Multidisciplinary approach combining food metabolomics and epidemiology identifies meglutol as an important bioactive metabolite in tempe, an Indonesian fermented food

This study introduces a multidisciplinary approach to investigate bioactive food metabolites often overlooked due to their low concentrations. We integrated an in-house food metabolite library (n = 494), a human metabolite library (n = 891) from epidemiological studies, and metabolite pharmacological databases to screen for food metabolites with potential bioactivity. We identified six potential metabolites, including meglutol (3-hydroxy-3-methylglutarate), an understudied low-density lipoprotein (LDL)-lowering compound. We further focused on meglutol as a case study to showcase the range of characterizations achievable with this approach. Green pea tempe was identified to contain the highest meglutol concentration (21.8 ± 4.6 mg/100 g). Furthermore, we identified a significant cross-sectional association between plasma meglutol (per 1-standard deviation) and lower LDL cholesterol in two Hispanic adult cohorts (n = 1,628) (β [standard error]: -5.5 (1.6) mg/dl, P = 0.0005). These findings highlight how multidisciplinary metabolomics can serve as a systematic tool for discovering and enhancing bioactive metabolites in food, such as meglutol, with potential applications in personalized dietary approaches for disease prevention.

Workshop summary: building an NHANES for the future

The American Society for Nutrition's (ASN) Committee on Advocacy and Science Policy (CASP) organized a workshop, "Building a National Health and Nutrition Examination Survey (NHANES) for the Future," held during NUTRITION 2023, which took place in Boston, MA in July 2023. CASP had already identified an urgent need for increased support and modernization to ensure that a secure future for NHANES is achievable. The survey faces challenges associated with data collection, stagnant funding, and a need for more granular data for subpopulations and groups at risk. The workshop provided an overview of NHANES, including the nutrition component, and the many other uses for the survey's data, which extend beyond nutrition. Speakers highlighted NHANES's current and emerging challenges, as well as possible solutions to address these challenges, especially with regard to response rates of underrepresented groups, linkage of survey data to other resources, incorporation of new survey methodologies, and emerging data needs. The workshop also included a "Town Hall" component to gather additional feedback on NHANES' challenges and proposed solutions from audience members. The workshop provided many possible action items that ASN will explore and use to inform effective continued advocacy in support of NHANES and to find possible opportunities for ASN and others to partner with the Centers for Disease Control and Prevention National Center for Health Statistics to strengthen this vital survey and maintain its robust and relevant data moving forward.

Association of Gut Microbiota-Related Metabolites and Type 2 Diabetes in Two Puerto Rican Cohorts

(1) Aims: Gut microbiota metabolites may play integral roles in human metabolism and disease progression. However, evidence for associations between metabolites and cardiometabolic risk factors is sparse, especially in high-risk Hispanic populations. We aimed to evaluate the cross-sectional and longitudinal relationships between gut microbiota related metabolites and measures of glycemia, dyslipidemia, adiposity, and incident type 2 diabetes in two Hispanic observational cohorts. (2) Methods: We included data from 670 participants of the Boston Puerto Rican Health Study (BPRHS) and 999 participants of the San Juan Overweight Adult Longitudinal Study (SOALS). Questionnaires and clinical examinations were conducted over 3 years of follow-up for SOALS and 6 years of follow-up for BPRHS. Plasma metabolites, including L-carnitine, betaine, choline, and trimethylamine N-oxide (TMAO), were measured at baseline in both studies. We used multivariable linear models to evaluate the associations between metabolites and cardiometabolic risk factors and multivariable logistic and Poisson regressions to assess associations with prevalent and incident type 2 diabetes, adjusted for potential confounding factors. Cohort-specific analyses were combined using a fixed-effects meta-analysis. (3) Results: Higher plasma betaine was prospectively associated with lower fasting glucose [-0.97 mg/dL (95% CI: -1.59, -0.34), p = 0.002], lower HbA1c [-0.02% (95% CI: -0.04, -0.01), p = 0.01], lower HOMA-IR [-0.14 (95% CI: -0.23, -0.05), p = 0.003], and lower fasting insulin [-0.27 mcU/mL (95% CI: -0.51, -0.03), p = 0.02]. Betaine was also associated with a 22% lower incidence of type 2 diabetes (IRR: 0.78, 95% CI: 0.65, 0.95). L-carnitine was associated with lower fasting glucose [-0.68 mg/dL (95% CI: -1.29, -0.07), p = 0.03] and lower HbA1c at follow-up [-0.03% (95% CI: -0.05, -0.01), p < 0.001], while TMAO was associated with higher fasting glucose [0.83 mg/dL (95% CI: 0.22, 1.44), p = 0.01] and higher triglycerides [3.52 mg/dL (95% CI: 1.83, 5.20), p < 0.0001]. Neither choline nor TMAO were associated with incident type 2 diabetes. (4) Conclusions: Higher plasma betaine showed consistent associations with a lower risk of glycemia, insulinemia, and type 2 diabetes. However, TMAO, a metabolite of betaine, was associated with higher glucose and lipid concentrations. These observations demonstrate the importance of gut microbiota metabolites for human cardiometabolic health.

Sugar-sweetened or artificially-sweetened beverage consumption, physical activity, and risk of cardiovascular disease in adults: a prospective cohort study

BACKGROUND

Whether physical activity could mitigate the adverse impacts of sugar-sweetened beverages (SSBs) or artificially sweetened beverages (ASBs) on incident cardiovascular disease (CVD) remains uncertain.

OBJECTIVES

This study aimed to examine the independent and joint associations between SSB or ASB consumption and physical activity and risk of CVD, defined as fatal and nonfatal coronary artery disease and stroke, in adults from 2 United States-based prospective cohort studies.

METHODS

Cox proportional hazards models were used to calculate hazard ratios (HRs) and 95% CIs between SSB or ASB intake and physical activity with incident CVD among 65,730 females in the Nurses' Health Study (1980-2016) and 39,418 males in the Health Professional's Follow-up Study (1986-2016), who were free from chronic diseases at baseline. SSBs and ASBs were assessed every 4-y and physical activity biannually.

RESULTS

A total of 13,269 CVD events were ascertained during 3,001,213 person-years of follow-up. Compared with those who never/rarely consumed SSBs or ASBs, the HR for CVD for participants consuming ≥2 servings/d was 1.21 (95% CI: 1.12, 1.32; P-trend < 0.001) for SSBs and 1.03 (95% CI: 0.97, 1.09; P-trend = 0.06) for those consuming ≥2 servings/d of ASBs. The HR for CVD per 1 serving increment of SSB per day was 1.18 (95% CI: 1.10, 1.26) and 1.12 (95% CI: 1.04, 1.20) for participants meeting and not meeting physical activity guidelines (≥7.5 compared with <7.5 MET h/wk), respectively. Compared with participants who met physical activity guidelines and never/rarely consumed SSBs, the HR for CVD was 1.47 (95% CI: 1.37, 1.57) for participants not meeting physical activity guidelines and consuming ≥2 servings/wk of SSBs. No significant associations were observed for ASB when stratified by physical activity.

CONCLUSIONS

Higher SSB intake was associated with CVD risk regardless of physical activity levels. These results support current recommendations to limit the intake of SSBs even for physically active individuals.

Plant-Based Diets and Risk of Hip Fracture in Postmenopausal Women

Importance

Previous research has found that vegetarian diets are associated with lower bone mineral density and higher risk of fractures, but these studies did not differentiate the quality of the plant-based foods.

Objective

To examine the association between the quality of plant-based diets (not necessarily vegan but also omnivorous) and hip fracture risk among postmenopausal women in the Nurses' Health Study.

Design, Setting, and Participants

This cohort study analyzed data from 70 285 postmenopausal women who participated in the US Nurses' Health Study from 1984 through 2014. Data were analyzed from January 1 to July 31, 2023.

Main outcomes and Measures

Hip fractures were self-reported on biennial questionnaires. Diet was assessed every 4 years using a validated semiquantitative food frequency questionnaire. Plant-based diet quality was assessed using 2 previously established indices: the healthful Plant-Based Diet Index (hPDI), for which healthy plant foods (whole grains, fruits, vegetables, nuts, legumes, vegetable oils, and tea or coffee) received positive scores, whereas less healthy plant foods (fruit juices, sweetened beverages, refined grains, potatoes, and sweets or desserts) and animal foods received reversed scores; and the unhealthful Plant-Based Diet Index (uPDI), for which positive scores were given to less healthy plant foods and reversed scores to healthy plant and animal foods. Quintile scores of 18 food groups were summed, with a theoretical range for both indices of 18 to 90 (highest adherence). Cox proportional hazards regression with time-varying covariates was used to compute hazard ratios (HRs) and 95% CIs for hip fracture.

Results

In total, 70 285 participants (mean [SD] age, 54.92 [4.48] years; 100% White women) were included, and 2038 cases of hip fracture were ascertained during the study and for up to 30 years of follow-up. Neither the hPDI (HR for highest vs lowest quintile, 0.97 [95% CI, 0.83-1.14]) nor the uPDI (HR for highest vs lowest quintile, 1.02 [95% CI, 0.87-1.20]) for long-term diet adherence was associated with hip fracture risk. However, when examining recent intake for the highest vs lowest quintiles, the hPDI was associated with 21% lower risk of hip fracture (HR, 0.79 [95% CI, 0.68-0.92]; P = .02 for trend), and the uPDI was associated with 28% higher risk (1.28 [95% CI, 1.09-1.51]; P = .008 for trend).

Conclusions and Relevance

Findings of this cohort study indicated that long-term adherence to healthful or unhealthful plant-based diets as assessed by hPDI and uPDI scores was not associated with hip fracture risk. Future research should clarify whether the associations observed with recent dietary intake are due to short-term effects of these dietary patterns, reverse causality, or both.

Nutrition and Health in the Lesbian, Gay, Bisexual, Transgender, Queer/Questioning Community: A Narrative Review

Sexual and gender minorities have a higher risk for health and nutrition-related disparities across the life course compared to the heterosexual or cisgender population. Experiences of stigmatization and discrimination are associated with diminished mental health quality and psychological distress, which are risk factors for developing various eating disorders. Other nutrition disparities include increased risk for food insecurity, body dissatisfaction, and weight complications, such as those experienced by the transgender population in association with gender-affirming hormone therapies. Despite the need for tailored nutrition recommendations that address the unique needs of the lesbian, gay, bisexual, transgender, queer/questioning (LGBTQ+) community, there are currently no such guidelines in North America. The purpose of this review is to summarize major LGBTQ+ nutrition disparities and highlight the need for tailored recommendations. We examine the evidence on mental health and social disparities in this group, including vulnerabilities to disordered eating, food insecurity, and healthcare provider discrimination. Importantly, we identify a scarcity of literature on dietary concerns and nutrition care guidelines for LGBTQ+ groups, including studies that address intersectionality and differences among specific gender and sexual orientations. These gaps underline the urgency of prioritizing nutrition for LGBTQ+ health needs and for developing tailored public health nutrition recommendations for this underserved population. Our review suggests that future LGBTQ+ health and nutrition research agendas should include personalized and precision nutrition, social determinants of health, diet quality, body image, and healthcare provider cultural competency and responsiveness. Moreover, the current evidence on LGBTQ+ nutrition and health will be strengthened when research studies (including clinical trials) with robust methodologies amplify inclusion and representation of this community to elucidate health and nutrition disparities in sexual and gender minorities.

The Intersection Between COVID-19, Cardiovascular Disease, and Diet: a Review

PURPOSE OF REVIEW

Cardiovascular disease (CVD) is one of the top comorbidities associated with COVID-19-both pre- and post-infection. This review examines the relationships between COVID-19 infection and cardiovascular health, with a specific focus on diet as an important modifiable risk factor.

