Supplemental Material can be found at: http://jn.nutrition.org/content/suppl/2014/12/31/jn.114.19912 5.DCSupplemental.html
The Journal of Nutrition Nutritional Epidemiology
See corresponding article on page 555.
Maya Vadiveloo,4 Niyati Parkeh,5,6 and Josiemer Mattei4* 4 Department of Nutrition, Harvard School of Public Health, Boston, MA; and 5Department of Nutrition, Food Studies, and Public Health, and 6Department of Population Health, NYU School of Medicine, New York University, New York, NY
Abstract Background: Consuming a wider variety of nutrient-dense foods may promote adherence to healthful dietary patterns, leading to improved dietary quality and enhanced metabolic health. Objective: We used the US Healthy Food Diversity (HFD) index to simultaneously measure dietary variety, quality, and proportionality, hypothesizing a priori that race/ethnicity may moderate associations between diet and health. Methods: A representative sample of adults (n = 7470) aged 20+ y with two 24-h recalls and complete outcome data from the cross-sectional NHANES 2003–2006 were selected. US HFD values were generated using a previously validated equation with a theoretical range from 0 to nearly 1, with higher scores indicative of more varied diets with a higher proportion of healthful food groups. Metabolic syndrome (MetS) was defined using the most recent harmonized definition. Survey-weighted multivariable linear and logistic regression, adjusted for demographic factors, smoking, energy, screen time, and leisure activity, were used to compute means and ORs (95% CIs). Results: Adults in the third vs. first US HFD tertile had 21% lower odds of MetS [OR (95% CI): 0.79 (0.64, 0.98)] as well as lower odds of hypertension [0.83 (0.70, 0.995] and elevated waist circumference [0.75 (0.66, 0.86] after multivariable adjustment (P-trend < 0.05). The age- and sex-adjusted odds of low serum HDL cholesterol and impaired fasting plasma glucose (P-trend < 0.05) were lower in the highest vs. lowest US HFD tertile but attenuated with multivariable adjustment (P = 0.06 and 0.22, respectively). Notably, the US HFD index was only protective against adiposity among non-Hispanic white (NHW) and non-Hispanic black (NHB) adults, and MetS associations were driven by NHW adults. No associations were observed among Hispanic adults for any MetS components. Conclusions: Greater healthful food variety was associated with lower odds of MetS and some MetS components in the total population, NHW adults, and NHB adults. This study provides preliminary evidence that healthful food diversity may protect against MetS and highlights the need for longitudinal and experimental research. J Nutr 2015;145:564–71.
Keywords:
dietary variety, dietary diversity, healthy food diversity, healthy variety, metabolic syndrome, health
and racial disparities, metabolic syndrome components
Introduction Cardiovascular disease (CVD)7 is the leading cause of mortality worldwide (1). A key intermediate risk factor for CVD is metabolic syndrome (MetS), which is defined as a clustering of 1
Supported by the NIH Ruth L Kirschstein Postdoctoral Fellowship (5 T32 DK 7703-19). Author disclosures: M Vadiveloo, N Parkeh, and J Mattei, no conflicts of interest. 3 Supplemental Table 1 is available from the ‘‘Online Supporting Material’’ link in the online posting of the article and from the same link in the online table of contents at http://jn.nutrition.org. 7 Abbreviations used: CVD, cardiovascular disease; DBP, diastolic blood pressure; DGA, Dietary Guidelines for Americans; HFD, Healthy Food Diversity; MetS, metabolic syndrome; MPED, MyPyramid Equivalent; NHB, non-Hispanic black; NHW, non-Hispanic white; SBP, systolic blood pressure; WC, waist circumference. * To whom correspondence should be addressed. E-mail: [email protected]. 2
564
anthropometric and biochemical aberrations including abdominal obesity, impaired fasting glucose, lipid dysregulation, and hypertension (2). Because of the adverse effects of insulin resistance and inflammation on CVD pathophysiology (3–5), adults with MetS are twice as likely to develop CVD within the next 5–10 y compared with those without these perturbations (2, 3). Although dietary changes can positively modify metabolic markers, it is difficult for most people to develop and sustain healthful dietary patterns (6), particularly given that transformations in food environments have expanded access to inexpensive, energydense foods (7–10). As a result, if lifestyle interventions to prevent and manage metabolic risk factors are going to be efficacious, they must consider novel strategies to induce changes in food choice.
