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Purpose: To improve sustainability, adjustments to current diets are necessary. Therefore, limited planetary resources are considered within the healthy reference diet proposed by the EAT-Lancet Commission. The agreement with nationwide food intake was evaluated with two indices which reflect this reference and German food intake recommendations., Methods: A healthy eating index (HEI-MON) reflecting the dietary guidelines of the German nutrition society and a planetary healthy eating index (PHEI-MON) reflecting the healthy reference diet were developed, with scores from 0 to 100. Both indices were applied to data from a nationally representative sample of the German population aged 18-79 years for which data from a 53-item food frequency questionnaire are available., Results: Mean scores for the indices were 53 for HEI-MON and 39 for PHEI-MON. A better adherence to either guideline could be found among women, persons of older age as well as persons with higher education level. The sub-scores for HEI-MON showed high agreement with the recommendations for side dishes, fruit/nuts, (processed) meat and cereals, but low agreement with the recommendations for free sugar and vegetables/legumes. PHEI-MON sub-scores were highest for poultry, fruits and potatoes, and lowest for nuts, red meat and legumes. High scores in one index do not necessarily correspond to high scores in the other index. Individuals with more plantbased diets had higher scores in both indices, while high sugar and meat consumption led to lower scores., Conclusions: More plant-based diets are crucial for individual and planetary health. Both indices reflect such diets which consider already health and sustainability aspects. At an individual level, the scores for both indices may differ considerably, but overall there is a huge potential in the population to adapt to a diet more in line with both guidelines., (© 2024. The Author(s).)

Background: The global climate crisis requires a paradigm shift in dietary concepts, respecting the needs of children. A global reference diet has been suggested by the EAT-Lancet Commission. On this basis, the detailed "Planetary Health Diet Index" (PHDI) has been proposed. The objective of this assessment is (1) to apply the PHDI to the Food-Based Dietary Guidelines, the so-called Optimized Mixed Diet (OMD) for children and adolescents in Germany in its original composition and (2) to check how the planetary value of the OMD could be improved by modifying food selection within meals while keeping the high nutrient densities of the guideline diet., Methods: The PHDI specifies 16 food groups and their proportion of total daily energy intake. The PHDI of the original OMD was calculated by assigning the foods of the 7-day menu to the PHDI food groups in order to score them. In this way, it became apparent which food groups had the potential to improve the sustainability. The diet was then updated by either reducing or increasing individual foods from these food groups in the meals and deriving the resulting PHDI. The nutrient densities of the original and updated daily OMD were calculated., Results: The original diet obtained a PHDI score of 68.24 points, representing 45.5% of the theoretical maximum of 150 points. The following food groups achieved 9.9 to 10 out of 10 points: fruits, total vegetables, fish & seafood, vegetable oils, chicken (and substitutes). Conversely, food groups receiving a zero score included tubers & potatoes, dairy, red meat, animal fat, and added sugars. The updated diet resulted in increased consumption of 'nuts & peanuts', 'legumes', 'green vegetables', 'whole grains', and decreased consumption of 'tubers & potatoes' and 'red meat'. Overall, the PHDI increased from 68.24 to 81.51 points with the updated OMD, reflecting a 13.27% increase compared to the original diet. The nutrient densities were not significantly affected, but even slightly increased for most nutrients., Conclusions: The PHDI was applied to demonstrate how the sustainability of the guideline diet for children and adolescents in Germany could be improved through changes in individual food groups that can be easily implemented in practice while maintaining high nutrient densities and acceptability for children., Trial Registration: NA., Competing Interests: Declarations Conflict of interest The authors declare that they have no competing interests. Ethics approval and consent to participate Not applicable. Consent for publication Not applicable., (© 2024. The Author(s).)

Background: Although national food guides are designed, ostensibly, to translate scientific evidence with respect to food, dietary patterns, and health, their development has increasingly become a corporate/political process as well as scientific one; often with corporate/political influences overriding science. Our aim was to construct an unbiased, sustainable, evidence-informed Universal Food Guide to serve as a template for countries to develop their unique guides, thereby, provide a valid resource for health professionals, health authorities, and the public., Methods: To address our aim, we conducted an integrative review of multiple evidence-informed sources (e.g., established databases, evidence syntheses, scholarly treatises, and policy documents) related to four areas: 1. Food guides' utility and conflicts of interest; 2. The evidence-based healthiest diet; 3. Constituents of the Universal Food Guide template; and 4. Implications for population health; regulation/governance; environment/climate/planetary health; and ethics., Results: The eating pattern that is healthiest for humans (i.e., most natural, and associated with maximal health across the life cycle; reduced non-communicable disease (NCD) risk; and minimal end-of-life illness) is whole food, low fat, plant-based, especially vegan, with the absence of ultra-processed food. Disparities in national food guide recommendations can be explained by factors other than science, specifically, corporate/political interests reflected in heavily government-subsidized, animal-sourced products; and trends toward dominance of daily consumption of processed/ultra-processed foods. Both trends have well-documented adverse consequences, i.e., NCDs and endangered environmental/planetary health. Commitment to an evidence-informed plant-based eating pattern, particularly vegan, will reduce risks/manifestations of NCDs; inform healthy food and nutrition policy regulation/governance; support sustainable environment/climate and planetary health; and is ethical with respect to 'best' evidence-based practice, and human and animal welfare., Conclusion: The Universal Food Guide that serves as a template for national food guides is both urgent and timely given the well-documented health-harming influences that corporate stakeholders/politicians and advisory committees with conflicts of interest, exert on national food guides. Such influence contributes to the largely-preventable NCDs and environmental issues. Policy makers, health professionals, and the public need unbiased, scientific evidence as informed by the Universal Food Guide, to inform their recommendations and choices., (© 2024. The Author(s).)

Introduction: The presence of food product indicators may facilitate consumers in making informed healthy choices. However, it may also mislead consumers. This study aims to determine the prevalence of food products carrying food product indicators; the compliance of products bearing Malaysia's Healthier Choice Logo (HCL) and nutrition and health claims (NHC) towards the local regulations; and the credibility of the aforementioned products as healthy food products based on the international regulation in the Malaysian market., Method: This is a cross-sectional market survey conducted from February to May 2023 on 3428 products sold in Malaysian supermarkets. Product information including the brand, name, nutrition information panel, food product indicator (front-of-pack nutrition labelling, NHC, other claims), ingredients list and manufacturer or importer were collected. Compliance of products carrying NHC and HCL is evaluated against local guidelines. Credibility as a healthy product is evaluated against the WHO Nutrient Profile Model for the Western Pacific Region on a subsample (products with HCL and/or NHC)., Results: 53% of food products surveyed had food product indicators (n=1809). A total of 32% carried at least one NHC (n=1101), of which 47% had excellent overall compliance (n=522). Only 4% carried Malaysia's HCL (n=138), of which 48% had excellent nutrient compliance (n=66). Only 13% of the products carrying Malaysia's HCL and NHC could be identified as absolute healthy food products as defined by the WHO standard (n=147)., Conclusion: Although half of the products surveyed had food product indicators, merely half of them had excellent compliance towards the standards. Only 13% of the subsample qualified as healthy food products. Voluntary application of the local HCL was low among food industries. Ensuring high standards of compliance and credibility of food products in the Malaysian market is crucial for food companies and government authorities., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objective: Local governments have an important role to play in creating healthy, equitable and environmentally sustainable food systems. This study aimed to develop and pilot a tool and process for local governments in Australia to benchmark their policies for creating healthy, equitable and environmentally sustainable food systems., Design: The Healthy Food Environment Policy Index (Food-EPI), developed in 2013 for national governments, was tailored to develop the Local Food Systems Policy Index (Local Food-EPI+) tool for local governments. To incorporate environmental sustainability and the local government context, this process involved a literature review and collaboration with an international and domestic expert advisory committee ( n 35) and local government officials., Setting: Local governments., Results: The tool consists of sixty-one indicators across ten food policy domains (weighted based on relative importance): leadership; governance; funding and resources; monitoring and intelligence; food production and supply chain; food promotion; food provision and retail in public facilities and spaces; supermarkets and food sources in the community; food waste reuse, redistribution and reduction; and support for communities. Pilot implementation of the tool in one local government demonstrated that the assessment process was feasible and likely to be helpful in guiding policy implementation., Conclusion: The Local Food-EPI+ tool and assessment process offer a comprehensive mechanism to assist local governments in benchmarking their actions to improve the healthiness, equity and environmental sustainability of food systems and prioritise action areas. Broad use of this tool will identify and promote leading practices, increase accountability for action and build capacity and collaborations.

