is supported by the federal Food Insecurity Nutrition Incentive (FINI) grant program. This study examined factors contributing to increased SNAP use at farmers' markets with an FINI-funded incentive program.

DESIGN

Implementation evaluation.

SETTING

Sixteen states and District of Columbia.

PARTICIPANTS

Two hundred eighty-two FINI-funded farmers' markets open in 2016.

MEASURES

Weekly SNAP sales and transactions per 1000 SNAP households in the Zip Code Tabulation Areas around markets.

ANALYSIS

Two-level hierarchical regression modeling.

RESULTS

Most farmers' markets (53%) had less than 100 SNAP transactions in 2016. Weekly SNAP sales and transactions per 1000 SNAP households were 69.9% and 47.7% higher, respectively, if more than 1 incentive was available versus 1. Not having paid market staff resulted in declines in these sales (-34.3%) and transactions (-38.1%) compared to markets with paid staff. There was a 6.2% and 5.1% increase in SNAP sales and transactions for each additional produce vendor. Weekly SNAP sales and transactions were about 2 to 3 times higher in rural areas compared to metropolitan. Clustering of markets within states explained 10% of the variation in weekly SNAP sales and transactions.

CONCLUSION

Four implementation factors were identified that may facilitate the reach of SNAP-based monetary incentive programs at farmers' markets to maximize reach and impact among SNAP shoppers.

Diet Quality and Total Daily Price of Foods Consumed among Iranian Diabetic Patients

Background:

The aim is to investigate the association between diet quality and daily price of foods consumed among Iranian diabetic patients.

Methods:

This cross-sectional study was conducted among 200 patients with type 2 diabetes mellitus (T2DM) aged 30–70 years. General information, socioeconomic status, anthropometric and biochemical characteristics, and food prices were collected by pretested questionnaires. Dietary intakes were assessed using a semi-quantitative reliable and valid food frequency questionnaire. Modified nutritionist IV and SPSS software were used for analyses.

Results:

The results of the present study indicated a direct relationship between total daily price of diet and nutrient adequacy ratio of Vitamin D, Vitamin B1, selenium, zinc, magnesium, potassium, and mean adequacy ratio of 11 micronutrients (Vitamin C, Vitamin E, Vitamin D, Vitamin B1, Vitamin B6, Vitamin B12, selenium, zinc, calcium, magnesium, and potassium) (P < 0.05). Furthermore, the total daily price of diet had a positive association with dietary intakes of protein, Vitamin D, Vitamin B1, selenium, zinc, magnesium and potassium among type 2 diabetic patients (P < 0.05). However, no significant relationship was observed between the total daily price of diet and anthropometric indices, biochemical characteristics, and socioeconomic status of participants in the present study (P > 0.05).

Conclusions:

This study showed that dietary quality and dietary intakes of energy, protein, and micronutrients were directly associated with the total daily price of foods among Iranian patients with type 2 diabetes.

Thinking about going wheat-free? Evidence of nutritional inadequacies in the dietary practices of wheat avoiders

AIM

To assess dietary intake and nutritional adequacy amongst self-identified symptomatic wheat-avoiders.

METHODS

Thirty-four self-identified symptomatic avoiders of wheat-based products without a diagnosis of coeliac disease or wheat allergy were recruited to participate in a dietary assessment study. Dietary intake was assessed via a three-day weighed food record. Participants were aged 33 to 83 years, were predominantly women (n = 30) and had been avoiding wheat for a mean of six years. Nutrient intakes were compared with Nutrient Reference Values. Food group intakes were assessed and consumption of wheat-containing and wheat-free cereal-based foods described.

RESULTS

Inadequate intakes of key protective nutrients such as fibre and calcium were common; many participants reported avoiding dairy as well as wheat. Intakes of total and saturated fat exceeded recommendations. Although 85% of the sample reported avoiding all wheat products, at least one third of cereal products and dishes consumed in this group, comprising mostly discretionary-type foods, were wheat based.

CONCLUSIONS

Dietary intake patterns and resulting nutrient imbalances in individuals restricting or eliminating wheat to manage symptoms are cause for concern. The situation is likely exacerbated by the tendency for many wheat avoiders to report also avoiding other foods, especially dairy products. A bi-disciplinary approach from medical practitioners and dietitians to individuals experiencing unexplained gastro-intestinal symptoms and strategies to support informed food choice is needed to combat longer-term health consequences of a diet with this nutritional profile.