ã 2015 American Society for Nutrition. Manuscript received June 25, 2014. Initial review completed August 16, 2014. Revision accepted December 8, 2014. First published online December 31, 2014; doi:10.3945/jn.114.199125.
Downloaded from jn.nutrition.org at UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL LIBRARY on April 6, 2015
Greater Healthful Food Variety as Measured by the US Healthy Food Diversity Index Is Associated with Lower Odds of Metabolic Syndrome and its Components in US Adults1–3
Methods Population and data collection. The NHANES is a continuous multistage, national health survey administered by the National Center for Health Statistics (31). Detailed information about the survey, laboratory, and examination procedures has been previously published (31–33). During each 2-y sampling cycle, a representative sample of ;10,000 noninstitutionalized individuals is interviewed and examined about demographic, dietary, and health-related information (34). In these analyses, we used data from the 2003–2006 NHANES and included adults aged $20 y with two 24-h dietary recalls, who were not pregnant or lactating, with self-reported energy intake between 400 and 7000 kilocalories (kcal), and with complete information on the outcome variables of interest (n = 3155 to 7188 depending on the outcome variable given sub-sampling methodology of NHANES). Nearly 90% of participants reported dietary data deemed complete and reliable by NHANES survey staff during the in-person and telephone-administered 24-h recalls (35, 36). Exposure variable. The US HFD index was developed based on a validated algorithm (37) that was adapted for a US population and was computed through use of the following equation: US HFD index ¼ 1 +s2i 3hv ð1Þ where si = share of food item or food group i based on volume in the total diet, hv ¼ + hf i 3si ; and hf = health factors of food. Details describing the development and validation of the index have been previously published (28). Briefly, individual food files were merged
with the MyPyramid Equivalent (MPED) databases 2.0 and 3.0 to disaggregate each individual food into its component parts (38). For example, the MPED database separates whole milk into its proportions of low-fat dairy and solid fat. Next, food shares (si) by volume were calculated by dividing individual food quantities by the total reported intake for each individual. The health value (hv) of the diet was calculated by multiplying each si by predetermined food group health weights and then summing the values. Health weights created for the 26 food groups and subgroups in the MPED database were informed by the 2000-kcal USDA dietary pattern in the 2010 Dietary Guidelines for Americans (DGA) (39). Specifically, the recommended proportions of each of the 26 food groups within the 2000-kcal USDA dietary pattern were used to weight the healthfulness of each food group (Supplemental Table 1). The US HFD index has a theoretical range between 0 and nearly 1, with higher scores reflecting diet patterns with greater variety and a higher proportion of DGA-recommended food groups. Outcome variables and covariates. Waist circumference (WC) and blood pressure were measured in the mobile examination center. Waist circumference was measured by trained personnel to the nearest 0.1 cm at the highest point of iliac crest at minimal respiration. After resting quietly in a seated position for 5 min, blood pressure was measured and the mean of up to 4 measurements was used to calculate mean systolic blood pressure (SBP) and diastolic blood pressure (DBP). Serum HDL cholesterol concentrations were assessed after precipitation of other lipoproteins with use of a heparin-manganese chloride mixture. Serum TG concentrations were determined from an enzymatic reaction hydrolyzing TGs to glycerol, and plasma glucose concentrations were assessed with use of an enzymatic reaction with hexokinase. Fasting plasma glucose and serum TG measurements were only available in a subset of participants who were invited to participate in the morning fasting subsample. We used the most recent harmonized definition of MetS from the International Diabetes Federation, AHA, and other organizations to define the presence of MetS (2), and participants with at least 3 of the 5 risk criteria were identified as having MetS. Risk criteria included the following: 1) elevated WC ($88 cm in women or $102 cm in men); 2) fasting plasma glucose $100 mg/dL or treatment of hyperglycemia; 3) SBP $130 mm Hg or DBP $85 mm Hg or use of antihypertensive medication; 4) serum TGs >150 mg/dL or treatment of dyslipidemia; or 5) serum HDL cholesterol
The Journal of Nutrition Nutritional Epidemiology
See corresponding article on page 555.