Purpose: Front-of-pack labelling systems, such as the Health Star Rating (HSR), aim to aid healthy consumer dietary choices and complement national dietary guidelines. Dietary guidelines aim to be holistic by extending beyond the individual nutrients of food, including other food components that indicate diet quality, including whole grains. We aimed to test the feasibility of including whole grains in the HSR algorithm, to better inform dietary guidance in Australia coherent with existing dietary guidelines., Methods: We assigned whole-grain points as a favourable component of the HSR based on the whole-grain content of foods. We compared the original, and three modified HSR algorithms (including altered thresholds for star ratings) using independent-samples median tests. Finally, we used Spearman's correlation to measure the strength of association between an item's nutritional composition (all components of the HSR algorithm including all favourable and unfavourable components) and their HSR using each algorithm., Results: Up to 10 points were added for products with ≥ 50% whole-grain content, with no points for products with < 25%. Adjusting the HSR score cut-off by 3 points for grain products created the greatest difference in median HSR between refined and whole-grain items (up to 2 stars difference), compared to the original algorithm (a maximum of 1 star)., Conclusions: The addition of whole grains to the HSR algorithm improved the differentiation of refined and whole-grain items, and therefore better aligned with dietary guidelines. Holistic approaches to food guidance systems are required to provide consistent messaging and inform positive food choices., (© 2024. The Author(s).)

Public procurement of food is crucial for ensuring proper nutrition and the provision of high-quality products in public institutions like schools and kindergartens. It should be seen as an investment in health promotion, particularly for young children. Notably, when no quality criteria are specified, the cheapest and often lowest-quality products are typically selected. This study analyzed 1126 public procurement orders processed by schools and kindergartens in Poland between November 2022 and March 2023, with a focus on cereal products and their derivatives. Of these orders, 197 met the inclusion criteria, yielding a total of 5084 cereal products for detailed analysis. The study assessed the quantities ordered and the quality characteristics specified in the procurement documents. The results revealed that the most commonly described criteria pertained to product composition, especially typical characteristics and the absence of additives. Sensorial characteristics such as consistency and color were also frequently specified, while sustainable public procurement criteria were mentioned the least, indicating their marginal importance in current procurement practices. This underscores the critical importance of establishing minimum standards for describing cereal products in terms of sensorial characteristics, composition, and sustainability. Such standards are essential for improving the quality of grain products supplied to public institutions and ensuring that these institutions actively contribute to promoting healthy eating habits among children.

Introduction: The Healthy Eating Index (HEI) is a comprehensive measure to assess diet quality. Because of the various factors that influence the nutritional status of older adults, there is a need to adapt an index that assesses the quality of the diet considering the dietary requirements of aging and health promotion. This study aimed to adapt the HEI for older adults, considering their needs for healthy eating., Methods: Food consumption data was collected by means of three non-consecutive 24-hour food recalls (R24h). For the adaptation of the Healthy Eating Index for Older Adults (HEI-OA), the components and scoring methodology of HEI-2015 were maintained and Brazilian food intake recommendations for the older population were used, which are in line with international recommendations. The validity of the HEI-OA was assessed by four ideal diets, Mann-Whitney's test, Spearman's correlation analysis and Cronbach's coefficient., Results: Content validity of the HEI-OA was confirmed by the maximum score for diets recommended to older adults and by the score between groups with known differences in diet quality. The HEI-OA total score did not correlate with total energy intake (TEI - total energy value: r = -0.141, p > 0.05). The total HEI-OA score showed a statistically significant correlation with several nutrients. These correlations allowed identifying that these nutrients are closely related to the components of the HEI-OA. The internal consistency value for the HEI-OA total score was 0.327, similar to the 2005 and 2010 versions of the HEI., Conclusion: The HEI was successfully adapted for use with older adults, presenting validity and reliability. The HEI-OA can be used to assess diet quality in line with international dietary guidelines for healthy aging., (© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.)

Introduction: Children's diets in the U.S. typically fail to meet dietary recommendations, contributing to associated adverse health outcomes. The Healthy, Hunger-Free Kids Act (HHFKA) of 2010 required the U.S. government to update nutrition standards for school meals to align with the Dietary Guidelines for Americans (DGAs). This study estimates the evolving impact of substituting school-prepared food for home-prepared food on overall daily diet quality and by subcomponents of diet quality. Subgroup analyses are performed by race/ethnicity and income., Methods: Two, nonconsecutive days of dietary recall data from the National Health and Nutrition Examination Survey (2005-March 2020) are used to calculate schoolchildren's Healthy Eating Index (HEI)-2020 scores. The study includes children with complete two-day dietary intakes who attend kindergarten through twelfth grade in a school offering lunch. An individual-level fixed effects regression is employed to examine the relationship of school food consumption on HEI-2020 scores before and after HHFKA-mandated changes in nutrition standards. Analyses were conducted on September 23, 2023., Results: Prior to changes in standards (2005-2008), school food did not impact diet quality within the overall group of children. In 2009-2012, positive associations between school food and diet quality emerged for low-income students and for non-Hispanic Black students. By 2013-2020, improvements were seen across all groups. The association between school food and diet quality was most attributable to more favorable consumption of dairy, fruit, whole grains, refined grains, added sugars and saturated fats., Conclusions: HHFKA-based nutrition standards were associated with beneficial dietary changes and reduced dietary disparities for children across diverse backgrounds., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

In 2019, the EAT-Lancet Commission proposed a Planetary Health Diet (PHD) to address challenges toward sustainable and healthy diets. However, its suitability within the Dutch context and a comparison with the Dutch Dietary Guidelines (DDG) needs investigation. Our study aimed to compare the PHD with DDG in terms of food groups, servings, nutritional content, and adequacy in adults. We modeled two theoretical diets, the PHD (PHD-NL) and another based on the DDG (DDG-NL), using the Dutch National Food Consumption Survey (FCS-2016) and Dutch Food Composition Database to calculate the nutritional content and compared it with the Dutch Dietary Reference Values (DRVs). The PHD included higher quantities of vegetables, fish, legumes, and nuts, while the DDG suggested more significant amounts of cereals, tubers, starchy vegetables, dairy, and red meat. We observed differences in macronutrient distribution; while both diets lacked sufficient vitamin D, calcium content was lower in the PHD-NL. The PHD-NL had higher levels of fiber, vegetable protein, unsaturated fats, and non-heme iron, while vitamins B2, B6, B12, and calcium were lower than the DDG-NL diet. The PHD-NL has nutritional adequacy in the Dutch context, except for vitamin D and calcium, although it is essential to be cautious with iron because of the bioavailability of non-heme iron in plant-based diets. These findings have implications for the adoption of a sustainable diet according to nutritional requirements, population health status, and sociocultural context, as well as compliance with specific dietary behaviors of populations.

