Diet indices are quantitative assessments of the quality of population intake. Understanding diet quality is crucial to support health and well-being; however, knowledge of diet quality across racial groups is limited. To examine diet quality of acial groups ‘White’, ‘Black’, ‘Asian’, and ‘Other’ in the United Kingdom (U.K.) and United States (U.S.), U.K. and U.S. national survey data were used to calculate Alternative Healthy Eating Index (AHEI-2010), Diet Quality Index-International (DQI-I), and EAT-Lancet scores. ANCOVA tests compared median total quality scores across racial groups adjusting for covariates. Kruskal–Wallis tests examined differences in individual component scores. Spearman correlations identified association of diet quality scores across indices. Highest diet quality scores were reported for U.K. and U.S. Asian groups. Most noticeable differences were apparent between U.S. Asian and White/Black groups (62% Asians within highest tertile of AHEI-2010 score vs. 29% Whites; P < 0.001). All racial groups demonstrated poor diet quality in terms of sustainability; EAT-Lancet scores were <40% of maximum total score for U.S. White, Black, and Other groups. AHEI-2010 diet quality scores were moderately associated with EAT-Lancet scores, evident across all groups (r = 0.53–0.65; P < 0.001). There is a need for all groups to increase intake of wholegrains, especially Black groups (mean Wholegrain score for U.S. Black group within DQI-I was 0.60 (maximum score of 5)) as demonstrated within AHEI-2010, DQI-I, and EAT-Lancet component scores. Additionally, increased intake of vegetables and legumes and decreased intake of processed and red meat would improve the adequacy, healthiness, and sustainability of U.K. and U.S. racial diets.

The Mediterranean-Dietary Approach to Stop Hypertension (DASH) Intervention for Neurodegenerative Delay (MIND) diet is a dietary pattern designed to prevent cognitive decline. Dietary adherence is assessed with the MIND diet scoring system, which is currently based on the American diet and serving sizes. It is known that serving sizes and consumed food products differ between countries. Existing literature lacks reporting on food products included within the MIND diet and weight or volume equivalents corresponding to MIND diet servings, impeding accurate comparisons across studies. This study sought to overcome these limitations by evaluating MIND food products consumed in the Dutch context and developing a scoring system based on consumed quantities in weight or volume amounts rather than in standard serving amounts. The third objective was to modify an existing Dutch brief FFQ (Eetscore-FFQ) to evaluate adherence to the MIND diet. We translated nine of the fifteen MIND food groups directly to grams and volumes using the United States Department of Agriculture measurement conversion table. For the remaining food groups, we employed indirect translation to align them as closely as possible to the original MIND diet. These translated quantities in weight and volumes amounts were subsequently rounded to the nearest Dutch household measures, resulting in the culturally adapted MIND-NL diet scoring. The development of the MIND-NL-Eetscore-FFQ, comprising seventy-two food items (forty-one questions), is described. Our adaption approach is reproducible and can be used to customize the MIND diet scoring system to other cultures.

Beyond obesity, visceral adipose tissue (VAT) has emerged as an important predictor of chronic disease, but the role of diet quality patterns (DQP) in VAT development is not well defined. Therefore, we conducted a systematic review of how various DQP are associated with VAT via literature searches in PubMed and EMBASE. We included observational investigations in disease-free adults/adolescents that related DQP to VAT assessed by imaging methods. The studies were evaluated separately for a priori and a posteriori DQP and according to design differences. Study quality was assessed using the Risk of Bias in Non-randomised Studies of Interventions tool. Of the 1807 screened articles, thirty-five studies met the inclusion criteria. The majority of a priori indices, for example, the Healthy Eating Index, showed significant inverse associations with VAT, while only a small proportion of a posteriori patterns were related to VAT. Results did not differ substantially by the method of exposure and outcome assessment or between studies with (n 20) or without (n 15) body-size adjustment, but significant findings were more common in younger v. older individuals, USA v. other populations and investigations with moderate v. serious risk of bias. The heterogeneity of the existing literature limited the ability to quantify the magnitude of the associations across studies. These findings suggest that a high-quality diet, as assessed by a priori DQP, is generally inversely associated with VAT, but results for a posteriori DQP are less consistent. As associations persisted after adjusting for body size, diet quality may beneficially influence VAT beyond its association with obesity.

