This study investigated associations between types and food sources of protein with overweight/obesity and underweight in Ethiopia.

We conducted a cross-sectional dietary survey using a non-quantitative FFQ. Linear regression models were used to assess associations between percentage energy intake from total, animal and plant protein and BMI. Logistic regression models were used to examine the associations of percentage energy intake from total, animal and plant protein and specific protein food sources with underweight and overweight/obesity.

Addis Ababa, Ethiopia.

1624 Ethiopian adults (992 women and 632 men) aged 18–49 years in selected households sampled using multi-stage random sampling from five sub-cities of Addis Ababa.

Of the surveyed adults, 31 % were overweight or obese. The majority of energy intake was from carbohydrate with only 3 % from animal protein. In multivariable-adjusted linear models, BMI was not associated with percentage energy from total, plant or animal protein. Total and animal protein intake were both associated with lower odds of overweight/obesity (OR per 1 % energy increment of total protein 0·92; 95 % CI: 0·86, 0·99; P = 0·02; OR per 1 % energy increment of animal protein 0·89; 95 % CI: 0·82, 0·96; P = 0·004) when substituted for carbohydrate and adjusted for socio-demographic covariates.

Increasing proportion of energy intake from total protein or animal protein in place of carbohydrate could be a strategy to address overweight and obesity in Addis Ababa; longitudinal studies are needed to further examine this potential association.

To examine the association between adherence to plant-based diets and mortality.

Prospective study. We calculated a plant-based diet index (PDI) by assigning positive scores to plant foods and reverse scores to animal foods. We also created a healthful PDI (hPDI) and an unhealthful PDI (uPDI) by further separating the healthy plant foods from less-healthy plant foods.

The VA Million Veteran Program.

315 919 men and women aged 19–104 years who completed a FFQ at the baseline.

We documented 31 136 deaths during the follow-up. A higher PDI was significantly associated with lower total mortality (hazard ratio (HR) comparing extreme deciles = 0·75, 95 % CI: 0·71, 0·79, Ptrend < 0·001]. We observed an inverse association between hPDI and total mortality (HR comparing extreme deciles = 0·64, 95 % CI: 0·61, 0·68, Ptrend < 0·001), whereas uPDI was positively associated with total mortality (HR comparing extreme deciles = 1·41, 95 % CI: 1·33, 1·49, Ptrend < 0·001). Similar significant associations of PDI, hPDI and uPDI were also observed for CVD and cancer mortality. The associations between the PDI and total mortality were consistent among African and European American participants, and participants free from CVD and cancer and those who were diagnosed with major chronic disease at baseline.

A greater adherence to a plant-based diet was associated with substantially lower total mortality in this large population of veterans. These findings support recommending plant-rich dietary patterns for the prevention of major chronic diseases.

To assess the association between diet cost and quality by place of residence.

We analysed cross-sectional data of the National Health and Nutrition Survey-2012. Diet cost was estimated by linking dietary data, obtained from a 7-d SFFQ, with municipality food prices, which were derived from a national expenditure survey. Diet quality was assessed using the Healthy Eating Index-2015 (HEI-2015). Association between quintiles of diet cost and HEI-2015 was assessed using linear regression analysis.

Mexico.

2438 adults (18–59 years).

Diet cost was positively associated with diet quality (HEI-2015) in urban but not in rural areas. Compared with quintile (Q1) of cost, the increment in diet quality score was 1·17 (95 % CI –0·06, 4·33) for Q2, 2·14 (95 % CI –0·06, 4·33) for Q3, 4·70 (95 % CI 2·62, 6·79) for Q4 and 6·34 (95 % CI 4·20, 8·49) for Q5 (P-trend < 0·001). Individuals in rural v. urban areas on average have higher quality diets at lower cost with higher intakes of whole grains and beans and lower intakes of Na, added sugars and saturated fats. Living in the South, being indigenous and having low socio-economic status were also associated with higher quality diets.

Diet cost was positively associated with diet quality, but only in urban areas. Further studies are needed to understand the relation between diet cost and quality in rural areas. To improve overall diet quality in Mexico, strategies that aim to reduce the cost of high-quality diets should consider the heterogeneity by place of residence.

To evaluate the validity and reproducibility of a 152-item semi-quantitative FFQ (SFFQ) for estimating flavonoid intakes.

Over a 1-year period, participants completed two SFFQ and two weighed 7-d dietary records (7DDR). Flavonoid intakes from the SFFQ were estimated separately using Harvard (SFFQHarvard) and Phenol-Explorer (SFFQPE) food composition databases. 7DDR flavonoid intakes were derived using the Phenol-Explorer database (7DDRPE). Validity was assessed using Spearman’s rank correlation coefficients deattenuated for random measurement error (r s ), and reproducibility was assessed using rank intraclass correlation coefficients.