RECENT FINDINGS

Pandemic era studies of individuals battling and recovering from COVID-19 infection suggest a strong link between metabolic diseases, such as CVD, and SARS-CoV-2 infection susceptibility and severity. Other studies also demonstrate how COVID-19 lockdown policies and quarantine recommendations led to drastic lifestyle changes associated with increased CVD risk, such as reduced physical activity and lower diet quality. At the same time, new research is emerging that plant-based diets, which have previously been associated with lower CVD risk, may lower COVID-19 infection rates and severity of symptoms. Diet, COVID-19, and CVD intersect through complex biological mechanisms and related behavioral factors evidenced by clinical trials and epidemiological studies. Diet may be a critical tool for modifying risk of communicable and non-communicable conditions in the post-pandemic world.

Methyl Donor Nutrient Intake and Incidence of Type 2 Diabetes: Results From Three Large U.S. Cohorts

OBJECTIVE

We examined whether intake of methyl donor nutrients, including vitamins B2, B6, and B12 and folate, from foods and/or supplements is associated with type 2 diabetes risk.

RESEARCH DESIGN AND METHODS

We included 203,644 women and men from the Nurses' Health Study (1984-2016), Nurses' Health Study 2 (1991-2017), and Health Professionals Follow-Up Study (1986-2016). Dietary data were collected every 2-4 years with use of semiquantitative food-frequency questionnaires. Cox proportional hazards models with time-varying covariates were used to evaluate associations between each nutrient and type 2 diabetes risk. We combined cohort-specific hazard ratios (HRs) using inverse variance-weighted fixed-effects meta-analyses.

RESULTS

During 4,900,181 person-years of follow-up, we documented 19,475 incident type 2 diabetes cases. In multivariable-adjusted meta-analyses, participants in the highest quintiles of total vitamin B2 and B6 intakes had lower risk of diabetes compared with those in the lowest quintiles (HR 0.93 [95% CI 0.89, 0.98] for B2 and 0.93 [0.89, 0.97] for B6). With stratification by source, significant associations remained for B2 from food but not from supplements. Neither association for B6 from food nor association for B6 from supplements attained significance. No association was observed between total B12 intake and diabetes. However, B12 from food was marginally associated with higher diabetes risk (1.05 [1.00-1.11]) but not after additional adjustment for red meat intake (1.04 [0.99-1.10]). No evidence of association was observed between intakes of folate and diabetes.

CONCLUSIONS

The results of our study suggest that higher intake of vitamin B2 and B6, especially B2 from food sources, may be associated with a modestly lower type 2 diabetes risk.

Nutritional redundancy in the human diet and its application in phenotype association studies

Studying human dietary intake may help us identify effective measures to treat or prevent many chronic diseases whose natural histories are influenced by nutritional factors. Here, by examining five cohorts with dietary intake data collected on different time scales, we show that the food intake profile varies substantially across individuals and over time, while the nutritional intake profile appears fairly stable. We refer to this phenomenon as 'nutritional redundancy' and attribute it to the nested structure of the food-nutrient network. This network enables us to quantify the level of nutritional redundancy for each diet assessment of any individual. Interestingly, this nutritional redundancy measure does not strongly correlate with any classical healthy diet scores, but its performance in predicting healthy aging shows comparable strength. Moreover, after adjusting for age, we find that a high nutritional redundancy is associated with lower risks of cardiovascular disease and type 2 diabetes.

A South Asian Mediterranean-style diet is associated with favorable adiposity measures and lower diabetes risk: The MASALA cohort

OBJECTIVE

The Mediterranean diet is associated with lower risks for type 2 diabetes (T2D) and cardiovascular disease in certain populations, although data among diverse groups are limited. This study evaluated cross-sectional and prospective associations between a novel South Asian Mediterranean-style (SAM) diet and cardiometabolic risk among US South Asian individuals.

METHODS

The study included 891 participants at baseline in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. Culturally relevant foods were grouped into nine categories to construct the SAM score. The study examined associations of this score with cardiometabolic risk factors and incident T2D.

RESULTS

At baseline, higher adherence to the SAM diet was associated with lower glycated hemoglobin (-0.43% ± 0.15% per 1-unit increase in SAM score; p = 0.004) and lower pericardial fat volume (-1.22 ± 0.55 cm³ ; p = 0.03), as well as a lower likelihood of obesity (odds ratio [OR]: 0.88, 95% CI: 0.79-0.98) and fatty liver (OR: 0.82, 95% CI: 0.68-0.98). Over the follow-up (~5 years), 45 participants developed T2D; each 1-unit increase in SAM score was associated with a 25% lower odds of incident T2D (OR: 0.75, 95% CI: 0.59-0.95).

CONCLUSIONS

A greater intake of a SAM diet is associated with favorable adiposity measures and a lower likelihood of incident T2D.

Physical Activity, Sedentary Behavior, and Risk of Coronavirus Disease 2019

INTRODUCTION

Data on the associations of prepandemic physical activity and sedentary behavior with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) severity, particularly milder illness, have been limited.

METHODS

We used data from 43,913 participants within the Nurses' Health Study II and Health Professionals Follow-Up Study who responded to periodic COVID-related surveys from May 2020 through March 2021. History of physical activity from the prepandemic period was assessed as the metabolic equivalents of task (MET)-hours per week of various activities of different intensity and sedentary behavior assessed from reports of time spent sitting from questionnaires completed 2016-2017. Multivariable logistic regression models were fitted to calculate the odds ratios (ORs) and 95% confidence intervals (CIs) for risk of SARS-CoV-2 infection and COVID-19 severity, as well as predicted COVID-19 defined using a validated symptom-based algorithm.

RESULTS

Higher levels of prepandemic physical activity were associated with a lower risk for SARS-CoV-2 infection. Compared to participants with <3 MET-hours per week, the multivariable-adjusted OR was 0.86 (95% CI: 0.74, 0.99; P trend =.07) for those with ≥27 MET-hours per week. Higher physical activity levels were also associated with lower risk of symptomatic SARS-CoV-2 infection (OR: 0.84; 95% CI: 0.72, 0.99; P trend = .05) and predicted COVID-19 (OR: 0.87; 95% CI: 0.78, 0.97; P trend = .01). Longer time sitting at home watching TV (OR: 0.85; 95% CI: 0.73, 0.97) or for other tasks (OR: 0.78; 95% CI: 0.66, 0.92) was associated with a lower risk of SARS-CoV-2 infection.

CONCLUSIONS

Our findings support a protective association between prepandemic physical activity and lower risk and severity of COVID-19.

Sugar- or artificially-sweetened beverage consumption, physical activity, and risk of cardiovascular disease in US adults

Background

The extent to which physical activity attenuates the detrimental effects of sugar (SSBs)- or artificially-sweetened beverages (ASBs) on the risk of cardiovascular disease is unknown.

Methods

We used Cox proportional-hazards models to calculate hazard ratios and 95% confidence interval [HR (CI)] between SSB or ASB intake and physical activity with cardiovascular disease risk among 65,730 women in the Nurses' Health Study (1980-2016) and 39,418 men in the Health Professional's Follow-up Study (1986-2016), who were free from chronic diseases at baseline. SSBs and ASBs were assessed every 4-years and physical activity biannually.

Results

A total of 13,269 cardiovascular events were ascertained during 3,001,213 person-years of follow-up. Compared with those that never/rarely consumed SSBs or ASBs, HR and 95% CI for cardiovascular disease for participants consuming ≥2 servings/day were 1.21 (95% CI,1.12 to 1.32; P-trend<0.001) and 1.03 (95% CI, 0.97 to 1.09; P-trend=0.06), respectively. In the joint analyses, for participants meeting and not meeting physical activity guidelines (<7.5 vs ≥7.5 MET-h/week) as well as consuming ≥2 servings/day of SSBs or ASBs, the HRs for cardiovascular disease were 1.15 (95% CI, 1.08 to 1.23) and 0.96 (95% CI, 0.91 to 1.02), and 1.47 (95% CI, 1.37 to 1.57) and 1.29 (95% CI, 1.22 to 1.37) respectively, compared with participants who met physical activity guidelines and never/rarely consumed these beverages. Similar patterns were observed when coronary heart disease and stroke were analyzed.

Conclusions

Our findings suggest that among physically active participants, higher SSB intake, but not ASBs, is associated with a higher cardiovascular risk. Our results support current recommendations to limit the intake of SSB and maintain adequate physical activity levels.

Adherence to Healthy Lifestyle Prior to Infection and Risk of Post-COVID-19 Condition

Importance

Few modifiable risk factors for post-COVID-19 condition (PCC) have been identified.

Objective

To investigate the association between healthy lifestyle factors prior to SARS-CoV-2 infection and risk of PCC.

Design, Setting, and Participants

In this prospective cohort study, 32 249 women in the Nurses' Health Study II cohort reported preinfection lifestyle habits in 2015 and 2017. Healthy lifestyle factors included healthy body mass index (BMI, 18.5-24.9; calculated as weight in kilograms divided by height in meters squared), never smoking, at least 150 minutes per week of moderate to vigorous physical activity, moderate alcohol intake (5 to 15 g/d), high diet quality (upper 40% of Alternate Healthy Eating Index-2010 score), and adequate sleep (7 to 9 h/d).

Main Outcomes and Measures

SARS-CoV-2 infection (confirmed by test) and PCC (at least 4 weeks of symptoms) were self-reported on 7 periodic surveys administered from April 2020 to November 2021. Among participants with SARS-CoV-2 infection, the relative risk (RR) of PCC in association with the number of healthy lifestyle factors (0 to 6) was estimated using Poisson regression and adjusting for demographic factors and comorbidities.

Results

A total of 1981 women with a positive SARS-CoV-2 test over 19 months of follow-up were documented. Among those participants, mean age was 64.7 years (SD, 4.6; range, 55-75); 97.4% (n = 1929) were White; and 42.8% (n = 848) were active health care workers. Among these, 871 (44.0%) developed PCC. Healthy lifestyle was associated with lower risk of PCC in a dose-dependent manner. Compared with women without any healthy lifestyle factors, those with 5 to 6 had 49% lower risk (RR, 0.51; 95% CI, 0.33-0.78) of PCC. In a model mutually adjusted for all lifestyle factors, BMI and sleep were independently associated with risk of PCC (BMI, 18.5-24.9 vs others, RR, 0.85; 95% CI, 0.73-1.00, P = .046; sleep, 7-9 h/d vs others, RR, 0.83; 95% CI, 0.72-0.95, P = .008). If these associations were causal, 36.0% of PCC cases would have been prevented if all participants had 5 to 6 healthy lifestyle factors (population attributable risk percentage, 36.0%; 95% CI, 14.1%-52.7%). Results were comparable when PCC was defined as symptoms of at least 2-month duration or having ongoing symptoms at the time of PCC assessment.

Conclusions and Relevance

In this prospective cohort study, pre-infection healthy lifestyle was associated with a substantially lower risk of PCC. Future research should investigate whether lifestyle interventions may reduce risk of developing PCC or mitigate symptoms among individuals with PCC or possibly other postinfection syndromes.

Abstract P152: Joint Association of Sugar- and Artificially-Sweetened Beverage Consumption and Physical Activity and Risk of Type 2 Diabetes in US Adults

Background: Consumption of sugar-sweetened beverages (SSBs) or artificially sweetened beverages (ASBs) and physical activity are independently associated with type 2 diabetes (T2D) risk; however, it is unknown whether there is an interaction of SSB/ASB intake and physical activity on risk of T2D.

Methods: We examined the independent and joint associations between habitual SSB/ASB intake and physical activity with incident T2D risk among 196,101 women and men from the Nurses’ Health Study (NHS, 1980-2016), NHSII (1991-2017), and Health Professional’s Follow-up Study (HPFS, 1986-2016), who were free from chronic diseases at baseline. Cox proportional hazards regressions were used to estimate hazard ratios and 95% confidence intervals (HR; CI), adjusting for demographic and lifestyle T2D risk factors.