The Cardiovascular Health Diet Index (CHDI) is a diet quality score based on the dietary guidelines of the American Heart Association for cardiovascular health but with some adaptations, such as red meat, dairy products, beans and ultra-processed foods in its components. The CHDI has shown good relative validity parameters; however, its association with health outcomes is still unclear. Thus, our aim was to investigate the association between the CHDI score with subclinical atherosclerosis. Data from the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil) cohort were used. Subclinical atherosclerosis was assessed by measuring coronary artery calcification at baseline (2008–2010) and second wave (2012–2014) and carotid intima-media thickness at baseline and at the third wave (2017–2019). The CHDI score (ranges from 0 to 110 points) was applied to dietary data obtained from an FFQ at baseline. Poisson regression with robust variance, linear regression and linear mixed-effects models were used to evaluate the association of the CHDI score with coronary artery calcification incidence (n 2224), coronary artery calcification progression (n 725) and changes in carotid intima-media thickness (n 7341) over time, respectively. After a median 8-year follow-up period, a 10-point increase in the CHDI score was associated with a decrease in carotid intima-media thickness of 0·002 mm (95 % CI –0·005, –0·001). No association was observed between the CHDI score and coronary artery calcification incidence and progression after a 4-year follow-up period. Higher scores in the CHDI were prospectively associated with decreased subclinical atherosclerosis after an 8-year follow-up period.

Dietary intake assessment is often complicated by intrinsic bias. This study investigated whether food purchase data could constitute a valid indication of dietary intake, by evaluating the extent to which diet quality as measured by supermarket food purchases is correlated with diet quality as measured by reported dietary intake. We used data from the Supreme Nudge cluster-randomised controlled supermarket trial (n 227). Data were collected at baseline from supermarket purchases (loyalty cards) and a dietary questionnaire (short forty-item FFQ) to compute two scores reflecting diet quality from purchasing data (purchased diet quality) and FFQ (consumed diet quality). Both scores constituted thirteen food groups and could theoretically range from 0 (low diet quality) to 130 (high diet quality). The relationship between purchased diet quality and consumed diet quality was assessed using correlation coefficients and the Bland–Altman limits-of-agreement method. Multiple linear regression was fitted between purchased diet quality and consumed diet quality, adjusted for age, sex, waist circumference, educational level and household size. Consumed and purchased diet qualities were modestly positively correlated (Pearson’s ρ = 0·31, 95 % CI 0·18, 0·42). A positive association from linear regression was found after confounding adjustments (βbaseline = 0·22, 95 % CI 0·10, 0·34). The purchased diet quality was systematically lower than the consumed diet quality. This study found that diet quality as measured by supermarket purchases provided a reasonable indication of diet quality as reported by short-FFQ, albeit modest.

Globally, more than 13 % of adolescents have clinically significant mental health problems, with anxiety and depression comprising over 40 % of cases. Despite the high prevalence of anxiety disorders among youth, dietary research has been focused on youth with depression, resulting in a significant knowledge gap regarding the impact of anxiety on adolescent diet quality. Adolescents with diagnosed anxiety disorders and healthy controls were included in this study. Anxiety symptoms were measured using the Screen for Child Anxiety-Related Disorders. Diagnosis of anxiety disorder was determined using the Kiddie Schedule for Affective Disorders and Schizophrenia interview. Five diet quality indices were scored from FFQ. Diet quality indices associated with anxiety symptoms in the correlation matrix were interrogated using multiple linear regression modelling. All models were adjusted for depression. One hundred and twenty-eight adolescents (mean age 14·8 years (sd: 2·1); 66·4 % female) were included in this cross-sectional analysis. Although healthy controls and outpatient participants had similar unhealthy dietary index subscale scores, outpatient participants had lower healthy index scores. Higher anxiety symptoms were associated with lower healthy dietary indices in univariate analysis; after adjusting for comorbid depression; however, anxiety symptoms were no longer associated with dietary indices following adjustment for multiple testing (P = 0·038 to P = 0·077). The association between anxiety symptoms and a poor diet is attenuated by depression. The results of this study support the need for an integrated approach to the assessment of mental and physical well-being and further research aimed at understanding the unique contribution of depression to healthy dietary patterns.