Yes We Can: Eating Healthy on a Limited Budget

OBJECTIVE

This study determined how people who live in low-income households can consume an affordable, nutritious diet.

DESIGN

A community-based participatory research (CBPR) project was completed that developed and priced 2 weeks of healthy menus that met US Department of Agriculture Dietary Guidelines for Americans. Prices were collected from a market basket survey of 13 stores in the city of Chico during October, 2010. Initial menu development began in 2011-2012. Menus were reviewed in 2017 and reflect current guidelines.

SETTING

Chico, CA.

MAIN OUTCOME MEASURES

Macro dietary objectives including the caloric content and servings of fat, sugar, whole grains, and fruits and vegetables. The cost of purchasing the market basket of goods for a family of 4 that achieved those objectives was determined.

RESULTS

The 2 weeks of menus all met dietary objectives on average. The daily cost varied from $19 to $31 when food was purchased from a bulk supermarket, with an average daily cost of $25. Average monthly cost was $756 in 2010 dollars, or $838 in 2015 dollars.

CONCLUSIONS AND IMPLICATIONS

People living in low-income households can afford to eat healthily. Using CBPR principles, daily targets, and technical support, public health partners can partner with community members for member-defined solutions that are affordable and meet dietary guidelines. Access to stores that sell low-price bulk items is important to being able to afford a healthy diet.

Education and Income Levels are Associated With Energy and Micronutrient Intake

Introduction: According to the literature, education and income are determinants factors of diet quality and consequently of micronutrient intake. However, this association is still little known among adults who live in middle-income countries. Objective: To estimate energy and micronutrients intake by men and women living in a capital city in southern Brazil, according to education and income levels, and to identify prevalence of inadequate micronutrient intake according also to education and income levels. Method: This is a second wave cross-sectional analysis of a population-based longitudinal study, the EpiFloripa Adultos, including 1,222 individuals of 22-63 years. Data on food consumption were obtained through applying two 24-hour dietary recalls, and the prevalence of inadequate micronutrient intake, following the recommendations of the Institute of Medicine and from the National Research Council. Results: A tendency of increased intake with an increase in income (calcium, vitamins C, E) and education levels (calcium, vitamins A, C, D) was observed for most of the micronutrients analyzed (p<0.05 in all cases); still, a prevalence of inadequacy according to Estimated Average Requirement (EAR) between 85.5-100% in intake of vitamins A, D and E were found for the whole sample. Iron inadequate intake was associated with education level and among women less than 50 years of age (p=0.018). Conclusion: The results showed an influence of the education and income levels on micronutrient intake, point to the need of daily food consumption, of minimally processed and in natura foods (as fruits, vegetables, whole grains, milk and its derivatives) as a means to reduce the encountered inadequacies.

Food price trends in South Korea through time series analysis

OBJECTIVES

This study analyzed the relative time trends of prices of healthy versus unhealthy foods in South Korea for the 20 years from 1995 to 2015.

STUDY DESIGN

Time series analysis was used.

METHODS

We analyzed price trends of selected food items in the food groups of grains, vegetables, meats, sweets, spices, fast foods, and non-alcoholic beverages. We obtained nominal prices from the monthly reports of the 2006 Consumer Price Survey for representative items in each food group.

RESULTS

The real price of processed meat increased by 1.2 percentage points less than the overall Consumer Price Index (CPI) increase, whereas beef prices increased by 2.4 percentage points more than the CPI increase. The price of soda was cheaper than that of other non-alcoholic beverages, whereas the real prices of milk showed statistically significantly larger yearly increases (by 1.4 percentage points, respectively) than that of the CPI. The yearly increases in the real prices of pizza, hamburgers, and fried chicken-three representative fast-food items that were mostly consumed by eating out or through home delivery-were statistically significantly less than those of the CPI (by 1.5, 1.4, and 0.3 percentage points, respectively).

CONCLUSIONS

Our results show that relatively healthy foods showed higher real price increases than the CPI increase, whereas the opposite occurred for unhealthy foods.