Purpose of Review: The aim was to identify indices of diet quality and health that could be applied to the environmental assessment of foods in order to provide metrics that collectively assess nutritional, health and environmental dimensions., Recent Findings: The review identified five major groups of indices: nutrient-food quantity-based; guideline-based; diversity-based; nutrient quality-based; health-based. Nutrient-food quantity-based and guideline type indices were the most frequently used to evaluate diet quality. Scaled assessment using a nutritional functional unit is the most common integration of diet quality with the environmental analysis of foods. There are fewer indices that measure the heath impacts of foods, but epidemiological dietary risk factors seem a promising approach to integrate diet and health impacts into the environmental assessment of foods. Five groups of nutritional and health indices were identified that can be applied when performing an environmental assessment of foods. This review proposes different methodological insights when doing such assessments to ensure transparency and comparability of the results., (© 2024. The Author(s).)

Optimizing diet quality is an important concept for college athletes. Purpose : To evaluate dietary quality of National Collegiate Athletic Association (NCAA) Division I athletes. Methods : Total 94 college athletes (n= 21 male, 73 female) from 19 different varsity teams at a single university completed a 24-hour dietary recall using the Automated Self-Administered 24-hour (ASA24) Dietary Assessment Tool. Diet quality was assessed using the Healthy Eating Index (HEI) with higher scores indicating better diet quality (range 0-100). Results : The average HEI score for the total sample was 59.2 ± 16.6 and only nine athletes achieved an HEI score ≥ 80. There were no significant differences in HEI scores between sexes, class, majors, sport played, or those who did or did not report taking previous nutrition coursework. Conclusions : The dietary quality was poor based on US dietary guidelines for the general population, which could have negative effects on health and performance.

The Dietary Guidelines for Americans (DGA) provides science-based advice on dietary intake to promote health, reduce risk of chronic disease, and meet nutrient needs. It is jointly published by the United States Departments of Health and Human Services and Agriculture (USDA) every 5 y. As chronic diseases continue to rise to pervasive levels, helping the United States population follow the DGA is especially important for improving the health of our nation. The DGA is developed using a rigorous and transparent scientific process, and with the advice of an independent, external committee of leading scientists. Career federal nutrition scientists who manage the process ensure that the methods used to develop the DGA remain state of the art. Unfortunately, misinformation about the scientific basis, transparency, and relevance of the DGA for the United States population threatens its credibility. The main objective of this article is to correct this misinformation with factual information about the process used to develop the DGA. The DGA provides guidelines for the general public, and its primary audience includes policymakers and nutrition and health professionals who help individuals and families consume a healthy dietary pattern. Providing accurate information may bolster trust in the recommendations among these audiences while improving implementation across sectors to promote better adherence to the DGA, thereby improving diet quality among the United States population., (Published by Elsevier Inc.)

Food-based dietary guidelines (FBDGs) are tools for promoting healthy eating habits. For the population of children under two years old in Latin America and the Caribbean (LAC), there is a lack of reviews analyzing the quality of these guidelines. The objective of this systematic review is to evaluate publicly available FBDGs for the population under two years old in LAC until mid-2023. Guidelines aimed at caregivers of children were included, sourced from government websites in LAC countries and the Food and Agriculture Organization (FAO) portal. Documents targeted at healthcare professionals were excluded. For qualitative analysis, the Agree II guidelines assessment tool and the FAO guide principles for developing healthy and sustainable diets were used. The results showed that more recently released and revised FBDGs with a greater number of pages obtained better scores in both assessments. Additionally, out of the 32 LAC countries, only 13 had these FBDGs available on websites for public access. As a limitation, this study faced challenges in standardizing the searches on government websites. The authors emphasize the need to develop FBDGs for the population under two years old that align with current health and sustainability needs and promote health education.

Background: This is the first study on dietary intakes of infants and young children in the Eastern Mediterranean Region, a region that is currently witnessing the nutrition transition. It aims at characterizing food consumption patterns amongst 0-4 year old children in Lebanon, evaluating their macro- and micronutrient intakes and assessing adherence to dietary recommendations., Methods: Based on a national cross-sectional survey in 2012 (n = 866), the study collected data on sociodemographic and anthropometric characteristics, and one 24-hour dietary recall was administered. Nutrient intakes were compared with reference values: Estimated Average Requirement (EAR), Adequate Intake (AI) and Acceptable Macronutrient Distribution Range (AMDR)., Results: Milk was the highest contributor to energy intake (EI) in infants (95.8 and 56.5% in 0-5.9 months and 6-11.9 months old infants, respectively), while its intake was lower among toddlers and preschoolers (35.4 and 15.1%, respectively). In contrast, intakes of sweets and sweetened beverages were the highest in preschoolers compared to younger children, contributing 18.5% EI in preschoolers. Compared to dietary guidelines, the lowest dietary adherence was found for vegetables (17.8-20.7%) and fruits (14.4-34.3%). Protein intake was within the recommendations for the vast majority of children. Although total fat intake was lower in toddlers and preschoolers compared to infants, more than 40% of toddlers and preschoolers exceeded the AMDR for fat and 87.3% of preschoolers exceeded the upper limit for saturated fat. Only 3.6% of toddlers and 11.5% of preschoolers exceeded the AI level for dietary fiber. Micronutrient intake assessment showed that mean intakes in infants exceeded the AI for all micronutrients, except for vitamin D and magnesium. In toddlers, vitamin D and calcium were below the EAR among 84.7, and 44.6%, respectively. In preschoolers, most of the children (91.9%) had inadequate intakes of vitamin D, and a third had inadequate intakes of folate, calcium and vitamin A., Conclusions: This study identified priority issues for nutrition intervention in infants and young children in Lebanon. Concerted multi-stakeholder efforts are needed to instill heathier food consumption and nutrient intake patterns early in life., (© 2022. The Author(s).)

Background & Aims: The World Cancer Research Fund (WCRF) and American Institute for Cancer Research (AICR) updated their cancer prevention recommendations in 2018. Adherence to these recommendations has been associated with lower cancer risk and mortality. However, adherence in relation to Cancer of Unknown Primary (CUP) risk has not been studied. This study investigates whether adherence to the WCRF/AICR recommendations is associated with CUP risk., Methods: Data from the prospective Netherlands Cohort Study on diet and cancer was used to measure adherence to the recommendations in relation to CUP risk. The cohort includes 120 852 participants (aged 55-69 years), who completed a self-administered questionnaire on cancer risk factors at baseline. Adherence was investigated with respect to body fatness, physical activity, plant foods, meat consumption and alcohol. Incident CUP cases were identified through record linkage to the Netherlands Cancer Registry and Dutch Pathology Registry. A follow-up of 20.3 years, resulted in 856 incident CUP cases and 3911 subcohort members with complete information available for case-cohort analyses. Multivariable adjusted hazard ratios were estimated using proportional hazards models and were adjusted for age at baseline, sex, cigarette smoking (status, frequency, and duration) and total energy intake., Results: Highest adherence appeared to be associated with decreased CUP risk in the age-sex adjusted model (HR: 0.76, 95% CI: 0.62-0.92). After additional adjustment for cigarette smoking (status, frequency, and duration), the association attenuated and was no longer statistically significant. No multiplicative interactions were observed between sex nor smoking status and overall adherence in relation to CUP., Conclusion: Within this cohort, highest adherence to the WCRF/AICR recommendations is not statistically significantly associated with decreased CUP risk after multivariable adjustment., Competing Interests: Conflicts of interest None declared., (Copyright © 2021 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Importance: Poor diet is a leading global factor associated with cardiometabolic disease (CMD). Understanding the quality of evidence of the associations between specific dietary factors and CMD, including effect size (relative risk [RR]) and uncertainty, is essential to guide policy and consumer actions to achieve healthy diet and public health goals., Objective: To assess the quality of evidence of the associations between specific dietary factors and CMD as well as the quantitative evidence for RRs and the uncertainty of these risk estimates., Evidence Review: PubMed and the reference lists of eligible articles were searched between May 1, 2015, and February 26, 2021, for systematic reviews with meta-analyses of randomized clinical trials and prospective cohort studies that analyzed the consumption of 1 or more of the dietary factors of interest; reported dose-response meta-analyses; included healthy adults; and assessed 1 or more of the outcomes of interest. Study characteristics and RR estimates were extracted in duplicate. For identified associations, quality of evidence was assessed using the Bradford-Hill criteria for causation., Findings: A total of 2058 potentially relevant reports were identified, from which 285 full-text articles were assessed for eligibility. The final selection of articles included 28 meta-analyses representing 62 associations between diet and CMD. Among these associations, 10 foods, 3 beverages, and 12 nutrients had at least probable evidence of associations with coronary heart disease, stroke, and/or diabetes. Most RRs ranged from 0.87 to 0.96 per daily serving change for protective associations and from 1.06 to 1.15 per daily serving change for harmful associations. Most identified associations were protective (n = 38) and a smaller number were harmful (n = 24), with a higher risk associated with higher intake., Conclusions and Relevance: This systematic review summarized the current quality of evidence of the associations of specific dietary factors with coronary heart disease, stroke, and diabetes. These findings may inform dietary guidance, the assessment of disease burden in specific populations, policy setting, and future research.