Despite the urgent need for plant-based dietary shifts, few studies have examined current diet trajectories using longitudinal data. This study analyzed dietary transitions of French adults over 8 years (2014-2022), assessing diet quality and the role of various socio-economic factors. Consumption data from 17 187 NutriNet-Santé cohort participants, weighted for the French Census, were collected via FFQ in 2014, 2018 and 2022. Adopting a gender-specific approach, consumption changes in twenty-three food groups were assessed over time. Diet quality was evaluated using the Comprehensive Diet Quality Index score, categorising foods into ‘healthy’ and ‘unhealthy’. Socio-economic analysis targeted four food groups (red meat (including fresh beef, pork, offal and lamb), processed meat (e.g. sausages, ham and bacon), legumes and whole-grain products), strongly linked to mortality risk and recognised as significant markers of the sustainable diet transition. All analyses were conducted using multi-adjusted mixed-effects models. Consumption of some healthy plant-based foods (nuts +59 %, legumes +22 %, whole-grain products +7 %) significantly increased over time, while consumption of some unhealthy foods (red meat −19 %, refined cereals −18 %, sweetened drinks −15 %) decreased. Conversely, consumption of prepared and mixed dishes (+16 %) and processed meat (+35 %) increased. These changes differed in magnitude between genders and translated into an improved diet quality score (Comprehensive Diet Quality Index). Occupational status was linked to longitudinal changes in food consumption, showing increased consumption of plant-based foods among students and higher socio-professional categories. Our findings provide accurate data on trends and factors for targeted initiatives, guiding strategic interventions for a sustainable dietary transition.

The aim of this study was to explore the associations between diet quality, socio-demographic measures, smoking, and weight status in a large, cross-sectional cohort of adults living in Yorkshire and Humber, UK. Data from 43, 023 participants aged over 16 years in the Yorkshire Health Survey, 2nd wave (2013–2015) were collected on diet quality, socio-demographic measures, smoking, and weight status. Diet quality was assessed using a brief, validated tool. Associations between these variables were assessed using multiple regression methods. Split-sample cross-validation was utilised to establish model portability. Observed patterns in the sample showed that the greatest substantive differences in diet quality were between females and males (3.94 points; P < 0.001) and non-smokers vs smokers (4.24 points; P < 0.001), with higher diet quality scores observed in females and non-smokers. Deprivation, employment status, age, and weight status categories were also associated with diet quality. Greater diet quality scores were observed in those with lower levels of deprivation, those engaged in sedentary occupations, older people, and those in a healthy weight category. Cross-validation procedures revealed that the model exhibited good transferability properties. Inequalities in patterns of diet quality in the cohort were consistent with those indicated by the findings of other observational studies. The findings indicate population subgroups that are at higher risk of dietary-related ill health due to poor quality diet and provide evidence for the design of targeted national policy and interventions to prevent dietary-related ill health in these groups. The findings support further research exploring inequalities in diet quality in the population.

Previous investigations on protein associations with diet quality and obesity still have inconclusive findings, possibly due to how protein intake was expressed. This study aimed to compare how different ways of expressing total protein intake may influence its relationships with diet quality and obesity. Usual protein intake was estimated from the 2011–12 Australian National Nutrition and Physical Activity Survey (n = 7637 adults, ≥19 years), expressed in grams (g/d), percent energy (%EI), and grams per actual kilogram body weight (g/kgBW/d). Diet quality was assessed using the 2013 Dietary Guidelines Index, and obesity measures included Body Mass Index (BMI) and waist circumference (WC). Sex-stratified multiple linear and logistic regressions were performed and adjusted for potential confounders. Total protein (g/d) was directly associated with diet quality (males, β = 0.15 (95% CI 0.12, 0.19); females, β = 0.25 (0.22, 0.29)), and this association was consistent across units. Protein intake (g/d) was directly associated with BMI (males, β = 0.07% (0.04%, 0.11%); females, β = 0.09% (0.04%, 0.15%)), and WC (males, β = 0.04 (0.01, 0.06); females, β = 0.05 (0.00, 0.09)). While in males, protein as %EI was associated with higher WC, no association was found in females. Adults with higher protein intake (g/d) had higher odds of overweight/obesity (males, OR = 1.01 (1.00, 1.01); females, OR = 1.01 (1.00, 1.01)), and central overweight/obesity (females, OR = 1.01 (1.00, 1.01)), but no significant association with females odds of overweight/obesity when protein was expressed in %EI. In conclusion, protein intake was positively associated with diet quality and obesity, yet these associations were stronger for women. The effect sizes also varied by measurement unit due to the different scales of those units.