Longitudinal change in the diet's monetary value is associated with its change in quality and micronutrient adequacy among urban adults

Background

Reducing diet costs may lead to the selection of energy-dense foods, such as refined grains or foods high in added sugars and/or fats, which can lower overall dietary quality. We examined the longitudinal association between the monetary value of the diet (MVD) and the overall dietary quality across sex, race and income groups.

Methods and findings

Longitudinal data from 1,466 adult urban participants from Healthy Aging in Neighborhoods of Diversity across the Life Span (HANDLS) study were used. Healthy Eating Index–2010 (HEI–2010) and Mean Adequacy Ratio (MAR) were computed and a national food price database was used to estimate MVD. Multiple linear regression analyses were conducted linking annual rates of change (Δ) in MVD to ΔHEI-2010 and ΔMAR, stratifying by sex, race and income groups. Among key findings, ΔHEI-2010 was comparable across socio-demographic groups, while ΔMAR was higher among women and individuals above poverty. Adjusting for key covariates, ΔMVD was positively associated with both ΔHEI-2010 and ΔMAR, and with a consistently stronger association among individuals above poverty, specifically for the total proteins and empty calories components of HEI-2010 and several nutrient adequacy ratios (NARs: vitamins C, E, B-6 and Zinc). ΔMVD-ΔMAR association was stronger in women, mainly influenced by ΔMVD’s positive associations with B-vitamins, copper, calcium, magnesium and phosphorus NARs. ΔMVD-Δvitamin D NAR’s positive relationship was stronger among Whites, while ΔMVD-Δvitamin B-12 NAR’s association was stronger among African-Americans.

Conclusions

In sum, a potential increase in MVD may have a stronger impact on dietary quality among urban adult women and above-poverty individuals.

Beverage consumption patterns among 4-19 y old children in 2009-14 NHANES show that the milk and 100% juice pattern is associated with better diets

BACKGROUND

Patterns of beverage consumption among children and adolescents can be indicative of food choices and total diet quality.

METHODS

Analyses of beverage consumption patterns among 8119 children aged 4-19 y were based on the first 24-h recall of the National Health and Nutrition Examination Survey (2009-14 NHANES). Four pre-defined beverage patterns were: 1) milk pattern; 2) 100% juice pattern; 3) milk and 100% juice pattern; and 4) other caloric beverages. Food- and nutrient-based diet quality measures included the Healthy Eating Index 2010.

RESULTS

Most children drank other caloric beverages, as opposed to milk (17.8%), 100% juice (5.6%), or milk and 100% juice (13.5%). Drinkers of milk and 100% juice had diets that did not differ from each other in total calories, total and added sugars, fiber, or vitamin E. Milk drinkers consumed more dairy and had higher intakes of calcium, potassium, vitamin A and vitamin D as compared to all other patterns. Juice drinkers consumed more total fruit, same amounts of whole fruit, and had higher intakes of vitamin C as compared to the other consumption patterns. Drinkers of both milk and 100% juice had the highest HEI 2010 scores of all the consumption patterns.

CONCLUSIONS

Beverage consumption patterns built around milk and/or 100% juice were relatively uncommon. Promoting the drinking of milk and 100% juice, in preference to other caloric beverages, may be an effective strategy to improve children's diet quality. Restricting milk and 100% juice consumption may encourage the selection of other caloric beverages.

Effect of Medical Nutrition Therapy for Patients With Type 2 Diabetes in a Low-/No-Cost Clinic: A Propensity Score-Matched Cohort Study

BACKGROUND

Although many studies have been conducted regarding the effectiveness of medical nutrition therapy (MNT) for type 2 diabetes management, less is known about the effectiveness of MNT for low-income adults. This study evaluated the contribution of MNT in improving A1C and blood pressure in a population of low-income adults with type 2 diabetes.

METHODS

This was a population-based, propensity score-matched cohort study using provincial health data from Altoona, Blair County, Pa. Patients who had been diagnosed with type 2 diabetes for at least 6 months before March 2014 were selected from two separate clinics that serve low-income populations. Patients who received MNT (n = 81) from a registered dietitian were compared to a matched group of patients who received primary care alone (n = 143). Outcome measures were A1C and systolic and diastolic blood pressure. The follow-up period was 1 year.

