Illustration of the Importance of Adjustment for within- and between-Person Variability in Dietary Intake Surveys for Assessment of Population Risk of Micronutrient Deficiency/Excess Using an Example Data Set

Nutrition intervention decisions should be evidence based. Single 24-h recalls are often used for measuring dietary intake in large dietary studies. However, this method does not consider the day-to-day variation in populations’ diets. We illustrate the importance of adjustment of single 24-h recall data to remove within-person variation using the National Cancer Institute method to calculate usual intake when estimating risk of deficiency/excess. We used an example data set comprising a single 24-h recall in a total sample of 1326 1–<10-year-old children, and two additional recalls in a sub-sample of 11%, for these purposes. Results show that risk of deficiency was materially overestimated by the single unadjusted 24-h recall for vitamins B12, A, D, C and E, while risk of excess was overestimated for vitamin A and zinc, when compared to risks derived from usual intake. Food sources rich in particular micronutrients seemed to result in overestimation of deficiency risk when intra-individual variance is not removed. Our example illustrates that the application of the NCI method in dietary surveys would contribute to the formulation of more appropriate conclusions on risk of deficiency/excess in populations to advise public health nutrition initiatives when compared to those derived from a single unadjusted 24-h recall.

An Alternative Nutrient Rich Food Index (NRF-ai) Incorporating Prevalence of Inadequate and Excessive Nutrient Intake

Most nutrient profiling models give equal weight to nutrients irrespective of their ubiquity in the food system. There is also a degree of arbitrariness about which nutrients are included. In this study, an alternative Nutrient Rich Food index was developed (NRF-ai, where ai denotes adequate intake) incorporating prevalence of inadequate and excessive nutrient intake among Australian adults. Weighting factors for individual nutrients were based on a distance-to-target method using data from the Australian Health Survey describing the proportion of the population with usual intake less than the Estimated Average Requirement defined by the Nutrient Reference Values for Australia and New Zealand. All nutrients for which data were available were included, avoiding judgements about which nutrients to include, although some nutrients received little weight. Separate models were developed for females and males and for selected age groups, reflecting differences in nutrient requirements and usual intake. Application of the new nutrient profiling models is demonstrated for selected dairy products and alternatives, protein-rich foods, and discretionary foods. This approach emphasises the need to identify foods that are rich in those specific nutrients for which intake is below recommended levels and can be used to address specific nutrient gaps in subgroups such as older adults. In addition, the new nutrient profiling model is used to explore other sustainability aspects, including affordability (NRF-ai per AUD) and ecoefficiency (NRF-ai/environmental impact score).

Change in Micronutrient Intake Among People with Relapsing-Remitting Multiple Sclerosis Adapting the Swank and Wahls Diets: An Analysis of Weighed Food Records

The low-saturated fat (Swank) and modified Paleolithic elimination (Wahls) diets have shown promise for MS symptoms; however, due to their restriction of specific foods, inadequate intake of micronutrients is concerning. Therefore, as part of a randomized trial, weighed food records were collected on three consecutive days and were used to evaluate the intake of micronutrients among people with relapsing remitting MS adapting these diets. After randomization to either the Swank or Wahls diets, diet education and support was provided by registered dietitians at baseline and throughout the first 12 weeks of the intervention. Usual intake of each micronutrient was estimated and then evaluated with the EAR-cut point method. At 12 weeks, the Swank group had significant reductions in the proportion with inadequate intake from food for vitamins C, D, and E, while the Wahls group had significant reductions for magnesium and vitamins A, C, D, and E. However, the proportion with inadequate intake significantly increased for calcium, thiamin, and vitamin B12 in the Wahls group and for vitamin A in the Swank group. Inclusion of intake from supplements reduced the proportion with inadequate intake for all micronutrients except calcium among the Wahls group but increased the proportion with excessive intake for vitamin D and niacin among both groups and magnesium among the Swank group. Both diets, especially when including intake from supplements, are associated with reduced inadequate intake compared to the normal diet of people with relapsing remitting MS.