This validation study included primarily participants from two large observational cohort studies.

Six hundred forty-one men and 724 women.

When compared with two 7DDRPE, the validity of total flavonoid intake assessed by SFFQPE was high for both men and women (r s = 0·77 and r s = 0·74, respectively). The r s for flavonoid subclasses ranged from 0·47 for flavones to 0·78 for anthocyanins in men and from 0·46 for flavonols to 0·77 for anthocyanins in women. We observed similarly moderate (0·4–0·7) to high (≥0·7) validity when using SFFQHarvard estimates, except for flavonesHarvard (r s = 0·25 for men and r s = 0·19 for women). The SFFQ demonstrated high reproducibility for total flavonoid and flavonoid subclass intake estimates when using either food composition database. The intraclass correlation coefficients ranged from 0·69 (flavonolsPE) to 0·80 (proanthocyanidinsPE) in men and from 0·67 (flavonolsPE) to 0·77 (flavan-3-ol monomersHarvard) in women.

SFFQ-derived intakes of total flavonoids and flavonoid subclasses (except for flavones) are valid and reproducible for both men and women.

To identify predominant dietary patterns in four African populations and examine their association with obesity.

Cross-sectional study.

We used data from the Africa/Harvard School of Public Health Partnership for Cohort Research and Training (PaCT) pilot study established to investigate the feasibility of a multi-country longitudinal study of non-communicable chronic disease in sub-Saharan Africa. We applied principal component analysis to dietary intake data collected from an FFQ developed for PaCT to ascertain dietary patterns in Tanzania, South Africa, and peri-urban and rural Uganda. The sample consisted of 444 women and 294 men.

We identified two dietary patterns: the Mixed Diet pattern characterized by high intakes of unprocessed foods such as vegetables and fresh fish, but also cold cuts and refined grains; and the Processed Diet pattern characterized by high intakes of salad dressing, cold cuts and sweets. Women in the highest tertile of the Processed Diet pattern score were 3·00 times more likely to be overweight (95 % CI 1·66, 5·45; prevalence=74 %) and 4·24 times more likely to be obese (95 % CI 2·23, 8·05; prevalence=44 %) than women in this pattern’s lowest tertile (both P<0·0001; prevalence=47 and 14 %, respectively). We found similarly strong associations in men. There was no association between the Mixed Diet pattern and overweight or obesity.

We identified two major dietary patterns in several African populations, a Mixed Diet pattern and a Processed Diet pattern. The Processed Diet pattern was associated with obesity.

According to most prospective studies, being underweight (BMI<18·5 kg/m2) is associated with significantly higher mortality than being of normal weight, especially among smokers. We aimed to explore in a generally lean population whether being underweight is significantly associated with increased all-cause mortality.

Prospective cohort study.

Korea Medical Insurance Corporation study with 14 years of follow-up.

After excluding deaths within the first 5 years of follow-up (1993–1997) to minimize reverse causation and excluding participants without information about smoking and health status, 94 133 men and 48 496 women aged 35–59 years in 1990 were included.

We documented 5411 (5·7 %) deaths in men and 762 (1·6 %) in women. Among never smokers, hazard ratios (HR) for underweight individuals were not significantly higher than those for normal-weight individuals (BMI=18·5–22·9 kg/m2): HR=0·87 (95 % CI 0·41, 1·84, P=0·72) for underweight men and HR=1·12 (95 % CI 0·76, 1·65, P=0·58) for underweight women. Among ex-smokers, HR=0·86 (95 % CI 0·38, 1·93, P=0·72) for underweight men and HR=3·77 (95 % CI 0·42, 32·29, P=0·24) for underweight women. Among current smokers, HR=1·60 (95 % CI 1·28, 2·01, P<0·001) for underweight men and HR=2·07 (95 % CI 0·43, 9·94, P=0·36) for underweight women.

The present study does not support that being underweight per se is associated with increased all-cause mortality in Korean men and women.

To examine the opinions of stakeholders on strategies to improve dietary quality of Supplemental Nutrition Assistance Program (SNAP) participants.

Participants answered a thirty-eight-item web-based survey assessing opinions and perceptions of SNAP and programme policy changes.

USA.

Survey of 522 individuals with stakeholder interest in SNAP, conducted in October through December 2011.