RESULTS

Improvements in A1C and systolic and diastolic blood pressure were statistically significant for patients who received MNT at uniform 3-month intervals through 1 year. At the 1-year follow-up, A1C reduction was -0.8% (P <0.01), systolic blood pressure reduction was -8.2 mmHg (P <0.01), and diastolic blood pressure reduction was -4.3 mmHg (P <0.05).

CONCLUSION

Although low-income individuals encounter a variety of barriers that reduce their capacity for success with and adherence to MNT, provision of nutrition therapy services by a registered dietitian experienced in addressing these barriers can be an effective addition to the existing medical components of type 2 diabetes care.

Socioeconomic Status Associated With Urinary Sodium and Potassium Excretion in Japan: NIPPON DATA2010

BACKGROUND

Although socioeconomic status (SES) may affect food and nutrient intakes, few studies have reported on sodium (Na) and potassium (K) intakes among individuals with various SESs in Japan. We investigated associations of SES with Na and K intake levels using urinary specimens in a representative Japanese population.

METHODS

This was a cross-sectional study of 2,560 men and women (the NIPPON DATA2010 cohort) who participated in the National Health and Nutrition Survey Japan in 2010. Casual urine was used to calculate estimated excretion in 24-hour urinary Na (E24hr-Na) and K (E24hr-K). The urinary sodium-to-potassium (Na/K) ratio was calculated from casual urinary electrolyte values. An analysis of covariance was performed to investigate associations of aspects of SES, including equivalent household expenditure (EHE), educational attainment, and job category, with E24hr-Na, E24hr-K, and the Na/K ratio for men and women separately. A stratified analysis was performed on educational attainment and the job category for younger (<65 years) and older (≥65 years) participants.

RESULTS

In men and women, average E24hr-Na was 176.2 mmol/day and 172.3, average E24hr-K was 42.5 and 41.3, and the average Na/K ratio was 3.61 and 3.68, respectively. Lower EHE was associated with a higher Na/K ratio in women and lower E24hr-K in men and women. A shorter education was associated with a higher Na/K ratio in women and younger men, and lower E24hr-K in older men and women.

CONCLUSION

Lower EHE and a shorter education were associated with a lower K intake and higher Na/K ratio estimated from casual urine specimens in Japanese men and women.

Research to Understand Milk Consumption Behaviors in a Food-Insecure Low-Income SNAP Population in the US

Milk, due to its affordability and nutritional value, can fortify the diets of families that experience food insecurity or find a high-quality diet cost-prohibitive. However, it can also be a leading source of excess calories and saturated fat. Yet, little is known about what influences consumer behavior of Supplemental Nutrition Assistance Program (SNAP) recipients toward the type of milk used or the prevalence of low-fat milk use among this population. This cross-sectional telephone survey of SNAP recipients (n = 520) documented that 7.5% of this population usually consumes low-fat milk, a prevalence that lags behind national figures (34.4%) for the same time-period. There was a weak association between sociodemographic characteristics of SNAP recipients and low-fat milk use. Instead, less low-fat milk consumption was associated with a knowledge gap and misperceptions of the nutritional properties of the different types of milk. Promoting low-fat milk use by correcting these misperceptions can improve the diet of America’s low-income population and reduce food insecurity by maximizing the nutritional value of the foods consumed.

Total Usual Intake of Shortfall Nutrients Varies With Poverty Among US Adults

OBJECTIVE

To examine shortfall nutrient intakes (ie, calcium, folate, potassium, magnesium, and vitamins A, C, D, and E) by poverty-to-income ratio (PIR).

DESIGN

National Health and Nutrition Examination Survey 2011-2012, a nationally representative, cross-sectional survey.

PARTICIPANTS

US adults with complete data on poverty status and diet were included (n = 4,524).

ANALYSIS

The National Cancer Institute method was used to estimate total usual micronutrient intakes from foods, beverages, medications, and dietary supplements reported on 2 24-hour dietary recalls using measurement error correction.

MAIN OUTCOME MEASURES

Calcium, folate, potassium, magnesium, and vitamins A, C, D, and E across 3 PIR categories: <130%, 130% to 350%, and ≥350%.

RESULTS

Mean intakes of folate, vitamin C, and vitamin D were significantly greater in men, and magnesium in women, across all PIR categories. Except for calcium in men and vitamin C in women, the highest PIR category had significantly higher mean total usual intakes of all remaining shortfall micronutrients. Importantly, men and women in the highest PIR category (≥350%) were significantly less likely to have intakes below the Estimated Average Requirement across all micronutrients compared with those in the lower PIR categories.