Nutritional Inadequacy: Unraveling the Methodological Challenges for the Application of the Probability Approach or the EAR Cut-Point Method—A Pregnancy Perspective

The aim of this study was to unravel the methodological challenges when exploring nutritional inadequacy, involving 608 healthy pregnant women. The usual intake of twenty-one nutrients was recorded by employing a validated FFQ. Simulated datasets of usual intake were generated, with randomly imposed uncertainty. The comparison between the usual intake and the EAR was accomplished with the probability approach and the EAR cut-point method. Point estimates were accompanied by bootstrap confidence intervals. Bootstrap intervals applied on the risk of inadequacy for raw and simulated data tended in most cases to overlap. A detailed statistical analysis, aiming to predict the level of inadequacy, as well as the application of the EAR cut-point method, along with bootstrap intervals, could effectively be used to assess nutrient inadequacy. However, the final decision for the method used depends on the distribution of nutrient-intake under evaluation. Irrespective of the applied methodology, moderate to high levels of inadequacy, calculated from FFQ were identified for certain nutrients (e.g. vitamins C, B6, magnesium, vitamin A), while the highest were recorded for folate and iron. Considering that micronutrient-poor, obesogenic diets are becoming more common, the underlying rationale may help towards unraveling the complexity characterizing nutritional inadequacies, especially in vulnerable populations.

Promoting Sustainable and Healthy Diets to Mitigate Food Insecurity Amidst Economic and Health Crises in Lebanon

Introduction: Lebanon, a middle-income Eastern Mediterranean country, continues to face detrimental economic, health and socio-political challenges that are further exacerbated by the COVID-19 pandemic. In parallel, the country has been experiencing a remarkable nutrition transition that has contributed to the burden of malnutrition and non-communicable diseases, all imposing serious repercussions on people's livelihoods, food security, and health. Such circumstances have prodded public demand for guidance on affordable, healthy, and sustainable dietary choices to alleviate the burden to this emerging unfortunate situation.Objective: The purpose of this study is to provide evidence-based sustainable and healthy dietary recommendations which balance the tradeoffs among the health, environmental footprint and cost dimensions of sustainability, while closely resembling the usual food consumption pattern.Methodology: Data from the latest available national food consumption survey was used as the usual food consumption pattern of Lebanese adults. Optimized dietary patterns were calculated using the optimization model Optimeal which produced patterns most similar to the usual diet and simultaneously satisfying the three main sets of constraints: health, environmental footprints, and cost. The identified healthy and sustainable dietary options were vetted by multiple key stakeholders from the government, academia, international, and national non-governmental organizations.Results: Compared to the usual intake, the optimized diet included higher intakes of whole grain bread, dark green vegetables, dairy products, and legumes, and lower intakes of refined bread, meat, poultry, added sugars, saturated fat, as compared to usual national mean consumption. The optimized dietary model resulted in a decrease in the associated environmental footprints: water use (−6%); and GHG (−22%) with no change in energy use. The cost of the optimized diet was not different from that of the usual intake.Conclusion: An evidence-based sustainable and healthy diet was developed for Lebanon providing the population and policy makers with some answers to a complex situation. Findings highlight the need for the development of sustainable food based dietary guidelines for Lebanon to promote diets that are healthy, sustainable, culturally acceptable, and affordable and that can alleviate food insecurity among the general population.

Load Carriage Exercise Increases Calcium Absorption and Retention in Healthy Young Women