Sleep apnoea is a known risk factor for cardiometabolic diseases (CMD), but it is unknown whether sleep apnoea or its symptoms contribute to increased CMD through an association with diet quality. This study assessed the association between sleep apnoea symptoms on future diet quality in the Bogalusa Heart Study (BHS). This prospective study included 445 participants who completed a sleep apnoea questionnaire in 2007–2010 and a FFQ in 2013–2016 (mean follow-up: 5·8 years; age 43·5 years; 34 % male; 71 % White/29 % Black persons). Diet quality was measured with the Alternate Healthy Eating Index (AHEI) 2010, the Healthy Eating Index (HEI) 2015 and the alternate Mediterranean diet score. Adjusted mean differences in dietary patterns by sleep apnoea risk, excessive snoring and daytime sleepiness were estimated with multivariable linear regression. Models included multi-level socio-economic factors, lifestyle and health characteristics including BMI, physical activity and depressive symptoms. Those with high sleep apnoea risk, compared with low, had lower diet quality 5·8 years later (percentage difference in AHEI (95 % CI −2·1 % (–3·5 %, −0·7 %)). Daytime sleepiness was associated with lower diet quality. After adjusting for dietary pattern scores from 2001 to 2002, having high sleep apnoea risk and excessive sleepiness were associated with 1·5 % (P < 0·05) and 3·1 % (P < 0·001) lower future AHEI scores, respectively. These findings suggest that individuals with sleep apnea or excessive sleepiness should be monitored for diet quality and targeted for dietary interventions to improve CMD risk.

The primary aim of this study was to examine the association between snack nutritional quality, overall diet quality and adiposity among Australian adolescents. The secondary aim was to assess the distribution of discretionary foods (i.e. energy-dense and nutrient-poor foods and beverages) and intakes from the five food groups at different levels of snack nutritional quality. Dietary data collected from nationally representative adolescents (12–18 years old) during a 24-h dietary recall in the National Nutrition and Physical Activity Survey were analysed (n 784). Snacks were defined based on participant-identified eating occasions. Snack nutritional quality was assessed using the Nutrient Profiling Scoring Criterion (NPSC), whereas diet quality was evaluated using the Dietary Guideline Index for Children and Adolescents. Adiposity was assessed through BMI Z-score waist circumference and waist:height ratio (WHtR). Higher nutritional quality of snacks, as assessed by the NPSC, has been associated with higher diet quality among both boys and girls (P < 0·001). However, there is no association between snacks nutritional quality with BMI Z-score, waist circumference and WHtR. Among both boys and girls, the consumption of fruits, vegetables and legumes/beans at snacks increased with improvement in snack nutritional quality. Conversely, the consumption of discretionary foods at snack decreased with improvement in snack nutritional quality. In conclusion, improved snack quality was associated with better diet quality in adolescents. However, there was no association between snack nutritional quality and adiposity. Future, snack nutrition quality indices should consider optimum snack characteristics related with adiposity and diet quality.

Children’s eating habits are established early in life and parents play a major role therein. Pregnancy is a teachable moment for the promotion of healthy eating because many women are concerned about their babies’ health and have frequent contact with healthcare providers. We aimed to investigate the association between diet quality during pregnancy and the offspring. A total of 691 sets of data on pregnant mothers and their 3-year-old offspring were obtained from the Seiiku Boshi cohort study. Dietary intake was assessed using a validated food frequency questionnaire for mothers in mid-to-late pregnancy and a validated diet history questionnaire for Japanese preschool children at the 36-month checkup. Diet quality was scored using the Japanese Food Guide Spinning Top. Maternal diet quality score was categorised into quartiles, and the association between offspring and maternal diet quality score, adjusted for socioeconomic factors, was assessed using multiple linear regression. The total offspring diet quality score showed a linear trend with the maternal diet quality score (the mean increments (confidential intervals) for each quartile were –0.12 (–1.32–1.08), 1.54 (0.34–2.73), and 1.22 (0.03–2.42)). In particular, offspring vegetable dishes scored higher in all quartiles of maternal vegetable dish scores than in the lowest quartile (0.69 (0.21–1.17), 0.97 (0.50–1.45), and 1.36 (0.88–1.83)). A high diet quality score during pregnancy was positively associated with that of offspring, suggesting the importance of nutritional education in pregnant women to improve their diet quality.