The top three barriers to improving dietary quality identified were: (i) unhealthy foods marketed in low-income communities; (ii) the high cost of healthy foods; and (iii) lifestyle challenges faced by low-income individuals. Many respondents (70 %) also disagreed that current SNAP benefit levels were adequate to maintain a healthy diet. Stakeholders believed that vouchers, coupons or monetary incentives for purchasing healthful foods might have the greatest potential for improving the diets of SNAP participants. Many respondents (78 %) agreed that sodas should not be eligible for purchases with SNAP benefits. More than half (55 %) believed retailers could easily implement such restrictions. A majority of respondents (58 %) agreed that stores should stock a minimum quantity of healthful foods in order to be certified as a SNAP retailer, and most respondents (83 %) believed that the US Department of Agriculture should collect data on the foods purchased with SNAP benefits.

Results suggest that there is broad stakeholder support for policies that align SNAP purchase eligibility with national public health goals of reducing food insecurity, improving nutrition and preventing obesity.

Adjustment for body weight and physical activity has been suggested as an alternative to adjusting for reported energy intake in nutritional epidemiology. We examined which of these approaches would yield stronger correlations between nutrients and their biomarkers.

A cross-sectional study in which dietary fatty acids, carotenoids and retinol were adjusted for reported energy intake and, separately, for weight and physical activity using the residual method. Correlations between adjusted nutrients and their biomarkers were examined.

USA.

Cases and controls from a nested case–control study of erythrocyte fatty acids and CHD (n 442) and of plasma carotenoids and retinol and breast cancer (n 1254).

Correlations between intakes and plasma levels of trans-fatty acids were 0·30 (energy-adjusted) and 0·16 (weight- and activity-adjusted); for erythrocyte levels, the corresponding correlations were 0·37 and 0·25. Energy-adjusted intakes of linoleic acid and α-linolenic acid were more strongly correlated with their respective biomarkers than weight- and activity-adjusted intakes, but the differences were not significant except for linoleic acid (erythrocyte). Weight- and activity-adjusted DHA intake was slightly more strongly correlated with its plasma biomarker than energy-adjusted intake (0·37 v. 0·34). Neither method made a difference for DHA (erythrocyte), carotenoids and retinol.

The effect of energy adjustment depends on the nutrient under investigation, and adjustment for energy calculated from the same questionnaire used to estimate nutrient intakes improves the correlation of some nutrients with their biomarkers appreciably. For the nutrients examined, adjustment using weight and physical activity had at most a small effect on these correlations.

To determine public attitudes towards federal spending on nutrition assistance programmes and support for policies to improve the nutritional impact of the Supplemental Nutrition Assistance Program (SNAP).

Participants answered survey questions by telephone assessing support for SNAP spending and proposed programme policy changes.

USA.

Survey of 3024 adults selected by random digit dialling conducted in April 2012, including 418 SNAP participants.

A majority (77 %; 95 % CI 75, 79 %) of all respondents supported maintaining or increasing SNAP benefits, with higher support among Democrats (88 %; 95 % CI 86, 90 %) than Republicans (61 %; 95 % CI 58, 65 %). The public supported policies to improve the nutritional impact of SNAP. Eighty-two per cent (95 % CI 80, 84 %) of respondents supported providing additional benefits to programme participants that can only be used on healthful foods. Sixty-nine per cent (95 % CI 67, 71 %) of respondents supported removing SNAP benefits for sugary drinks. A majority of SNAP participants (54 %; 95 % CI 48, 60 %) supported removing SNAP benefits for sugary drinks. Of the 46 % (95 % CI 40, 52 %) of SNAP participants who initially opposed removing sugary drinks, 45 % (95 % CI 36, 54 %) supported removing SNAP benefits for sugary drinks if the policy also included additional benefits to purchase healthful foods.

The US public broadly supports increasing or maintaining spending on SNAP. The majority of respondents, including SNAP participants, supported policies to improve the nutritional impact of SNAP by restricting the purchase of sugary drinks and incentivizing purchase of healthful foods with SNAP benefits.

To assess the validity of FAO data on the availability of fish and vegetable oils as an indicator of national n-3 fatty acid (FA) intake and to estimate the worldwide population living in countries with low n-3 FA intake.

Levels of the essential FA α-linolenic acid (ALA) and DHA, measured by GC in adipose tissue from participants in the present study and from published studies in eleven other countries, were used to validate ALA and fish availability estimated from FAO food balance sheets. On the basis of the validated FAO data for ALA and fish availability, we estimated the global prevalence of low n-3 FA availability.

Rural and urban areas of Bulgaria.

Fifty men and fifty-eight women.