Background: Improving beverage patterns of children and adolescents is recommended for combatting obesity and reducing disease risk. Therefore, it is important to assess beverage intake quality in this population. For adults, the Healthy Beverage Index (HBI) was created to assess beverage intake quality, but a similar tool did not exist for children and adolescents., Objective: The objective was to develop an HBI for US Children and Adolescents (HBI-CA), and then assess the validity and reliability of this tool., Design: Modeled after the adult HBI, age-specific, evidence-based beverage recommendations were compiled. Ten components were included to assess beverage intake quality. Validity and reliability were assessed using cross-sectional data and methods similar to those used for the evaluation of the Healthy Eating Index., Participants: The 2015-2016 National Health and Nutrition Examination Survey provided 24-hour dietary recall data for 2,874 children and adolescents aged 2 to 19 years., Main Outcome Measures: HBI-CA scores were the main outcome measure., Statistical Analyses Performed: To assess validity, independent t tests were used to determine differences in HBI-CA component and total scores among groups, and principal component analysis was completed to examine multidimensionality of the HBI-CA. Pearson bivariate correlations were used to assess reliability., Results: The HBI-CA produced a (mean ± standard error) total score of 69.2 ± 0.8, which is similar to the adult HBI mean total score of 63. Principal component analysis identified six factors, indicating the multidimensionality of the HBI-CA, with more than one combination of components contributing to variation in total scores. Most HBI-CA components were significantly correlated to the total score, with met fluid requirements, total beverage energy, sugar-sweetened beverage, and water components demonstrating the strongest correlations (r range = 0.335-0.735; P ≤ 0.01)., Conclusions: The results provide preliminary evidence to support the validity and reliability of the HBI-CA. If future research establishes the predictive validity and sensitivity of the HBI-CA, this tool could be useful to quantify the beverage intake quality of children and adolescents., (Copyright © 2022 Academy of Nutrition and Dietetics. Published by Elsevier Inc. All rights reserved.)

Background: Dietary habits formed in early childhood can track into later life with important impacts on health. Food-based dietary guidelines (FBDGs) may have a role in improving population health but are lacking for young children., Objectives: We aimed to establish a protocol for addressing nutrient shortfalls in 1- to 5-y-old children (12-60 mo) using diet modeling in a population-based sample., Methods: Secondary analysis of 2010-2011 Irish National Pre-School Nutrition Survey data (n = 500) was conducted to identify typical food consumption patterns in 1- to 5-y-olds. Nutrient intakes were assessed against dietary reference values [European Food Safety Authority (EFSA) and Institute of Medicine (IOM)]. To address nutrient shortfalls using diet modeling, 4-d food patterns were developed to assess different milk-feeding scenarios (human milk, whole or low-fat cow milk, and fortified milks) within energy requirement ranges aligned with the WHO growth standards. FBDGs to address nutrient shortfalls were established based on 120 food patterns., Results: Current mean dietary intakes for the majority of 1- to 5-y-olds failed to meet reference values (EFSA) for vitamin D (≤100%), vitamin E (≤88%), DHA (22:6n-3) + EPA (20:5n-3) (IOM; ≤82%), and fiber (≤63%), whereas free sugars intakes exceeded recommendations of <10% energy (E) for 48% of 1- to 3-y-olds and 75% of 4- to 5-y-olds. "Human milk + Cow milk" was the only milk-feeding scenario modeled that predicted sufficient DHA + EPA among 1- to 3-y-olds. Vitamin D shortfalls were not correctable in any milk-feeding scenario, even with supplementation (5 µg/d), apart from the "Follow-up Formula + Fortified drink" scenario in 1- to 3-y-olds (albeit free sugars intakes were estimated at 12%E compared with ≤5%E as provided by other scenarios). Iron and vitamin E shortfalls were most prevalent in scenarios for 1- to 3-y-olds at ≤25th growth percentile., Conclusions: Using WHO growth standards and international reference values, this study provides a protocol for addressing nutrient shortfalls among 1- to 5-y-olds, which could be applied in country-specific population health., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

Phytate (PA) serves as a phosphate storage molecule in cereals and other plant foods. In food and in the human body, PA has a high affinity to chelate Zn 2+ and Fe 2+ , Mg 2+ , Ca 2+ , K + , Mn 2+ and Cu 2+ . As a consequence, minerals chelated in PA are not bio-available, which is a concern for public health in conditions of poor food availability and low mineral intakes, ultimately leading to an impaired micronutrient status, growth, development and increased mortality. For low-income countries this has resulted in communications on how to reduce the content of PA in food, by appropriate at home food processing. However, claims that a reduction in PA in food by processing per definition leads to a measurable improvement in mineral status and that the consumption of grains rich in PA impairs mineral status requires nuance. Frequently observed decreases of PA and increases in soluble minerals in in vitro food digestion (increased bio-accessibility) are used to promote food benefits. However, these do not necessarily translate into an increased bioavailability and mineral status in vivo. In vitro essays have limitations, such as the absence of blood flow, hormonal responses, neural regulation, gut epithelium associated factors and the presence of microbiota, which mutually influence the in vivo effects and should be considered. In Western countries, increased consumption of whole grain foods is associated with improved health outcomes, which does not justify advice to refrain from grain-based foods because they contain PA. The present commentary aims to clarify these seemingly controversial aspects.

An unhealthy dietary pattern is an important risk factor for non-communicable diseases. Front-of-Pack nutritional labels such as Nutri-Score can be used to improve food choices. In addition, products can be improved through reformulation. The current study investigates to what extent Nutri-Score aligns with the Dutch Health Council dietary guidelines and whether it can be used as an incentive for reformulation. Nutri-Score calculations were based on the Dutch Branded Food database (2018). The potential shift in Nutri-Score was calculated with product improvement scenarios. The Nutri-Score classification is in line with these dietary guidelines: increase the consumption of fruit and vegetables, pulses, and unsalted nuts. It is, however, less in line with the recommendations to limit (dairy) drinks with added sugar, reduce the consumption of red meat and replace refined cereal products with whole-grain products. The scenario analyses indicated that a reduction in sodium, saturated fat or sugars resulted in a more favourable Nutri-Score in a large variety of food groups. However, the percentage of products with an improved Nutri-Score varied greatly between the different food groups. Alterations to the algorithm may strengthen Nutri-Score in order to help consumers with their food choices.