Maya Vadiveloo,4 Niyati Parkeh,5,6 and Josiemer Mattei4* 4 Department of Nutrition, Harvard School of Public Health, Boston, MA; and 5Department of Nutrition, Food Studies, and Public Health, and 6Department of Population Health, NYU School of Medicine, New York University, New York, NY
Abstract Background: Consuming a wider variety of nutrient-dense foods may promote adherence to healthful dietary patterns, leading to improved dietary quality and enhanced metabolic health. Objective: We used the US Healthy Food Diversity (HFD) index to simultaneously measure dietary variety, quality, and proportionality, hypothesizing a priori that race/ethnicity may moderate associations between diet and health. Methods: A representative sample of adults (n = 7470) aged 20+ y with two 24-h recalls and complete outcome data from the cross-sectional NHANES 2003–2006 were selected. US HFD values were generated using a previously validated equation with a theoretical range from 0 to nearly 1, with higher scores indicative of more varied diets with a higher proportion of healthful food groups. Metabolic syndrome (MetS) was defined using the most recent harmonized definition. Survey-weighted multivariable linear and logistic regression, adjusted for demographic factors, smoking, energy, screen time, and leisure activity, were used to compute means and ORs (95% CIs). Results: Adults in the third vs. first US HFD tertile had 21% lower odds of MetS [OR (95% CI): 0.79 (0.64, 0.98)] as well as lower odds of hypertension [0.83 (0.70, 0.995] and elevated waist circumference [0.75 (0.66, 0.86] after multivariable adjustment (P-trend < 0.05). The age- and sex-adjusted odds of low serum HDL cholesterol and impaired fasting plasma glucose (P-trend < 0.05) were lower in the highest vs. lowest US HFD tertile but attenuated with multivariable adjustment (P = 0.06 and 0.22, respectively). Notably, the US HFD index was only protective against adiposity among non-Hispanic white (NHW) and non-Hispanic black (NHB) adults, and MetS associations were driven by NHW adults. No associations were observed among Hispanic adults for any MetS components. Conclusions: Greater healthful food variety was associated with lower odds of MetS and some MetS components in the total population, NHW adults, and NHB adults. This study provides preliminary evidence that healthful food diversity may protect against MetS and highlights the need for longitudinal and experimental research. J Nutr 2015;145:564–71.
Keywords:
dietary variety, dietary diversity, healthy food diversity, healthy variety, metabolic syndrome, health
and racial disparities, metabolic syndrome components
Introduction Cardiovascular disease (CVD)7 is the leading cause of mortality worldwide (1). A key intermediate risk factor for CVD is metabolic syndrome (MetS), which is defined as a clustering of 1
Supported by the NIH Ruth L Kirschstein Postdoctoral Fellowship (5 T32 DK 7703-19). Author disclosures: M Vadiveloo, N Parkeh, and J Mattei, no conflicts of interest. 3 Supplemental Table 1 is available from the ‘‘Online Supporting Material’’ link in the online posting of the article and from the same link in the online table of contents at http://jn.nutrition.org. 7 Abbreviations used: CVD, cardiovascular disease; DBP, diastolic blood pressure; DGA, Dietary Guidelines for Americans; HFD, Healthy Food Diversity; MetS, metabolic syndrome; MPED, MyPyramid Equivalent; NHB, non-Hispanic black; NHW, non-Hispanic white; SBP, systolic blood pressure; WC, waist circumference. * To whom correspondence should be addressed. E-mail: [email protected]. 2
564
anthropometric and biochemical aberrations including abdominal obesity, impaired fasting glucose, lipid dysregulation, and hypertension (2). Because of the adverse effects of insulin resistance and inflammation on CVD pathophysiology (3–5), adults with MetS are twice as likely to develop CVD within the next 5–10 y compared with those without these perturbations (2, 3). Although dietary changes can positively modify metabolic markers, it is difficult for most people to develop and sustain healthful dietary patterns (6), particularly given that transformations in food environments have expanded access to inexpensive, energydense foods (7–10). As a result, if lifestyle interventions to prevent and manage metabolic risk factors are going to be efficacious, they must consider novel strategies to induce changes in food choice.