Results: There were 20,430 incident T2D cases over follow-up of 36, 26, and 30 years in NHS, NHSII, and HPFS, respectively. In multivariable-adjusted models, we confirmed that participants with higher SSBs, ASBs and lower physical activity were independently at higher T2D risk, compared to lower intakes and higher activity levels. In joint analyses for these exposures, participants who did not meet physical activity guidelines and consumed gt 2 servings/day of SSBs had a significantly higher risk of T2D than those who met physical activity guidelines and never/rarely consumed SSBs (1.51; 1.43, 1.60); we observed similar findings for ASBs: 1.29; 1.23, 1.36). Among participants who met physical activity guidelines, those who consumed gt 2 servings/day of SSBs had a HR of 1.23 (1.16, 1.30); the HR for ASBs was 1.07 (1.02, 1.13). Consistent results were observed for women and men.

Conclusions: Long-term habitual intake of SSBs or ASBs combined with lower physical activity was associated with higher risk of T2D in three large prospective cohort studies. These findings suggest that even when individuals are physically active, higher consumption of SSBs is associated with a higher risk of T2D. Our results support recommendations and policies to limit the intake of SSB and increase physical activity levels.

Abstract P216: Carbohydrate Quantity and Quality, and Risk of Type 2 Diabetes: Results From Three Large Prospective US Cohorts

Background: High-quality carbohydrate sources, such as whole grains, have been associated with a lower risk of type 2 diabetes (T2D), whereas low-quality carbohydrate sources, such as refined grains and added sugar, have been associated with a higher T2D risk. However, few studies have considered how replacing dietary carbohydrate with other macronutrients may influence T2D risk.

Objective: We examined whether isocaloric substitution of high- or low-quality carbohydrate for fat, protein, and their subtypes is associated with T2D risk.

Methods: We included 75,430 women from the Nurses' Health Study (1984-2016), 85,630 women from the Nurses' Health Study II (1991-2017), and 40,261 men from the Health Professionals Follow-Up Study (1986-2016) who were free of T2D, CVD, and cancer at baseline. Dietary data were collected every 2-4 years using a validated, semi-quantitative food frequency questionnaire. High-quality carbohydrate was defined as carbohydrate from whole grains, fruits, vegetables, and legumes. Low-quality carbohydrate was defined as carbohydrate from refined grains, added sugars, and potatoes. We used Cox proportional hazards regression with time-varying covariates to model the substitution of 5% of energy intake from high- and low-quality carbohydrate for isocaloric amounts of fat, protein, and their subtypes [polyunsaturated fat (PUFA), animal and plant monounsaturated fat (MUFA), saturated fat, trans fat, and animal and plant protein]. Cohort-specific estimates were combined using inverse variance-weighted fixed effects meta-analyses.

Results: During 4,859,845 years of follow-up, we documented 20,141 incident T2D cases. In multivariable-adjusted meta-analyses, isocaloric substitution of high-quality carbohydrate for total fat [HR (95% CI) 0.94 (0.93, 0.96)], total MUFA [0.95 (0.91, 0.98)], MUFA from animal sources [0.92 (0.88, 0.95)], total protein [0.91 (0.89, 0.94)], or animal protein [0.94 (0.91, 0.97] was associated with a lower T2D risk. On the other hand, the substitution of low-quality carbohydrate for plant MUFA [1.06 (1.02-1.10)] or plant protein [1.06 (1.02-1.11)] was associated with a higher risk of T2D. When we restricted high-quality carbohydrate sources to whole grains, the results were similar or stronger. Additionally, substitution of whole grain carbohydrate for saturated fat [0.87 (0.84, 0.91)], trans fat [0.87 (0.83, 0.92)], PUFA [0.88 (0.84, 0.92)], plant MUFA [0.92 (0.87, 0.96)], or plant protein [0.91 (0.86, 0.97)] was associated with lower T2D risk.

Conclusions: The effect of carbohydrate substitution on T2D risk depends not only on the nutrient being substituted but also on the quality of the carbohydrate. Substitution of high-quality carbohydrate, especially carbohydrate from whole grains (i.e. whole wheat bread, oatmeal), for fat or protein, especially animal sources (i.e. beef, poultry), may lower T2D risk.

Healthy Eating Patterns and Risk of Total and Cause-Specific Mortality

Importance

The current Dietary Guidelines for Americans recommend multiple healthy eating patterns. However, few studies have examined the associations of adherence to different dietary patterns with long-term risk of total and cause-specific mortality.

Objective

To examine the associations of dietary scores for 4 healthy eating patterns with risk of total and cause-specific mortality.

Design, Setting, and Participants

This prospective cohort study included initially healthy women from the Nurses' Health Study (NHS; 1984-2020) and men from the Health Professionals Follow-up Study (HPFS; 1986-2020).

Exposures

Healthy Eating Index 2015 (HEI-2015), Alternate Mediterranean Diet (AMED) score, Healthful Plant-based Diet Index (HPDI), and Alternate Healthy Eating Index (AHEI).

Main Outcomes and Measures

The main outcomes were total and cause-specific mortality overall and stratified by race and ethnicity and other potential risk factors.

Results

The final study sample included 75 230 women from the NHS (mean [SD] baseline age, 50.2 [7.2] years) and 44 085 men from the HPFS (mean [SD] baseline age, 53.3 [9.6] years). During a total of 3 559 056 person-years of follow-up, 31 263 women and 22 900 men died. When comparing the highest with the lowest quintiles, the pooled multivariable-adjusted HRs of total mortality were 0.81 (95% CI, 0.79-0.84) for HEI-2015, 0.82 (95% CI, 0.79-0.84) for AMED score, 0.86 (95% CI, 0.83-0.89) for HPDI, and 0.80 (95% CI, 0.77-0.82) for AHEI (P < .001 for trend for all). All dietary scores were significantly inversely associated with death from cardiovascular disease, cancer, and respiratory disease. The AMED score and AHEI were inversely associated with mortality from neurodegenerative disease. The inverse associations between these scores and risk of mortality were consistent in different racial and ethnic groups, including Hispanic, non-Hispanic Black, and non-Hispanic White individuals.

Conclusions and Relevance

In this cohort study of 2 large prospective cohorts with up to 36 years of follow-up, greater adherence to various healthy eating patterns was consistently associated with lower risk of total and cause-specific mortality. These findings support the recommendations of Dietary Guidelines for Americans that multiple healthy eating patterns can be adapted to individual food traditions and preferences.

Neighborhood socioeconomic status and mortality in the nurses' health study (NHS) and the nurses' health study II (NHSII)

Few studies have prospectively examined long-term associations between neighborhood socioeconomic status (nSES) and mortality risk, independent of demographic and lifestyle risk factors.

Methods

We assessed associations between nSES and all-cause, nonaccidental mortality among women in the Nurses' Health Study (NHS) 1986-2014 (N = 101,701) and Nurses' Health Study II (NHSII) 1989-2015 (N = 101,230). Mortality was ascertained from the National Death Index (NHS: 19,228 deaths; NHSII: 1556 deaths). Time-varying nSES was determined for the Census tract of each residential address. We used principal component analysis (PCA) to identify nSES variable groups. Multivariable Cox proportional hazards models were conditioned on age and calendar period and included time-varying demographic, lifestyle, and individual SES factors.

Results

For NHS, hazard ratios (HRs) comparing the fifth to first nSES quintiles ranged from 0.89 (95% confidence interval [CI] = 0.84, 0.94) for percent of households receiving interest/dividends, to 1.11 (95% CI = 1.06, 1.17) for percent of households receiving public assistance income. In NHSII, HRs ranged from 0.72 (95% CI: 0.58, 0.88) for the percent of households receiving interest/dividends, to 1.27 (95% CI: 1.07, 1.49) for the proportion of households headed by a single female. PCA revealed three constructs: education/income, poverty/wealth, and racial composition. The racial composition construct was associated with mortality (HRNHS: 1.03; 95% CI = 1.01, 1.04).

Conclusion

In two cohorts with extensive follow-up, individual nSES variables and PCA component scores were associated with mortality. nSES is an important population-level predictor of mortality, even among a cohort of women with little individual-level variability in SES.

Habitual coffee consumption and subsequent risk of type 2 diabetes in individuals with a history of gestational diabetes - a prospective study

BACKGROUND

Females with a history of gestational diabetes mellitus (GDM) are at higher risk of developing type 2 diabetes mellitus (T2D) later in life.

OBJECTIVE

This study prospectively examined whether greater habitual coffee consumption was related to a lower risk of T2D among females with a history of GDM.

METHODS

We followed 4522 participants with a history of GDM in the NHS II for incident T2D between 1991 and 2017. Demographic, lifestyle factors including diet, and disease outcomes were updated every 2-4 y. Participants reported consumption of caffeinated and decaffeinated coffee on validated FFQs. Fasting blood samples were collected in 2012-2014 from a subset of participants free of diabetes to measure glucose metabolism biomarkers (HbA1c, insulin, C-peptide; n = 518). We used multivariable Cox regression models to calculate adjusted HRs and 95% CIs for the risk of T2D. We estimated the least squares mean of glucose metabolic biomarkers according to coffee consumption.

RESULTS

A total of 979 participants developed T2D. Caffeinated coffee consumption was inversely associated with the risk of T2D. Adjusted HR (95% CI) for ≤1 (nonzero), 2-3, and 4+ cups/d compared with 0 cup/d (reference) was 0.91 (0.78, 1.06), 0.83 (0.69, 1.01), and 0.46 (0.28, 0.76), respectively (P-trend = 0.004). Replacement of 1 serving/d of sugar-sweetened beverage and artificially sweetened beverage with 1 cup/d of caffeinated coffee was associated with a 17% (risk ratio [RR] = 0.83, 95% CI: 0.75, 0.93) and 9% (RR = 0.91, 95% CI: 0.84, 0.99) lower risk of T2D, respectively. Greater caffeinated coffee consumption was associated with lower fasting insulin and C-peptide concentrations (all P-trend <0.05). Decaffeinated coffee intake was not significantly related to T2D but was inversely associated with C-peptide concentrations (P-trend = 0.003).

CONCLUSIONS

Among predominantly Caucasian females with a history of GDM, greater consumption of caffeinated coffee was associated with a lower risk of T2D and a more favorable metabolic profile.

Long-term diet and risk of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and Coronavirus Disease 2019 (COVID-19) severity

BACKGROUND

The role of diet on Coronavirus Disease 2019 (COVID-19) is emerging. We investigated the association between usual diet before the onset of the pandemic and risk and severity of subsequent SARS-CoV-2 infection.

METHODS

We included 42,935 participants aged 55-99 y in 2 ongoing cohort studies, the Nurses' Health Study II and Health Professionals Follow-up Study, who completed a series of COVID-19 surveys in 2020 and 2021. Using data from FFQs before COVID-19, we assessed diet quality using the Alternative Healthy Eating Index (AHEI)-2010, the alternative Mediterranean Diet (AMED) score, an Empirical Dietary Index for Hyperinsulinemia (EDIH), and an Empirical Dietary Inflammatory Pattern (EDIP). We calculated multivariable-adjusted ORs and 95% CIs for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection and severity of COVID-19 after controlling for demographic, medical, and lifestyle factors.

RESULTS

Among 19,754 participants tested for SARS-CoV-2, 1941 participants reported a positive result. Of these, 1327 reported symptoms needing assistance and another 109 were hospitalized. Healthier diets, represented by higher AHEI-2010 and AMED scores and lower EDIH and EDIP scores, were associated with lower likelihood of SARS-CoV-2 infection (quartile 4 compared with quartile 1: OR: 0.80; 95% CI: 0.69, 0.92 for AHEI-2010; OR: 0.78; 95% CI: 0.67, 0.92 for AMED; OR: 1.36; 95% CI: 1.16, 1.57 for EDIH; and OR: 1.13; 95% CI: 0.99, 1.30 for EDIP; all P-trend ≤ 0.01). In the analysis of COVID-19 severity, participants with healthier diet had lower likelihood of severe infection and were less likely to be hospitalized owing to COVID-19. However, associations were no longer significant after controlling for BMI and pre-existing medical conditions.