A Mediterranean-style diet is a healthy eating pattern that may benefit cancer risk, but evidence among Americans is scarce. We examined the prospective association between adherence to such a diet pattern and total cancer risk. A Mediterranean-style dietary pattern (MSDP) score was derived from a semi-quantitative food frequency questionnaire at exam 5 (1991-1995). Subjects included 2966 participants of the Framingham Offspring Study who were free of prevalent cancer. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs), adjusting for demographic, lifestyle, and anthropometric measures. Cox-models were also used to examine effect modification by lifestyle and anthropometric measures. During 18 years of median follow-up, 259 women and 352 men were diagnosed with cancer. Women with moderate or higher adherence to the MSDP had ≥25% lower risks of cancer than women with the lowest MSDP (HR (moderate vs. lowest): 0.71, 95% CI: 0.52-0.97 and HR (highest vs. lowest): 0.74; 95% CI: 0.55-0.99). The association between MSDP score and cancer risk in men was weaker except in non-smokers. Beneficial effects of the MSDP in women were stronger among those who were not overweight. In this study, higher adherence to MSDP was associated with lower cancer risk, especially among women.

The home food environment (HFE) is associated with dietary intake; yet measuring HFE quality often requires burdensome collection of detailed inventories. This project evaluated the capacity of the Home Inventory to Describe Eating and Activity, version 2 (Home-IDEA2) to capture HFE quality by measuring the presence or absence of household foods. Validity was tested using a modified application of the Healthy Eating Index-2010 (HEI). Comparative data were drawn from the National Food Acquisition and Purchase Survey (FoodAPS) Food-at-Home Public Use File. HEI scores were calculated for 4202 households in FoodAPS using Home-IDEA2 inventories and full reported inventories. Paired t-tests compared: (1) estimated vs. total edible grams (EEG; TEG); (2) limited vs. all reported foods; and (3) EEG + limited foods vs. TEG + all reported foods. Sensitivity and range of scores were compared. Mean HEI scores for Home-IDEA2 were higher ( p < 0.003) than FoodAPS: (1) 51.6 ± 16.1 vs. 49.6 ± 18.1 (food amounts); (2) 53.5 ± 15.8 vs. 49.8 ± 15.4 (food items); (3) 55.5 ± 15.7 vs. 49.8 ± 15.4 (full instrument); differences were small. Scores demonstrated comparable sensitivity and range. The study found that the Home-IDEA2 can capture HFE quality adequately with low data collection burden.

Background and Aims: An attempt to recommend scale up of dietary diversity data at household and individual level for improving the food and nutrition security, the study was conducted with the objective to explore the dietary diversity (DD) and its associated risk factors among reproductive age women in India., Methodology: A total of 5,48,806 women aged 15-49 years were asked how often they consume various types of food groups (daily, weekly, occasionally, or never). Association between adequate DD and its covariates such as individual and household were measured by using logistic regression., Results: Most of the population consumed dark green leafy vegetables, milk/curd and pulses/beans. Only 1.7% of women consumed diet with adequate diversity or five or more food groups. Women's educations, gestation status, wealth status, sex of household head, household size, religion, place of residence and land ownership were significantly associated with adequate DD. The percentages of population with adequate DD varies from 7% to <1% in different states of India which shows that good-quality-diet is a major issue in entire country., Conclusion: There is an urgent need of programs focused on availability of food with maximum diversity at minimum cost in order to reduce maternal and child mortality in India. To reduce geographic variation in achieving adequate DD, new approaches are required in developing multiple interventions to address major preventable causes of DD. Individual state government should also take serious measure to improve the consumption of variety of food groups., Competing Interests: Declaration of competing interest None of the authors reported a conflict of interest related to the study., (Copyright © 2021 Diabetes India. Published by Elsevier Ltd. All rights reserved.)

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

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., (Copyright © The Author(s) on behalf of the American Society for Nutrition 2021.)

The EAT-Lancet Commission has proposed a model diet to improve the health of human beings and that of the planet. Recently, we proposed the Planetary Health Diet Index (PHDI) to assess adherence of the population to this model diet. In this study, we aimed to evaluate adherence to the PHDI and obesity outcomes using baseline data from 14,515 participants in the Brazilian Longitudinal Study of Adult Health (ELSA-Brasil). The dietary data were assessed using a 114-item FFQ. Body mass index (BMI) and waist circumference (WC) were both used continuously and categorized. Linear and multinomial regression models adjusted for potential confounding factors were performed to assess the relationship between adherence to PHDI and outcomes. An inverse association was observed between adherence to PHDI and obesity indicators. Individuals with high adherence to the PHDI had lower BMI (β-0.50 95% CI-0.73:-0.27) and WC (β-1.70 95% CI-2.28:-1.12) values. They were also 24% less likely to be overweight (OR 0.76 95% CI 0.67:0.85) or obese (OR 0.76 95% CI 0.65:0.88), and they were 14% and 27% less likely to have increased WC (OR 0.86 95% CI 0.75:0.98) or substantially increased WC (OR 0.73 95% CI 0.64:0.83) than those with lower adherence. Our results showed that higher adherence to the PHDI may decrease obesity indicators.

One of the most notable changes in the epidemiology of esophageal cancer (EC) is the rising incidence and prevalence of esophageal adenocarcinoma (EAC) in developed countries. The aim of this systematic review was to collect and summarize all the available evidence regarding lifestyle, diet, and EAC risk. We searched the PubMed and Scopus databases in January 2021 for studies providing information about lifestyle, diet, WCRF/AICR recommendations, and EAC risk; published in English; without a time filter. The Newcastle-Ottawa Scale was used to assess risk of bias. The results are stratified by risk factor. A total of 106 publications were included. Half of the case-control studies were judged as high quality, whilst practically all cohort studies were judged as high quality. Body mass index and waist circumference were associated with increased EAC risk. Physical activity did not appear to have a significant direct role in EAC risk. A diet rich in fruit, vegetables, and whole grains appeared to be more protective than a Western diet. Alcohol does not seem to be related to EAC, whereas smokers, particularly heavy smokers, have an increased risk of EAC. Prevention remains the best option to avert EAC. Comprehensible and easy to follow recommendations should be provided to all subjects. Protocol ID number: CRD-42021228762, no funds received.

Given that there is only a limited body of evidence available concerning the dietary habits of Spanish university students, the present study assesses the quality of this group's diet, their adherence to the National Food-Based Dietary Guidelines, and the predictive factors of their diet quality. To do so, a cross-sectional study was performed on a sample of 1055 students. The quality of the participants' diets was then analysed by using the Spanish Healthy Eating Index, and then their level of compliance was assessed in light of the dietary recommendations put forth by the Spanish Society for Community Nutrition. According to these standards, only 17.4% of the participants had a healthy diet. The level of compliance with the recommendations was poor, highlighting especially the low levels of "fruit" and "vegetables" that they consumed as well as high levels of "cold meats and cuts" and "sweets". The factors that predicted a worse diet are being male, living alone, low levels of physical activity, smoking, high alcohol intake, leading a sedentary lifestyle, psychological distress, and insomnia ( p < 0.005). Furthermore, participants with low or high body weights showed signs of a higher quality diet ( p < 0.001). The present findings suggest that a significant proportion of university students ought to change their dietary habits; these also attest to the importance of developing strategies that are directly targeted at university students in order to promote a healthy diet.