There is an increasing need for valid, rapid diet screening tools. A significant association between the Prime Diet Quality Score (PDQS) and reduced risk of cardiovascular disease (CVD) has been demonstrated in the US but evidence of its use in Europe is lacking. The aim of this study was to amend the PDQS for a UK/Irish population and determine validity and reliability in those at risk of CVD. Participants were recruited via online adverts across the island of Ireland. The PDQS was amended for a UK/Irish population and participants completed PDQS and reference measure (4-day food diary (FD)) on two occasions. PDQS score was calculated directly from PDQS and indirectly from FDs. Validity was determined using Spearman correlation coefficients (SCCs) (r), intraclass correlation coefficients (ICCs) and weighted kappa. Reliability was determined using SCCs (r), ICCs, weighted kappa and coefficient of variation.

‘Data were available for n = 115 (Month 0) and n = 108 (Month 3) participants for validity and n = 110 for reliability assessment (PDQS completed at both timepoints)’. PDQS score from PDQS was significantly correlated with PDQS score from FDs at months 0 (r = 0.59, P < 0.01) and 3 (r = 0.65, P < 0.01), with similar associations observed via ICCs. Weighted kappa indicated moderate agreement. PDQS score at month 0 was significantly correlated with PDQS score at month 3 (r = 0.78, P < 0.01), with similar associations observed via ICCs. Weighted kappa indicated moderate agreement. Results indicate that the amended PDQS is a valid and reliable tool to determine diet quality in a UK/Irish population at risk of CVD.

Multimorbidity, the existence of two or more concurrent chronic conditions in a single individual, represents a major global health challenge. The Nutrition Society’s 2023 Winter Conference at the Royal Society, London focused on the topic of ‘Diet and lifestyle strategies for prevention and management of multimorbidity’, with symposia designed to explore pathways for prevention of multimorbidity across the lifecourse, the role of ageing, the gut-brain-heart connection and lifestyle strategies for prevention and management of multimorbidity. It also considered machine learning and precision nutrition approaches for addressing research challenges in multimorbidity. The opening plenary lecture discussed advancing diet and lifestyle research to address the increasing burden and complexity of multimorbidity. The two-day programme concluded with a plenary which addressed the key dietary risk factors and policies in multimorbidity prevention.

Bitter taste perception plays a dual role in human nutrition and evolutionary biology; being identifiable in nutrient-dense foods such as cruciferous vegetables and historically signalled toxic compounds. The TAS2R38 gene, part of the taste 2 receptor family, is central to individual differences in bitter taste perception(1). While genetic variations are influential, dietary habits and food preparation also impact taste perception. However, research investigating the interplay between these factors and genetic variations in influencing bitter taste sensitivity and food intake is limited. This study aimed to elucidate the relationship between bitter taste sensitivity and TAS2R38 haplotype variations in the context of bitter food consumption among Australian adults. A cross-sectional, mixed-methods study was conducted. Healthy adults who had maintained a stable diet for at least three months were eligible. Data collection was via an online survey (REDCap), capturing self-reported demographics, dietary patterns specific to bitter foods including metrics of bitter food avoidance, frequency, liking and perceived healthfulness, alongside a Dietary Quality Index (DQI) derived from a food frequency questionnaire(2). Bitter taste sensitivity was assessed using self-reported intensity perceptions of 6-n-propylthiouracil (PROP) taste strips(3). Genotyping was conducted via TaqMan qPCR assays on DNA extracted from buccal swabs to ascertain TAS2R38 haplotypes. Data analysis utilised Analysis of Covariance (ANCOVA) and regression models, with all tests adjusted for confounding variables such as gender, age, and smoking status. A total of 222 participants (47.5 ± 17.7 years; 86% female; BMI 27.3 ± 7.1 kg/m2) completed the study. PROP sensitivity was strongly correlated with TAS2R38 haplotype, with supertasters predominantly having PAV/PAV, medium tasters with PAV/AVI, and non-tasters with AVI/AVI (p = 0.002). However, no relationship was observed between PROP sensitivity and either the frequency, liking, or avoidance of bitter foods (p>0.05). DQI was significantly related to bitter food consumption; individuals in the lowest DQI quintile consumed bitter foods more frequently than those in the third (p = 0.007) and top quintiles (p = 0.001). The perceived healthfulness of bitter foods was significantly higher in those with AVI/AVI haplotypes (non-tasters) compared to those with PAV/AVI (medium tasters) (p = 0.001). Counterintuitively, participants who reported greater enjoyment of bitter tastes consumed bitter foods less frequently (p<0.001). Our study confirms that TAS2R38 variants are predictive of PROP taste sensitivity, consistent with literature that identifies PAV/PAV individuals as supertasters. However, neither PROP sensitivity nor TAS2R38 haplotype influenced bitter food frequency or preference consumption patterns. Interestingly, those with lower Dietary Quality Index scores and less enjoyment of bitter taste consumed bitter foods more often. These observations highlight the need to investigate other factors influencing bitter food intake, such as additional sensory characteristics or psychological and behavioural aspects.