CONCLUSIONS

Diet may be an important modifiable risk factor for SARS-CoV-2 infection, as well as for severity of COVID-19. This association is partially mediated by BMI and pre-existing medical conditions.

Stability and reproducibility of proteomic profiles in epidemiological studies: comparing the Olink and SOMAscan platforms

Limited data exist on the performance of high-throughput proteomics profiling in epidemiological settings, including the impact of specimen collection and within-person variability over time. Thus, the Olink (972 proteins) and SOMAscan7Kv4.1 (7322 proteoforms of 6596 proteins) assays were utilized to measure protein concentrations in archived plasma samples from the Nurses' Health Studies and Health Professionals Follow-Up Study. Spearman's correlation coefficients (r) and intraclass correlation coefficients (ICCs) were used to assess agreement between (1) 42 triplicate samples processed immediately, 24-h or 48-h after blood collection from 14 participants; and (2) 80 plasma samples from 40 participants collected 1-year apart. When comparing samples processed immediately, 24-h, and 48-h later, 55% of assays had an ICC/r ≥ 0.75 and 87% had an ICC/r ≥ 0.40 in Olink compared to 44% with an ICC/r ≥ 0.75 and 72% with an ICC/r ≥ 0.40 in SOMAscan7K. For both platforms, >90% of the assays were stable (ICC/r ≥ 0.40) in samples collected 1-year apart. Among 817 proteins measured with both platforms, Spearman's correlations were high (r > 0.75) for 14.7% and poor (r < 0.40) for 44.8% of proteins. High-throughput proteomics profiling demonstrated reproducibility in archived plasma samples and stability after delayed processing in epidemiological studies, yet correlations between proteins measured with the Olink and SOMAscan7K platforms were highly variable.

Healthy Lifestyle Score Including Sleep Duration and Cardiovascular Disease Risk

INTRODUCTION

Although insufficient or prolonged sleep duration is associated with cardiovascular disease, sleep duration is not included in most lifestyle scores. This study evaluates the relationship between a lifestyle score, including sleep duration and cardiovascular disease risk.

METHODS

A prospective analysis among 67,250 women in the Nurses' Health Study and 29,114 men in Health Professionals Follow-up Study (1986-2016) was conducted in 2021. Lifestyle factors were updated every 2-4 years using self-reported questionnaires. The traditional lifestyle score was defined as not smoking, having a normal BMI, being physically active (≥30 minutes/day of moderate physical activity), eating a healthy diet, and drinking alcohol in moderation. Low-risk sleep duration, defined as sleeping ≥6 to <8 hours/day, was included as an additional component in the updated lifestyle score. Cox proportional hazard regression models were used to estimate cardiovascular disease risk. The likelihood-ratio test and C-statistics were used to compare both scores.

RESULTS

A total of 11,710 incident cardiovascular disease cases during follow-up were documented. The multivariable-adjusted hazard ratios comparing 6 with 0 low-risk factors in the healthy lifestyle score including sleep duration were 0.17 (95% CI=0.12, 0.23) for cardiovascular disease, 0.14 (95% CI=0.10, 0.21) for coronary heart disease, and 0.20 (95% CI=0.12, 0.33) for stroke. Approximately 66% (95% CI=56%, 75%) of cardiovascular disease, 67% (95% CI=54%, 77%) of coronary heart disease, and 62% (95% CI=42%, 76%) of stroke cases were attributable to poor adherence to a healthy lifestyle including sleep. Adding sleep duration to the score slightly increased the C-statistics from 0.64 (95% CI=0.63, 0.64) to 0.65 (95% CI=0.64, 0.65) (p<0.001).

CONCLUSIONS

Adopting a healthy lifestyle including sleep recommendations could substantially reduce the risk of cardiovascular disease in U.S. adults.

Plasma metabolite profiles related to plant-based diets and the risk of type 2 diabetes

AIMS/HYPOTHESIS

Plant-based diets, especially when rich in healthy plant foods, have been associated with a lower risk of type 2 diabetes. However, whether plasma metabolite profiles related to plant-based diets reflect this association was unknown. The aim of this study was to identify the plasma metabolite profiles related to plant-based diets, and to evaluate the associations between the identified metabolite profiles and the risk of type 2 diabetes.

METHODS

Within three prospective cohorts (Nurses' Health Study, Nurses' Health Study II and Health Professionals Follow-up Study), we measured plasma metabolites from 10,684 participants using high-throughput LC MS. Adherence to plant-based diets was assessed by three indices derived from the food frequency questionnaire: an overall Plant-based Diet Index (PDI), a Healthy Plant-based Diet Index (hPDI), and an Unhealthy Plant-based Diet Index (uPDI). Multi-metabolite profiles related to plant-based diet were identified using elastic net regression with a training/testing approach. The prospective associations between metabolite profiles and incident type 2 diabetes were evaluated using multivariable Cox proportional hazards regression. Metabolites potentially mediating the association between plant-based diets and type 2 diabetes risk were further identified.

RESULTS

We identified multi-metabolite profiles comprising 55 metabolites for PDI, 93 metabolites for hPDI and 75 metabolites for uPDI. Metabolite profile scores based on the identified metabolite profiles were correlated with the corresponding diet index (Pearson r = 0.33-0.35 for PDI, 0.41-0.45 for hPDI, and 0.37-0.38 for uPDI, all p<0.001). Metabolite profile scores of PDI (HR per 1 SD higher = 0.81 [95% CI 0.75, 0.88]) and hPDI (HR per 1 SD higher = 0.77 [95% CI 0.71, 0.84]) showed an inverse association with incident type 2 diabetes, whereas the metabolite profile score for uPDI was not associated with the risk. Mutual adjustment for metabolites selected in the metabolite profiles, including trigonelline, hippurate, isoleucine and a subset of triacylglycerols, attenuated the associations of diet indices PDI and hPDI with lower type 2 diabetes risk. The explainable proportion of PDI/hPDI-related diabetes risk by these metabolites ranged between 8.5% and 37.2% (all p<0.05).

CONCLUSIONS/INTERPRETATION

Plasma metabolite profiles related to plant-based diets, especially a healthy plant-based diet, were associated with a lower risk of type 2 diabetes among a generally healthy population. Our findings support the beneficial role of healthy plant-based diets in diabetes prevention and provide new insights for future investigation.

A healthy plant-based diet is favorably associated with cardiometabolic risk factors among participants of South Asian ancestry

BACKGROUND

Plant-based diets are recommended for chronic disease prevention, yet there has been little focus on plant-based diet quality among participants of South Asian ancestry who consume a predominantly plant-based diet.

OBJECTIVES

We evaluated cross-sectional and prospective associations between plant-based diet quality and cardiometabolic risks among participants of South Asian ancestry who are living in the United States.

METHODS

We included 891 participants of South Asian ancestry who completed the baseline visit in the Mediators of Atherosclerosis in South Asians Living in America (MASALA) study. The prospective analysis included 735 participants who completed exam 2 (∼5 years after baseline). The plant-based diet quality was assessed using 3 indices: an overall plant-based diet index (PDI) that summarizes the consumption of plant foods, a healthy PDI (hPDI) that measures consumption of healthy plant foods, and an unhealthy PDI (uPDI) that reflects consumption of less healthy plant foods.

RESULTS

At baseline, the PDI score was inversely associated with fasting glucose. We observed inverse associations between PDI and hPDI scores and HOMA-IR, LDL cholesterol, weight, and BMI (all P values < 0.05). Higher scores on the hPDI, but not PDI, were associated with lower glycated hemoglobin, higher adiponectin, a smaller visceral fat area, and a smaller pericardial fat volume. Each 5-unit higher hPDI score was associated with lower likelihoods of fatty liver (OR: 0.76; 95% CI: 0.64, 0.90) and obesity (OR: 0.88; 95% CI: 0.80, 0.97). There were no associations between uPDI scores and cardiometabolic risks. Prospectively, after covariate adjustment for baseline values, each 5-unit higher hPDI score was associated with an 18% lower risk of incident type 2 diabetes (OR: 0.82; 95% CI: 0.67, 1.00).

CONCLUSIONS

A higher intake of healthful plant-based foods was associated with a favorable cardiometabolic risk profile. Dietary recommendations to lower chronic disease risks among participants of South Asian ancestry should focus on the quality of plant-based foods.

Associations between predicted vitamin D status, vitamin D intake, and risk of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) severity

BACKGROUND

Vitamin D may have a role in immune responses to viral infections. However, data on the association between vitamin D and severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and coronavirus disease 2019 (COVID-19) severity have been limited and inconsistent.

OBJECTIVE

We examined the associations of predicted vitamin D status and intake with risk of SARS-CoV-2 infection and COVID-19 severity.

METHODS

We used data from periodic surveys (May 2020 to March 2021) within the Nurses' Health Study II. Among 39,315 participants, 1768 reported a positive test for SARS-CoV-2 infection. Usual vitamin D intake from foods and supplements were measured using a semiquantitative, pre-pandemic food-frequency questionnaire in 2015. Predicted 25-hydroxyvitamin D [25(OH)D] concentration were calculated based on a previously validated model including dietary and supplementary vitamin D intake, UV-B, and other behavioral predictors of vitamin D status.

RESULTS

Higher predicted 25(OH)D concentrations, but not vitamin D intake, were associated with a lower risk of SARS-CoV-2 infection. Comparing participants in the highest quintile of predicted 25(OH)D concentrations with the lowest, the multivariable-adjusted OR was 0.76 (95% CI: 0.58, 0.99; P-trend = 0.04). Participants in the highest quartile of UV-B (OR: 0.76; 95% CI: 0.66, 0.87; P-trend = 0.002) and UV-A (OR: 0.76; 95% CI: 0.66, 0.88; P-trend < 0.001) also had a lower risk of SARS-CoV-2 infection compared with the lowest. High intake of vitamin D from supplements (≥400 IU/d) was associated with a lower risk of hospitalization (OR: 0.51; 95% CI: 0.29, 0.91; P-trend = 0.04).

CONCLUSIONS

Our study provides suggestive evidence on the association between higher predicted circulating 25(OH)D concentrations and a lower risk of SARS-CoV-2 infection. Greater intake of vitamin D supplements was associated with a lower risk of hospitalization. Our data also support an association between exposure to UV-B or UV-A, independently of vitamin D and SARS-CoV-2 infection, so results for predicted 25(OH)D need to be interpreted cautiously.

Intake of fruits and vegetables according to pesticide residue status in relation to all-cause and disease-specific mortality: Results from three prospective cohort studies

BACKGROUND

Intake of conventionally grown fruits and vegetables (FVs) is an important route of exposure to pesticide residues in the general population. However, whether health risk stemming from exposure to pesticides through diet could offset benefits of consuming FVs is unclear.

OBJECTIVE

We assessed the association of FV intake, classified according to their pesticide residue status, with total and cause-specific mortality.

METHODS

We followed 137,378 women (NHS, 1998-2019, and NHSII, 1999-2019) and 23,502 men (HPFS, 1998-2020) without cardiovascular disease, cancer, or diabetes at baseline. FV intake was assessed using validated food frequency questionnaires and categorized as having high- or low-pesticide-residues using data from the USDA Pesticide Data Program. Cox proportional hazards models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CI) for total and cause-specific mortality associated with high- and low-pesticide-residue FV intake.