CONCLUSIONS AND IMPLICATIONS

Even with dietary supplements, large proportions of US adults have micronutrient intakes below the Estimated Average Requirement. Adults at the highest adjusted income have higher micronutrient intakes and lower risk of inadequacy than those with lower incomes.

Dietary Intake Contributions of Food and Beverages by Source and Food Security Status in US Adults

OBJECTIVE

To compare the consumption patterns and diet quality of foods and beverages obtained from various sources by food security status.

DESIGN

Cross-sectional analysis of 2011-2012 National Health and Nutrition Examination Survey data.

PARTICIPANTS

A total of 4,789 adults (aged >19 years) with dietary intake and food security data.

MAIN OUTCOME MEASURES

The contribution of foods and beverages to energy, nutrients, and diet quality by locations where food was obtained was compared across food security status.

ANALYSIS

Descriptive analysis and logistic regression.

RESULTS

Almost all US adults consumed food and beverages obtained from grocery stores, regardless of food security status (about 95%), which accounted for one half to two thirds of total macronutrient intakes. The diet quality of foods from grocery stores was better in highly food-secure adults. Convenience stores are used most by very low food-secure adults; those foods had the poorest diet quality profile. Dietary patterns of marginally food-secure adults more closely resembled sources and intakes of low and very low food-secure adults.

CONCLUSIONS AND IMPLICATIONS

Food-insecure adults use food sources differently, resulting in diet quality differences of foods and beverages obtained. Place-based interventions in the food environment may have differential effects by food security status.

Fibre-Related Dietary Patterns: Socioeconomic Barriers to Adequate Fibre Intake in Polish Adolescents. A Short Report

There is no complete explanation for the association between socioeconomic status (SES), fibre, and whole diet described by dietary patterns. The aim of this short report was to increase the understanding of adolescent dietary patterns related to fibre in their social context. A cross-sectional study was conducted involving 1176 adolescents aged 13–18 years from central and north-eastern Poland. The overall SES was composed of five single factors: place of residence, self-declared economic situation of family, self-declared economic situation of household, paternal and maternal education. The consumption frequency of nine dietary fibre sources was collected using Block’s questionnaire and was expressed in points. Fibre dietary patterns (DPs) were drawn by cluster analysis and odds ratios (ORs) adjusted for age, sex, and BMI were calculated. Three fibre-related DPs were identified: “High-fibre” (mean frequency of total fibre intake 22.7 points; range: 0–36), “Average-fibre” (17.7 points), “Low-fibre” (14.6 points). The “High-fibre” DP was characterized by a relatively higher frequency consumption of white bread, fruit, fruit or vegetable juices, potatoes, green salad and prepared vegetables, and a moderate frequency consumption of high-fibre or bran cereals and wholegrain bread compared to the “Low-fibre” DP. The “Average-fibre” DP was characterized by a relatively higher frequency consumption of wholegrain bread and high-fibre or bran cereals and a moderate frequency consumption of fruit, fruit or vegetable juices, green salad and prepared vegetables compared to the “Low-fibre” DP. Less likely to adhere to the “High-fibre” DP were adolescents with low SES (OR: 0.55, 95% CI: 0.39–0.77) or average SES (0.58, 95% CI: 0.41–0.81) in comparison with high SES (reference) as a result of elementary or secondary paternal or maternal education, rural residence, and lower household economic situation. Similar associations were found for the “Average-fibre” DP. Low and average socioeconomic status resulting from lower parents’ education, rural residence, and lower economic situation were inversely associated with achieving a relatively high fibre intake in Polish adolescents. Consuming single high-fibre foods was not sufficient to achieve a high-fibre diet in Polish adolescents. These data suggest that the consumption of a wide variety of dietary fibre sources—both relatively high-fibre and low-fibre foods—may help Polish adolescents in achieving a relatively high-fibre diet.

[Vitamin B12 levels in the patient population attending an urban health centre in Madrid]

INTRODUCTION

Vitamin B₁₂ levels are usually measured in Primary Care when the patients have symptoms or risk factors associated with its deficiency, mostly in the elderly. However, no evidence has been found to support the recommendation of screening in the general population. The aim of this study is to assess the relevance of having extended the screening of vitamin B₁₂ deficiency to a younger population, after observing an increase in the prescription of this injected vitamin in a population under 65 years, by analysing the vitamin B₁₂ values obtained.