Food insecurity, the inadequate or insecure access to food due to financial constraints, is a growing concern in high-income countries like Australia(1). Food insecure adults may have reduced diet quality due to constraints on food purchasing and consumption(2) but further research is needed to understand how the severity of food insecurity impacts diet quality in an Australian setting. This study aimed to examine the relationship between diet quality and increasing severity of household food insecurity using validated measurement tools. A cross-sectional, online survey of Australian adults (aged 18 years+) used the USDA Household Food Security Six-item Short Form to classify respondents as food secure or marginally, moderately, or severely food insecure. The Australian Recommended Food Score (ARFS; score between 0–73) determined diet quality (ARFS total) and sub-scale scores for eight food groups(3), with higher scores indicating higher diet quality. Diet quality score results are further categorised as “needs work” (<33), “getting there” (33-38), “excellent” (39-46) or “outstanding” (47+). Survey-weighted linear regression (adjusted for age, sex, income, education, location, household composition) analyses indicate that 45% of participants were living in households that experienced food insecurity, comprising 7% marginally, 18% moderately and 20% severely food insecure households. The ARFS total survey-weighted mean score for the whole sample (n = 804) was 32.4 (SD = 9.8). As the severity of household food insecurity increased, ARFS scores decreased. Marginally food insecure respondents reported a mean ARFS score three points lower than food-secure adults (B=-2.7; 95%CI [−5.11, −0.34]; p = 0.03), and scores reduced by six points for moderately (B=-5.6; 95%CI [−7.26, −3.90]; p<0.001) and twelve points for severely food insecure respondents (B=-11.5; 95%CI [−13.21, −9.78]; p<0.001). Marginally food insecure respondents had significantly lower vegetable sub-scale scores, moderately food insecure respondents had significantly lower sub-scale scores for all food groups except dairy, severely food insecure respondents had significantly lower scores for all sub-scale scores. Poorer diet quality is evident in adults living with any food insecurity but gets progressively worse as the severity of food insecurity increases. Interventions to reduce food insecurity and increase diet quality are required to prevent adverse nutrition-related health outcomes in food-insecure populations in Australia and beyond.