RESULTS

A total of 27,026 deaths, including 4,318 from CVD and 6,426 from cancer, were documented during 3,081,360 person-years of follow-up. In multivariable-adjusted analyses, participants who consumed ≥4 servings/day of low-pesticide-residue FVs had 36% (95% CI: 32%-41%) lower mortality risk compared to participants who consumed <1 serving/day. The corresponding estimate for high-pesticide residue FV intake was 0.93 (95% CI: 0.81-1.07). This pattern was similar across the three most frequent causes of death (cardiovascular disease, cancer and respiratory diseases).

CONCLUSIONS

High-pesticide-residue FV intake was unrelated whereas low-pesticide residue FV intake was inversely related to all-cause mortality, suggesting that exposure to pesticide residues through diet may offset the beneficial effect of FV intake on mortality.

Changes in metabolomics profiles over ten years and subsequent risk of developing type 2 diabetes: Results from the Nurses' Health Study

BACKGROUND

Metabolomics profiles were consistently associated with type 2 diabetes (T2D) risk, but evidence on long-term metabolite changes and T2D incidence is lacking. We examined the associations of 10-year plasma metabolite changes with subsequent T2D risk.

METHODS

We conducted a nested T2D case-control study (n=244 cases, n=244 matched controls) within the Nurses' Health Study. Repeated metabolomics profiling (170 targeted metabolites) was conducted in participant blood specimens from 1989/1990 and 2000/2001, and T2D occurred between 2002 and 2008. We related 10-year metabolite changes (Δ-values) to subsequent T2D risk using conditional logistic models, adjusting for baseline metabolite levels and baseline levels and concurrent changes of BMI, diet quality, physical activity, and smoking status.

FINDINGS

The 10-year changes of thirty-one metabolites were associated with subsequent T2D risk (false discovery rate-adjusted p-values [FDR]<0.05). The top three high T2D risk-associated 10-year changes were (odds ratio [OR] per standard deviation [SD], 95%CI): Δisoleucine (2.72, 1.97-3.79), Δleucine (2.53, 1.86-3.47), and Δvaline (1.93, 1.52-2.44); other high-risk-associated metabolite changes included alanine, tri-/diacylglycerol-fragments, short-chain acylcarnitines, phosphatidylethanolamines, some vitamins, and bile acids (ORs per SD between 1.31and 1.82). The top three low T2D risk-associated 10-year metabolite changes were (OR per SD, 95% CI): ΔN-acetylaspartic acid (0.54, 0.42-0.70), ΔC20:0 lysophosphatidylethanolamine (0.68, 0.56-0.82), and ΔC16:1 sphingomyelin (0.68, 0.56-0.83); 10-year changes of other sphingomyelins, plasmalogens, glutamine, and glycine were also associated with lower subsequent T2D risk (ORs per SD between 0.66 and 0.78).

INTERPRETATION

Repeated metabolomics profiles reflecting the long-term deterioration of amino acid and lipid metabolism are associated with subsequent risk of T2D.

Weight Stigma and Social Media: Evidence and Public Health Solutions

Weight stigma is a pressing issue that affects individuals across the weight distribution. The role of social media in both alleviating and exacerbating weight bias has received growing attention. On one hand, biased algorithms on social media platforms may filter out posts from individuals in stigmatized groups and concentrate exposure to content that perpetuates problematic norms about weight. Individuals may also be more likely to engage in attacks due to increased anonymity and lack of substantive consequences online. The critical influence of social media in shaping beliefs may also lead to the internalization of weight stigma. However, social media could also be used as a positive agent of change. Movements such as Body Positivity, the Fatosphere, and Health at Every Size have helped counter negative stereotypes and provide more inclusive spaces. To support these efforts, governments should continue to explore legislative solutions to enact anti-weight discrimination policies, and platforms should invest in diverse content moderation teams with dedicated weight bias training while interrogating bias in existing algorithms. Public health practitioners and clinicians should leverage social media as a tool in weight management interventions and increase awareness of stigmatizing online content among their patients. Finally, researchers must explore how experiences of stigma differ across in-person and virtual settings and critically evaluate existing research methodologies and terminology. Addressing weight stigma on social media will take a concerted effort across an expansive set of stakeholders, but the benefits to population health are consequential and well-worth our collective attention.

Prepregnancy plant-based diets and the risk of gestational diabetes mellitus: a prospective cohort study of 14,926 women

BACKGROUND

Emerging evidence suggests beneficial impacts of plant-based diets on glucose metabolism among generally healthy individuals. Whether adherence to these diets is related to risk of gestational diabetes mellitus (GDM) is unknown.

OBJECTIVES

We aimed to examine associations between plant-based diets and GDM in a large prospective study.

METHODS

We included 14,926 women from the Nurses' Health Study II (1991-2001), who reported ≥1 singleton pregnancy and without previous GDM before the index pregnancy. Prepregnancy adherence to plant-based diets was measured by an overall plant-based diet index (PDI), healthful plant-based diet index (hPDI), and unhealthful plant-based diet index (uPDI) as assessed by FFQs every 4 y. Incident first-time GDM was ascertained from a self-reported physician diagnosis, which was previously validated by review of medical records. We used log-binomial models with generalized estimating equations to calculate RRs and 95% CIs for associations of PDIs with GDM.

RESULTS

We documented 846 incident GDM cases over the 10-y follow-up among 20,707 pregnancies. Greater adherence to the PDI and hPDI was associated with lower GDM risk. For the PDI, the multivariable-adjusted RR (95% CI) comparing the highest and lowest quintiles (Q5 compared with Q1) was 0.70 (0.56, 0.87) (Ptrend = 0.0004), and for each 10-point increment was 0.80 (0.71, 0.90). For the hPDI, the RR (95% CI) of Q5 compared with Q1 was 0.75 (0.59, 0.94) (Ptrend = 0.009) and for each 10-point increment was 0.86 (0.77, 0.95). After further adjustment for prepregnancy BMI, the associations were attenuated but remained significant: for the PDI, the RR (95% CI) for each 10-point increment was 0.89 (0.79, 1.00) and the corresponding RR (95% CI) was 0.89 (0.80, 0.99) for the hPDI. The uPDI was not associated with GDM.

CONCLUSIONS

Our study suggests that greater prepregnancy adherence to a healthful plant-based diet was associated with lower risk of GDM, whereas an unhealthful plant-based diet was not related to GDM risk.

Diet quality and risk and severity of COVID-19: a prospective cohort study

OBJECTIVE

Poor metabolic health and unhealthy lifestyle factors have been associated with risk and severity of COVID-19, but data for diet are lacking. We aimed to investigate the association of diet quality with risk and severity of COVID-19 and its interaction with socioeconomic deprivation.

DESIGN

We used data from 592 571 participants of the smartphone-based COVID-19 Symptom Study. Diet information was collected for the prepandemic period using a short food frequency questionnaire, and diet quality was assessed using a healthful Plant-Based Diet Score, which emphasises healthy plant foods such as fruits or vegetables. Multivariable Cox models were fitted to calculate HRs and 95% CIs for COVID-19 risk and severity defined using a validated symptom-based algorithm or hospitalisation with oxygen support, respectively.

RESULTS

Over 3 886 274 person-months of follow-up, 31 815 COVID-19 cases were documented. Compared with individuals in the lowest quartile of the diet score, high diet quality was associated with lower risk of COVID-19 (HR 0.91; 95% CI 0.88 to 0.94) and severe COVID-19 (HR 0.59; 95% CI 0.47 to 0.74). The joint association of low diet quality and increased deprivation on COVID-19 risk was higher than the sum of the risk associated with each factor alone (Pinteraction=0.005). The corresponding absolute excess rate per 10 000 person/months for lowest vs highest quartile of diet score was 22.5 (95% CI 18.8 to 26.3) among persons living in areas with low deprivation and 40.8 (95% CI 31.7 to 49.8) among persons living in areas with high deprivation.

CONCLUSIONS

A diet characterised by healthy plant-based foods was associated with lower risk and severity of COVID-19. This association may be particularly evident among individuals living in areas with higher socioeconomic deprivation.

Development and Validation of a Novel Food-Based Global Diet Quality Score (GDQS)

BACKGROUND

Poor diet quality is a major driver of both classical malnutrition and noncommunicable disease (NCD) and was responsible for 22% of adult deaths in 2017. Most countries face dual burdens of undernutrition and NCDs, yet no simple global standard metric exists for monitoring diet quality in populations and population subgroups.

OBJECTIVES

We aimed to develop an easy-to-use metric for nutrient adequacy and diet related NCD risk in diverse settings.

METHODS

Using cross-sectional and cohort data from nonpregnant, nonlactating women of reproductive age in 10 African countries as well as China, India, Mexico, and the United States, we undertook secondary analyses to develop novel metrics of diet quality and to evaluate associations between metrics and nutrient intakes and adequacy, anthropometry, biomarkers, type 2 diabetes, and iteratively modified metric design to improve performance and to compare novel metric performance to that of existing metrics.

RESULTS

We developed the Global Diet Quality Score (GDQS), a food-based metric incorporating a more comprehensive list of food groups than most existing diet metrics, and a simple means of scoring consumed amounts. In secondary analyses, the GDQS performed comparably with the Minimum Dietary Diversity - Women indicator in predicting an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy and with anthropometric and biochemical indicators of undernutrition (including underweight, anemia, and serum folate deficiency), and the GDQS also performed comparably or better than the Alternative Healthy Eating Index - 2010 in capturing NCD-related outcomes (including metabolic syndrome, change in weight and waist circumference, and incident type 2 diabetes).

CONCLUSIONS

The simplicity of the GDQS and its ability to capture both nutrient adequacy and diet-related NCD risk render it a promising candidate for global monitoring platforms. Research is warranted to validate methods to operationalize GDQS assessment in population surveys, including a novel application-based 24-h recall system developed as part of this project.

The Global Diet Quality Score is Associated with Higher Nutrient Adequacy, Midupper Arm Circumference, Venous Hemoglobin, and Serum Folate Among Urban and Rural Ethiopian Adults

BACKGROUND

Nutritionally inadequate diets in Ethiopia contribute to a persisting national burden of adult undernutrition, while the prevalence of noncommunicable diseases (NCDs) is rising.

OBJECTIVES

To evaluate performance of a novel Global Diet Quality Score (GDQS) in capturing diet quality outcomes among Ethiopian adults.

METHODS

We scored the GDQS and a suite of comparison metrics in secondary analyses of FFQ and 24-hour recall (24HR) data from a population-based cross-sectional survey of nonpregnant, nonlactating women of reproductive age and men (15-49 years) in Addis Ababa and 5 predominately rural regions. We evaluated Spearman correlations between metrics and energy-adjusted nutrient adequacy, and associations between metrics and anthropometric/biomarker outcomes in covariate-adjusted regression models.

RESULTS

In the FFQ analysis, correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B12 adequacy were 0.32 in men and 0.26 in women. GDQS scores were inversely associated with folate deficiency in men and women (GDQS Quintile 5 compared with Quintile 1 OR in women, 0.50; 95% CI: 0.31-0.79); inversely associated with underweight (OR, 0.63; 95% CI: 0.44-0.90), low midupper arm circumference (OR, 0.61; 95% CI: 0.45-0.84), and anemia (OR, 0.59; 95% CI: 0.38-0.91) in women; and positively associated with hypertension in men (OR: 1.77, 95% CI: 1.12-2.80). For comparison, the Minimum Dietary Diversity-Women (MDD-W) was associated more positively (P < 0.05) with overall nutrient adequacy in men and women, but also associated with low ferritin in men, overweight/obesity in women, and hypertension in men and women. In the 24HR analysis (restricted to women), the MDD-W was associated more positively (P < 0.05) with nutrient adequacy than the GDQS, but also associated with low ferritin, while the GDQS was associated inversely with anemia.