There is a paucity of data on whether Australian university students are meeting specific nutrient guidelines, and the relationship between diet and physical activity patterns with body composition and metabolic health. In this study, biomedical students from The University of Queensland were recruited (150 males and 211 females, 19-25 years), and nutritional intake (ASA24-Australia) and physical activity levels (Active Australia Survey) quantified. Body composition (height, waist circumference, body mass, BMI, and percentage body fat; BOD POD) and metabolic health (oral glucose tolerance test) were also measured. Median daily energy intake was 6760 kJ in females and 10,338 kJ in males, with more than 30% of total energy coming from energy-dense, nutrient-poor foods. Only 1 in 10 students met fruit or vegetable recommendations, with less than one third meeting recommendations for fibre, calcium, and potassium. Intakes of calcium and iron were particularly low among female students, with only 16% and 6% of students meeting the recommended dietary intake (RDI), respectively. The majority of males and almost half of all females exceeded the suggested dietary target (SDT) for sodium. Sufficient physical activity (≥150 min over ≥5 sessions per week) was met by more than 80% of students. Body composition and blood glucose concentrations were largely normal but an early sign of insulin resistance (HOMA-IR > 2.0), measured in a subset of students, was present in 21% of males and 17% of females. Modest reductions in blood glucose levels and percentage body fat were associated with increasing vigorous activity. Low intakes of fibre, calcium, and potassium could be corrected by increasing fruit, vegetable, and dairy intake, and, among females, health promotion messages focusing on iron-rich foods should be prioritised. While these nutrient deficiencies did not translate into immediate metabolic heath concerns, dietary behaviours can track into adulthood and have lasting effects on overall health.

Background: Plant-based diets have been associated with lower risk of various diseases, including type 2 diabetes, cardiovascular disease, and other cardiometabolic risk factors. However, the association between plant-based diet quality and breast cancer remains unclear., Methods: We prospectively followed 76,690 women from the Nurses' Health Study (NHS, 1984-2016) and 93,295 women from the NHSII (1991-2017). Adherence to an overall plant-based diet index (PDI), a healthful PDI (hPDI), and an unhealthful PDI (uPDI) was assessed using previously developed indices. Cox proportional hazards models were used to estimate HR and 95% confidence intervals (CI) for incident invasive breast cancer., Results: Over 4,841,083 person-years of follow-up, we documented 12,482 incident invasive breast cancer cases. Women with greater adherence to PDI and hPDI were at modestly lower risk of breast cancer [(HR Q5 vs. Q1 , 0.89; 95% CI, 0.84-0.95); (HR Q5 vs. Q1 , 0.89; 95% CI, 0.83-0.94)]. We observed significant heterogeneity by estrogen receptor (ER) status, with the strongest inverse association between hPDI and breast cancer observed with ER-negative tumors [HR Q5 vs. Q1 , 0.77; 95% CI, 0.65-0.90; P trend < 0.01]. We also found an inverse association between extreme quintiles of healthy plant foods and ER-negative breast cancer [HR, 0.74; 95% CI, 0.61-0.88; P trend < 0.01]., Conclusions: This study provides evidence that adherence to a healthful plant-based diet may reduce the risk of breast cancer, especially those that are more likely to be aggressive tumors., Impact: This is the first prospective study investigating the relation between healthful and unhealthful plant-based dietary indices and risk of total and subtype-specific breast cancer., (©2021 American Association for Cancer Research.)

Healthy Eating Index (HEI) is a diet quality measure that assesses the population's compliance towards dietary guidelines. In Malaysia, diet quality measure, though existing, has some limitations in terms of application and relevance. This study aims to develop a new standardized Malaysian Healthy Eating Index (S-MHEI) that can measure the diet quality of all Malaysians regardless of their energy requirement level. The Malaysian Dietary Guidelines (MDG) 2010 and MDG for Children and Adolescents (MDGCA) 2013 were used as main references in developing the index components. In addition, the latest Malaysian Adults Nutrition Survey (MANS) and Adolescent Nutrition Survey (ANS) were also referred to ensure the relevance of the components selected. For adequacy components, the least restrictive method was used in setting the standard for the scoring system. Meanwhile, the scoring system for moderation components was built based on the Recommended Nutrient Intake (RNI) 2017. The new S-MHEI comprises of 11 components with a maximum total score of 100. The least restrictive method allowed the index to be used across energy requirement levels. However, the index will not be sensitive towards adhering to the specific recommended amount of intake-which in effect, made the index focus on measuring diet quality rather than diet quantity.

Food-Based Dietary Guidelines (FBDG) include dietary recommendations based on food groups according to the general and accepted nutrition principles and current scientific evidence. Adoption of FBDG contributes to the prevention of malnutrition in all its forms, promotes human health, and reduces environmental impact. The present review aims to perform an international comparative analysis of the FBDG adopted in different countries from three different continents (America, Asia, and Europe), with particular reference to the Spanish Food Safety and Nutrition Agency (AESAN, Agencia Española de Seguridad Alimentaria y Nutrición) Scientific Committee dietary recommendations. A total of twelve countries with the most updated FBDG and/or closest to the traditional and cultural preferences of Spain were finally selected. All the reviewed FBDG provided recommendations for fruits, vegetables, cereals, legumes, nuts, milk and dairy products, meat and derivatives, fish, eggs, water, and oil; however, remarkable differences regarding recommended amounts were found among countries.

Background: Diet, in particular the Mediterranean diet, has been associated with better cognitive function and less cognitive decline in older populations., Objectives: To quantify associations of a healthy diet, defined by adherence to either the Mediterranean diet, the WHO guidelines, or Dutch Health Council dietary guidelines, with cognitive function and cognitive decline from middle age into old age., Methods: From the Doetinchem Cohort Study, a large population-based longitudinal study, 3644 participants (51% females) aged 45-75 y at baseline, were included. Global cognitive function, memory, processing speed, and cognitive flexibility were assessed at 5-y time intervals up to 20-y follow-up. Adherence to the Mediterranean diet was measured with the modified Mediterranean Diet Score (mMDS), adherence to the WHO dietary guidelines with the Healthy Diet Indicator (HDI), and adherence to the Dutch Health Council dietary guidelines 2015 with the modified Dutch Healthy Diet 2015 index (mDHD15-index). The scores on the dietary indices were classified in tertiles (low, medium, high adherence). Linear mixed models were used to model level and change in cognitive function by adherence to healthy diets., Results: The highest tertiles of the mMDS, HDI, and mDHD15-index were associated with better cognitive function compared with the lowest tertiles (P values <0.01), for instance at age 65 y equal to being 2 y cognitively younger in global cognition. In addition, compared with the lowest tertiles, the highest tertiles of the mMDS, HDI, and mDHD15-index were statistically significantly associated with 6-7% slower global cognitive decline from age 55 to 75 y, but also slower decline in processing speed (for mMDS: 10%; 95% CI: 2, 18%; for mDHD15: 12%; 95% CI: 6, 21%) and cognitive flexibility (for mDHD15: 10%; 95% CI: 4, 18%)., Conclusions: Healthier dietary habits, determined by higher adherence to dietary guidelines, are associated with better cognitive function and slower cognitive decline with aging from middle age onwards., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Society for Nutrition.)