Chronic pain affects 20-30% of people worldwide(1). While the impact of nutrition and dietary patterns on bodily pain has gained attention in recent years, the underlying linking mechanisms remain poorly understood; it is possible that body weight, specifically adiposity, may be a mediating factor(2). Thus, the primary aim of this study was to explore whether adiposity mediates the relationship between diet quality and bodily pain. This cross-sectional analysis included 654 adults (57% women, mean age 50.4 ± 1.1 years, BMI 29.0 ± 6.2 kg/m2) with complete diet, adiposity, and pain measures from the Whyalla Intergenerational Study of Health (2008-09). Diet quality was calculated using the Dietary Guideline Index (DGI total score, core and non-core scores)(3), and pain assessed via the Short Form-36 bodily pain scale (SF36-BPS) transformed percent score. Adiposity was determined from body mass index (BMI), waist circumference (WC), and body fat percent (BF, via dual energy x-ray absorptiometry). Mediation analyses determined the role of adiposity in the direct and indirect relationships between diet quality and pain in the whole population, then stratified by sex (self-report). There were no significant indirect or direct effects between DGI total scores and SF36-BPS, for any measure of adiposity. Direct effects were observed for DGI core-food scores on SF36-BPS for each measure of adiposity (BMI, β = 0.258, 95% CI 0.048, 0.467; WC β = 0.246, 95% CI 0.037, 0.455; BF β = 0.247, 95% CI 0.040, 0.454; all p<0.05). Each measure of adiposity accounted for <10% of the relationship between diet quality and pain, with a better-quality diet associated with less bodily pain (higher SF36-BPS). Relationships differed by sex; with no direct or indirect effects seen between DGI scores and SF36-BPS for men while, in women, there was non-mediation with direct positive effects between DGI total score and SF36-BPS for each measure of adiposity (BMI, β = 0.362, 95% CI 0.132, 0.591; WC β = 0.345, 95% CI 0.116, 0.574; BF β = 0.357, 95% CI 0.130, 0.584; all p<0.05). Also in women, body fat mediated 85% of the relationship between DGI non-core scores on bodily pain (indirect effect β=-0.242, 95% CI −0.358, −0.126, p <0.05). While adiposity did not mediate the relationship between diet quality and pain, this study highlights that diet quality plays a role in the pain experience with higher consumption of core foods showing direct associations with lower levels of bodily pain. Moreover, sex differences were observed, with less bodily pain in women associated with higher overall diet quality. Interestingly, body fat drove the relationship between higher pain scores and greater consumption of non-core foods (discretionary), but body fat alone was associated with consumption of fewer discretionary foods. This anomaly requires further investigation.

Snacking is a common eating behaviour among adolescents accounting for more than a quarter of their total energy intake but the relationship between snacks and overall diet quality remains unclear(1). Hence, the aim of this study was to examine characteristics of snacks among Australian adolescents (12-18 years) according to their level of diet quality. This secondary analysis uses one day of 24-hour dietary recall data from the 2011 - 2012 National Nutrition and Physical Activity Survey (n = 935). Snacks were defined based on participant-identified eating occasions(2). The Dietary Guideline Index for Children and Adolescents (DGI-CA) was used to assessed adherence to the Australian Dietary Guidelines(3), with the highest tertile of the DGI-CA score indicating high adherence. The means (95% confidence intervals [CI]) for daily snack frequency and snack energy density (ED; kJ/g) were estimated for boys and girls, using linear regression, adjusted for age, area-level disadvantage, and energy misreporting. The differences in means and proportions across tertiles of DGI-CA scores were tested by using F- and Chi square-tests, respectively. The results show no significant differences in the mean frequency of snacks across tertiles of DGI-CA scores in either boys (lowest tertile mean = 2.2, 95% CI [2.0, 2.4] snacks/day, highest tertile = 2.1 [1.9, 2.3]) or girls (lowest tertile = 1.9 [1.7, 2.1] snacks/day, highest tertile = 2.2 [1.9, 2.4]). The mean ED of snacks decreased as DGI-CA scores increased in both boys (lowest tertile = 8.42, 95% CI [7.1, 10] kJ/g, highest tertile = 6.32 [5.4, 7.4] kJ/g) and girls (lowest tertile = 8.99 [7.8, 10.3] kJ/g, highest tertile = 5.92 [5.1, 6.9] kJ/g). As DGI-CA scores increased, the proportion of both boys and girls consuming discretionary foods at snacks (such as soft drinks) decreased, while foods from the five food groups (such as apples) increased (p-values < 0.05). In conclusion, snack ED, but not frequency, and the types of foods consumed by adolescents at snacks varied by a level of diet quality. Snack ED decreased with increasing diet quality and adolescents with higher diet quality had higher intakes of foods from the five food groups and lower intakes of discretionary foods at snacks. Encouraging the consumption of lower-ED foods from the five food groups at snacks presents an opportunity to enhance adolescent diet quality. Future studies should explore snack-specific strategies to improve overall diet quality of adolescents.