CONCLUSIONS

The GDQS performed capably in capturing nutrient adequacy-related outcomes in Ethiopian adults. Prospective studies are warranted to assess the GDQS' performance in capturing NCD outcomes in sub-Saharan Africa.

Higher Global Diet Quality Score Is Inversely Associated with Risk of Type 2 Diabetes in US Women

BACKGROUND

We have developed a diet quality metric intended for global use. To assess its utility in high-income settings, an evaluation of its ability to predict chronic disease is needed.

OBJECTIVES

We aimed to prospectively examine the ability of the Global Diet Quality Score (GDQS) to predict the risk of type 2 diabetes in the United States, examine potential differences of association by age, and compare the GDQS with other diet quality scores.

METHODS

Health, lifestyle, and diet information was collected from women (n = 88,520) in the Nurses' Health Study II aged 27-44 y at baseline through repeated questionnaires between 1991 and 2017. The overall GDQS consists of 25 food groups. Points are awarded for higher intake of healthy groups and lower intake of unhealthy groups (maximum of 49 points). Multivariable HRs were computed for confirmed type 2 diabetes using proportional hazards models. We also compared the GDQS with the Minimum Diet Diversity score for Women (MDD-W) and the Alternate Healthy Eating Index-2010 (AHEI-2010).

RESULTS

We ascertained 6305 incident cases of type 2 diabetes during follow-up. We observed a lower risk of diabetes with higher GDQS; the multivariable HR comparing extreme quintiles of the GDQS was 0.83 (95% CI: 0.76, 0.91; P-trend < 0.001). The magnitude of association was similar between women aged <50 y and those aged ≥50 y. An inverse association was observed with lower intake of unhealthy components (HR comparing extreme quintiles of the unhealthy submetric: 0.76; 95% CI: 0.69, 0.84; P-trend < 0.001) but was not with the healthy submetric. The inverse association for each 1-SD increase in the GDQS (HR: 0.93; 95% CI: 0.91, 0.96) was stronger (P < 0.001) than for the MDD-W (HR: 1.00; 95% CI: 0.94, 1.04) but was slightly weaker (P = 0.03) than for the AHEI-2010 (HR: 0.91; 95% CI: 0.88, 0.94).

CONCLUSIONS

A higher GDQS was inversely associated with type 2 diabetes risk in US women of reproductive age or older, mainly from lower intake of unhealthy foods. The GDQS performed nearly as well as the AHEI-2010.

Exploration of Machine Learning and Statistical Techniques in Development of a Low-Cost Screening Method Featuring the Global Diet Quality Score for Detecting Prediabetes in Rural India

BACKGROUND

The prevalence of type 2 diabetes has increased substantially in India over the past 3 decades. Undiagnosed diabetes presents a public health challenge, especially in rural areas, where access to laboratory testing for diagnosis may not be readily available.

OBJECTIVES

The present work explores the use of several machine learning and statistical methods in the development of a predictive tool to screen for prediabetes using survey data from an FFQ to compute the Global Diet Quality Score (GDQS).

METHODS

The outcome variable prediabetes status (yes/no) used throughout this study was determined based upon a fasting blood glucose measurement ≥100 mg/dL. The algorithms utilized included the generalized linear model (GLM), random forest, least absolute shrinkage and selection operator (LASSO), elastic net (EN), and generalized linear mixed model (GLMM) with family unit as a (cluster) random (intercept) effect to account for intrafamily correlation. Model performance was assessed on held-out test data, and comparisons made with respect to area under the receiver operating characteristic curve (AUC), sensitivity, and specificity.

RESULTS

The GLMM, GLM, LASSO, and random forest modeling techniques each performed quite well (AUCs >0.70) and included the GDQS food groups and age, among other predictors. The fully adjusted GLMM, which included a random intercept for family unit, achieved slightly superior results (AUC of 0.72) in classifying the prediabetes outcome in these cluster-correlated data.

CONCLUSIONS

The models presented in the current work show promise in identifying individuals at risk of developing diabetes, although further studies are necessary to assess other potentially impactful predictors, as well as the consistency and generalizability of model performance. In addition, future studies to examine the utility of the GDQS in screening for other noncommunicable diseases are recommended.

Application of the Global Diet Quality Score in Chinese Adults to Evaluate the Double Burden of Nutrient Inadequacy and Metabolic Syndrome

BACKGROUND

The double burdens of under- and overnutrition are changing the health of individuals and the economic and disease burdens in China. Poor diet plays an important role; however, a valid and easily operationalized metric that could capture the full range of characteristics of the diet that are relevant to both under- and overnutrition is lacking in China.

OBJECTIVES

We aimed to examine the application of the Global Diet Quality Score (GDQS) to evaluate nutrient inadequacy and metabolic syndrome in different demographic groups of Chinese adults.

METHODS

A total of 35,146 individuals (men 14,978, women 20,168) aged >18 y from the 2010-2012 China National Nutrition and Health Survey were included. We scored the GDQS using average intakes of 25 food groups from 3 d of 24-h dietary recalls. Double burden was defined as coexisting metabolic syndrome and nutrient inadequacy.

RESULTS

Diet quality assessed by GDQS was significantly higher in urban than in rural residents (20.8 compared with 18.7), and increased with both educational level and household income (P-trends < 0.0001). A higher GDQS score was inversely associated with metabolic syndrome and nutrient inadequacy, or both (P-trends < 0.0001): multivariate adjusted ORs comparing extreme quintiles of GDQS were 0.79 (95% CI: 0.69, 0.91) for metabolic syndrome, 0.17 (95% CI: 0.14, 0.20) for nutrient inadequacy, and 0.59 (95% CI: 0.50, 0.69) for the double burden. These associations were consistent across different household income levels (P-interaction = 0.26), suggestively stronger in younger (<50 y), females, urban residents, and the more highly educated (P-interaction < 0.05) compared with their counterparts.

CONCLUSIONS

A higher GDQS was inversely associated with a double burden of nutrient inadequacy and metabolic syndrome across various subgroups of Chinese adults. The finding supports the use of the GDQS in different demographic groups of Chinese adults to assess diet quality and nutritional status.

Higher Global Diet Quality Score Is Associated with Less 4-Year Weight Gain in US Women

BACKGROUND

We have developed a simple and globally applicable tool, the Global Diet Quality Score (GDQS), to measure diet quality.

OBJECTIVES

To test the utility of the GDQS, we examined the associations of the GDQS with weight change and risk of obesity in US women.

METHODS

Health, lifestyle, and diet information were collected from women (n = 68,336) in the Nurses' Health Study II (aged 27-44 y in 1991) through repeated questionnaires (1991-2015). The GDQS has 25 food groups (maximum = 49 points) and scoring higher points reflects a healthier diet. The association between GDQS change in 4-y intervals and concurrent weight change was computed with linear models adjusted for confounders.

RESULTS

Mean ± SD weight gain across 4-y periods was 1.68 ± 6.26 kg. A >5-point improvement in GDQS was associated with -1.13 kg (95% CI: -1.19, -0.77 kg) weight gain compared with a score change of <±2 points. For each 5-point increase, weight gain was 0.83 kg less for age <50 y compared with 0.71 kg less for age ≥50 y (P-interaction < 0.05). A >5-point score decrease was associated with 1.13 kg (95% CI: 1.04, 1.22 kg) more weight gain in women aged <50 y and 0.81 kg more (95% CI: 0.63, 0.98 kg) in women aged ≥50 y. Compared with little change in score, obesity RR was 0.77 (95% CI: 0.74, 0.81) for a >5-point increase and 1.32 (95% CI: 1.26, 1.37) for a >5-point decrease. Risk of obesity did not differ by age. Compared with other diet quality scores, the Alternate Healthy Eating Index-2010 had somewhat stronger associations than the GDQS (P < 0.05) but the GDQS had stronger associations than the Minimum Dietary Diversity for Women score (P < 0.05).

CONCLUSIONS

Improvement of diet quality as measured by the GDQS was associated with less weight gain and risk of obesity in US women. The association was stronger for women aged <50 y. Associations similar in direction and magnitude were observed between the GDQS and obesity across age groups.

There's an App for That: Development of an Application to Operationalize the Global Diet Quality Score

BACKGROUND

The global diet quality score (GDQS) is a simple, standardized metric appropriate for population-based measurement of diet quality globally.

OBJECTIVES

We aimed to operationalize data collection by modifying the quantity of consumption cutoffs originally developed for the GDQS food groups and to statistically evaluate the performance of the operationalized GDQS relative to the original GDQS against nutrient adequacy and noncommunicable disease (NCD)-related outcomes.

METHODS

The GDQS application uses a 24-h open-recall to collect a full list of all foods consumed during the previous day or night, and automatically classifies them into corresponding GDQS food group. Respondents use a set of 10 cubes in a range of predetermined sizes to determine if the quantity consumed per GDQS food group was below, or equal to or above food group-specific cutoffs established in grams. Because there is only a total of 10 cubes but as many as 54 cutoffs for the GDQS food groups, the operationalized cutoffs differ slightly from the original GDQS cutoffs.

RESULTS

A secondary analysis using 5 cross-sectional datasets comparing the GDQS with the original and operationalized cutoffs showed that the operationalized GDQS remained strongly correlated with nutrient adequacy and was equally sensitive to anthropometric and other clinical measures of NCD risk. In a secondary analysis of a longitudinal cohort study of Mexican teachers, there were no differences between the 2 modalities with the beta coefficients per 1 SD change in the original and operationalized GDQS scores being nearly identical for weight gain (-0.37 and -0.36, respectively, P < 0.001 for linear trend for both models) and of the same clinical order of magnitude for waist circumference (-0.52 and -0.44, respectively, P < 0.001 for linear trend for both models).

CONCLUSION

The operationalized GDQS cutoffs did not change the performance of the GDQS and therefore are recommended for use to collect GDQS data in the future.

Performance of the Global Diet Quality Score with Nutrition and Health Outcomes in Mexico with 24-h Recall and FFQ Data

BACKGROUND

The Global Diet Quality Score (GDQS) is intended as a simple global diet quality metric feasible in low- and middle-income countries facing the double burden of malnutrition.

OBJECTIVE

The aim of this study was to evaluate the performance of the GDQS with markers of nutrient adequacy and chronic disease in nonpregnant nonlactating (NPNL) Mexican women of reproductive age and to compare it with the Alternate Healthy Eating Index-2010 (AHEI-2010) and the Minimum Dietary Diversity for Women (MDD-W).

METHODS

We included NPNL women aged 15 to 49 y from the Mexican National Health and Nutrition Surveys (2012 and 2016) with 24-h recall (n = 2542) or a FFQ (n = 4975) (separate samples). We evaluated the correlation of the GDQS with the energy-adjusted intake of several nutrients and evaluated its association with health parameters using covariate-adjusted linear regression models.

RESULTS

The GDQS was positively correlated with the intake of calcium, folate, iron, vitamin A, vitamin B-12, zinc, fiber, protein, and total fat (rho = 0.09 to 0.38, P < 0.05) and was inversely correlated with the intake of added sugar (rho = -0.37 and -0.38, P < 0.05) using both instruments, and with total fat, SFA, and MUFA only with 24-h recall data (rho = -0.06 to -0.16, P < 0.05). The GDQS was inversely associated with serum ferritin, BMI, waist circumference, and serum total and LDL cholesterol using FFQ data (P < 0.05), and was positively associated with serum folate using 24-h recall data (P < 0.05). Similar correlations and associations were observed with the MDD-W (only with micronutrients) and the AHEI-2010 (only with chronic disease-related nutrients and health markers).

CONCLUSIONS

In comparison to other diet metrics, the GDQS can capture both dimensions of nutrient adequacy and health markers related to the risk of chronic disease. The performance of the GDQS was satisfactory with either 24-h recall or FFQ.