MATERIAL AND METHOD

A descriptive, retrospective, observational study was conducted on a sample consisting of 5,531 patients from Barajas Health Primary Centre, Madrid, between 2008 and 2012, and on whom a blood test was performed for any reason, with values of vitamin B₁₂.

RESULTS

A deficiency was found in 9.1% (SD 2.3) of the patients, of whom 49.4% were less than 65 years. The deficiencies were associated (P<.001, 95% CI) with age, dementia, changes in blood red cell counts, memory, and with the taking of metformin and proton pump inhibitors (P=.007).

CONCLUSION

The prevalence of vitamin B₁₂ deficiency in our served population is similar in patients older and younger than 65 years. The extended screening was relevant.

Pregnancy: An Underutilized Window of Opportunity to Improve Long-term Maternal and Infant Health-An Appeal for Continuous Family Care and Interdisciplinary Communication

Physiologic adaptations during pregnancy unmask a woman's predisposition to diseases. Complications are increasingly predicted by first-trimester algorithms, amplify a pre-existing maternal phenotype and accelerate risks for chronic diseases in the offspring up to adulthood (Barker hypothesis). Recent evidence suggests that vice versa, pregnancy diseases also indicate maternal and even grandparent's risks for chronic diseases (reverse Barker hypothesis). Pub-Med and Embase were reviewed for Mesh terms "fetal programming" and "pregnancy complications combined with maternal disease" until January 2017. Studies linking pregnancy complications to future cardiovascular, metabolic, and thrombotic risks for mother and offspring were reviewed. Women with a history of miscarriage, fetal growth restriction, preeclampsia, preterm delivery, obesity, excessive gestational weight gain, gestational diabetes, subfertility, and thrombophilia more frequently demonstrate with echocardiographic abnormalities, higher fasting insulin, deviating lipids or clotting factors and show defective endothelial function. Thrombophilia hints to thrombotic risks in later life. Pregnancy abnormalities correlate with future cardiovascular and metabolic complications and earlier mortality. Conversely, women with a normal pregnancy have lower rates of subsequent diseases than the general female population creating the term: "Pregnancy as a window for future health." Although the placenta works as a gatekeeper, many pregnancy complications may lead to sickness and earlier death in later life when the child becomes an adult. The epigenetic mechanisms and the mismatch between pre- and postnatal life have created the term "fetal origin of adult disease." Up to now, the impact of cardiovascular, metabolic, or thrombotic risk profiles has been investigated separately for mother and child. In this manuscript, we strive to illustrate the consequences for both, fetus and mother within a cohesive perspective and thus try to demonstrate the complex interrelationship of genetics and epigenetics for long-term health of societies and future generations. Maternal-fetal medicine specialists should have a key role in the prevention of non-communicable diseases by implementing a framework for patient consultation and interdisciplinary networks. Health-care providers and policy makers should increasingly invest in a stratified primary prevention and follow-up to reduce the increasing number of manifest cardiovascular and metabolic diseases and to prevent waste of health-care resources.

Relationship between food insecurity, child weight status, and parent-reported child eating and snacking behaviors

PURPOSE

Prior studies showed that food insecurity may increase the odds of obesity in children and adults. We still know very little about the familial aggregation of obesity in food-insecure households or the mechanisms by which food insecurity confers an increased risk of obesity to children. The purpose of this study was to compare children and mothers from food-insecure and food-secure households in their weight status, child eating patterns/behaviors, and maternal feeding practices.

DESIGN AND METHODS

Fifty mothers of 8-10-year-old children were asked to complete questionnaires, including the U.S. Household Food Security survey, and had their own and their children's heights and weights measured.

RESULTS

The odds of a child being obese were five times higher for children from food-insecure households compared with children from food-secure households (95% confidence interval 1.15-20.8). In univariate analyses, children from food-insecure households showed significantly greater external eating, both past satiation and in the absence of hunger (p < .03), and mothers from food-insecure households expressed significantly greater concern about their children's weight and used restrictive feeding practices to a greater extent (p < .03) when compared with families from food-secure households. A greater proportion of children from food-secure households consumed three to four snacks per day (45.9 vs. 15.4%), while a higher proportion of children from food-insecure households consumed five or more snacks per day (15.4 vs. 0%; p = .02).