Adipose tissue ALA and DHA levels (0·34 % and 0·11 % of total FA, respectively) in Bulgaria were lower than those of the eleven other countries with available data. A strong positive correlation was found between adipose tissue DHA and fish availability (r = 0·88) and between adipose tissue ALA and ALA availability (r = 0·92). Approximately half of the world's population lived in middle- and low-income countries with limited access to n-3 FA (fish < 400 g/week and ALA < 4 % of total vegetable oils), with the largest proportion being in South-East Asia (53·6 %), followed by Africa (27·1 %) and Eastern Europe (8·5 %). Of this half, 33 % lived in countries such as Bulgaria where n-3 FA was almost unavailable (fish < 200 g/week and ALA < 2 % of total vegetable oils).

Very low availability of n-3 FA is extensive worldwide.

To identify dietary patterns among young adults and the relationships with socio-economic, demographic and lifestyle characteristics.

Population-based, cross-sectional analysis of a cohort study. Food intake was assessed by a frequency questionnaire, and dietary patterns were identified using principal components analysis.

Southern Brazil.

A total of 4202 men and women aged 23 years, who participated in the 1982 Pelotas Birth Cohort Study.

Five dietary patterns were identified: common Brazilian, processed food, vegetable/fruit, dairy/dessert and tubers/pasta. Subjects who had low own or maternal educational levels, low social position or who were always poor throughout life had high adherence to the common Brazilian dietary pattern. In contrast, the processed food pattern was more likely to be followed by those belonging to middle and high social position and who were never poor. Men and smokers showed high adherence to the processed food and common Brazilian dietary patterns. Vegetable/fruit pattern was more likely to be followed by women and subjects engaged in physical activity. Women also showed high adherence to the dairy/dessert pattern.

Our study among young Brazilian adults has identified distinct dietary patterns that are clearly influenced by socio-economic and lifestyle characteristics, which have important policy implications in a country with marked social and economic inequalities.

To quantify the health and economic outcomes associated with changes in folic acid consumption following the fortification of enriched grain products in the USA.

Cost-effectiveness analysis.

Annual burden of disease, quality-adjusted life years (QALY) and costs were projected for four steady-state strategies: no fortification, or fortifying with 140, 350 or 700 μg folic acid per 100 g enriched grain. The analysis considered four health outcomes: neural tube defects (NTD), myocardial infarctions (MI), colon cancers and B12 deficiency maskings.

The US adult population subgroups defined by age, gender and race/ethnicity, with folate intake distributions from the National Health and Nutrition Examination Surveys (1988–1992 and 1999–2000), and reference sources for disease incidence, utility and economic estimates.

The greatest benefits from fortification were predicted in MI prevention, with 16 862 and 88 172 cases averted per year in steady state for the 140 and 700 μg fortification levels, respectively. These projections were between 6261 and 38 805 for colon cancer and 182 and 1423 for NTD, while 15–820 additional B12 cases were predicted. Compared with no fortification, all post-fortification strategies provided QALY gains and cost savings for all subgroups, with predicted population benefits of 266 649 QALY gained and $3·6 billion saved in the long run by changing the fortification level from 140 μg/100 g enriched grain to 700 μg/100 g.

The present study indicates that the health and economic gains of folic acid fortification far outweigh the losses for the US population, and that increasing the level of fortification deserves further consideration to maximise net gains.

Low-carbohydrate diets could lead to reduced fruit and vegetable intake, which may be protective against CVD. The role of carbohydrate intake in modifying the association between fruits and vegetables and CVD has not been evaluated.

To evaluate whether carbohydrate intake affects the association between fruits and vegetables and CVD.

We included participants from two large prospective studies, the Nurses’ Health Study (NHS) and the Health Professionals’ Follow-Up Study (HPFS). We followed 70 870 eligible NHS females for 16 years and 38 918 eligible HPFS males for 14 years. Diet was assessed from an FFQ updated every 4 years. Our primary outcome was ischaemic CVD (fatal and non-fatal myocardial infarction and ischaemic stroke). We used Cox proportional hazards models to evaluate the relationship between fruits and vegetables and ischaemic CVD within groups with low, moderate or high carbohydrate intake.

Fruit intake was strongly related with carbohydrate intake, but vegetables showed a very small correlation. Vegetable intake showed stronger associations with ischaemic CVD among the low carbohydrate group (multivariate risk ratio (RR) = 0·82 for an increment of 3 servings/d; 95 % CI 0·68, 0·99); green leafy vegetables and carotene-rich fruits and vegetables followed a similar pattern. Total fruit intake was associated with a lower risk of ischaemic CVD only among participants with moderate carbohydrate intake (RR = 0·81 comparing extreme quintiles; 95 % CI 0·70, 0·94).

Total vegetables, green leafy vegetables and carotene-rich fruits and vegetables showed stronger associations with ischaemic CVD among the low carbohydrate group. No consistent trends were observed for fruit intake.