Validation of Global Diet Quality Score Among Nonpregnant Women of Reproductive Age in India: Findings from the Andhra Pradesh Children and Parents Study (APCAPS) and the Indian Migration Study (IMS)

BACKGROUND

In India, there is a need to monitor population-level trends in changes in diet quality in relation to both undernutrition and noncommunicable diseases.

OBJECTIVES

We conducted a study to validate a novel diet quality score in southern India.

METHODS

We included data from 3041 nonpregnant women of reproductive age (15-49 years) from 2 studies in India. Diet was assessed using a validated food frequency questionnaire (FFQ). The Global Diet Quality Score (GDQS) was calculated from 25 food groups (16 healthy; 9 unhealthy), with points for each group based on the frequency and quantity of items consumed in each group. We used Spearman correlations to examine correlations between the GDQS and several nutrient intakes of concern. We examined associations between the GDQS [overall, healthy (GDQS+), and unhealthy (GDQS-) submetrics] and overall nutrient adequacy, micro- and macronutrients, body mass index (BMI), midupper arm circumference, hemoglobin, blood pressure, high density lipoprotein (HDL), and total cholesterol (TC).

RESULTS

The mean GDQS was 23 points (SD, 3.6; maximum, 46.5). In energy-adjusted models, positive associations were found between the overall GDQS and GDQS+ and intakes of calcium, fiber, folate, iron, monounsaturated fatty acid (MUFA), protein, polyunsaturated fatty acid (PUFA), saturated fatty acid (SFA), total fat, and zinc (ρ = 0.12-0.39; P < 0.001). Quintile analyses showed that the GDQS was associated with better nutrient adequacy. At the same time, the GDQS was associated with higher TC, lower HDL, and higher BMI. We found no associations between the GDQS and hypertension.

CONCLUSIONS

The GDQS was a useful tool for reflecting overall nutrient adequacy and some lipid measures. Future studies are needed to refine the GDQS for populations who consume large amounts of unhealthy foods, like refined grains, along with healthy foods included in the GDQS.

Changes in the Global Diet Quality Score, Weight, and Waist Circumference in Mexican Women

BACKGROUND

Evidence on concurrent changes in overall diet quality and weight and waist circumference in women of reproductive age from low- and middle-income countries is limited.

OBJECTIVES

We examined the associations of changes in the Global Diet Quality Score (GDQS) and each GDQS food group with concurrent weight and waist circumference change in Mexican women.

METHODS

We followed prospectively 8967 nonpregnant nonlactating women aged 25-49 y in the Mexican Teachers' Cohort between 2006 and 2008. We assessed diet using an FFQ of the previous year and anthropometric measures were self-reported. Regression models were used to examine 2-y changes in the GDQS and each food group (servings/d) with weight and waist circumference changes within the same period, adjusting for demographic and lifestyle factors.

RESULTS

Compared with those with little change in the GDQS (-2 to 2 points), women with the largest increase in the GDQS (>5 points) had less weight (β: -0.81 kg/2 y; 95% CI: -1.11, -0.51 kg/2 y) and waist circumference gain (β: -1.05 cm/2 y; 95% CI: -1.62, -0.48 cm/2 y); likewise, women with the largest decrease in the GDQS (<-5 points) had more weight (β: 0.36 kg/2 y; 95% CI: 0.06, 0.66 kg/2 y) and waist circumference gain (β: 0.71 cm/2 y; 95% CI: 0.09, 1.32 cm/2 y). Increased intake of dark green leafy vegetables, cruciferous vegetables, deep orange vegetables, citrus fruits, and fish and shellfish was associated with less weight gain. In addition, deep orange vegetables, low fat and high fat dairy, whole grains, and fish were associated with less waist circumference gain within the 2-y period.

CONCLUSIONS

Improvements in diet quality over a 2-y period reflected by an increase in the GDQS and changes in consumption of specific components of the GDQS were associated with less weight and waist circumference gain in Mexican women.

The Global Diet Quality Score Is Inversely Associated with Nutrient Inadequacy, Low Midupper Arm Circumference, and Anemia in Rural Adults in Ten Sub-Saharan African Countries

BACKGROUND

Key nutrient deficits remain widespread throughout sub-Saharan Africa (SSA) whereas noncommunicable diseases (NCDs) now cause one-third of deaths. Easy-to-use metrics are needed to track contributions of diet quality to this double burden.

OBJECTIVES

We evaluated comparative performance of a novel food-based Global Diet Quality Score (GDQS) against other diet metrics in capturing nutrient adequacy and undernutrition in rural SSA adults.

METHODS

We scored the GDQS, Minimum Dietary Diversity-Women (MDD-W), and Alternative Healthy Eating Index-2010 (AHEI-2010) using FFQ data from rural men and nonpregnant, nonlactating women of reproductive age (15-49 y) in 10 SSA countries. We evaluated Spearman correlations between metrics and energy-adjusted nutrient intakes, and age-adjusted associations with BMI, midupper arm circumference (MUAC), and hemoglobin in regression models.

RESULTS

Correlations between the GDQS and an energy-adjusted aggregate measure of dietary protein, fiber, calcium, iron, zinc, vitamin A, folate, and vitamin B-12 adequacy were 0.34 (95% CI: 0.30, 0.38) in men and 0.37 (95% CI: 0.32, 0.41) in women. The GDQS was associated (P < 0.05) with lower odds of low MUAC [GDQS quintile (Q) 5 compared with Q1 OR in men: 0.44, 95% CI: 0.22, 0.85; women: 0.57, 95% CI: 0.31, 1.03] and anemia (Q5/Q1 OR in men: 0.56, 95% CI: 0.32, 0.98; women: 0.60, 95% CI: 0.35, 1.01). The MDD-W correlated better with some nutrient intakes, though associated marginally with low MUAC in men (P = 0.07). The AHEI-2010 correlated better with fatty acid intakes, though associated marginally with low MUAC (P = 0.06) and anemia (P = 0.14) in women. Overweight/obesity prevalence was low, and neither the GDQS, MDD-W, nor AHEI-2010 were predictive.

CONCLUSIONS

The GDQS performed comparably with the MDD-W in capturing nutrient adequacy-related outcomes in rural SSA. Given limited data on NCD outcomes and the cross-sectional study design, prospective studies are warranted to assess GDQS performance in capturing NCD outcomes in SSA.

Metabolite patterns link diet, obesity, and type 2 diabetes in a Hispanic population

INTRODUCTION

Obesity is a precursor of type 2 diabetes (T2D).

OBJECTIVES

Our aim was to identify metabolic signatures of T2D and dietary factors unique to obesity.

METHODS

We examined a subsample of the Boston Puerto Rican Health Study (BPRHS) population with a high prevalence of obesity and T2D at baseline (n = 806) and participants (without T2D at baseline) at 5-year follow-up (n = 412). We determined differences in metabolite profiles between T2D and non-T2D participants of the whole sample and according to abdominal obesity status. Enrichment analysis was performed to identify metabolic pathways that were over-represented by metabolites that differed between T2D and non-T2D participants. T2D-associated metabolites unique to obesity were examined for correlation with dietary food groups to understand metabolic links between dietary intake and T2D risk. False Discovery Rate method was used to correct for multiple testing.

RESULTS

Of 526 targeted metabolites, 179 differed between T2D and non-T2D in the whole sample, 64 in non-obese participants and 120 unique to participants with abdominal obesity. Twenty-four of 120 metabolites were replicated and were associated with T2D incidence at 5-year follow-up. Enrichment analysis pointed to three metabolic pathways that were overrepresented in obesity-associated T2D: phosphatidylethanolamine (PE), long-chain fatty acids, and glutamate metabolism. Elevated intakes of three food groups, energy-dense takeout food, dairy intake and sugar-sweetened beverages, associated with 13 metabolites represented by the three pathways.

CONCLUSION

Metabolic signatures of lipid and glutamate metabolism link obesity to T2D, in parallel with increased intake of dairy and sugar-sweetened beverages, thereby providing insight into the relationship between dietary habits and T2D risk.

Associations of network-derived metabolite clusters with prevalent type 2 diabetes among adults of Puerto Rican descent

INTRODUCTION

We investigated whether network analysis revealed clusters of coregulated metabolites associated with prevalent type 2 diabetes (T2D) among Puerto Rican adults.

RESEARCH DESIGN AND METHODS

We used liquid chromatography-mass spectrometry to measure fasting plasma metabolites (>600) among participants aged 40-75 years in the Boston Puerto Rican Health Study (BPRHS; discovery) and San Juan Overweight Adult Longitudinal Study (SOALS; replication), with (n=357; n=77) and without (n=322; n=934) T2D, respectively. Among BPRHS participants, we used unsupervised partial correlation network-based methods to identify and calculate metabolite cluster scores. Logistic regression was used to assess cross-sectional associations between metabolite clusters and prevalent T2D at the baseline blood draw in the BPRHS, and significant associations were replicated in SOALS. Inverse-variance weighted random-effect meta-analysis was used to combine cohort-specific estimates.

RESULTS

Six metabolite clusters were significantly associated with prevalent T2D in the BPRHS and replicated in SOALS (false discovery rate (FDR) <0.05). In a meta-analysis of the two cohorts, the OR and 95% CI (per 1 SD increase in cluster score) for prevalent T2D were as follows for clusters characterized primarily by glucose transport (0.21 (0.16 to 0.30); FDR <0.0001), sphingolipids (0.40 (0.29 to 0.53); FDR <0.0001), acyl cholines (0.35 (0.22 to 0.56); FDR <0.0001), sugar metabolism (2.28 (1.68 to 3.09); FDR <0.0001), branched-chain and aromatic amino acids (2.22 (1.60 to 3.08); FDR <0.0001), and fatty acid biosynthesis (1.54 (1.29 to 1.85); FDR <0.0001). Three additional clusters characterized by amino acid metabolism, cell membrane components, and aromatic amino acid metabolism displayed significant associations with prevalent T2D in the BPRHS, but these associations were not replicated in SOALS.

CONCLUSIONS

Among Puerto Rican adults, we identified several known and novel metabolite clusters that associated with prevalent T2D.

Circulating Plasma Metabolites and Cognitive Function in a Puerto Rican Cohort

BACKGROUND

Minorities, including mainland Puerto Ricans, are impacted disproportionally by Alzheimer's disease (AD), dementia, and cognitive decline. Studying blood metabolomics in this population has the potential to probe the biological underpinnings of this health disparity.

OBJECTIVE

We performed a comprehensive analysis of circulating plasma metabolites in relation to cognitive function in 736 participants from the Boston Puerto Rican Health Study (BPRHS) who underwent untargeted mass-spectrometry based metabolomics analysis and had undergone a battery of in-person cognitive testing at baseline.

METHODS

After relevant exclusions, 621 metabolites were examined. We used multivariable regression, adjusted for age, sex, education, apolipoprotein E genotype, smoking, and Mediterranean dietary pattern, to identify metabolites related to global cognitive function in our cohort. LASSO machine learning was used in a complementary analysis to identify metabolites that could discriminate good from poor extremes of cognition. We also conducted sensitivity analyses: restricted to participants without diabetes, and to participants with good adherence to Mediterranean diet.

RESULTS

Of 621 metabolites, FDR corrected (p < 0.05) multivariable linear regression identified 3 metabolites positively, and 10 negatively, associated with cognitive function in the BPRHS. In a combination of FDR-corrected linear regression, logistic regression regularized via LASSO, and sensitivity analyses restricted to participants without diabetes, and with good adherence to the Mediterranean diet, β-cryptoxanthin plasma concentration was consistently associated with better cognitive function and N-acetylisoleucine and tyramine O-sulfate concentrations were consistently associated with worse cognitive function.

CONCLUSION

This untargeted metabolomics study identified potential biomarkers for cognitive function in a cohort of Puerto Rican older adults.