ã 2015 American Society for Nutrition. Manuscript received June 25, 2014. Initial review completed August 16, 2014. Revision accepted December 8, 2014. First published online December 31, 2014; doi:10.3945/jn.114.199125.
Downloaded from jn.nutrition.org at UNIVERSITY OF MASSACHUSETTS MEDICAL SCHOOL LIBRARY on April 6, 2015
Greater Healthful Food Variety as Measured by the US Healthy Food Diversity Index Is Associated with Lower Odds of Metabolic Syndrome and its Components in US Adults1–3
Methods Population and data collection. The NHANES is a continuous multistage, national health survey administered by the National Center for Health Statistics (31). Detailed information about the survey, laboratory, and examination procedures has been previously published (31–33). During each 2-y sampling cycle, a representative sample of ;10,000 noninstitutionalized individuals is interviewed and examined about demographic, dietary, and health-related information (34). In these analyses, we used data from the 2003–2006 NHANES and included adults aged $20 y with two 24-h dietary recalls, who were not pregnant or lactating, with self-reported energy intake between 400 and 7000 kilocalories (kcal), and with complete information on the outcome variables of interest (n = 3155 to 7188 depending on the outcome variable given sub-sampling methodology of NHANES). Nearly 90% of participants reported dietary data deemed complete and reliable by NHANES survey staff during the in-person and telephone-administered 24-h recalls (35, 36). Exposure variable. The US HFD index was developed based on a validated algorithm (37) that was adapted for a US population and was computed through use of the following equation: US HFD index ¼ 1 +s2i 3hv ð1Þ where si = share of food item or food group i based on volume in the total diet, hv ¼ + hf i 3si ; and hf = health factors of food. Details describing the development and validation of the index have been previously published (28). Briefly, individual food files were merged
with the MyPyramid Equivalent (MPED) databases 2.0 and 3.0 to disaggregate each individual food into its component parts (38). For example, the MPED database separates whole milk into its proportions of low-fat dairy and solid fat. Next, food shares (si) by volume were calculated by dividing individual food quantities by the total reported intake for each individual. The health value (hv) of the diet was calculated by multiplying each si by predetermined food group health weights and then summing the values. Health weights created for the 26 food groups and subgroups in the MPED database were informed by the 2000-kcal USDA dietary pattern in the 2010 Dietary Guidelines for Americans (DGA) (39). Specifically, the recommended proportions of each of the 26 food groups within the 2000-kcal USDA dietary pattern were used to weight the healthfulness of each food group (Supplemental Table 1). The US HFD index has a theoretical range between 0 and nearly 1, with higher scores reflecting diet patterns with greater variety and a higher proportion of DGA-recommended food groups. Outcome variables and covariates. Waist circumference (WC) and blood pressure were measured in the mobile examination center. Waist circumference was measured by trained personnel to the nearest 0.1 cm at the highest point of iliac crest at minimal respiration. After resting quietly in a seated position for 5 min, blood pressure was measured and the mean of up to 4 measurements was used to calculate mean systolic blood pressure (SBP) and diastolic blood pressure (DBP). Serum HDL cholesterol concentrations were assessed after precipitation of other lipoproteins with use of a heparin-manganese chloride mixture. Serum TG concentrations were determined from an enzymatic reaction hydrolyzing TGs to glycerol, and plasma glucose concentrations were assessed with use of an enzymatic reaction with hexokinase. Fasting plasma glucose and serum TG measurements were only available in a subset of participants who were invited to participate in the morning fasting subsample. We used the most recent harmonized definition of MetS from the International Diabetes Federation, AHA, and other organizations to define the presence of MetS (2), and participants with at least 3 of the 5 risk criteria were identified as having MetS. Risk criteria included the following: 1) elevated WC ($88 cm in women or $102 cm in men); 2) fasting plasma glucose $100 mg/dL or treatment of hyperglycemia; 3) SBP $130 mm Hg or DBP $85 mm Hg or use of antihypertensive medication; 4) serum TGs >150 mg/dL or treatment of dyslipidemia; or 5) serum HDL cholesterol