Objectives Aerobic exercise (EX) reduces circulating ionized Ca (iCa) and increases parathyroid hormone (PTH), but the cause and consequences on Ca handling are unknown. The objective of this study was to determine the effects of EX on Ca kinetics using dual stable Ca isotopes. Methods Twenty-one healthy women (26.2 ± 6.7 yr; BMI: 22.8 ± 2.1 kg/m2) completed a randomized, crossover study consisting of two 6 day iterations separated by ≥2 wk. One iteration consisted of 3 d of load carriage EX 2 h after breakfast (1 hr treadmill walking at 65% VO2max wearing a vest weighing 30% body wt) on days 0, 2, 4, and the other a no-EX control (CON). Diet was controlled during each iteration, and matched to the volunteer's usual intake. On day 0, volunteers received one IV bolus of 42Ca, and oral 44Ca with each meal (0600,1200, and 1700). Serial blood draws and 3 urine pools (U1: 0600–1000, U2: 1000–2000, U3: 2000–0800) were collected on day 0; spot urines were collected on days 1–5. Ca isotope ratios were analyzed by Thermal Ionization Mass Spectrometry and total Ca by Siemens Dimension; fractional Ca absorption (FCA) was measured and kinetic modeling determined, rates of Ca deposition (VO+) and resorption (VO–) from bone, and bone Ca balance (Vbal). Circulating PTH and iCa were also measured before, during and after exercise. Data were analyzed by paired T-test or linear mixed models using SPSS. Results On day 0, PTH increased 45 min into EX as compared to pre (+36 pg/ml, P &lt; 0.001) with max increases 15 min post EX (+70.5 pg/ml, P &lt; 0.001). No changes were observed during CON. Compared to pre-EX, iCa decreased at 45 min into EX (-0.14 mmol, P = 0.01) with max 15 min post EX (–0.273 mmol, P &lt; 0.001). Urinary Ca (UCa) was lower during EX in the U1 pool (25 ± 11 mg) vs. CON (38 ± 16 mg, P = 0.001) with no differences in U2 and U3 (P &gt; 0.05). FCA was greater during EX (26.6 ± 8.1%) compared to CON (23.9 ± 8.3%, P &lt; 0.05). Vbal was less negative during EX (–61.3 ± 111 mg) vs. CON (–108 ± 23.5 mg, P &lt; 0.05), but VO+ (574 ± 241 vs. 583 ± 260 mg) and VO– (–636 ± 243 vs. –692 ± 252 mg) were not different (P &gt; 0.05). Conclusions During EX, an increase in FCA and decrease in UCa resulted in a positive shift in Ca balance. The rapid reduction in circulating iCa may be due to a change in the miscible Ca pool, resulting in increased PTH and changes in intestinal and renal Ca handling that support a more positive Ca balance. Funding Sources Defense Health Program.

Total Protein Usual Intake Is Associated With Reduced Risk of All-Cause and Heart Disease Mortality in US Adults

Objectives Studies have linked animal protein intake with an increased risk in mortality from all-causes and certain chronic diseases, including cancer and heart disease. The objective of the current analysis was to examine associations between usual intake of total and animal protein from various sources and all-cause, cancer, and heart disease-related mortality risk. Methods Data for adults (≥19 y; N = 54,830) from the Third National Health and Nutrition Examination Survey (NHANES) and NHANES 1999–2014 were linked with mortality data through 2015. Individual protein usual intakes were estimated using the National Cancer Institute method. Hazard ratio (HR) models were fit for mortality types (all cause, cancer, heart disease) and measures of total and animal protein usual intake. Multivariable analysis further adjusted for age, gender, ethnicity, waist circumference, smoking status, education level, chronic condition status (i.e., based on cancer, myocardial infarct, and diabetes/diabetes medication reported), weight loss attempts, and % kcal from total fat. Results Total protein usual intake was associated with 10% and 13% lowered risk of mortality from all-causes [HR = 0.90; CI: 0.82–0.99; P = 0.003] and heart disease [HR = 0.87; CI: 0.72–1.05; P = 0.05], respectively. No associations were observed between total protein intake and cancer mortality risk [HR = 0.98; CI: 0.80–1.21; P = 0.84]. No associations were seen between animal protein intake and mortality risk from all-causes [Quartile trend HR = 0.97; confidence intervals (CI): 0.91–1.04; P = 0.32], cancer [HR = 1.08; CI: 0.95–1.23; P = 0.13] and heart disease [HR = 0.98; CI: 0.85–1.13; P = 0.73]. No associations were seen between total dairy protein intake and all-cause and cancer mortality risk, however, there was an 11% reduced risk in heart disease mortality [HR = 0.89; CI: 0.80–1.00; P = 0.008]. No significant associations were seen between total red meat (beef, pork, lamb) protein usual intake and all-cause, cancer, and heart disease-related mortality risk. Conclusions These results contradict previous findings that have linked animal protein intake to increased mortality risk from all-causes, cancer and heart disease. Further, total protein consumption may help lower all-cause and heart disease-related mortality risk in adults. Funding Sources Funded by the Beef Checkoff.