Abstract 022: Plasma Metabolome Related To Plant-based Diets And The Association With Type 2 Diabetes: A Prospective Cohort Study

Background: Plant-based diets have been associated with a lower risk of type 2 diabetes. However, the underlying mechanisms are not completely understood, and the evidence using objective approaches to assess the adherence of plant-based diets is limited.

Methods: In the Nurses’ Health Study (NHS), NHSII, and Health Professionals Follow-Up Study, we characterized the plasma metabolome related to plant-based diets and examined its association with the incidence of type 2 diabetes among 10 699 participants. Plasma metabolomic profiling was conducted by liquid chromatography-tandem mass spectrometry. Adherence to plant-based diets was assessed by three plant-based diet indices derived from the food frequency questionnaire: an overall plant-based diet index (PDI), a healthful PDI (hPDI), and an unhealthful PDI (uPDI). Metabolomic signatures reflecting the adherence to plant-based diets were created using elastic net regression, and their associations with risk of type 2 diabetes were subsequently evaluated using multivariable Cox proportional hazards regression.

Results: Among 263 metabolites measured, nearly half were significantly associated with PDI (41.4%, 109 of 263), hPDI (51.7%, 136 of 263), and uPDI (40.3%, 106 of 263) after Bonferroni correction. We developed a metabolomic signature comprising 53 metabolites for PDI, 76 metabolites for hPDI, and 88 metabolites for uPDI, each robustly correlated with the corresponding diet index (r=0.34-0.36 for PDI, 0.43-0.44 for hPDI, and 0.36-0.37 for uPDI). We observed an inverse association of PDI metabolomic signature (HR 0.86, 95% CI 0.79-0.93 per one standard deviation) and hPDI metabolomic signature (0.79, 0.72-0.86) with type 2 diabetes risk after adjustment for body mass index and other potential confounders. These two inverse associations remained significant even further adjusting for the corresponding diet index PDI and hPDI. The metabolomic signature for uPDI was not associated with type 2 diabetes risk (1.00, 0.93-1.09).

Conclusion: Plasma metabolome can robustly reflect adherence and metabolic response to plant-based diets. Metabolomic signatures reflecting greater adherence to an overall plant-based diet, especially a healthful plant-based diet, were associated with a lower risk of type 2 diabetes. These findings support and provide mechanistic insights on the important role of healthful plant-based diets in diabetes prevention.

Abstract 034: A Healthy Lifestyle Score Including Sleep Duration And Risk Of Cardiovascular Disease

Objectives: The aim of this study was to evaluate the relationship between a lifestyle score including sleep duration and CVD risk, and to estimate whether adding sleep duration into a traditional lifestyle score improved CVD risk prediction.

Methods: A prospective analysis was conducted among 67250 women in the Nurses’ Health Study and 29279 men in the Health Professionals Follow-up Study who were followed from 1986 to 2016. The traditional lifestyle score was defined as not smoking, normal BMI(18.5-24.9 kg/m 2 ), ≥30 min/d of moderate physical activity, higher diet quality (top 40% of AHEI), moderate alcohol intake (women:5-15g/day; men:5-30g/day). Low-risk sleep duration, defined as sleeping ≥6 to <8 hours/day, was included as an additional component. Cox proportion hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) of CVD, CHD, and stroke. We used the likelihood ratio test and C-statistics to compare the predictive value of the two scores.

Results: A total of 11826 incident CVD cases were documented. In multivariable-adjusted models, each low-risk factor was independently and significantly associated with lower risk of CVD, CHD, and stroke. The multivariable-adjusted HRs (95% CIs) comparing six with zero low-risk factors in the healthy lifestyle score were 0.17(0.12, 0.23) for CVD, 0.15(0.10, 0.22) for CHD, and 0.19(0.12, 0.33) for stroke. Approximately 67% of CVD and CHD cases, and 62% stroke cases were attributable to poor adherence to a healthy lifestyle. P- value for likelihood ratio test comparing nested models including the traditional lifestyle score vs traditional lifestyle score plus sleep duration was <0.001. Adding sleep duration to the traditional score prediction model increased the C-statistics from 0.63 (95% CI: 0.62, 0.63) to 0.64 (95% CI: 0.63, 0.65)( P <0.001).

Conclusions: Incorporating sleep duration into traditional lifestyle scores improves prediction of CVD risk and warrants consideration for inclusion in lifestyle recommendations.

Fruit and Vegetable Intake and Mortality: Results From 2 Prospective Cohort Studies of US Men and Women and a Meta-Analysis of 26 Cohort Studies

BACKGROUND

The optimal intake levels of fruit and vegetables for maintaining long-term health are uncertain.

METHODS

We followed 66 719 women from the Nurses' Health Study (1984-2014) and 42 016 men from the Health Professionals Follow-up Study (1986-2014) who were free from cardiovascular disease (CVD), cancer, and diabetes at baseline. Diet was assessed using a validated semiquantitative food frequency questionnaire at baseline and updated every 2 to 4 years. We also conducted a dose-response meta-analysis, including results from our 2 cohorts and 24 other prospective cohort studies.

RESULTS

We documented 33 898 deaths during the follow-up. After adjustment for known and suspected confounding variables and risk factors, we observed nonlinear inverse associations of fruit and vegetable intake with total mortality and cause-specific mortality attributable to cancer, CVD, and respiratory disease (all P_nonlinear<0.001). Intake of ≈5 servings per day of fruit and vegetables, or 2 servings of fruit and 3 servings of vegetables, was associated with the lowest mortality, and above that level, higher intake was not associated with additional risk reduction. In comparison with the reference level (2 servings/d), daily intake of 5 servings of fruit and vegetables was associated with hazard ratios (95% CI) of 0.87 (0.85-0.90) for total mortality, 0.88 (0.83-0.94) for CVD mortality, 0.90 (0.86-0.95) for cancer mortality, and 0.65 (0.59-0.72) for respiratory disease mortality. The dose-response meta-analysis that included 145 015 deaths accrued in 1 892 885 participants yielded similar results (summary risk ratio of mortality for 5 servings/d=0.87 [95% CI, 0.85-0.88]; P_nonlinear<0.001). Higher intakes of most subgroups of fruits and vegetables were associated with lower mortality, with the exception of starchy vegetables such as peas and corn. Intakes of fruit juices and potatoes were not associated with total and cause-specific mortality.

CONCLUSIONS

Higher intakes of fruit and vegetables were associated with lower mortality; the risk reduction plateaued at ≈5 servings of fruit and vegetables per day. These findings support current dietary recommendations to increase intake of fruits and vegetables, but not fruit juices and potatoes.

Changes in Plant-Based Diet Indices and Subsequent Risk of Type 2 Diabetes in Women and Men: Three U.S. Prospective Cohorts

OBJECTIVE

We evaluated the associations between changes in plant-based diets and subsequent risk of type 2 diabetes.

RESEARCH DESIGN AND METHODS

We prospectively followed 76,530 women in the Nurses' Health Study (NHS) (1986-2012), 81,569 women in NHS II (1991-2017), and 34,468 men in the Health Professionals Follow-up Study (1986-2016). Adherence to plant-based diets was assessed every 4 years with the overall plant-based diet index (PDI), healthful PDI (hPDI), and unhealthful PDI (uPDI). We used multivariable Cox proportional hazards models to estimate hazard ratios (HRs). We pooled results of the three cohorts using meta-analysis.

RESULTS

We documented 12,627 cases of type 2 diabetes during 2,955,350 person-years of follow-up. After adjustment for initial BMI and initial and 4-year changes in alcohol intake, smoking, physical activity, and other factors, compared with participants whose indices remained relatively stable (±3%), participants with the largest decrease (>10%) in PDI and hPDI over 4 years had a 12-23% higher diabetes risk in the subsequent 4 years (pooled HR, PDI 1.12 [95% CI 1.05, 1.20], hPDI 1.23 [1.16, 1.31]). Each 10% increment in PDI and hPDI over 4 years was associated with a 7-9% lower risk (PDI 0.93 [0.91, 0.95], hPDI 0.91 [0.87, 0.95]). Changes in uPDI were not associated with diabetes risk. Weight changes accounted for 6.0-35.6% of the associations between changes in PDI and hPDI and diabetes risk.

CONCLUSIONS

Improving adherence to overall and healthful plant-based diets was associated with a lower risk of type 2 diabetes, whereas decreased adherence to such diets was associated with a higher risk.

Dietary Inflammatory Potential and Risk of Cardiovascular Disease Among Men and Women in the U.S

BACKGROUND

Inflammation plays an important role in cardiovascular disease (CVD) development. Diet modulates inflammation; however, it remains unknown whether dietary patterns with higher inflammatory potential are associated with long-term CVD risk.

OBJECTIVES

This study sought to examine whether proinflammatory diets are associated with increased CVD risk.

METHODS

We prospectively followed 74,578 women from the Nurses' Health Study (NHS) (1984-2016), 91,656 women from the NHSII (1991-2015), and 43,911 men from the Health Professionals Follow-up Study (1986-2016) who were free of CVD and cancer at baseline. Diet was assessed by food frequency questionnaires every 4 years. The inflammatory potential of diet was evaluated using a food-based empirical dietary inflammatory pattern (EDIP) score that was pre-defined based on levels of 3 systemic inflammatory biomarkers.

RESULTS

During 5,291,518 person-years of follow-up, we documented 15,837 incident CVD cases, including 9,794 coronary heart disease (CHD) cases and 6,174 strokes. In pooled analyses of the 3 cohorts, after adjustment for use of anti-inflammatory medications and CVD risk factors including body mass index, a higher dietary inflammatory potential, as indicated by higher EDIP scores, was associated with an increased risk of CVD (hazard ratio [HR] comparing the highest to lowest quintiles: 1.38; 95% confidence interval [CI]: 1.31 to 1.46; p for trend <0.001), CHD (HR: 1.46; 95% CI: 1.36 to 1.56; p for trend <0.001), and stroke (HR: 1.28; 95% CI: 1.17- to 1.39; p for trend <0.001). These associations were consistent across cohorts and between sexes, and they remained significant after further adjustment for other dietary quality indices. In a subset of study participants (n = 33,719), a higher EDIP was associated with a higher circulating profile of proinflammatory biomarkers, lower levels of adiponectin, and an unfavorable blood lipid profile (p < 0.001).

CONCLUSIONS

Dietary patterns with a higher proinflammatory potential were associated with higher CVD risk. Reducing the inflammatory potential of the diet may potentially provide an effective strategy for CVD prevention.

The Leptin System and Diet: A Mini Review of the Current Evidence

Leptin promotes satiety and modulates energy balance and weight. Diet-induced obesity leads to leptin resistance, exacerbating overeating. We reviewed the literature on the relationship between diet and leptin, which suggests that addressing leptin resistance through dietary interventions can contribute counteracting obesity. Albeit some limitations (e.g., limited rigor, small samples sizes), studies in animals and humans show that diets high in fat, carbohydrates, fructose, and sucrose, and low in protein are drivers of leptin resistance. Despite methodological heterogeneity pertaining to this body of literature, experimental studies show that energy-restricted diets can reduce leptinemia both in the short and long term and potentially reverse leptin resistance in humans. We also discuss limitations of this evidence, future lines of research, and implications for clinical and public health translations. Main limitations include the lack of a single universally-accepted definition of leptin resistance, and of adequate ways to accurately measure it in humans. The use of leptin sensitizers (drugs) and genetically individualized diets are alternatives against leptin resistance that should be further researched in humans. The tested very-low-energy intervention diets are challenging to translate into wide clinical or population recommendations. In conclusion, the link between nutritional components and leptin resistance, as well as research indicating that this condition is reversible, emphasizes the potential of diet to recover sensitivity to this hormone. A harmonized definition of leptin resistance, reliable methods to measure it, and large-scale, translational, clinical, and precision nutrition research involving rigorous methods are needed to benefit populations through these approaches.