PRACTICE IMPLICATIONS

These findings provide further support for an association between food insecurity and childhood obesity and suggest that differences in external eating, child snacking patterns, and select maternal feeding practices may be implicated in food-insecure children's overconsumption of calories. When caring for food-insecure children, healthcare providers should screen for problematic eating patterns and feeding practices.

Dietary changes needed to reach nutritional adequacy without increasing diet cost according to income: An analysis among French adults

OBJECTIVE

To explore the dietary changes needed to achieve nutritional adequacy across income levels at constant energy and diet cost.

MATERIALS AND METHODS

Individual diet modelling was used to design iso-caloric, nutritionally adequate optimised diets for each observed diet in a sample of adult normo-reporters aged ≥20 years (n = 1,719) from the Individual and National Dietary Survey (INCA2), 2006-2007. Diet cost was estimated from mean national food prices (2006-2007). A first set of free-cost models explored the impact of optimisation on the variation of diet cost. A second set of iso-cost models explored the dietary changes induced by the optimisation with cost set equal to the observed one. Analyses of dietary changes were conducted by income quintiles, adjusting for energy intake, sociodemographic and socioeconomic variables, and smoking status.

RESULTS

The cost of observed diets increased with increasing income quintiles. In free-cost models, the optimisation increased diet cost on average (+0.22 ± 1.03 euros/d) and within each income quintile, with no significant difference between quintiles, but with systematic increases for observed costs lower than 3.85 euros/d. In iso-cost models, it was possible to design nutritionally adequate diets whatever the initial observed cost. On average, the optimisation at iso-cost increased fruits and vegetables (+171 g/day), starchy foods (+121 g/d), water and beverages (+91 g/d), and dairy products (+20 g/d), and decreased the other food groups (e.g. mixed dishes and salted snacks), leading to increased total diet weight (+300 g/d). Those changes were mostly similar across income quintiles, but lower-income individuals needed to introduce significantly more fruit and vegetables than higher-income ones.

CONCLUSIONS

In France, the dietary changes needed to reach nutritional adequacy without increasing cost are similar regardless of income, but may be more difficult to implement when the budget for food is lower than 3.85 euros/d.

Neighborhood, Family and Peer-Level Predictors of Obesity-Related Health Behaviors Among Young Adolescents

Objective

This longitudinal study examines peer social functioning (PSF), familism, and neighborhood socioeconomic status (NSES) on adolescents' obesity risk.

Methods

Participants ( N  = 2,144) were originally sampled from 16 middle schools in Southern California (45% male; 45% Hispanic) as part of an alcohol and other drug use prevention program (CHOICE). Multilevel regression modeling tested main effects and interaction terms of PSF, familism, and NSES assessed at Wave 5 ( M age = 14.15) on body mass index and risk of obesity-related behaviors at Wave 6.

Results

Higher PSF predicted healthier eating habits, less screen time, and more physical activity. Higher familism also predicted more physical activity. The positive effect of PSF on healthy eating was stronger among youth who reported higher familism. PSF also moderated the associations of NSES with healthy eating and physical activity.

Conclusion

Findings emphasize the importance of targeting both peer and family factors, which may be more amenable to change than NSES.

How expensive is a cardioprotective diet? Analysis from the CRESSIDA study

OBJECTIVE

To determine whether a cardioprotective dietary intervention based on UK dietary guidelines was more expensive than a conventional UK diet.

DESIGN

Cost analysis of food records collected at baseline and after a 12-week dietary intervention of a cardioprotective diet v. conventional UK diet.

SETTING

A randomized controlled dietary intervention study (CRESSIDA; ISRCTN 92382106) investigating the impact of following a diet consistent with UK dietary guidelines on CVD risk.

SUBJECTS

Participants were healthy UK residents aged 40-70 years. A sub-sample of participants was randomly selected from those who completed the cardioprotective dietary intervention (n 20) or the conventional UK dietary intervention (n 20).

RESULTS

Baseline diet costs did not differ between groups; mean daily food cost for all participants was £6·12 (sd £1·83). The intervention diets were not more expensive: at end point the mean daily cost of the cardioprotective diet was £6·43 (sd £2·05) v. the control diet which was £6·53 (sd £1·53; P=0·86).