A nutrient profiling model (NPM) was developed in 2005 in the UK to regulate the marketing of foods to children. It was revised in 2018, but the new version has not been finalised. The Eatwell Guide (EWG) is the UK's official food-based dietary guidelines. The aim of this study was to evaluate the agreement between the 2005 and 2018 versions of the NPM and the EWG. Using recent National Diet and Nutrition Surveys, we estimated the healthiness of individual diets based on an EWG dietary score and a NPM dietary index. We then compared the percentage of agreement and Cohen's kappa for each combination of the EWG score and NPM index across the range of observed values for the 2005 and 2018 versions. A total of 3028 individual diets were assessed. Individuals with a higher (i.e., healthier) EWG score consumed a diet with, on average, a lower (i.e., healthier) NPM index both for the 2005 and 2018 versions. Overall, there was good agreement between the EWG score and the NPM dietary index at assessing the healthiness of representative diets of the UK population, when a low cut-off for the NPM dietary index was used, irrespective of the version. This suggests that dietary advice to the public is broadly aligned with NPM-based food policies and vice-versa.

Importance: The 2020 Dietary Guidelines Advisory Committee conducted a systematic review of existing research on diet and health to inform the current Dietary Guidelines for Americans. The committee answered this public health question: what is the association between dietary patterns consumed and all-cause mortality (ACM)?, Objective: To ascertain the association between dietary patterns consumed and ACM., Evidence Review: Guided by an analytical framework and predefined inclusion and exclusion criteria developed by the committee, the US Department of Agriculture's Nutrition Evidence Systematic Review (NESR) team searched PubMed, the Cochrane Central Register of Controlled Trials, and Embase and dual-screened the results to identify articles that were published between January 1, 2000, and October 4, 2019. These studies evaluated dietary patterns and ACM in participants aged 2 years and older. The NESR team extracted data from and assessed risk of bias in included studies. Committee members synthesized the evidence, developed conclusion statements, and graded the strength of the evidence supporting the conclusion statements., Findings: A total of 1 randomized clinical trial and 152 observational studies were included in the review. Studies enrolled adults and older adults (aged 17-84 years at baseline) from 28 countries with high or very high Human Development Index; 53 studies originated from the US. Most studies were well designed, used rigorous methods, and had low or moderate risks of bias. Precision, directness, and generalizability were demonstrated across the body of evidence. Results across studies were highly consistent. Evidence suggested that dietary patterns in adults and older adults that involved higher consumption of vegetables, fruits, legumes, nuts, whole grains, unsaturated vegetable oils, fish, and lean meat or poultry (when meat was included) were associated with a decreased risk of ACM. These healthy patterns were also relatively low in red and processed meat, high-fat dairy, and refined carbohydrates or sweets. Some of these dietary patterns also included intake of alcoholic beverages in moderation. Results based on additional analyses with confounding factors generally confirmed the robustness of main findings., Conclusions and Relevance: In this systematic review, consuming a nutrient-dense dietary pattern was associated with reduced risk of death from all causes.

High sodium and low potassium intakes are associated with increased levels of blood pressure and risk of cardiovascular diseases. Assessment of habitual dietary habits are helpful to evaluate their intake and adherence to healthy dietary recommendations. In this study, we determined sodium and potassium food-specific content and intake in a Northern Italy community, focusing on the role and contribution of adherence to Mediterranean diet patterns. We collected a total of 908 food samples and measured sodium and potassium content using inductively coupled plasma mass spectrometry. Using a validated semi-quantitative food frequency questionnaire, we assessed habitual dietary intake of 719 adult individuals of the Emilia-Romagna region. We then estimated sodium and potassium daily intake for each food based on their relative contribution to the overall diet, and their link to Mediterranean diet patterns. The estimated mean sodium intake was 2.15 g/day, while potassium mean intake was 3.37 g/day. The foods contributing most to sodium intake were cereals (33.2%), meat products (24.5%, especially processed meat), and dairy products (13.6%), and for potassium they were meat (17.1%, especially red and white meat), fresh fruits (15.7%), and vegetables (15.1%). Adherence to a Mediterranean diet had little influence on sodium intake, whereas potassium intake was greatly increased in subjects with higher scores, resulting in a lower sodium/potassium ratio. Although we may have underestimated dietary sodium intake by not including discretionary salt use and there may be some degree of exposure misclassification as a result of changes in food sodium content and dietary habits over time, our study provides an overview of the contribution of a wide range of foods to the sodium and potassium intake in a Northern Italy community and of the impact of a Mediterranean diet on intake. The mean sodium intake was above the dietary recommendations for adults of 1.5-2 g/day, whilst potassium intake was only slightly lower than the recommended 3.5 g/day. Our findings suggest that higher adherence to Mediterranean diet patterns has limited effect on restricting sodium intake, but may facilitate a higher potassium intake, thereby aiding the achievement of healthy dietary recommendations.

Aim: Hospital food provision is subject to multiple constraints (meal production, organization, health safety, environmental respect) which influence the meal tray offered to the patient. Multiple diets can add complexity and contribute to non-consumption of the meal. To avoid undernutrition, it appeared necessary to propose guidelines for foods and diets in hospitals., Methods: These guidelines were developed using the Delphi method, as recommended by the HAS (French Health Authority), based on a formal consensus of experts and led by a group of practitioners and dieticians from the AFDN (French Association of Nutritionist Dieticians) and SFNCM (French Society of Clinical Nutrition and Metabolism)., Results: Twenty-three recommendations were deemed appropriate and validated by a panel of 50 national experts, following three rounds of consultations, modifications and final strong agreement. These recommendations aim to define in adults: 1-harmonized vocabulary related to food and diets in hospitals; 2-quantitative and qualitative food propositions; 3-nutritional prescriptions; 4-diet patterns and patient adaptations; 5-streamlining of restrictions to reduce unnecessary diets and without scientific evidence; 6-emphasizing the place of an enriched and adapted diet for at-risk and malnourished patients., Conclusion: These guidelines will enable catering services and health-care teams to rationalize hospital food and therapeutic food prescriptions in order to focus on individual needs and tasty foods. All efforts should be made to create meals that follow these recommendations while promoting the taste quality of the dishes and their presentation such that the patient rediscovers the pleasure of eating in the hospital.

There are numerous dietary recommendations during pregnancy. However, there are limited recommendations during the lactation period, a nutritionally vulnerable period for women. The Mediterranean Diet and adherence to the Healthy Food Pyramid (HFP) is considered as the standard for healthy eating. In this study, we investigated the differences in adherence to the HFP in pregnant, lactating, and non-pregnant/non-lactating (NPNL) women concerning sociodemographic factors. A sociodemographic and nutritional and lifestyle questionnaire (AP-Q) were used to assess adherence to the HFP, including lifestyle. The AP-Q score ranges from 0 to 10 meaning the higher the score, the greater the adherence to the HFP. Lactating women had the lowest AP-Q score (6.13 [5.31; 6.82]) compared to the pregnant (6.39 [5.56; 7.05]) and NPNL women (6.27 [5.43; 6.88]), while pregnant women had the highest scores. Maternal age was positively correlated with AP-Q score in pregnant (rho = 0.22; p -Value < 0.001) and lactating women (rho = 0.18; p -Value < 0.001), but not in NPNL women. Educational level and monthly income had a positive influence on the degree of adherence to the HFP. In conclusion, breastfeeding mothers of young age and low socioeconomic and educational level would be the target population to carry out nutritional interventions that improve their adherence to the HFP. The knowledge gained from this study can help to design recommendation guidelines and nutritional educational interventions for a given population.