Usual Intake of Resistant Starch by Diabetes Group in US Adults: NHANES 2013–2018

Objectives To examine differences in the usual intake of dietary resistant starch (RS) in US adults across diabetes group (no diabetes, prediabetes, diabetes) and age categories (20–39y, 40–59y, ≥60y) using data from the National Health and Nutrition Examination Survey (NHANES) 2013 – 2018 cycles. Methods RS values from a published database were matched to food codes reportedly consumed by each participant who had one or more reliable 24-hour dietary recall. Demographic (age & sex), laboratory (glycated hemoglobin), diabetes questionnaire, and dietary datasets were included in the analyses. Diabetes group was determined by participant responses to the diabetes questionnaire and glycated hemoglobin (HgA1c) values. Prediabetes and diabetes were defined as having HgA1c values between 5.7% and 6.4% and ≥ 6.5%, respectively. Usual RS intake was calculated using the National Cancer Institute method. RS intake data were adjusted for energy and are presented as mean g ± SEM (99% CI). Independent samples t-tests were used to compare mean intake across sub-populations of interest and P &lt; 0.01 indicates statistical significance. Results 14,640 adults (48.7% male) were included in the analyses. Overall usual RS intake was comparable between males (2.0 ± 0.034 g/1,000 kcal) and females (2.0 ± 0.031 g/1,000 kcal; P = 0.623). RS intake differed among diabetes group within each age category in females (P &lt; 0.001), where RS intake was lowest in the no diabetes group (1.9 ± 0.038 g/1,000 kcal) and greatest in the diabetes group (2.2 ± 0.060 g/1,000 kcal). However, RS intake did not differ in males across diabetes group within each age category. Conclusions Females with diabetes had higher usual intake of RS compared to those with prediabetes and no diabetes across all age categories. However, we did not observe this same finding in males. Overall, males and females consumed similar amounts of RS when adjusting for energy. It is unclear if RS intake differed by sex based on unadjusted, or total, daily energy intake. Future research is needed to understand if greater usual intake of RS in adults with diabetes corresponds to improved glycemic outcomes. Funding Sources None.

Usual Nutrient Intake of Older Adults in the U.S. Is Lower Among SNAP Participants Compared to Income-Eligible Non-Participants

Objectives Policy proposals to limit use of the Supplemental Nutrition Assistance Program (SNAP) and to allow dietary supplement (DS) purchase with SNAP benefits draw attention to knowledge gap of usual nutrient intake and adherence to the Dietary Reference Intake recommendations from foods alone and with DS (total intake) among low-income older adults. To address this gap, the estimated distributions of usual nutrient intake (from foods alone and total) and risk of inadequate intake among U.S. older adults participating in SNAP were compared with income-eligible non-participants. Methods Data from 4,791 older adults (≥60 years) from the 2007–2016 National Health and Nutrition Examination Survey were used in this cross-sectional secondary analysis. DS data from an in-home inventory and dietary data from up to two 24-hour recalls were used to estimate usual nutrient intake distributions (total and from foods alone) and the proportion of the population below the Estimated Average Requirement (EAR) using an adapted National Cancer Institute method. Pairwise t-tests compared SNAP participants and eligible non-participants with significance set at P &lt; 0.05. Results SNAP participants had lower usual intake from foods alone compared to eligible non-participants for vitamins B6 (P = 0.046) and E (P = 0.027); the risk of inadequate intake was higher among SNAP participants compared to eligible non-participants for vitamin E (P = 0.0004). Similarly, total usual nutrient intake was lower among SNAP participants compared to eligible non-participants for magnesium (P = 0.019), zinc (P = 0.0003), vitamin C (P = 0.02) and vitamin D (P = 0.0002) and the proportion not meeting the EAR was higher among SNAP participants compared to eligible non-participants for magnesium (P = 0.044). Conclusions Older adults participating SNAP had lower usual intake and meet the EAR less compared to eligible non-participants for certain nutrients. The proportion at risk of inadequate intake was lower when all nutrients sources were examined compared to foods alone. Future policies should focus on improving nutrient intake among food assistance participants and their food security. Funding Sources Supported by University of Kentucky Center for Poverty Research through funding by the U.S. Department of Agriculture, Food and Nutrition Service, Contract Number 12319819C0006.