CONCLUSIONS

There was no evidence that consumption of a cardioprotective diet was more expensive than a conventional dietary pattern. Despite the perception that healthier foods are less affordable, these results suggest that cost may not be a barrier when modifying habitual intake and under tightly controlled trial conditions. The identification of specific food groups that may be a cost concern for individuals may be useful for tailoring interventions for CVD prevention for individuals and populations.

Challenges to the Mediterranean diet at a time of economic crisis

AIMS

The traditional Mediterranean diet (MD) is reportedly associated with lower risk of major chronic diseases and long considered to contribute to the reduced rates of cardiovascular and cerebrovascular events and to the highest life expectancy in adults who lived near the Mediterranean Sea. But despite its widely documented health benefits, adherence to this dietary pattern has been rapidly declining over the last decades due to a clear socioeconomic influence. The present review provides an overview of the evidence on the current major determinants of adherence to the Mediterranean diet, with a particular emphasis on Mediterranean Countries at a time of economic crisis; second it explores emerging socioeconomic inequalities in other domains of healthy dietary behaviours such as dietary variety, access to organic foods and food purchasing behaviour.

DATA SYNTHESIS

According to ecological evidence, the Mediterranean Countries that used to have the highest adherence to the Mediterranean pattern in the Sixties, more recently experienced the greatest decrease, while Countries in Northern Europe and some other Countries around the world are currently embracing a Mediterranean-like dietary pattern. A potential cause of this downward trend could be the increasing prices of some food items of the Mediterranean diet pyramid. Recent evidence has shown a possible involvement of the economic crisis, material resources becoming strong determinants of the adherence to the MD just after the recession started in 2007-2008. Beyond intake, the MD also encourages increasing dietary diversity, while international dietary recommendations suggest replacing regular foods with healthier ones.

CONCLUSIONS

Socioeconomic factors appear to be major determinants of the adherence to MD and disparities also hold for other indices of diet quality closely related to this dietary pattern.

Can Families Eat Better Without Spending More? Improving Diet Quality Does Not Increase Diet Cost in a Randomized Clinical Trial among Youth with Type 1 Diabetes and Their Parents

BACKGROUND

Although cost is a frequently cited barrier to healthful eating, limited prospective data exist.

OBJECTIVE

To examine the association of diet cost with diet quality change.

DESIGN

An 18-month randomized clinical trial evaluated a dietary intervention.

PARTICIPANTS AND SETTING

Youth with type 1 diabetes duration ≥1 year, age 8.0 to 16.9 years, receiving care at an outpatient tertiary diabetes center in Boston, MA, participated along with a parent from 2010 to 2013 (N=136). Eighty-two percent of participants were from middle- to upper-income households.

INTERVENTION

The family-based behavioral intervention targeted intake of whole plant foods.

MAIN OUTCOME MEASURES

Diet quality as indicated by the Healthy Eating Index 2005 (HEI-2005) (which measures conformance to the 2005 Dietary Guidelines for Americans) and whole plant food density (cup or ounce equivalents per 1,000 kcal target food groups) were calculated from 3-day food records of youth and parent dietary intake at six and four time points, respectively. Food prices were obtained from two online supermarkets common to the study location. Daily diet cost was calculated by summing prices of reported foods.

STATISTICAL ANALYSES PERFORMED

Random effects models estimated treatment group differences in time-varying diet cost. Separate models for youth and parent adjusted for covariates examined associations of time-varying change in diet quality with change in diet cost.

RESULTS

There was no treatment effect on time-varying diet cost for either youth (β -.49, 95% CI -1.07 to 0.08; P=0.10) or parents (β .24, 95% CI -1.61 to 2.08; P=0.80). In addition, time-varying change in diet quality indicators was not associated with time-varying change in diet cost for youth. Among parents, a 1-cup or 1-oz equivalent increase in whole plant food density was associated with a $0.63/day lower diet cost (β -.63, 95% CI -1.20 to -0.05; P=0.03).

CONCLUSIONS

Improved diet quality was not accompanied by greater cost for youth with type 1 diabetes and their parents participating in a randomized clinical trial. Findings challenge the prevailing assumption that improving diet quality necessitates greater cost.