Mandated policies to improve food environments in public settings are an important strategy for governments. Most Australian governments have mandated policies or voluntary standards for healthy food procurement in healthcare facilities, however, implementation and compliance are poor. A better understanding of the support required to successfully implement such policies is needed. This research explored food retailers' experiences in implementing a mandated food and nutrition policy (the Policy) in healthcare settings to identify barriers, enablers, and impacts of compliance. Three 90-min workshops facilitated by two public health practitioners were undertaken with 12 food retailers responsible for operating 44 outlets across four hospitals in Perth, Western Australia. Workshop discussions were transcribed non-verbatim and inductive thematic content was analyzed. Three main themes were identified: (1) food retailers had come to accept their role in implementing the Policy; (2) the Policy made it difficult for food retailers to operate successfully, and; (3) food retailers needed help and support to implement the Policy. Findings indicate the cost of implementation is borne by food retailers. Communications campaigns, centralized databases of classified products, reporting frameworks, recognition of achievements, and dedicated technical expertise would support achieving policy compliance. Feasibility assessments prior to policy implementation are recommended for policy success.

Background: Healthy eating guidelines for school-aged children are available but without advice on portion sizes. This is a concern because consuming large portions is associated with an increased risk of overweight/obesity. The present study aimed to calculate recommended portion sizes for school-aged children based on weight for age and use them to develop a meal plan to meet nutritional needs within energy requirements., Methods: Portion size data on foods consumed by school-aged children (4-18 years) were extracted from two sources: (i) British National Diet and Nutrition Survey (1997) and (ii) Avon Longitudinal Study of Parents and Children (1997-2006). Foods were allocated to groups based on the UK Eatwell Guide and the US My Plate Model. Portion sizes were developed for a variety of foods. A meal plan that included portion size guidance and met healthy eating guidelines was developed based on the number of portions of each food group needed to meet dietary requirements., Results: Portion sizes were developed for 131 foods that were commonly eaten by children in age groups 4-6, 7-10, 11-14 and 15-18 years. The meal plan met requirements for energy and nutrients as specified by UK dietary reference values, except for vitamin D for which there are few dietary sources., Conclusions: Food portion sizes informed by usual intake in UK children can help inform dietary advice for a range of childhood settings and for parents. The meal plan included a wide variety of foods to encourage dietary diversity and meet energy and nutrient needs for school-aged children., (© 2021 The British Dietetic Association Ltd.)

The EAT-Lancet Commission has proposed a planetary health diet. We propose the development of the Planetary Health Diet Index (PHDI) based on this proposed reference diet. We used baseline dietary data obtained through a 114-item FFQ from 14,779 participants of the Longitudinal Study on Adult Health, a multicenter cohort study conducted in Brazil. The PHDI has 16 components and a score from 0 to 150 points. Validation and reliability analyses were performed, including principal component analyses, association with selected nutrients, differences in means between groups (for example, smokers vs. non-smokers), correlations between components and total energy intake, Cronbach's alpha, item-item correlations, and linear regression analysis between PHDI with carbon footprint and overall dietary quality. The mean PHDI was 60.4 (95% CI 60.2:60.5). The PHDI had six dimensions, was associated in an expected direction with the selected nutrients and was significantly ( p < 0.001) lower in smokers (59.0) than in non-smokers (60.6). Cronbach's alpha value was 0.51. All correlations between components were low, as well as between components and PHDI with total energy intake. After adjustment for age and sex, the PHDI score remained associated ( p < 0.001) with a higher overall dietary quality and lower carbon footprint. Thus, we confirmed the PHDI validity and reliability.

The current protein requirement estimates in children were largely determined from studies using the nitrogen balance technique, which has been criticized for potentially underestimating protein needs. Indeed, recent advances in stable isotope techniques suggests protein requirement as much as 60% higher than current recommendations. Furthermore, there is not a separate recommendation for children who engage in higher levels of physical activity. The current evidence suggests that physical activity increases protein requirements to support accretion of lean body masses from adaptations to exercise. The indicator amino acid oxidation and the 15 N-end product methods represent alternatives to the nitrogen balance technique for estimating protein requirements. Several newer methods, such as the virtual biopsy approach and 2 H 3 -creatine dilution method could also be deployed to inform about pediatric protein requirements, although their validity and reproducibility is still under investigation. Based on the current evidence, the Dietary Reference Intakes for protein indicate that children 4-13 years and 14-18 years require 0.95 and 0.85 g·kg -1 ·day -1 , respectively, based on the classic nitrogen balance technique. There are not enough published data to overturn these estimates; however, this is a much-needed area of research.

MaestraNatura is an innovative nutrition education program aimed at both enhancing awareness about the importance of a healthy food-lifestyle relationship and the ability to transfer the theoretical principles of nutrition guidelines to everyday life. The educational contents of the program resulted from the analysis of the answers to a questionnaire submitted to students aged 6-13 in order to assess their degree of knowledge about nutritional facts. Educational paths were specifically designed and implemented to address the main knowledge gaps identified through the analysis of the answers and were then tested for teachers' satisfaction in a sample of 56 schools in the north, centre, and south of Italy, involving 790 classes, 600 teachers, and 15,800 students. The results showed an approval rating from teachers from 90% to 94%. Said paths were designed for primary (6-10 years old) and first-level secondary (11-13 years old) school students. In addition, in a pilot study carried out in nine Educational Institutes located in an area close to Rome (Lazio region), a specific path was tested for effectiveness in increasing students' knowledge about fruit and vegetables by conducting questionnaires before (T0) and after (T1) the didactic activities. Results showed a significant increase in right answers at T1 with respect to T0 (z = 2.142, p = 0.032). Fisher's exact probability test showed an answer variability depending on the issue considered. In conclusion, this work could be considered as a first necessary step toward the definition of new educational program, aimed at increasing food literacy and favouring a healthier relationship with food, applicable in a widespread and effective manner, also outside of Italy.

Improving dietary habits at a young age could prevent adverse health outcomes. The aim was to gain insight into the adequacy of the dietary intake of Dutch toddlers, which may provide valuable information for preventive measures. Data obtained from the Dutch National Food Consumption Survey 2012-2016 were used, which included 672 children aged one to three years. Habitual intakes of nutrients were evaluated according to recommendations set by the Dutch Health Council. Specific food groups were evaluated according to the Dutch food-based dietary guidelines. For most nutrients, intakes were estimated to be adequate. High intakes were found for saturated fatty acids, retinol, iodine, copper, zinc, and sodium. No statement could be provided on the adequacy of intakes of alpha-linoleic acids, N-3 fish fatty acids, fiber, and iron. 74% of the toddlers used dietary supplements, and 59% used vitamin D supplements specifically. Total median intakes of vegetables, bread, and milk products were sufficient. Consumption of bread, potatoes and cereals, milk products, fats, and drinks consisted largely of unhealthy products. Consumption of unfavorable products may have been the cause of the observed high and low intakes of several nutrients. Shifting towards a healthier diet that is more in line with the guidelines may positively affect the dietary intake of Dutch toddlers and prevent negative health impacts, also later in life.

Unhealthy eating is associated with various diseases, such as cardiovascular, neurodegenerative, or oncological. There are neither economical nor behavior-related questionnaires available in the German language to assess general dietary behavior. Therefore, the aim of this validation study was to develop an instrument considering these aspects and verifying its construct and criterion validity. The new questionnaire is based on the general nutrition recommendations of the World Health Organization and the German Nutrition Society. It consists of 16 items that contrast dietary behaviors on a semantic differential scale. Our German-speaking convenience sample consisted of 428 participants. The construct validity of the General Dietary Behavior Inventory (GDBI) could be confirmed by examining convergent and discriminant validity. Furthermore, criterion validity was confirmed (significant negative correlations with body weight, Body Mass Index, and positive correlations with physical/mental health as well as life satisfaction). A cluster analysis revealed two different dietary behavior clusters representing a rather healthy and a rather unhealthy dietary behavior cluster. The results indicate that the GDBI is a validated and economical instrument to assess general dietary behavior. In practical research, this questionnaire helps to assess dietary behavior and to derive interventions for a healthy dietary behavior in concordance with international nutrition recommendations.